Paradoxical worsening of tuberculosis in a heart-lung transplant recipient.
We report on a heart-lung transplant recipient who presented with pulmonary tuberculosis (TB) 2.5 months after transplantation and then developed a paradoxical reaction after 4 months of adequate anti-TB treatment. She eventually recovered with anti-TB and high-dose steroid treatments.


METHODS
Using sequential bronchoalveolar lavages, we assessed the inflammatory response in the lung and investigated the alveolar immune response against a Mycobacterium tuberculosis antigen.


RESULTS
The paradoxical reaction was characterized by a massive infiltration of the alveolar space by M. tuberculosis antigen-specific CD4(+) T cells and by the presence of a CD4(-)CD8(-) T lymphocyte subpopulation bearing phenotypic markers (CD16(+)/56(+)) classically associated with NK cells.


CONCLUSIONS
This case report illustrates that even solid organ transplant recipients receiving intense triple-drug immune suppression may be able to develop a paradoxical reaction during TB treatment. Transplant physicians should be aware of this phenomenon in order to differentiate it from treatment failure.
Place
S
S
Laboratory of Vaccinology and Mucosal Immunity, Erasme Univeristy Hospital, Free University of Brussels, Brussels, Belgium.
Knoop
C
C
Remmelink
M
M
Baldassarre
S
S
Van Vooren
J-P
JP
Jacobs
F
F
Mascart
F
F
Estenne
M
M
D000328:Adult; D018893:Bronchoalveolar Lavage / Q000379:methods; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology; D005260:Female; D016041:Heart-Lung Transplantation; D006801:Humans; D007165:Immunosuppression Therapy; D007694:Killer Cells, Natural / Q000276:immunology; D008297:Male; D009169:Mycobacterium tuberculosis / Q000254:growth & development / Q000302:isolation & purification*; D013601:T-Lymphocytes / Q000276:immunology; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000276:immunology* / Q000382:microbiology