Nephropathology Specialty Conference

Case #4

A 33-year-old male 7 months post kidney transplantation presented with fever, cough, and an acute increase of serum creatinine from 1.9 to 2.6 mg/dl.  He was the recipient of a living related kidney for end stage renal disease due to unknown causes.  The patient was maintained on daily tacrolimus, prednisone and mycophenolate mofetil.  A chest x-ray (CXR) showed bilateral diffuse nodular infiltrates.  Acid-fast bacilli were identified in granulomas in the transbronchial biopsy specimen and in broncholaveolar lavage (BAL) fluid.  The BAL fluid grew Mycobacteruim tuberculosis in culture.  Urine and blood cultures were negative for M. tuberculosis.  After diagnosis of M. tuberculosis infection, tacrolimus and mycophenolate mofetil were discontinued.  The serum creatinine decreased to 1.7 mg/dl one week after the initiation of antituberculous therapy.  Three days later the creatinine rose to 2.3 mg/dl and a renal allograft biopsy was performed.

After the biopsy the patient was treated with additional oral prednisone and the creatinine remained at 2.1 ñ2.2 mg/dl.  On follow up seven months later the CXR was clear and at three years post-transplantation the patient is well with a functioning allograft; the serum creatinine is 2.6 mg/dl.

Shane M. Meehan
University of Chicago

 

LM - 2 slides

Click on picture to enlarge

Diagnosis: Granulomatous interstitial nephritis in a renal allograft (miliary tuberculosis)

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