CASE REPORTOpen Access
Concomitant pulmonary tuberculosis and
tuberculous appendicitis in a recipient of a renal
transplant: a case report
Mohammad R Ardalan1, Mohammadali M Shoja2and Kamyar Ghabili2*
Introduction: Tuberculosis is still a serious infection among recipients of renal transplants. Although the ileocecal
region is the most affected part in intestinal tuberculosis, acute tuberculous appendicitis is quite a rare entity. We
report a case of concomitant pulmonary tuberculosis and tuberculous appendicitis in a recipient of a renal
Case presentation: A 27-year-old Iranian woman, who had been the recipient of a renal transplant five years
earlier, presented with a two-week history of coughing, fever and weight loss. The cause of her end-stage renal
disease was chronic pyelonephritis. There were fine crackles noted during a chest examination, and a plain chest
radiography showed fine miliary nodules throughout her entire lung fields. Sputum and bronchial aspirate
examination was positive for acid-fast bacilli, suggestive of Mycobacterium tuberculosis infection. A chest computed
tomography scan revealed widespread miliary nodules, compatible with miliary tuberculosis. She developed severe
abdominal pain and abdominal surgery disclosed a perforated appendicitis. Histopathological examination of the
resected appendix revealed widespread caseating epithelioid granulomas, suggestive of tuberculosis.
Conclusion: Our case report highlights a rare presentation of tuberculosis in a patient who has undergone renal
transplant. Such unusual presentation of tuberculosis, particularly among patients receiving potent
immunosuppressive protocols, should be considered by clinicians.
Tuberculosis (TB) remains a major health hazard parti-
cularly in developing countries . Renal transplant
recipients are at high risk of a number of infections
including mycobacterial diseases [2,3]. The cumulative
incidence of post-transplant TB in developing countries
is as high as 13.3% with a relatively high rate of extra-
pulmonary TB. Although the ileocecal region is the
most affected part in gastrointestinal TB, acute tubercu-
lous appendicitis is quite a rare entity . Here, the
authors report a renal transplant recipient who devel-
oped concomitant pulmonary TB and tuberculosis
A 27-year-old Iranian woman, recipient of a living,
unrelated renal transplant five years earlier, presented
with a productive cough, weight loss and fever. The
cause of her end-stage renal disease was chronic pyelo-
nephritis. Six weeks prior to her admission, her immu-
nosuppressant regimen was switched from oral
cyclosporine (100 mg, twice daily) to oral sirolimus (1
mg, twice daily) with a diagnosis of chronic allograft
nephropathy (serum creatinine level of 2 mg/dL). Her
mycophenolate mofetil dose was decreased from 2000 to
1000 mg/day and prednisolone was continued with the
previous dose (5 mg, daily). Four weeks later, she devel-
oped a mild cough, weakness and anorexia. Her condi-
tion progressed to a more constant cough and weight
loss until she was hospitalized.
Physical examination revealed her blood pressure to
be 110/60 mm/Hg, respiratory rate 20/min, pulse rate
* Correspondence: firstname.lastname@example.org
2Tuberculosis and Lung Disease Research Center, Tabriz University of Medical
Sciences, Tabriz, Iran
Full list of author information is available at the end of the article
Ardalan et al. Journal of Medical Case Reports 2011, 5:191
JOURNAL OF MEDICAL
© 2011 Ardalan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
examination revealed fine crackles mainly on her lower
lung fields. On admission, the laboratory findings were
as follows: white blood cell count 5.1 × 109/L, hemoglo-
bin 7.2 g/dL, hematocrit 22.4%, mean corpuscular
volume 75 fL (normal range, 77-97 fL), mean corpuscu-
lar hemoglobin 24 pgm (normal range, 26-32 pgm),
mean corpuscular hemoglobin concentration 32% (nor-
mal, 32-36%), platelet count 213 × 109/L, fasting blood
glucose 105 mg/dL, blood urea 62 mg/dL, serum creati-
nine 1.9 mg/dL, sodium 135 mEq/L, potassium 4.5
mEq/L, aspartate aminotransferase 37 IU/L, alanine ami-
notransferase 45 IU/L, alkaline phosphatase 1106 IU/L
and total bilirubin 1 mg/dL. A urine analysis was
On the first day of admission, sirolimus and mycophe-
nolate mofetil were discontinued and cyclosporine (200
mg/day) was started. The dose of prednisolone was not
altered (5 mg, daily). A chest X-ray showed fine miliary
nodules throughout the entire lung fields. Echocardio-
graphy revealed normal pericardium and cardiac cham-
bers. Her left ventricular ejection fraction was 65%. An
ultrasound examination of her renal allograft did not
reveal any pathologic finding. A 6 mm induration was
observed on a TB skin test. Sputum and bronchial aspi-
rate examination was positive for acid-fast bacilli, sug-
gestive of Mycobacterium tuberculosis infection. A chest
computed tomography (CT) scan illustrated widespread
miliary nodules throughout the lung fields, compatible
with miliary TB (Figure 1).
