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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 3  |  Page : 465-467
Vaginal tuberculosis in an elderly kidney transplant recipient


1 Nephrology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Nephrology Research Center, Baqiyatallah University of Medical Sciences; Dr. Taheri Medical Research Group, Tehran, Iran

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   Abstract 

Female genital tuberculosis (FGTB) is extremely rare in post-menopausal women. A 59-year-old woman developed vaginal tuberculosis one year after receiving a kidney transplant from a living donor. Her complaints included abdominal pain, fever, and weight loss. Furthermore, her tu­berculin skin test was negative. She was successfully treated with quadruple anti-TB therapy for 6 months.

How to cite this article:
Nemati E, Taheri S, Nourbala MH, Einollahi B. Vaginal tuberculosis in an elderly kidney transplant recipient. Saudi J Kidney Dis Transpl 2009;20:465-7

How to cite this URL:
Nemati E, Taheri S, Nourbala MH, Einollahi B. Vaginal tuberculosis in an elderly kidney transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Nov 29];20:465-7. Available from: https://www.sjkdt.org/text.asp?2009/20/3/465/50781

   Introduction Top


Tuberculosis (TB) frequently presents with pul­monary involvement; although with the resur­gence of tuberculosis worldwide, there have been reports of unusual sites being affected by the disease. A recent study from Saudi Arabia found 78% prevalence of extra-pulmonary in­fection compared with 22% of pulmonary TB in hemodialysis patients. [1] Extra-pulmonary TB commonly usually presents with nonspecific cli­nical and laboratory findings, which delay diag­nosis and management.

Female genital TB (FGTB) is extremely rare in post-menopausal women, [2] and can be a conse­quence of the atrophic endometrium of post me­ nopausal women. We report a case of FGTB in a post-menopausal kidney transplant patient.


   Case Report Top


A 59-year-old post menopausal woman with a history of kidney transplantation performed in 1998. She presented 1.5 years later to our outpa­tient department with complaints of abdominal pain, intermittent fever, fatigue, and weight loss (3 kg) during the past two months. She had been receiving triple immunosuppressive treatment with cyclosporine (CsA-ME; Neoral, Novartis Pharma, Basel, Switzerland) 250 mg/day, pred­nisolone 7.5 mg/day, and azathioprine 100 mg/ day. She was married and had three children.

On physical examination the patient had body temperature 38.5°C, blood pressure 120/70 mmHg, pulse rate 78/min, respiratory rate 16/ min, and tenderness in the right lower quadrant of the abdomen.

The laboratory results included serum creati­nine 1.2 mg/dL, blood urea nitrogen (BUN) 15 mg/dL, WBC 5100 (neutrophil 83%), hemoglobin 12.1 g/dL, C-reactive protein (CRP) ++, and ESR 43 mm/hr. Her tuberculin skin test was negative. Cytomegalovirus antigen was not de­tected in serum of the patient. Urine culture and 3 consecutive blood cultures were negative. Chest X ray showed no definitive feature, and ul­trasound of the abdomen and pelvis was unre­markable.

For further evaluation of the right lower quad­rant abdominal pain, a trans-vaginal examination with colposcopy that showed a blue purplish cervix with nodular vegetations covered with necrotic white spots. Histopathologic exam of the biopsies of the vegetations revealed granu­lomatous reactions with caseous necrosis sur­rounded by epithelioid macrophages, giant cells, and lymphocytes, but Ziehl-Neelsen staining of the tissue was negative.

The patient was treated with rifampicin 600 mg/day, isoniazide 300 mg/day, pyrazinamide 1500 mg/day, and ethambutol 800 mg/day, and the cyclosporine dose was increased to a level of 300 mg/day. Four days after the administration of anti-TB drugs, the fever subsided and the pa­tient was discharged from the hospital two week later. She underwent therapy with pyrazinamide and ethambutol for two months, and rifampicin and isoniazide for 6 months. Through the past 10 years, her allograft remained functional and her creatinine level was 1.2 mg/dL at her last admission.


   Discussion Top


Despite the considerable progress in preven­tion and treatment of tuberculosis, the number of deaths correspond to this condition in the past decade is estimated to be about 30 million worldwide.

