Case 51
With discussion
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CASE 51 (May 2010)

Clinical information

The patient is a 20-year-old man. He had end-stage renal disease due to reflux nephropathy. He was kidney-trasplanted after 6 months on hemodialysis. Graft was well except for an episode of acute cellular rejection, Banff type IA, at one post-transplantation year; he received steroid boluses and the renal fuction return to normality. Four post-transplantation years he newly presented serum creatinine increase: 2.4 mg/dL; a renal biopsy showed acute cellular rejection type IB, with mild chronic changes, without signs of chronic rejection or other alterations. He was treated with steroid boluses; serum creatinine continued between 1.8 and 2.9 mg/dL in the 4 following weeks. One month after boluses the patient is evaluated for fever, general malaise and skin lesions treated as impetigo, without biopsy or culture.

One week later the fever continued and patient presented pain on graft area; his serum creatinine was 3.5 mg/dL. Many microbiological studies were performed, all negative. He received multiple antibiotics but fever persisted. The studies were negative for tuberculosis, including sputum and bronchoalveolar lavage. Test for cytomegalovirus were negative. Serum creatinine continued increasing, the fever persisted and pain in graft area increased. Immunosuppression was reduced. Creatinine increased to 8.5 mg/dL and patient required hemodialysis.

Because enlargement of the graft, pain and persistent fever graft nephrectomy was carried out.

See the images.

Figure 1. Note the whitish dots on the surface of the graft

Figure 2. The withish dots are also seen on cut, in cortex and medulla.

Figure 3. There are many lesions similar to this that appears in the image, corresponding to whitish dots seen on macroscopic inspection. H&E, X100.

Figure 4. H&E, X200.

Figure 5. H&E, X400.

Figure 6. H&E, X400.

Figure 7. Several parenchymal areas had almost normal appearance (left) and other showed prominent tubulitis (right). H&E, left, X200; rigth, X400.

Figure 8. Other areas had chronic changes, tubulointerstitial (left) and arterial (right). H&E, both X200.

Figure 9. Methenamine-silver stain, contrasted with fast-green, X400.

Figure 10. Mucicarmin staining, both X400.

Zhiel Neelsen staining: Negative for acid-fast bacilli.

What is your diagnosis?

See diagnosis and discussion