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Kaposi’s sarcoma (KS) is a vascular neoplasm associated with human herpesvirus-8 (HHV-8) that mainly occurs in immunocompromised individuals, particularly following solid organ transplantation. Its presentation may mimic infectious or inflammatory lesions, complicating diagnosis. Patients with prior infections and chronic kidney disease are at higher risk of both infectious reactivation and malignancy. We describe a case of KS arising shortly after kidney transplantation, emphasizing the challenges of immunosuppression management and early malignancy recognition.
A 39-year-old mixed-race male contractor, with no history of hypertension, diabetes, or toxic habits, was diagnosed in 2019 with nephrotic syndrome treated with 10 weeks of corticosteroids led to full remission.
In 2022, he developed hypertension, tachycardia, severe anemia, and urinary symptoms (nocturia and foamy urine).
Laboratory tests showed urea 26.9 mmol/L and creatinine 1044 µmol/L, eGFR 5.2mL/min/1.73m2. Urinalysis revealed proteinuria (++), hematuria, leukocyturia (2+), and casts, with 24-hour proteinuria of 4.1 g/day. Abdominal ultrasound showed normal-sized kidneys with increased echogenicity, reduced corticomedullary differentiation, and grade 2 hepatic steatosis.
An excisional lymph node biopsy (January 2023) confirmed tuberculous lymphadenitis, treated with anti-TB therapy. Viral markers for HIV, HBV and HCV were negative. The patient underwent a living-donor kidney transplant in India (September 2023). Post-transplant therapy included tacrolimus (target level between 8 to 12mg3 , low to moderate risk), mycophenolate mofetil (500 mg twice daily), prednisolone tapered to 5 mg/day, antihypertensives, ethambutol, co-trimoxazole, and valganciclovir prophylaxis.
A few months later, he presented with low back pain, severe anemia, and subcutaneous erythematous nodules. Urine TB-LAM was negative. Skin lesion biopsy diagnosed Kaposi’s sarcoma. Immunosuppression was reduced by discontinuing mycophenolate and targeting tacrolimus to 3-5 mg, with close graft monitoring under multidisciplinary follow-up with nephrology, oncology, and infectious disease teams.
This case illustrates a dual challenge: the patient was not followed up after his first episode of nephrotic syndrome, possibly interpreting the clinical remission as the resolution of the problem; follow-up after transplantation was likewise not strict and he presented with a full-blown malignancy.
The onset of Kaposi’s sarcoma shortly after transplantation is rare in the absence of multiple challenges including previous immunosuppression and chronic infectious- inflammatory disease, as in this case. The risk of overimmunosuppression is enhanced by the lack of laboratory that measure tacrolimus levels, in Mozambique. This case underlines the diagnostic and therapeutic challenges in managing kidney transplant recipients in low incomes countries.
