title: Successful treatment of multidrug-resistant tuberculosis following drug-induced hepatic necrosis requiring liver transplant.
abstract: A 28-year-old female developed multidrug-resistant (MDR) tuberculous lymphadenitis following a trip to India. She was initially treated with a four-drug regimen of first-line anti-tuberculosis medications, but when sensitivities indicated resistance to isoniazid and rifampin, her regimen was altered to ciprofloxacin (CFX), pyrazinamide (PZA) and ethambutol. She subsequently developed a rash, flu-like symptoms and fever, which progressed to acute hepatic necrosis despite discontinuation of medication. The clinical presentation and subsequent investigations suggested a hypersensitivity reaction, possibly related to the quinolone. The patient subsequently had an orthoptic liver transplant; second-line anti-tuberculosis medications were restarted to which she responded clinically and radiologically. Our findings raise the possibility that the CFX and PZA combination was responsible for the hepatic necrosis. The patient also illustrates that active, even MDR tuberculosis is not a contraindication to hepatic transplant.
authors.affiliation: Pharmacy and Vaccine Services, BC Centre for Disease Control, Vancouver, Canada. fawziah.marra@bccdc.ca
authors.forename: F
authors.initials: F
authors.lastname: Marra
authors.forename: V C
authors.initials: VC
authors.lastname: Cox
authors.forename: J M
authors.initials: JM
authors.lastname: FitzGerald
authors.forename: S
authors.initials: S
authors.lastname: Moadebi
authors.forename: R K
authors.initials: RK
authors.lastname: Elwood
mesh_terms: D000328:Adult; D000890:Anti-Infective Agents / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000494:pharmacology* / Q000627:therapeutic use*; D056486:Chemical and Drug Induced Liver Injury; D002939:Ciprofloxacin / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D004342:Drug Hypersensitivity; D018432:Drug Resistance, Multiple; D005260:Female; D006801:Humans; D008099:Liver / Q000473:pathology*; D016031:Liver Transplantation; D009336:Necrosis; D011718:Pyrazinamide / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy*
chemical_list: D000890:Anti-Infective Agents; D000995:Antitubercular Agents; D011718:Pyrazinamide; D002939:Ciprofloxacin