Acute appendicitis mistaken as acute rejection in renal transplant recipients.
NC Talwalkar, D Javali, K Venkatesh, S Iyer, M Venkatesh, UB Joshi
Banglore Kidney Foundation, Padmanabhanagar, Karnataka.
N C Talwalkar
Banglore Kidney Foundation, Padmanabhanagar, Karnataka.
Case histories of 2 renal transplant recipients are reported who had presenting features of fever, leukocytosis and pain/tenderness over right iliac fossa and were diagnosed to be due to acute appendicitis rather than more commonly suspected acute rejection episode which has very similar features. Diagnosis of acute appendicitis was suspected on the basis of rectal examination and later confirmed by laparotomy. The purpose of this communication is to emphasize the need for proper diagnosis in patient with such presentation; otherwise wrong treatment may be received.
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Talwalkar N C, Javali D, Venkatesh K, Iyer S, Venkatesh M, Joshi U B. Acute appendicitis mistaken as acute rejection in renal transplant recipients. J Postgrad Med 1994;40:39-40
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Talwalkar N C, Javali D, Venkatesh K, Iyer S, Venkatesh M, Joshi U B. Acute appendicitis mistaken as acute rejection in renal transplant recipients. J Postgrad Med [serial online] 1994 [cited 2021 Apr 11 ];40:39-40
Available from: https://www.jpgmonline.com/text.asp?1994/40/1/39/571
Several gastrointestinal complications following renal transplant have been reported. These include pancreatitis, diverculitis, gastric and colonic ulcerations etc. Acute appendicitis is however, not a commonly reported complication after renal transplant. Similarly, several infective complications have been reported in renal transplant. It is very important to diagnose this infective complication and offer prompt surgical treatment in these immunocompromised patients.
We present here two cases which mimic the features of transplant rejection but were detected to be suffering from acute appendicitis.
Case 1: A 45-year-old man was maintaining normal health and renal functions after 8 months of renal transplant. He was hospitalised in view of acute pain over transplanted kidney in right iliac fossa, fever and raised serum creatinine. Initially the pain was mild to moderate in intensity, intermittent and localised over the graft. His blood pressure was found to be high (190/110 mm of Hg - his usual blood pressure being 140/90 mm of Hg) but his urine output was normal. On admission his WBC count was 8700 cells per cmm, serum creatinine was 1.9 mg%, BUN was 29 mgs%, urine showed albumin ++ and WBC ++. At this stage a possibility of acute rejection was considered in view of classical features of fever, pain over graft, hypertension and abnormal renal functions. Transplant renal ultrasound was normal with no feature of rejection. By this time the patient developed generalised ' pain and tenderness all over abdomen, with mild distension. At this stage the rectal examination suggested signs of peritoneal irritation. He also developed high fever and leukocytosis of 12,500 cells per cmm. Plain x-ray of abdomen showed gas under diaphragm. Diagnosis of acute appendicitis with perforation was considered. Within 36 hours of hospitalisation the patient was subjected to laparotomy. Appendix was found to be inflammed, congested and there were early gangrenous changes at the tip with perforation. He was discharged in asymptomatic state with normal renal functions within 4 days post-operatively. Histology confirmed features of acute inflammation and gangrene at one end of the appendicular specimen.
Case 2: A 24-year-old man developed intermittent fever, and slowly rising serum creatinine over 2 days within 3 weeks of live related renal transplant. On examination he had fever of 101?F. BP was 160/100 mm Hg and tenderness was present over graft in right illiac fossa. WBC count was 9200 cells/cmm; urine showed albumin with WBCs; Serum creatinine was 2.3 mg% and BUN 46 mg%. Renal ultrasound examination supported the clinical suspicion of acute rejection: there was mild increase in pyramidal index. Hence the patient was initially given the first dose of steroid pulse therapy. On the next day the patient had severe pain in the epigastric and umbilical areas with rebound tenderness and severe tenderness on rectal examination. Plain X-ray of abdomen showed some loops of distended bowel but there were no signs of perforation. By this time the leukocytosis was marked (21000 cell/cmm).
Exploratory Laparotomy confirmed features of acute inflammatory appendicitis with mild peritoneal reaction. Histology confirmed the same. After antibiotics, withdrawal of steroid therapy and other supportive treatment, patient was discharged with normal renal functions.
The important aspect is about making a clinical diagnosis of acute appendicitis in transplant patients where it may mimic many features of acute rejection. Generally the transplanted kidney is placed in right iliac fossa and the pain/tenderness of appendicitis may be mistaken as signs of acute rejection in transplanted kidney. Fever and leukocytosis are common in both the conditions.
Though abnormal renal functions are hallmarks of rejection, any infective episode in a transplant patient can result in mild abnormalities of renal functions. It is more important to note that in such immunocompromised patients, the signs of inflammation would be suppressed and hence there may be delay or even wrong interpretation of clinical signs and laboratory findings. An experienced ultrasonologist using high frequency (5 ml) probe should be able to diagnose the signs of inflammed appendix. These were missed on our cases. The purpose of this communication is to emphasize the need for a correct diagnosis between appendicitis and rejection in a transplant patient with the graft in the right iliac fossa. Ultrasound findings by experienced ultrasonologist must be carefully analysed.
Vincenti F, Parfrey PS, Briggs W. Skeletal, gastrointestinal, hepatic and haematological disorders following kidney transplant. In: Garavoy M, editor. Renal Transplantation. Edinburgh: Churchill Livingstone; 1986, pp 250-255.