A 45-year-old male received a simultaneous pancreas kidney (SPK) transplant due to diabetes and end-stage renal disease (ESRD) . After transplantation, he had no major clinical complications and was discharged on postoperative day 30. His previous tuberculin skin test (TST) was negative, and he denied known TB exposure. The immunosuppressive regimen included basiliximab, prednisone, tacrolimus, and mycofenolate mofetil. During the second month posttransplant, he returned to the hospital complaining of fever, night sweats, and chills. Abdominal ultrasonography revealed perigraft collections (renal and pancreatic abscesses), whereas the chest radiograph was normal. He received broad-spectrum antibacterial treatment and underwent percutaneous drainage of the abscesses, with transient resolution of fever. Laboratorial analysis revealed acid-fast bacilli (AFB) on Ziehl-Neelsen stain. Antituberculous therapy was started with standard drugs: rifampin, isoniazid, pyrazinamide, and ethambutol
Concurrently, considering that the recipient's TB abscesses were located near the grafts, suggesting donor involvement, the transplant harvesting center was contacted for additional information regarding the donor and the other organ recipients. At that time, two recipients had already died, and a look-back investigation was carried out (Figure 1).
The patient subsequently presented with anti-TB drug toxicities: haemolytic anaemia (related to rifampicin) and blurred vision (due to ethambutol), both in the 2nd month of treatment resulting in a change of therapy. At this time, the patient presented disseminated disease involving grafts, lungs, CNS, and thyroid.The clinical deterioration of the patient imposed immunosuppressive cessation, leading to acute cellular rejection of the grafts, and dual graft loss with return to hemodialysis and insulin therapy. The patient underwent exploratory laparotomy with a surgical finding of caseating necrosis all over the mesenterium and around pancreatic graft, but affecting the renal graft. The removal of the renal graft was the only viable treatment encountered (Figure 2). After several ultrasound guided punctures to drain intra-abdominal TB abscesses and 18 months of anti-TB therapy, the patient was considered cured. However, he died from complications related to ESRD and dialysis, two years after transplantation.