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Kidney Week

Abstract: PO2466

The Diagnostic Dilemma of Diffuse Lymphadenopathy in a Kidney Transplant Recipient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Krouse, Michael Christopher, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
  • Singh, Priyamvada, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
  • Guerrero Nunez, Tomas Ignacio, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Introduction

Immunological balance is critical for transplant recipients. An optimum amount of immunosuppression prevents rejection while avoiding infection and cancers. Constitutional symptoms and lymphadenopathy could be present in both scenarios and could pose a diagnostic challenge.

Case Description


A 36-year-old male immigrant from India (ten years ago) with PMH of ESRD secondary to IgAN received a DDKT (9/2019, EBV D+/R+, on tacrolimus and myfortic). He was admitted with extensive retroperitoneal and mesenteric lymphadenopathy and a hypodense structure in the left upper abdomen (3.8 x 5.1 cm) on CT scan along with constitutional symptoms of fevers, constipation, and abdominal pain for ten days duration three months after transplant. Vital signs and physical examination were unremarkable except for low-grade fever. Aside from mild anemia (Hb 10 mg/dL), laboratory analysis was normal. PET scan revealed hypermetabolic lymphadenopathy in the neck, abdomen, and pelvis and consolidative changes in the left lung base and a right-sided loculated pleural effusion. Extensive workup - CMV PCR, pan-culture, fungal infections, and flow cytometry – was negative. CT-guided retroperitoneal lymph node biopsy, incisional biopsy of the mesenteric mass, and an endobronchial ultrasound-guided transbronchial needle aspiration of subcarinal LN were non-diagnostic. Finally, exploratory laparotomy and resection of the mesenteric mass revealed granuloma formation with multinucleated giant cells concerning for TB. The AFB culture grew mycobacterium tuberculosis on day 24. He is currently on antitubercular treatment.

Discussion

Our case highlights the importance of a high degree of clinical suspicion for infectious etiology in transplant recipients, especially those from countries with a high prevalence of TB. Our patient bore a distant immigration history and a negative tuberculin test and did not have a history of exposure. Still, he was at increased risk of activation of latent TB due to his immunocompromised state. Extra-abdominal TB, like abdominal TB, poses a diagnostic challenge as the presentation can be non-specific and the AFB stain and culture can be non-diagnostic. Thus, a tissue biopsy becomes key to diagnosis. PTLD was high on differential given the PET-avid LAP. PET-avid lesions imply a hypermetabolic state which can happen in both malignancies and infections.