Endocrine Abstracts

Tuberculosis (TB) infection incidence is still high among solid organ transplant recipients. TB in recipients can manifest several years after transplantation, especially in developing countries. Atypical clinical presentations and extrapulmonary involvement are not uncommon in recipients. Herein, we reported a kidney transplant recipient with TB abscess who admitted with fever and swelling on thyroid gland region.

Case: A 57-year old female recipient underwent a successful deceased kidney transplantation 4 years ago. She applied to our outpatient clinic with fever and swelling on the thyroid gland region. She complained fever for 20 days without sweating and tender swelling with hyperemia in front of her neck. On physical examination there was only hyperemic, hard, fixed, 6×8 cm diameter swelling in the midline of the neck which was enlarged to the right side. The laboratory tests revealed neutrophilic leukocytosis (15.0 K/mm³), elevated CRP (23.7 mg/dl), creatinine (1.5 mg/dl) and PTH (698 pg/ml); low 25-OH vitamin D (<8 μg/l), calcium (8.3 mg/dl) and TSH (0.269 μIU/l); normal free T4 (1.2 ng/dl) and thyroglobulin (32 ng/ml) levels. Ultrasonography revealed hypoechogenic nodular thyroid gland and a 7.5×7 cm heterogeneous cyst. Neck computed tomography showed a 7.5×7 cm diameter abscess on the right cervical region extending to the upper mediastinum. Thyroid and parathyroid scintigraphies (Tc-99m pertechnetate + Tc-99m MIBI) revealed that the mass was unrelated to these glands. Secondary hyperparathyroidism due to vitamin D deficiency was diagnosed. Empirically meropenem and teicoplanin were administered. The drainage of the abscess was performed with micropuncture. Because of the mediastinitis risk the abscess was drained totally. Mycobacterium tuberculosis was detected with polymerase chain reaction of suppurative drainage material. A four-drug regimen with isoniazid, rifampycin, ethambutol and pyrazinamide was initiated. The abscess resolved and she was discharged with anti-tuberculosis regimen and immunosuppressive drug dose arrangement.

Conclusion: Extrapulmonary or disseminated TB infection rate after transplantation is 30–50%. Although TB occurs within the first year of the transplantation in 95% of the cases, it may appear late as in the present case. Extrapulmonary TB infection should be kept in mind in recipients with atypical suppurative lesions in thyroid region as was the case in our patient.