Clinical Pearls & Morning Reports
Published December 7, 2022
Hypercalcemia has many possible causes, but very few are associated with concurrent pulmonary nodules and splenomegaly. Granulomatous diseases such as sarcoidosis, histoplasmosis, and tuberculosis are associated with hypercalcemia. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: Do pulmonary nodules commonly develop after solid-organ transplantation?
A: The development of pulmonary nodules is a relatively common problem after solid-organ transplantation, and frequently prompts an infectious diseases consultation. Common bacterial infections are unlikely to cause pulmonary nodules and rarely manifest with discrete small nodules, but uncommon pathogens such as legionella or nocardia may produce this radiologic appearance. Mycobacterial infections, including infections with M. tuberculosis and nontuberculous mycobacteria, often cause pulmonary nodules. Fungal infections frequently cause pulmonary nodules; commonly encountered organisms include aspergillus species, mucorales, and endemic fungi such as Histoplasma capsulatum, Blastomyces dermatitidis, and coccidioides.
Q: In the United States, does tuberculosis account for a high percentage of donor-derived infections after solid-organ transplantation?
A: A 10-year review of the incidence of donor-derived diseases after solid-organ transplantation in the United States showed that tuberculosis accounted for 4% of all donor-derived infections. This review also showed that donor-derived tuberculosis occurred up to 148 days after transplantation, whereas donor-derived histoplasmosis occurred within 90 days after transplantation.
A: Tuberculosis is one of the most common infections worldwide and is a major cause of death. Owing to a concerted public health effort over the course of many decades, the incidence in the United States is very low – at approximately 2.2 cases per 100,000 persons – and typically occurs in persons who have resided in a region outside the United States where the disease is endemic. The post-transplantation incidence overall is between 1.2% and 6.4% in high-income countries. The clinical presentation can vary, but among solid-organ transplant recipients, 16% present with disseminated tuberculosis. The majority of cases will occur within 1 year after transplantation and can be caused by reactivation of latent tuberculosis, newly acquired tuberculosis after transplantation, or donor-derived tuberculosis.
A: In any unwell solid-organ transplant recipient, the epidemiologic exposures of the recipient must be considered, but so must the exposures of the donor. Donor-derived diseases are an important cause of post-transplantation death and complications. Potential organ donors are screened extensively for transmissible diseases through questionnaires (in living donors) and laboratory screening tests, primarily to identify and manage any potential bloodborne infections such as infections with human immunodeficiency virus, hepatitis B virus, and hepatitis C virus. However, other donor-derived diseases, including cancer, can occur, as can other infections such as histoplasmosis and tuberculosis. Deceased organ donors are not routinely screened for latent tuberculosis infection or for histoplasmosis because there is usually insufficient time to allow for such screening.