Identification and Treatment of Tuberculosis in Pediatric Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: Case Series and Review of the Literature

Abstract

Background: Tuberculosis is a rare but life-threatening complication in patients who received hematopoietic stem cell transplantation. Early identification and intervention are essential to prevent severe complications.

Case presentation: We report two pediatric patients who developed tuberculosis after receiving hematopoietic stem cell transplantation for thalassemia major among 330 recipients between January 2012 and August 2019. Patient A presented with pulmonary tuberculosis and patient B presented with lymph node tuberculosis mimicking post-transplantation lymphoproliferative disorder associated with Epstein-Barr virus reactivation. Patient B's condition was deteriorated, and shortly after the initiation of anti-tuberculosis therapy, the patient was found to have disseminated pulmonary tuberculosis. Patient B was also found to have tuberculous granulomas, an uncommon manifestation of tuberculosis causing severe airway obstruction. Both patients developed critical respiratory failure and required mechanical ventilation; however, they recovered with almost full resolution of pulmonary lesions after multiple treatment adjustments.

Conclusion: Tuberculosis must be carefully evaluated in all pediatric patients that receive hematopoietic stem cell transplantation, regardless of the identification of other pathogens. Prophylactic tuberculosis therapy should be considered for high-risk pediatric hematopoietic stem cell transplantation recipients from tuberculosis-endemic regions.

Keywords: hematopoietic stem cell transplantation; pediatric; thalassemia; tuberculosis.

Figure 1

Chest radiographs and bronchoscopy images of patients A and B during the course of treatment. Chest CT images of patient A revealed: (A) small nodular opacities in both lungs; (B) pulmonary infiltrates; and (C) dissolution of pulmonary lesions. Chest CT images of patient B revealed: (D) enlarged mediastinal and peribronchial lymph nodes; (E) massive infiltration, consolidation, and atelectasis of the right upper lobe of the lungs; and (F) a nearly full recovery and dissolution of pulmonary infiltrates. Bronchoscopy images of patient B on (G, H) day 127 post-HSCT and (I) day 137 post-HSCT showing tubercular granulomas obstructing the airways. (J) Bronchoscopy images showing tubercular granulomas within the respiratory tract mucosa that did not regrow following two cryosurgeries. CT, computed tomography; HSCT, hematopoietic stem cell transplantation.