A 41-year-old Caucasian woman underwent a primary double lung transplantation for cystic fibrosis in 2006.

Her medical history was otherwise unremarkable and the patient had no known history of pulmonary tuberculosis or tuberculosis contact.

On December 2015, she underwent retransplantation for chronic lung allograft dysfunction.

During the month preceding retransplantation, 4 sputum specimens remained negative for acid-fast bacilli and specific M. tuberculosis culture and real-time polymerase chain reaction (PCR) testing.

On postoperative day 42, deterioration of her respiratory status prompted a chest-computerized tomography (CT) scan revealing sub-centimeter bilateral nodules primarily located in the apical posterior lobes and a bilateral pleural effusion (Fig.1).

The same day, a bronchoalveolar lavage (BAL) yielded a positive real-time PCR for rifampicin-susceptible M. tuberculosis, confirmed by culture on postoperative day 62.

Tuberculin skin test (TST) or interferon-γ release assay (IGRA) test were not performed.

All the BALs performed on postoperative period yielded no other pathogen except for the one performed on day 60 that cultured Pseudomonas aeruginosa; the adjunctive antibiotic therapy was imipenem-cilastatin, 3 g/d.

Histological examination of a lung biopsy performed 6 weeks after retransplantation revealed a caseating granuloma and necrosis.

Acid-fast bacilli were identified as rifampicin-susceptible M. tuberculosis by real-time PCR.

On postoperative day 65, the patient's status worsened with severe hypoxemia, shock unresponsive to high dose cathecolamines, and multiorgan failure.

The patient died on postoperative day 70, despite treatment combining isoniazid, rifampicin, ethambutol, and pyrazinamide.

Retrospective real-time PCR testing of the explanted lung and BALs performed on postoperative days 1, 7, and 21 remained negative.

The organ donor died of posttraumatic intracerebral hemorrhage.

He was a 47-year-old man with no history of lung disease or risk factors for tuberculosis other than chronic alcohol use and smoking.

TST results were not available.

During hospitalization, a lung CT-scan showed no signs of active or previous tuberculosis and no TST or IGRA test results were available.

Routine cultures of per-transplantation right lung biopsy yielded Candida albicans.

Retrospective M. tuberculosis real-time PCR yielded negative results on the left and right donor-lung biopsies.

Both kidneys from the same donor were transplanted into 2 other recipients.

Six months after transplantation, neither of the kidney recipients had developed any signs or symptoms suggestive of active tuberculosis.