Renal Failure, 33(10): 1040–1042, (2011) Copyright © Informa Healthcare USA, Inc. ISSN 0886-022X print/1525-6049 online DOI: 10.3109/0886022X.2011.618921
CASE REPORT
Differential Diagnosis of an Unusual Pelvic Mass in a Renal Transplant Recipient: Multidrug-Resistant Abdominopelvic Tuberculosis Erhan Tatar1 , Ozkan Gungor1 , Ozgur Firat2 , Fatih Kircelli1 , Bilgin Arda3 , Mustafa Harman4 , Huseyin Toz1 and Cuneyt Hoscoskun2
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1 Division
of Nephrology, Ege University School of Medicine, Izmir, Turkey; 2 Department of General Surgery, Ege University School of Medicine, Izmir, Turkey; 3 Department of Infectious Disease and Clinical Microbiology, Ege University School of Medicine, Izmir, Turkey; 4 Department of Radiology, Ege University School of Medicine, Izmir, Turkey
Abstract Renal transplant patients are more prone to tuberculosis infection due to the underlying intense immunosuppression, with an incidence 20–74 times higher than that in the general population. It is associated with graft dysfunction and increased mortality rates. It can be frequently pulmonary but extra-pulmonary involvement is not rare, and in the latter case, it may be misinterpreted as genital malignancies. In this case report, we discuss a renal transplant patient with pelvic pain and fever, who was later diagnosed as having abdominopelvic tuberculosis. Keywords: abdominopelvic, tuberculosis, multidrug resistant, pelvic mass, renal transplantation
In this case report, we discuss a renal transplant patient with pelvic pain and fever, who was later diagnosed as having multidrug-resistant abdominopelvic TB.
INTRODUCTION Tuberculosis infection (TB) is an important health issue in the general population especially in the endemic regions of the world.1 Due to the underlying intense immunosuppression, renal transplant patients are more prone to TB, with an incidence 20–74 times higher than that in the general population.2,3 Its diagnosis and management is challenging due to the complicated nature of transplantation. In this patient population, TB has been associated with graft dysfunction and increased mortality rates.4–6 Not only the overall immunosuppression, but also older age and coexisting diseases such as diabetes, chronic liver disease, and co-infections have been associated with predisposition to TB.7 TB can be frequently pulmonary, but extrapulmonary involvement is not rare, affecting 16% of the transplant patients.8 Of these, pelvic TB is relatively rare and may be misdiagnosed as genital malignancy or other pelvic diseases due to its location.9,10 Genital TB is also a major cause of infertility in the developing countries.11
CASE A 43-year-old woman was admitted to the emergency room with fever and pelvic pain. Her past history revealed a pre-emptive renal transplantation from a living related donor (aunt) 3 years ago. There were five human leukocyte antigen mismatches. She did not have any self or family history of TB and no visit to an endemic region for TB. She was seropositive for cytomegalovirus infection and did not have a previous hepatitis B or C infection. Her donor was antiCmv Ig G positive. Her induction therapy consisted of basiliximab; the maintenance immunosuppressive regimen included prednisolone, tacrolimus (TAC), and mycophenolate sodium (MPS). At the time of admission, she received 5 mg/day prednisolone, 1080
Address correspondence to Erhan Tatar, Division of Nephrology, Ege University School of Medicine, 35100 Bornova, Izmir, Turkey. Tel.: +90.232.3904254; E-mail:
[email protected] Received 18 May 2011; Revised 13 July 2011; Accepted 14 July 2011
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Abdominopelvic Tuberculosis and Renal Transplantation 1041
mg/day MPS, and 2 mg/day TAC. Her TAC level at the last visit was 6.4 ng/mL. She did not have any rejection attacks since her transplantation, and her last serum creatinine was 1.6 mg/dL. Her chest X-ray was normal at the pre- and post-transplant period. She had fever (38.4◦ C), was normotensive (110/70 mmHg), and had generalized abdominal pain at physical examination. Complete blood count revealed leukocytosis (16.100/m3 ): primarily neutrophilia anemia (hemoglobin: 8.9 g/dL), (14.450/mm3 ), and thrombocytosis (426.000/mm3 ) at the time of admission. C-reactive protein level was 17.64 mg/dL (
