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  • 44 year old female with a diagnosis of IgA nephropathy and FSGS (focal segmental glomerulo sclerosis) who underwent a live donor kidney transplant. Post-operatively she was treated for a borderline acute cellular rejection with C4d positivity. Seven months post-transplant she presented with a urinary tract infection that progressed to complaints of dysuria, flank pain, and fullness over the allograft despite broad-coverage antibiotics. A CT scan showed bladder thickening at the site of implantation of the ureter and retro-peritoneal lymphadenopathy (Figures 112-56112-58). Biopsy of the bladder and of an enlarged lymph node revealed a spindle cell neoplasm with prominent vascular channels filled with red blood cells. Immunohistochemical stains confirmed Human Herpes Virus-8 (HHV-8) in the neoplastic cells and the diagnosis of Kaposi sarcoma (Figures 112-62112-65).

  • Initial treatment was discontinuation of tacrolimus and mycophenolate mofetil, remaining only on 5 mg daily of prednisone. Pegylated liposomal doxorubicin was started. By the fourth cycle, all symptoms had resolved.

  • Follow-up CT scans of the abdomen and pelvis showed complete resolution of the findings (Figures 112-59112-61).

  • Currently she is on low dose sirolimus and 5 mg prednisone with a normal creatinine.

  • This case is especially interesting because it occurred in a female, had no dermatologic manifestations, and involved the bladder.

  • As exemplified here, in the setting of immunosuppression all lesions should be biopsied unless a diagnosis is evident and undisputable.

FIGURE 112-56

At the time of diagnosis, the bladder wall in the region of the transplant ureter implantation was thickened (yellow arrow).

FIGURE 112-57

Retro-peritoneal adenopathy (green arrows) was also observed. Note the aorta (red arrow) as well as a left-sided IVC (blue arrow). Left-sided IVCs occur in approximately 0.5% of the population. In this specific case, it crossed over to the right side together with the left renal vein.

FIGURE 112-58

Retro-peritoneal adenopathy (green arrows) observed in a coronal section.

FIGURE 112-59

Post treatment, the findings have resolved completely.

FIGURE 112-60

Post-treatment, the retro-peritoneal adenopathy resolved completely. Note the aorta (red arrow) and the IVC. The IVC is located on the left side (blue arrow) below the level of the the left renal vein, but on the right side (retro-hepatic, black arrow) after it crosses over with the left renal vein.

FIGURE 112-61

Follow up PET-CT scan post treatment shows not evidence of abnormal FDG activity.

FIGURE 112-62

Kaposi sarcoma consists of numerous vascular channels filled with red blood cells, H&E stain 100x

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