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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 4  |  Page : 251-253

A case of postkidney transplant patient with gastric tuberculosis mimicking gastric malignancy


1 Department of Nephrology, Fortis Hospital, Noida, Uttar Pradesh, India
2 Department of Hepatology and Gastroenterology; Department of Liver Transplant, Fortis Hospital, Noida, Uttar Pradesh, India

Date of Web Publication18-Dec-2018

Correspondence Address:
Dr. Manoj Kumar Singhal
Fortis Hospital, Sector 62, Noida - 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_49_18

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  Abstract 


A 60-year-old male patient, who is a known case of end-stage kidney disease postliving donor renal transplantation on triple maintenance immunosuppression, presented with persistent dyspeptic symptoms 8 months posttransplant, not relieved with prolonged proton-pump inhibitor therapy. On endoscopy, found to have large ulcerated nodular lesion in the body of stomach suggestive of malignancy. On biopsy, it was diagnosed with primary gastric tuberculosis (TB). Complete clinical and endoscopic resolution was achieved following anti-TB treatment.

Keywords: Gastric malignancy, gastric tuberculosis, immunosuppression, renal transplant


How to cite this article:
Singhal MK, Porwal A, Khandelwal R, Rastogi M. A case of postkidney transplant patient with gastric tuberculosis mimicking gastric malignancy. Indian J Transplant 2018;12:251-3

How to cite this URL:
Singhal MK, Porwal A, Khandelwal R, Rastogi M. A case of postkidney transplant patient with gastric tuberculosis mimicking gastric malignancy. Indian J Transplant [serial online] 2018 [cited 2019 Mar 23];12:251-3. Available from: http://www.ijtonline.in/text.asp?2018/12/4/251/247794




  Introduction Top


The prevalence of tuberculosis (TB) has increased in both immunocompetent and immunocompromised host, and it can affect virtually any organ system in the body. In transplanted patients, the incidence of gastrointestinal TB (GITB) infection is 50 times more frequent than general population. GITB usually involves ileum and cecum; involvement of esophagus, stomach, and duodenum is seen in 1%–2% cases. Here, we report a rare case of 60-year-old renal transplant recipient with isolated gastric TB mimicking gastric malignancy.


  Case Report Top


A 60-year-old gentleman, known case of hypertension with coronary artery disease with severe left ventricular dysfunction (ejection fraction: 25%) and end-stage renal disease (ESRD), was on maintenance hemodialysis (HD) for 1 month. He underwent live-related kidney transplant in December 2016. The patient received antithymocyte globulin (ATG) induction (150 mg) and was on triple immunosuppression, i.e., tacrolimus, mycophenolate mofetil, and prednisolone postkidney transplant. Immediate posttransplant period was uneventful. Doses of immunosuppressants were optimized according to trough tacrolimus level.

One month posttransplant, he developed left epididymo-orchitis with funiculitis which was managed conservatively with intravenous antibiotics.

Eight months posttransplant, the patient presented with off and on fever with recurrent vomiting, dysphagia, and epigastric discomfort for 3–4 weeks. His clinical and biochemical parameters were unremarkable. His symptoms persisted even after treatment with antacids and proton-pump inhibitors (PPIs) for 2 weeks. Upper GI endoscopy revealed large gastric ulcer in the gastric body region that morphologically looked like a malignant ulcer [Figure 1]a. Tissue biopsy showed ulceration with exudate along with dense mixed inflammation and noncaseating epithelioid cell granulomas with Langerhans giant cells in the lamina propria. Ziehl–Neelsen (ZN) stain for acid-fast bacilli (AFB) was positive, and there was no evidence of malignancy in the sections examined. The patient was then started on antitubercular therapy. Dose of immunosuppressants was optimized. Repeat endoscopy after 6 months of antitubercular treatment showed complete resolution of the ulcerated nodular lesion [Figure 1]b.
Figure 1: (a) Upper gastrointestinal endoscopy showing large ulcer in the gastric body region. (b) Upper gastrointestinal endoscopy showing healed gastric ulcer after antitubercular therapy

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  Discussion Top


The prevalence of GITB in renal transplant patients is about 0.2%–0.6% (in developing countries), occurring about 50 times more frequently than in general population. It has a higher frequency during the 1st posttransplant year (32%–57% of all cases) and may be related to higher doses of immunosuppressants used in initial period and during episodes of acute rejection.[1],[2],[3],[4]

The most common site of the GITB is ileocecal region. The esophagus, stomach, and duodenum are rarely involved. Isolated gastric TB, without evidence of pulmonary or other gastrointestinal involvement, is extremely rare, even in parts of the world where intestinal TB is common, and is almost always located in the antrum or prepyloric region.[5],[6],[7],[8]

The relative rarity of gastric TB can be attributed to the bactericidal properties of gastric acid, the scarcity of lymphoid tissue in the gastric wall, and the continuous motor activity of the stomach.[9] Ingestion of unpasteurized milk infected with bovine TB, long-term use of PPI, or a severely immunocompromised condition[7] could be the possible causes of isolated gastric TB; however, the available current evidence is inconclusive.

