Ardalan et al. Journal of Medical Case Reports 2011, 5:191 http://www.jmedicalcasereports.com/content/5/1/191 be detected on careful examination of a hematoxylin- eosin stained specimen, histochemical stains such as Grocott’s methenamine silver are used most often for identification of these organisms (for review see [6]). Therefore, the fungi infections should be considered in differential diagnoses of TB when caseating necrosis is seen, particularly in immunosuppressive patients. Renal transplantation increases the risk of TB infec- tion by nearly 50-fold compared to the normal popula- tion [7]. Moreover, potential pre-disposing factors for development of post-transplant TB include episodes of rejection [5,8,9], diabetes mellitus [9,10], longer pre- transplant period on hemodialysis [8], chronic liver dis- ease, and co-existing infections [10]. In our patient, however, no predisposing factor was found. The gastrointestinal system is one of the least preva- lent extra-pulmonary sites of TB (3%) which commonly appears in ileocecal region. However, tuberculous appendicitis is a very rare scenario [3]. Although reports indicate an incidence of 0.1 to 3.0% for TB appendicitis in all appendectomies [6,7], prevalence of gastrointest- inal TB in renal transplant recipients varies between 0.2% and 0.6% [5]. Extension from the ileocecal region and hematogenous spread are the major proposed mechanisms of appendiceal TB [5]. In non-transplant patients, abdominal pain is the most common present- ing symptom of gastrointestinal TB [11]. However, gas- trointestinal bleeding followed by fever and abdominal pain was the most prevalent symptom in renal trans- plant recipients with gastrointestinal TB [5]. Jarrett and colleagues attributed these differences in presentation to decreased inflammatory response in immune-compro- mised patients [5]. In our case report, the sudden onset of right lower quadrant abdominal pain was suggestive of appendicitis. In addition, since the definite diagnosis of tuberculous appendicitis is mainly based on the gran- ulomatous lesions in post-surgical histopathological examination, pre-operative diagnosis of tuberculous appendicitis may not be clinically feasible [12,13]. Conclusion Due to the widespread use of the potent immunosup- pressant combinations in the transplant era, clinicians should be familiar with unusual and rare presentations of TB. Concomitant pulmonary TB and tuberculosis appendicitis should be considered as a rare infectious complication in renal transplant recipients. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Page 3 of 3 Abbreviations CT: computed tomography; TB: tuberculosis. Author details 1Department of Nephrology, Tabriz University of Medical Sciences, Tabriz, Iran. 2Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Authors’ contributions MRA contributed to acquisition of the data and interpreted experiments. MMS and KG interpreted experiments and revised the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 17 August 2010 Accepted: 20 May 2011 Published: 20 May 2011 References 1. Ram R, Swarnalatha G, Prasad N, Dakshinamurty KV: Tuberculosis in renal transplant recipients. Transpl Infect Dis 2007, 9(2):97-101. 2. Ardalan MR, Shoja MM, Tubbs RS, Ghabili K: Transplant renal artery stenosis associated with acute cytomegalovirus infection: resolution following ganciclovir administration. Ren Fail 2009, 31(10):982-984. 3. 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