A case of shoulder pain post-renal transplant: an unusual etiology

Abstract

A 37-year-old renal allograft recipient presented in the outpatient department with complaint of left shoulder pain 3 months after renal transplant. His immunosuppression included cyclosporine 6 mg/kg/day, mycophenolate 500 mg twice daily and prednisolone 10 mg/day. He was treated for hepatitis C infection pretransplant with interferon. Posttransplant management was complicated by an episode of acute graft dysfunction. Kidney biopsy was suggestive of acute tubulointerstitial nephritis with borderline acute cellular rejection, which was treated with three doses of methylprednisolone 500 mg each. This episode recovered only partially and serum creatinine stabilized at 2.5–3 mg/dL. In the second month after transplant, he developed cytomegalovirus infection, which was treated with intravenous ganciclovir. Shoulder pain was dull aching, poorly localized around the shoulder and was progressively increasing in intensity requiring opioids for control. On examination, he had stable vitals and a physical examination showed an unrestricted range of motion at the shoulder and mild tenderness at the anterior region of the shoulder joint. Complete blood count and tranaminases were within normal limits. Erythrocyte sedimentation rate and C reactive protein were increased to 36 mm and 18 ng/L respectively. An X-ray of the left shoulder showed a lytic lesion in the upper end of the humerus (Figure 1). An MRI of the shoulder raised a possibility of infective or infiltrative lesion in the upper end of the humerus (Figure 2). Excision biopsy of the lesion was done, which established the diagnosis of Aspergillus osteomyelitis (Figures 3 and ​and4).4). The patient was treated with oral voriconazole 200 mg BD for 8 weeks with complete resolution of symptoms. Fig. 1. Frontal radiograph of left shoulder showing a lytic lesion involving head and proximal shaft of humerus (arrow) with narrow zone of transition. There is associated soft tissue swelling. Fig. 2. Saggital STIR images of the left shoulder show abnormal T2 hyperintense signal abnormality involving proximal humeral marrow (long arrow) with adjacent abscess formation (short arrow). Normal saggital STIR images of the left shoulder (right). Fig. 3. Photomicrograph shows large, thick-walled septate hyphae with acute angle branching along with few inflammatory cells (hematoxylin and eosin stain ×40). Fig. 4. Photomicrograph showing large, thick-walled septate hyphae with acute angle branching against RBC background (Gomori Methenamine-silver Stain ×10). Inset showing the same at ×40.