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

Figures & data

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.

Table 1 Case Reports of Tuberculosis in Pediatric Patients Who Received Hematopoietic Stem Cell Transplant Recipients from 1990 to 2019

No.	Authors, Year (Refs)	Country/Region	Age, Gender	Stem Cell Source	Primary Disease	TB Onset After HSCT	Diagnosis After Onset of Symptoms	TB location	GVHD Prophylaxis at TB Diagnosis	TB Regimens	Outcome
1	Present case 1	Mainland China	8 yr, F	HLA 9/10 unrelated donor	TM	73 days	80 days	Pulmonary	Cyclosporine, mycophenolate	H/R/Z for a week, H/R/Z/S/Lzd/Lfx for 5 weeks, then oral H/R/Z for a year	Alive
2	Present case 2	Mainland China	9 yr, M	Haplo-PBSC+ unrelated UCB	TM	89 days	114 days	Lymph nodes, then pulmonary dissemination	Tacrolimus	H/R/Z for a week then H/R/Z/Lzd/Lfx (R was switched to L after a week) for 7 weeks (S was given from the third week for 4 weeks); Continued with oral intake of H/L/Z for a month after discharged, then reduced to H/L due to elevated enzyme levels until the last follow up	Alive
3	Fan WC et al 2015^Citation6	Taiwan	-	-	-	-	-	-	-	3 cases identified among 39 children from 1997 to 2006
4	Vercino R et al 2012^Citation2	Spain	8 yr, M	BMT	Bone marrow aplasia	50 days	1.5 months	Pulmonary/disseminated	Cyclosporine, mycophenolate	H/R/Z/M	Deceased
5	Biral E et al 2012^Citation12	Ukraine	10 yr, M	Alternative donor	ALL	2 months	>4 months	Pulmonary	Cyclosporine, methylprednisolone	H/R/Z/M	Alive
6	Lee JW et al 2011^Citation9	Taiwan	17 yr, M	BMT	ALL	2 months	3 months	Pulmonary	Cyclosporine	-	Deceased
7	Lee JW et al 2011^Citation9	Taiwan	14 yr, F	PBSC	ALL	8 months	Suspected TB exposure to Patient 5 at 4 months after HSCT	Pulmonary	Cyclosporine, beclomethasone	H/R/Z/Lfx then R/Z/Lfx/Cs	Alive
8	George B et al 2005^Citation10	India – 4 pediatric cases identified from 1986 to 2004	-	BMT	-	-	-	-	All patients were on steroids for GVHD	-	All patients responded well to anti-TB medications
9	Chen CC et al 1999^Citation11	Taiwan	10 yr, M	BMT	ALL	4 months	-	Pulmonary	Prednisolone, cyclosporine	H/R/Z	Deceased
10	Ip MSM et al^Citation7	Hong Kong	17 yr, M	Allogeneic BMT	MDS	120 days	-	Pulmonary	-	H/R/S/Z for months, then H/R/S for 3 months, then H/R for another 3 months	Alive
11	Ip MSM et al^Citation7	Hong Kong	17 yr, M	Allogeneic BMT	AML	550 days	-	Normal chest CT scan, positive lung Gallium scan	-	H/R/Z/O for 3 months, then H/R/O for 9 months	Alive
12	Ip MSM et al^Citation7	Hong Kong	17 yr, F	MUD	CML	28 days	-	Pulmonary	-	Patient died before the diagnosis of TB	Deceased

Abbreviations: ALL, acute lymphoblastic leukemia; Allo, allogeneic; AML, acute myeloid leukemia; BMT, bone marrow transplantation; CML, chronic myeloid leukemia; Cs, cycloserine; CT, computed tomography; H, isoniazid; HSCT, hematopoietic stem cell transplantation; L, rifapentine; Lfx, levofloxacin; Lzd, linezolid; M, ethambutol; MDS, myelodysblastic syndrome; MUD, matched unrelated donor; O, ofloxacin; PBSC, peripheral blood stem cell; R, rifampin; S, streptomycin; TB, tuberculosis; TM, thalassemia major; UCB, umbilical cord blood; Z, pyrazinamide.

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