1. Pre-Transplant Evaluation and Post-Transplant Outcomes that Went in Unexpected Directions!
Karam M. Obeid
Infectious Diseases and International Medicine
University of Minnesota
2/20/2018

2. History 61 yo Somali female with HCV-induced liver cirrhosis.
Undergoing OLT evaluation.
Referred to ID 02/2015 for positive QuantiFERON.
Treponemal AB and TP-PA positive.

3. History Exposure History:
Born in Somalia, spent time in Kenya in a refugee camp.
hosted a relative who had active TB.
immigrated to USA in 2006.
Was not compliant with LTBI therapy upon arrival to USA.
She currently lives in Minneapolis.
She is married to her current husband for 7 years. Ex husband passed away in Kenya/Somalia from unknown reasons.

4. History
No fever, no chills, no weight loss (edema and ascites), no night sweats.
No cough, no dyspnea, no hemoptysis, no chest pain.
Has chronic dysuria, no gross hematuria.

5. Laboratory Findings

6. Laboratory Findings

7. Laboratory Findings NA 132, K 4, Cl 104, Bicarb 20, BUN 26, Cr 1.3
AST 30, ALT 34, Alk Phos 80, T bili 2.4, AFP 16
WBC 4,Hgb 10, Plat 80
ANC 1.4, ALC 1.4, Eosinophils 0.2, Mono 0.5

8. Laboratory Findings Urine Cx either negative or normal flora
5/7/ :20
7/1/ :31
7/8/ :50
10/20/ :07
11/18/ :00
11/18/ :30
2/13/ :43
WBC Urine
64 (H)
19 (H) 2
23 (H) 1
5 (H)
RBC Urine
>182 (H)
48 (H)
11 (H)
7 (H)
16 (H)
3 (H)
Urine Cx either negative or normal flora

9. CXR 2/17/2015

10. Questions Discussion

11. Ann Intern Med 2008;149:177-84

12. Ann Intern Med 2008;149:177-84

13. QuantiFERON also positive in:
M kansasii
M marinum
M szulgai

14. Progress Received IM B-PCN x3 for latent Syphilis.
Chart review revealed evaluation by GYN and urology for hematuria:
US kidneys, CT abdomen and pelvis, cystoscopy, urine cytology all unremarkable.
Endometrial biopsy: chronic endometritis.

15. Workup for active TB vs LTBI
Ascites negative for AFB smear and cx.
Serum-ascitic albumin 1.8.
WBC in fluid 100, L 40% and Others 60%
Urine for AFB x1
Negative for AFB smear
Positive cx for MAI
Urine for AFB x3
Negative smear x3
Positive cx for MAI X2

16. GU tract is the second most common extrapulmonary TB after LN.
GU infection due to NTM is very rare (case reports).
Pathophysiology assumed to be either due to trauma or hematogenous/lymphatic spread.
Disseminated disease is usually limited to patients with immunosuppressive conditions.
Most of the case reports of MAI infection in liver cirrhosis patients were limited to peritonitis or pneumonia.

20. Follow up Was started on zithromax, ethambutol, rifampin.
N/V with rifampin and rifabutin.
Switched to zithromax, ethembutol, and moxifloxacin.
Repeat urine for AFB smear and cultures
Negative AFB smear positive 9/2015
Negative AFB and cx starting 11/2015 X4/4

21. Follow up Successfully underwent OLT and KAT 2/8/2017. Liver pathology
without granulomas
c/w HCV, α1-antitrypsin deficiency, and poorly differentiated HCC

22. Follow up

23. AFP and OLT
AFP is glycoprotein that is produced in early fetal life by the liver.
Produced by HCC, hepatoblastoma, non-seminomatous germ-cell tumors in ovary and testis.
20% of HCC do not produce AFP.
1000 ng/mL seems the appropriate cutoff to exclude patients from OLT.
AFP decreases to < 20 ng/mL within 2 months post-OLT.

24. CT c/a/p 2/19/2017 IMPRESSION:
1. No definite evidence of metastatic disease.
2. Nodularity of the right adrenal gland measuring 3.7 x 2.3 cm. This is new from comparison exam. Density is identical in arterial and portal venous phase making adrenal hemorrhage most likely, potentially postoperative. Metastatic lesion is difficult to exclude in this exam
alone. Attention on short-term follow-up is suggested.
3. Post surgical changes of a liver transplant with associated free fluid surrounding the transplant liver. Abdominal drain terminates adjacent to the liver.
4. Postsurgical changes of a right lower quadrant kidney transplant. Ureteral stent in place.
5. Moderate right pleural effusion and small left pleural effusion.
6. There is a 4 mm nodularity associated with the right major fissure; location likely entails that it is a lymph node, but may also be pleural fluid versus a nodule. Attention on follow-up is recommended.
7.Rim-enhancing fluid collections associated with the anterior wall incision site. Fluid within the collections has fluid density. This likely represents a seroma/hematoma, although infection cannot beexcluded.

25. Serial CTs started to show non-specific pulmonary nodules starting 4/2017.

26. CT chest 12/30/2017

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11. UP TO DATE

32. Thank You
Questions