Cerebral Abscess Masquerading as Tuberculoma in a Post-Renal Transplant Chronic Kidney Disease Patient - Diagnostic and Therapeutic Challenge

Sep 29, 2026

Solid organ transplant recipients face heightened risk of serious infections. A 48-year-old male with renal transplantation, chronic kidney disease stage 4, uncontrolled diabetes, and prior tuberculous pleural effusion developed neurological symptoms. Initial suspicion favored intracranial tuberculosis reactivation, but contrast MRI showed a rim-enhancing parieto-occipital lesion with diffusion restriction consistent with cerebral abscess. Magnetic resonance spectroscopy demonstrated elevated lactate and amino acid peaks, excluding tuberculoma or high-grade glioma. Management combined CKD-adjusted antimicrobials and supportive immunosuppression modification.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages8

Reading Time20 min

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Introduction

Diagnostic challenge in post-renal transplant patients

Imaging and microbiological considerations

Key clinical message

Clinical Case Reports CASE REPORT OPEN ACCESS Cerebral Abscess Masquerading as Tuberculoma in a Post-Renal Transplant Chronic Kidney Disease Patient: A Diagnostic and Therapeutic Challenge Sakib Abrar1 | Ibrahim Khalil2 | Md. Imran Hossain3 | Sunjida Amin Promi4 1Department of Internal Medicine, Dhaka Medical College and Hospital, Dhaka, Bangladesh | 2Dhaka Medical College and Hospital, Dhaka, Bangladesh | 3Manikganj Medical College and Hospital, Manikganj, Bangladesh | 4Chattogram Medical College, Chattogram, Bangladesh Correspondence: Ibrahim Khalil ([ibrahim124904@gmail.com](ibrahim124904@gmail.com)) Received: 23 June 2025 | Revised: 17 December 2025 | Accepted: 23 December 2025 Keywords: cerebral abscess | chronic kidney disease | immunosuppression | renal transplant | tuberculoma ABSTRACT Solid organ transplant recipients are at increased risk of acquiring serious infections. We present a case ofa 48-year-old male with a history of renal transplantation in 2012, chronic kidney disease (CKD) Stage 4, hypertension, uncontrolled diabetes mellitus, and prior tuberculous pleural effusion. Laboratory investigations revealed significant renal impairment, persistent hyponatremia, hypokalemia, and subtherapeutic tacrolimus levels (2.50 ng/mL), reflecting challenges of CKD and chronic immunosuppression with mycophenolate mofetil and tacrolimus. Given his immunocompromised state and TB history, initial suspicion centered on intracranial TB reactivation. Brain MRI with contrast revealed a rim-enhancing lesion in the right parieto-occipital region with central diffusion restriction, suggestive of a cerebral abscess. Magnetic resonance spectroscopy (MRS) demonstrated elevated lactate (1.33 ppm) and amino acid peaks, confirming the diagnosis and excluding tuberculoma or high-grade glioma. Treatment included intravenous ceftriaxone, dexamethasone, and a CKD-adjusted anti-TB regimen (rifampicin, isoniazid, ethambutol, pyrazinamide), alongside phenytoin and continued immunosuppressants. This case underscores the diagnostic complexity of distinguishing cerebral abscesses from tuberculomas in post-transplant patients, highlighting the pivotal role of multi-modal imaging (MRI, MRS) and tailored therapy to manage infection, immunosuppression, and comorbidities effectively. 1 | Introduction Cerebral abscesses in post-renal transplant patients represent a rare but life-threatening complication, particularly in the context of chronic immunosuppression and a history of tuberculosis (TB) . These patients, often with chronic kidney disease (CKD), face heightened susceptibility to opportunistic infections due to impaired T-cell-mediated immunity from immunosuppressive therapies such as mycophenolate mofetil and tacrolimus [1] . The diagnostic challenge is compounded by the potential for cerebral abscesses to mimic other intracranial pathologies, such as tuberculomas, especially in patients with prior TB exposure [2] . This manuscript presents the case ofa 48-year-old male with a history of renal transplantation in 2012, CKD Stage 4, hypertension, uncontrolled diabetes mellitus, and a prior episode of tuberculous pleural effusion with hemorrhagic features, who presented with unconsciousness, headache, and vomiting. Initial suspicion of TB reactivation due to his immunocompromised state and TB history was revised to a cerebral abscess following advanced neuroimaging, highlighting the complexity of diagnosis and management in this population. Infections remain a leading cause of morbidity and mortality in renal transplant recipients, with central nervous system (CNS) complications occurring in up to 5% of cases [3]. Cerebral abscesses, though uncommon, have an incidence of approximately This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial

FAQs

Why is infection risk higher in solid organ transplant recipients in this case?

Immunosuppressive therapy and comorbid chronic kidney disease impair immune surveillance, increasing susceptibility to serious infections and atypical presentations.

What imaging findings supported the diagnosis of cerebral abscess instead of tuberculoma?

Contrast brain MRI showed a rim-enhancing lesion with central diffusion restriction, and MRS revealed elevated lactate and amino acid peaks consistent with cerebral abscess, helping exclude tuberculoma or high-grade glioma.

How was treatment tailored for the patient’s chronic kidney disease and immunosuppressed state?

Therapy included intravenous antibiotics for cerebral abscess plus a CKD-adjusted anti-TB regimen given the TB history, along with medications such as dexamethasone and continued adjustment of immunosuppressants.

Sep 29, 2026

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