248.8: Mycobacterium tuberculosis Colitis and Cytomegalovirus in A Renal Transplant Recipient: An Infrequent Association

Introduction: Chronic diarrhea, infectious or inflammatory, is a frequent cause of consultation in transplant recipients. Immunosuppressants are the most common reason, but microorganisms like cytomegalovirus (CMV), clostridium difficile, campylobacter, are often reported. Tuberculosis can occur, but it has a low prevalence, described between 0.3 and 1.7%. Method: We described a 32-year woman with a history of membranoproliferative glomerulonephritis, recipient of a deceased-donor kidney transplant 12 years ago. She received basiliximab and steroids as induction therapy and maintenance with tacrolimus, mycophenolate and deflazacort. She consulted with a 7-day history of liquid diarrhea, no blood, nor mucus with abdominal pain, nausea, and fever up to 39°C. She manifested a 10kg loss of weight in a 6 month-period with no other symptoms. Upon admission, she had tachycardia, mild abdominal pain in left flank. Blood workup showed normal leukocytes and platelets, absolute lymphocyte count of 0.8x103/ L, hemoglobin 8.9g/dL, creatinine 1.51mg/dL, high C-reactive protein, and low level of albumin. Low iron, TSAT and high ferritin level. Normal folic acid and vitamin B12. Coproscopic showed blood, no leukocytes. Blood cultures, molecular panel identification of multiple gastroenterology pathogens (filmarrayTM), VIH, viral load with transcriptase-polymerase-chain-reaction (PCR) in blood for CMV were negative. Chest radiography was normal. Contrast abdominal tomography showed thickening and enhacement of the walls of the cecum, hepatic flexure, ileocecal valve and distal ileum. In ascending colon, a 4cm decreased of the lumen was seeing. Multiple round nodes smaller than 10mm after contrast were observed. Total colonoscopy showed colitis in transverse and left colon with 80% stenosis of the lumen. Biopsy documented active chronic colitis with a marked ulcerative component. No microorganisms, dysplasia or malignancy were observed. Real time-PCR was processed for CMV in colonic tissue and PCR for mycobacterium tuberculosis (MT) both reported positive. Co-infection with intestinal CMV and MT was diagnosed. She was treated with valganciclovir for 4 weeks and tetraconjugate with isoniazid(H), rifampicin(R), pyrazinamide(Z), ethambutol(E) and pyridoxine. During treatment, presented elevated transaminases and uric acid attributed to hepatotoxicity for H. It was switched to moxifloxacin with improved in hepatic profile. Moxifloxacin, R and Z were continued for 9 months. The patient had resolution of the diarrhea, recovery of weight, anemia and renal function. Conclusion: CMV is a common etiological agent in kidney transplant recipients with diarrhea, co-infection with other microorganisms, such as, MT can worsen the clinical course and without treatment can lead to death. Having a high index of suspicion is essential. A rigorous diagnostic approach is necessary and performing PCR on tissue can contribute to allow early diagnosis and timely treatment.