A 43 Year-Old Woman with Fever Eleven Years after Kidney Transplantation

WHAT IS YOUR DIAGNOSIS? Our patient was a 43 year-old woman referred due to fever eleven years after allograft renal transplantation. She was healthy until 4 months ago on a combination of mycophenolate mofetil (1 gr twice daily) and cyclosporine (50 mg twice daily). Preliminary evaluations for sustained fever without any concomitant symptoms in another center had revealed only diffuse ground glass opacities in both lungs on chest computed tomography (CT) scan (Figure 1). Before admission, based on positive cytomegalovirus (CMV) immunoglobulin G (IgG), mycophenolate mofetil had been discontinued due to an assumption of reactivation of CMV infection. A combination of ganciclovir plus prednisolone 10 mg daily and then valganciclovir for approximately three months resulted in fever cessation. One week after discontinuation of the aforementioned regimen, she became febrile again. A new consolidation in left lower lobe was the prominent finding (Figure 2). She rejected CT-guided biopsy; empirical amphotericin B and standard regimen of anti-tuberculosis (TB) were initiated. Finally, she was referred to our center for further evaluation. On admission, she was stable without remarkable findings in physical examination. Complete blood cell count, liver biochemistry and renal function test were all within normal range. During recent admission, valganciclovir and anti-TB were discontinued and bronchoscopy was performed. Serum and bronchoalveolar lavage (BAL) specimens were negative for galactomannan. Acid-fast bacilli were seen by direct Ziehl-Neelsen staining along with positive result of polymerase chain reaction (PCR) for Mycobacterium tuberculosis. Anti-TB regimen was initiated again, cyclosporine stopped and prednisolone dosage increased to 20 mg daily. Two weeks later the patient became febrile again associated with cough and malaise. The previous consolidation revealed further extension with central cavitation (Figure 3). A new work-up including bronchoscopy and open lung biopsy in the primary center solely confirmed the diagnosis of tuberculosis. She was referred again due to new-onset fever, non-purulent cough and mild exertional dyspnea without remarkable finding in physical examination.