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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 2  |  Page : 198-200
Tuberculous Tracheo-Esophageal Fistula in a Renal Transplant Patient


Hamed Al-Essa Organ Transplantation Center, Kuwait

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   Abstract 

The incidence of mycobacterial infection (TB) is significantly higher in patients with end-stage renal disease and renal transplant recipients than in normal individuals. Tracheoesophageal fistulas (TEF) resulting from Mycobacterium tuberculosis infection are uncommon. We describe a 44-year old renal transplant recipient with such a lesion that had typical clinical presentation and radiological appearance of TEF and was successfully treated conservatively.

How to cite this article:
Samhan M, Al-Mousawi M, Halim M, Nampoory M. Tuberculous Tracheo-Esophageal Fistula in a Renal Transplant Patient. Saudi J Kidney Dis Transpl 2005;16:198-200

How to cite this URL:
Samhan M, Al-Mousawi M, Halim M, Nampoory M. Tuberculous Tracheo-Esophageal Fistula in a Renal Transplant Patient. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2020 Feb 16];16:198-200. Available from: http://www.sjkdt.org/text.asp?2005/16/2/198/32941

   Introduction Top


The incidence of tuberculosis (TB) is signi­ficantly higher in patients with end-stage renal disease and renal transplant recipients than in normal individuals. These patients suffer from defects in cell-mediated immunity that result in decreased host resistance to infection.

Tracheoesophageal fistulas (TEF) resulting from Mycobacterium tuberculosis infection are uncommon. We describe a renal transplant recipient with such a lesion that had typical clinical presentation and radiological appea­rance of TEF and was successfully treated conservatively.


   Case Report Top


A 44 year-old ex-soldier was diagnosed in April 1999 to suffer from chronic renal failure (CRF) of unknown etiology and was main­tained on peritoneal dialysis therapy. He received living unrelated kidney transplant in August 1999 and was maintained on triple immunosuppressive therapy with cyclosporine, mycophenolate mofetil and prednisolone. Three months later, the patient started follow-up in our center. His clinical condition was remark­able for impaired renal graft function (serum creatinine 170 -200 µmol/l), iron deficiency anemia (hemoglobin 96 grams/l), and slowly progressive dysphagia to solid food of one­year duration, which was not present prior to transplantation. Two weeks later, he was admitted to our center with productive cough, fever of 38.3° C and chills of three days duration, with clinical and radiological signs of chest infection, without detected lymphadenopathy.

Relevant microbiology and serology exami­nations for typical and atypical infection were requested. While waiting for the microbiology reports, the patient was empirically treated with cephotaxime, erythromycin, and gancyclovir. The chest condition became worse and the patient started to complain of choking especially after taking liquids. Esophagoscopy revealed diverticulum-like lesion at 32 cm from incisors, with necrotic base and signs of chronic inflam­mation. The biopsy from this diverticulum showed chronic inflammatory and granuloma­tous lesions but was negative for malignancy. One week later, gastrograffin swallow with chest computerized tomography (CT) scan revealed mid-esophageal lesion with tracheo­esophageal fistula.

Sputum became positive for acid-fast bacilli (AFB) and sputum culture was reported to be positive for Mycobacterium tuberculosis. The patient was diagnosed to have tuberculous tracheo-esophageal fistula and miliary tuber­culous chest infection and he was treated with ethambutol, rifampicin, isoniazed, pyrazinamide and vitamin B6. Other antibiotics and antiviral drugs were discontinued. Gastrostomy feeding tube was inserted and all forms of oral feeding were stopped.

The patient condition showed slow but progressive improvement. Sputum became negative for AFB three weeks after the initiation of the anti-TB treatment. The productive cough and choking became much less, and repeated chest CT scan with gastrograffin swallow showed healing of the TEF. Oral feeding was started after eight weeks of treatment and the gastrostomy tube was removed after ten weeks of treatment.

During follow-up as outpatient six months later, the patient developed biopsy proven tuber­culous osteomyelitis of the right tibia, and the diagnosis was confirmed by the microbiological tests. This condition responded well to the extended course of anti-tuberculous treatment.

Triple immunosuppression therapy was maintained during the whole period of treat­ment and the cyclosporine dose was adjusted according to its blood levels. The renal graft function remained stable. The anti-TB treat­ment was discontinued 20 months after initiation of treatment.


   Discussion Top


The reported frequency of TB in the trans­plant population ranges from 0.2% to 15%, which is 6 to 62 times the incidence in the general population. [1],[2],[3] Geographic differences influence this wide range of figures. In the developing countries, the reported higher incidence of TB following renal transplant­ation may be the result of poor nutrition and inadequate environmental sanitation. [4] Post transplantation TB may present in pulmonary, extra-pulmonary or miliary form. Diagnosis of TB is usually late and associated with serious morbidity as well as high risk of mortality. The average rate of mortality directly related to TB in transplant recipients ranges from 15 to 31%. [1],[3],[5] Esophageal TB is a rare disease, usually seen in patients with obvious TB else­where. It is generally caused by local extension from mediastinal lymph nodes; hence, the location is more common in the middle third of the esophagus, just above the tracheal bifurcation.

The majority of acquired non-malignant TEF result from complications of prolonged mechanical ventilation. [6] Other causes include TB, or foreign body impaction. TEF presents clinically mostly with cough associated with food indigestion. Diagnosis is usually late and confirmed by endoscopy, radiology and histopathology. Treatment is difficult, pro­longed, and requires surgical intervention in most cases.

TEF has been previously reported in chronic renal failure patients, but this is the first case to be reported in renal transplant recipient. This case has presented with typical symptoms and signs, and diagnosis was made within 10 days of starting symptoms, with full micro­biological, radiological and histopathological documentation. The patient responded to conservative treatment and the kidney graft function remained stable during the whole course of therapy.

 
   References Top

1.Sinnott JT 4th, Emmanuel PJ. Mycobacterial infections in the transplant patients. Seminars Respir Infect 1990;5:65-73.  Back to cited text no. 1    
2.Delaney V, Sumrani N, Hong JH, Sommer B. Mycobacterial infection in renal allograft recipients. Transplant Proc 1993:25:2288.  Back to cited text no. 2    
3.Sayinar A, Ece T, Duman S, et al. Tuberculosis in renal transplant recipients. Transplantation 1999;68:1268-71.  Back to cited text no. 3    
4.Koseoglu F, Emiroglu R, Karakayali H, et al. Prevalence of mycobacterial infection in solid organ transplant recipients. Transplant Proc 2001;33:1782-4.  Back to cited text no. 4    
5.Sundberg R, Shapiro R, Darras F, et al. A tuberculosis outbreak in a renal transplant program. Transplant Proc 1991;23:3091-2.  Back to cited text no. 5  [PUBMED]  
6.Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired non-malignant tracheo-esophageal fistula. Ann Thorac Surg 1991;52:759-65.  Back to cited text no. 6  [PUBMED]  

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Correspondence Address:
Mahmoud Samhan
Hamed Al-Essa Organ Transplantation Center, P O Box 6031, Hawaly 32035
Kuwait
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PMID: 18202498

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    Abstract
    Introduction
    Case Report
    Discussion
    References
 

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