In the evening of her fourth day of admission, our
patient developed an increasing right lower quadrant
abdominal pain spreading to her entire abdomen. Physi-
cal examination revealed widespread abdominal tender-
ness and rebound. An ultrasonographic study of her
abdomen disclosed a small fluid collection in the right
lower quadrant. Two cysts were detected in her left ovary
(54 × 32 mm and 33 × 31 mm). An abdominal CT scan
with oral contrast revealed that her pancreas and spleen
were normal. Her colonic wall thickness was measured as
4 mm and free fluid was visible in dependent parts of her
abdominal cavity. Her peritoneal cavity was then opened
with a midline incision and widespread peritonitis was
found. Her inflamed appendix (9 × 6 cm) was perforated
at its tip. Her ileocecal area and cecum were inflamed
with fragile tissues. A cecostomy was performed and a
drain was placed. Histopathological examination of the
resected appendix revealed caseating epithelioid granulo-
mas, epithelioid histiocytes and Langhans giant cells in
the sub-mucosa and sub-serosa of her appendix (Figure
2). The histological picture, along with positive mycobac-
terial cultures from the sputum and bronchial aspirate,
was suggestive of tuberculous appendicitis. After surgery,
chemotherapy for TB was started and continued for nine
months. An immunosuppressive regimen was continued
with cyclosporine, mycophenolate mofetil and predniso-
lone. During follow-up visits, the pulmonary and abdom-
inal signs and symptoms were resolved.
Our case report showed the occurrence of pulmonary
TB and tuberculous appendicitis in a renal transplant
recipient. In our patient, TB-induced inflammation,
luminal obstruction and superimposing infection were
the most likely causes of the acute appendicitis. Tuber-
culous appendicitis was diagnosed based on the report
of caseating epithelioid granulomas in a histopathologi-
cal examination of the resected appendix, together with
positive mycobacterial cultures from the sputum and
bronchial aspirate. The definite diagnosis of tuberculous
appendicitis requires identification of the causative
organism through culture or microbiological evaluation
of the resected specimen . Caseating epithelioid gran-
ulomas could be reported in a number of fungal infec-
tions including histoplasmosis, cryptococcosis, and
coccidioidomycosis. Although the two latter fungi can
Figure 1 CT scan shows the typical radiological presentation of
Figure 2 Histopathologic examination of the resected
specimen revealed epithelioid granulomas in sub-mucosa and
sub-serosa. Hematoxylin-eosin staining, 10 × 40 magnification.
Ardalan et al. Journal of Medical Case Reports 2011, 5:191
Page 2 of 3
be detected on careful examination of a hematoxylin- Download full-text
eosin stained specimen, histochemical stains such as
Grocott’s methenamine silver are used most often for
identification of these organisms (for review see ).
Therefore, the fungi infections should be considered in
differential diagnoses of TB when caseating necrosis is
seen, particularly in immunosuppressive patients.
Renal transplantation increases the risk of TB infec-
tion by nearly 50-fold compared to the normal popula-
tion . Moreover, potential pre-disposing factors for
development of post-transplant TB include episodes of
rejection [5,8,9], diabetes mellitus [9,10], longer pre-
transplant period on hemodialysis , chronic liver dis-
ease, and co-existing infections . In our patient,
however, no predisposing factor was found.
The gastrointestinal system is one of the least preva-
lent extra-pulmonary sites of TB (3%) which commonly
appears in ileocecal region. However, tuberculous
appendicitis is a very rare scenario . Although reports
indicate an incidence of 0.1 to 3.0% for TB appendicitis
in all appendectomies [6,7], prevalence of gastrointest-
inal TB in renal transplant recipients varies between
0.2% and 0.6% . Extension from the ileocecal region
and hematogenous spread are the major proposed
mechanisms of appendiceal TB . In non-transplant
patients, abdominal pain is the most common present-
ing symptom of gastrointestinal TB . However, gas-
trointestinal bleeding followed by fever and abdominal
pain was the most prevalent symptom in renal trans-
plant recipients with gastrointestinal TB . Jarrett and
colleagues attributed these differences in presentation to
decreased inflammatory response in immune-compro-
mised patients . In our case report, the sudden onset
of right lower quadrant abdominal pain was suggestive
of appendicitis. In addition, since the definite diagnosis
of tuberculous appendicitis is mainly based on the gran-
ulomatous lesions in post-surgical histopathological
examination, pre-operative diagnosis of tuberculous
appendicitis may not be clinically feasible [12,13].
