Tuberculosis while on Lung transplant wait list & on ECMO as bridge to transplant- An ethical and clinical challenge

Abstract

Introduction: The incidence of Tuberculosis(TB) is 4 times more in patients with Interstitial lung diseases(ILD). Active TB is considered as contraindication for lung transplant. We report a case of a patient with Idiopathic Pulmonary Fibrosis(IPF) with COVID 19 exacerbation who, while being bridged to transplant on ECMO, tested positive for Tuberculosis and underwent a bilateral lung transplantation.

Case: 40 year old male, known case of IPF, admitted with severe COVID ARDS was evaluated and listed for Bilateral Lung transplantation. In view of acute deterioration, he was initiated on ECMO as a bridge to transplant. His Broncho Alveolar Lavage(BAL) showed AFB and CBNAAT confirmed Mycobacterium tuberculosis which was rifampicin sensitive. He was initiated on antitubercular drugs and subsequently underwent bilateral lung transplant. He was weaned off ECMO and his further BAL samples did not show evidence of M. Tb. He had a series of post-operative complications including Acute kidney injury, weaning failure and Acute coronary syndrome with LV dysfunction and eventually succumbed.

Discussion: This case poses a unique ethical challenge of whether or not to proceed for transplant in patients who test positive for pulmonary tuberculosis while on waitlist and on ECMO as bridge to transplant. However, the unfavorable outcome of the transplant reinforces the available data that active tuberculosis is associated with high mortality in lung transplant. Further guidance is required to manage such patients to improve lung transplant survival rates, especially in TB endemic regions such as India.