Although genitalia are the most common extra­pulmonary sites for TB infection, it is rare in post menopausal women, and FGTB is mostly diagnosed in the course of evaluation of infer­tility. Numerous studies have shown the critical relevance of chronic diseases in the incidence of TB. It is estimated that the overall incidence of developing TB in kidney transplant population is around 15%. [3]

The tuberculin skin test is used for detection of TB infection for its ease of administration and sensitivity, [4] however, it may be negative in patients with impairment of immune system such as transplant patients or chronic kidney disease. [5],[6]

Factors that raise suspicion of TB infection include history of TB exposure, residence in an endemic area, malnutrition, high risk popula­tion, previous positive tuberculin skin test, im­munocompromised conditions, or prior chest X-ray (CXR) findings suggestive of TB. [7]

Incidence of TB in the kidney transplant pa­tients can be due to reactivation of dormant TB is the usual mode of acquisition or transmission through donor kidney. [4] In a survey conducted in the United States, risk factors for TB transmi­ssion to kidney transplant patients included end­stage renal disease due to systemic lupus ery­thematosus, graft loss and history of rejection at the first year post transplantation. [8]

FGTB is usually considered as a secondary complication of pulmonary TB; however, in some cases this condition is thought to be a primary infection. Sexual transmission of the infection is a proposed route for female genita­lia tuberculosis. [9] TB in male genitalia, may result from disseminated infection from the urinary bladder. Since urinary tract tuberculosis can follow kidney transplantation, [10] the close pro­ximity of the renal allograft and female geni­talia could be relevant to the FGTB in our case; however, the donor did not any evidence of TB.

In conclusion, our case report may be the first reported FGTB in a post-menopausal kidney allograft recipient, who was successfully treated with a 6-month anti-TB quadruple drug therapy.

 
   References Top

1.Abdelrahman M, Sinha AK, Karkar A. Tuberculosis in end-stage renal disease patients on hemodialysis. Hemodial Int 2006;10(4):360-4.   Back to cited text no. 1    
2.Maestre MA, Manzano CD, Lopez RM. Postmenopausal endometrial tuberculosis. Int J Gynaecol Obstet 2004;86:405-6.  Back to cited text no. 2    
3.Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid-organ transplant recipients: Impact and implications for management. Clin Infect Dis 1998;27(5):1266-77.  Back to cited text no. 3    
4.Khosroshahi HT, Shoja EA, Beiglu LG, Hassan AP. Tuberculin testing of kidney allograft recipients and donors before transplantation. Transplant Proc 2006;38(7):1982-4.  Back to cited text no. 4    
5.Ravn P, Munk ME, Andersen AB, et al. Reactivation of tuberculosis during immuno­suppressive treatment in a patient with a positive QuantiFERON-RD1 test. Scand J Infect Dis 2004;36(6-7):499-501.  Back to cited text no. 5    
6.Rutsky EA, Rostand SG. Mycobacteriosis in patients with chronic renal failure. Arch Intern Med 1980;140(1):57-61.  Back to cited text no. 6    
7.Kasiske BL, Ramos EL, Gaston RS, et al. The evaluation of renal transplant candidates: Cli­nical practice guidelines. Patient Care and Education Committee of the American Society of Transplant Physicians. J Am Soc Nephrol 1995;6:1-34.  Back to cited text no. 7    
8.Irish A. Hypercoagulability in renal transplant recipients. Identifying patients at risk of renal allograft thrombosis and evaluating strategies for prevention. Am J Cardiovasc Drugs 2004; 4:139-49.  Back to cited text no. 8    
9.Richards MJ, Angus D. Possible sexual trans­mission of genitourinary tuberculosis. Int J Tuberc Lung Dis 1998;2(5):439.  Back to cited text no. 9    
10.Peters TG, Reiter CG, Boswell RL. Transmi­ssion of tuberculosis by kidney transplan­tation. Transplantation 1984;38(5):514-6.  Back to cited text no. 10    

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Correspondence Address:
Saeed Taheri
Nephrology Research Center, Baqiyatallah University of Medical Sciences, MullaSadra St., P.O. Box, 14155-6437, 1435915371 Tehran
Iran
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PMID: 19414953

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    Abstract
    Introduction
    Case Report
    Discussion
    References
 

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