When an Infected Meniscus Portends a Perforated Viscus

A 59-year-old woman with a status of post-renal transplant 7 years prior for autosomal dominant polycystic kidney disease on tacrolimus and mycophenolate mofetil presented with subacute left knee and right wrist pain. She received local steroid injections to both areas as an outpatient without improvement in her symptoms. She had recently traveled to India, her home country, to visit relatives. Aspiration of the knee revealed 4+ acid fast bacilli on smear, and she was taken for surgical debridement. She was started on empiric antibiotics for presumed infection with rapidly growing mycobacteria. Her course was complicated by acute onset abdominal pain with pneumoperitoneum and mesenteric abscess on imaging, requiring exploratory laparotomy. Surgical cultures from all sites were positive for Mycobacterium tuberculosis. Her medications were adjusted to rifabutin, isoniazid, pyrazinamide, and ethambutol. Pretransplant screening results were unknown. She was discharged in stable condition and completed 12 months of medical therapy.