Due to the widespread use of the potent immunosup-
pressant combinations in the transplant era, clinicians
should be familiar with unusual and rare presentations
of TB. Concomitant pulmonary TB and tuberculosis
appendicitis should be considered as a rare infectious
complication in renal transplant recipients.
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
CT: computed tomography; TB: tuberculosis.
1Department of Nephrology, Tabriz University of Medical Sciences, Tabriz,
Iran.2Tuberculosis and Lung Disease Research Center, Tabriz University of
Medical Sciences, Tabriz, Iran.
MRA contributed to acquisition of the data and interpreted experiments.
MMS and KG interpreted experiments and revised the manuscript. All
authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Received: 17 August 2010 Accepted: 20 May 2011
Published: 20 May 2011
1. Ram R, Swarnalatha G, Prasad N, Dakshinamurty KV: Tuberculosis in renal
transplant recipients. Transpl Infect Dis 2007, 9(2):97-101.
2. Ardalan MR, Shoja MM, Tubbs RS, Ghabili K: Transplant renal artery
stenosis associated with acute cytomegalovirus infection: resolution
following ganciclovir administration. Ren Fail 2009, 31(10):982-984.
3.Ardalan MR, Ghaffari A, Ghabili K, Shoja MM: Lepromatous leprosy in a
kidney transplant recipient: a case report. Exp Clin Transplant 2011,
4. Singh MK, Arunabh Kapoor VK: Tuberculosis of the appendix -a report of
17 cases and a suggested aetiopathological classification. Postgrad Med J
5. Jarrett O, Grim SA, Benedetti E, Clark NM: Gastrointestinal tuberculosis in
renal transplant recipients: case report and review of the literature.
Transpl Infect Dis 2011, 13(1):52-57.
6. Mukhopadhyay S, Gal AA: Granulomatous lung disease: an approach to
the differential diagnosis. Arch Pathol Lab Med 2010, 134(5):667-690.
7. Qunibi WY, al-Sibai MB, Taher S, Harder EJ, de Vol E, al-Furayh O, Ginn HE:
Mycobacterial infection after renal transplantation–report of 14 cases
and review of the literature. Q J Med 1990, 77(282):1039-1060.
8. Basiri A, Hosseini-Moghaddam SM, Simforoosh N, Einollahi B, Hosseini M,
Foirouzan A, Pourrezagholi F, Nafar M, Zargar MA, Pourmand G, Tara A,
Mombeni H, Moradi MR, Afshar AT, Gholamrezaee HR, Bohlouli A,
Nezhadgashti H, Akbarzadehpasha A, Ahmad E, Salehipour M, Yazdani M,
Nasrollahi A, Oghbaee N, Azad RE, Mohammadi Z, Razzaghi Z: The risk
factors and laboratory diagnostics for post renal transplant tuberculosis:
a case-control, country-wide study on definitive cases. Transpl Infect Dis
9. Chen CH, Lian JD, Cheng CH, Wu MJ, Lee WC, Shu KH: Mycobacterium
tuberculosis infection following renal transplantation in Taiwan. Transpl
Infect Dis 2006, 8(3):148-156.
10.John GT, Shankar V, Abraham AM, Mukundan U, Thomas PP, Jacob CK: Risk
factors for post-transplant tuberculosis. Kidney Int 2001, 60(3):1148-1153.
11. Horvath KD, Whelan RL: Intestinal tuberculosis: return of an old disease.
Am J Gastroenterol 1998, 93(5):692-696.
12.Goyal N, Khurana N: Tuberculosis of the appendix: An unusual
occurrence with review of literature. ANZ J Surg 2009, 79(9):662.
13.Siu YP, Tong MK, Kwok YL, Leung KT, Kwan TH, Lam CS, Au TC: An unusual
case of both upper and lower gastrointestinal bleeding in a kidney
transplant recipient. Transpl Infect Dis 2008, 10(4):276-279.
Cite this article as: Ardalan et al.: Concomitant pulmonary tuberculosis
and tuberculous appendicitis in a recipient of a renal transplant: a case
report. Journal of Medical Case Reports 2011 5:191.
Ardalan et al. Journal of Medical Case Reports 2011, 5:191
Page 3 of 3