Indian Journal of Tuberculosis 233 (Received on 6.9.2012; Accepted after revision on 31.5.2013) [Indian J Tuberc 2013; 60: 233-236] Case Report TUBERCULAR ILEAL PERFORATION - ATYPICAL, ACUTE PRESENTATION IN A RENAL TRANSPLANT RECIPIENT - A CASE REPORT Prashant G.Kedlaya 1 *, S.G. Subramanyam 2 **, H. Raja 3 ** and P. Divya 3 *** 1. Associate Professor 2. Professor 3. Assistant Professor Departments of Nephrology*, Surgery** and Pathology*** St. John’s Medical College Hospital, Bangalore Correspondence: Dr. Prashant G. Kedlaya, Associate Professor, Department of Nephrology, St. John’s Medical College Hospital, Sarjapur Road, Bangalore - 560 034; Tel.: 080 22065301; Fax: 080 25633844; E-mail: [email protected] Summary: Extrapulmonary tuberculosis (TB) is more common than pulmonary TB in immuno-suppressed renal transplant recipients. Atypical presentation of TB and disseminated TB is known in transplant recipients. Usually intestinal TB presents with pain abdomen, intermittent subacute intestinal obstruction, diarrhoea and/or constitutional symptoms like fever and weight loss. Here we report a case of renal allograft recipient on regular hospital follow up, presented with acute abdomen with no previous symptoms of fever, weight loss or abdominal symptoms and was diagnosed to have tubercular ileal perforation on exploratory laporatomy and confirmed by histopathological examination. This patient succumbed to the illness due to sepsis despite timely surgery, broad spectrum antibiotics and antitubercular therapy. Key words: Renal transplant, Extrapulmonary TB, Ileal perforation INTRODUCTION Tuberculosis is responsible for significant morbidity and also mortality in renal transplant recipients in developing countries. 1 Often, tuberculosis in renal transplant recipients is disseminated and extrapulmonary. Defective cell mediated immunity due to cumulative effects of immuno-suppressive antirejection drugs in transplant recipients favours tuberculosis. 2 Also use of immuno-suppressive agents masks the inflammatory response and hence manifestations of infection like fever, pain at site of tissue injury are masked. Hence clinical manifestations of pulmonary or extra- pulmonary TB are atypical. 3 Here, we report a young renal transplant recipient, three years post transplant with stable renal functions, presenting acutely with pain abdomen with no previous symptoms like fever, altered bowel habits, past pain abdomen, decreased appetite and an urgent exploratory laprotomy revealed ‘ileal perforation’, multiple tubercules on intestinal surface and multiple mesentric matted lymphnodes. Tuberculosis was confirmed by histopathological examination of surgical specimen. CASE REPORT A 38-year-old male patient received a renal allograft from his 58-year-old mother with full ‘6 antigen’ HLA match in 2008. His native kidney disease was presumed chronic glomerulonephritis and he was on maintenance hemodialysis for six months before renal transplantation. He was negative for Hepatitis B, Hepatitis C and HIV virus and both donors and recipients were CMV IgG positive. He was on triple immuno-suppression, Tacrolimus, Mycophenolate mofetil and prednisolone. His post surgical period was uneventful and he reached a nadir serum creatinine of 1.1mg/dl on third post operative day. Eleven months later, patient had herpes zoster of right side D4 and D5 dermatome, which was managed with Tab. Acyclovir and also reduction in immuno-suppressive drug mycophenolate mofetil. One and half years post transplant, patient had an episode of acute cellular rejection (Banff Ib) during an attempt at calcineurin inhibitor withdrawal.