Longer time on HD (due to immunosuppressive effects of ESRD and HD), pre-transplant diabetes mellitus, elderly patients, alcohol abuse, and chronic liver disease have been pointed as risk factors for developing post-transplant pulmonary TB. So are prolonged steroid therapy after renal transplant and the presence and number of acute rejection episodes (with immunosuppression augmentation), but the evidence available for same risk factors causing gastric TB is scarce.[10]

In this patient, risk factors such as induction immunosuppression with ATG, maintenance immunosuppression with tacrolimus, and long-term PPI use may have contributed to the development of GITB.

Endoscopic finding of single and multiple ulcers and hypertrophic nodular lesions surrounding a stenotic pyloric channel has been associated with this disease. A definitive diagnosis essentially relies on a histological study, normally involving ZN staining for AFB and culture. PCR testing of biopsy specimen may facilitate diagnosis in doubtful cases.[9]

Although treatable, GITB is potentially lethal.[1] In renal transplants, mortality associated with GITB is extremely high and varies between 20% and 30%.[1] Early diagnosis is fundamental for successful treatment.

In conclusion, here, we report a case of isolated gastric TB, which mimicked advanced malignancy and responded well to anti-TB medication. In renal transplant recipients, high net immunosuppression and prolonged use of PPI may increase the risk of unusual site and presentation of gastric TB. Nonspecific clinical presentation, difficulty in diagnosis, and high mortality associated with GITB warrant rigorous diagnostic investigation and early institution of antituberculous therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid-organ transplant recipients: Impact and implications for management. Clin Infect Dis 1998;27:1266-77.  Back to cited text no. 1
    
2.
Jarrett O, Grim SA, Benedetti E, Clark NM. Gastrointestinal tuberculosis in renal transplant recipients: Case report and review of the literature. Transpl Infect Dis 2011;13:52-7.  Back to cited text no. 2
    
3.
Qunibi WY, al-Sibai MB, Taher S, Harder EJ, de Vol E, al-Furayh O, et al. Mycobacterial infection after renal transplantation – Report of 14 cases and review of the literature. Q J Med 1990;77:1039-60.  Back to cited text no. 3
    
4.
Azevedo P, Freitas C, Silva H, Aguiar P, Farrajota P, Almeida M, et al. A case series of gastrointestinal tuberculosis in renal transplant patients. Case Rep Nephrol 2013;2013:213273.  Back to cited text no. 4
    
5.
Padma V, Anand NN, Rajendran SM, Gurukal S. Primary tuberculosis of stomach. J Indian Med Assoc 2012;110:187-8.  Back to cited text no. 5
    
6.
Debi U, Ravisankar V, Prasad KK, Sinha SK, Sharma AK. Abdominal tuberculosis of the gastrointestinal tract: Revisited. World J Gastroenterol 2014;20:14831-40.  Back to cited text no. 6
    
7.
Lin OS, Wu SS, Yeh KT, Soon MS. Isolated gastric tuberculosis of the cardia. J Gastroenterol Hepatol 1999;14:258-61.  Back to cited text no. 7
    
8.
Amarapurkar DN, Patel ND, Amarapurkar AD. Primary gastric tuberculosis – Report of 5 cases. BMC Gastroenterol 2003;3:6.  Back to cited text no. 8
    
9.
Bandyopadhyay SK, Bandyopadhyay R, Chatterjee U. Isolated gastric tuberculosis presenting as haematemesis. J Postgrad Med 2002;48:72-3.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
John GT, Shankar V, Abraham AM, Mukundan U, Thomas PP, Jacob CK, et al. Risk factors for post-transplant tuberculosis. Kidney Int 2001;60:1148-53.  Back to cited text no. 10
    


    Figures

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1 Immunosuppressants
Reactions Weekly. 2019; 1737(1): 160
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