Ardalan et al. Journal of Medical Case Reports 2011, 5:191 http://www.jmedicalcasereports.com/content/5/1/191 examination revealed fine crackles mainly on her lower lung fields. On admission, the laboratory findings were as follows: white blood cell count 5.1 × 109/L, hemoglo- bin 7.2 g/dL, hematocrit 22.4%, mean corpuscular volume 75 fL (normal range, 77-97 fL), mean corpuscu- lar hemoglobin 24 pgm (normal range, 26-32 pgm), mean corpuscular hemoglobin concentration 32% (nor- mal, 32-36%), platelet count 213 × 109/L, fasting blood glucose 105 mg/dL, blood urea 62 mg/dL, serum creati- nine 1.9 mg/dL, sodium 135 mEq/L, potassium 4.5 mEq/L, aspartate aminotransferase 37 IU/L, alanine ami- notransferase 45 IU/L, alkaline phosphatase 1106 IU/L and total bilirubin 1 mg/dL. A urine analysis was unremarkable. On the first day of admission, sirolimus and mycophe- nolate mofetil were discontinued and cyclosporine (200 mg/day) was started. The dose of prednisolone was not altered (5 mg, daily). A chest X-ray showed fine miliary nodules throughout the entire lung fields. Echocardio- graphy revealed normal pericardium and cardiac cham- bers. Her left ventricular ejection fraction was 65%. An ultrasound examination of her renal allograft did not reveal any pathologic finding. A 6 mm induration was observed on a TB skin test. Sputum and bronchial aspi- rate examination was positive for acid-fast bacilli, sug- gestive of Mycobacterium tuberculosis infection. A chest computed tomography (CT) scan illustrated widespread miliary nodules throughout the lung fields, compatible with miliary TB (Figure 1). In the evening of her fourth day of admission, our patient developed an increasing right lower quadrant abdominal pain spreading to her entire abdomen. Physi- cal examination revealed widespread abdominal tender- ness and rebound. An ultrasonographic study of her abdomen disclosed a small fluid collection in the right lower quadrant. Two cysts were detected in her left ovary (54 × 32 mm and 33 × 31 mm). An abdominal CT scan Page 2 of 3 with oral contrast revealed that her pancreas and spleen were normal. Her colonic wall thickness was measured as 4 mm and free fluid was visible in dependent parts of her abdominal cavity. Her peritoneal cavity was then opened with a midline incision and widespread peritonitis was found. Her inflamed appendix (9 × 6 cm) was perforated at its tip. Her ileocecal area and cecum were inflamed with fragile tissues. A cecostomy was performed and a drain was placed. Histopathological examination of the resected appendix revealed caseating epithelioid granulo- mas, epithelioid histiocytes and Langhans giant cells in the sub-mucosa and sub-serosa of her appendix (Figure 2). The histological picture, along with positive mycobac- terial cultures from the sputum and bronchial aspirate, was suggestive of tuberculous appendicitis. After surgery, chemotherapy for TB was started and continued for nine months. An immunosuppressive regimen was continued with cyclosporine, mycophenolate mofetil and predniso- lone. During follow-up visits, the pulmonary and abdom- inal signs and symptoms were resolved. Discussion Our case report showed the occurrence of pulmonary TB and tuberculous appendicitis in a renal transplant recipient. In our patient, TB-induced inflammation, luminal obstruction and superimposing infection were the most likely causes of the acute appendicitis. Tuber- culous appendicitis was diagnosed based on the report of caseating epithelioid granulomas in a histopathologi- cal examination of the resected appendix, together with positive mycobacterial cultures from the sputum and bronchial aspirate. The definite diagnosis of tuberculous appendicitis requires identification of the causative organism through culture or microbiological evaluation of the resected specimen [5]. Caseating epithelioid gran- ulomas could be reported in a number of fungal infec- tions including histoplasmosis, cryptococcosis, and coccidioidomycosis. Although the two latter fungi can Figure 1 CT scan shows the typical radiological presentation of miliary tuberculosis. Figure 2 Histopathologic examination of the resected specimen revealed epithelioid granulomas in sub-mucosa and sub-serosa. Hematoxylin-eosin staining, 10 × 40 magnification.