Dr SIVAKAJANI BALAKUMAR1, Prof MAJONI SANDAWANA WILLIAM1,2, Dr KIRSTY CAMPELL3
1department of nephrology, Tiwi , Australia, 2department of nephrology, royal darwin hospital, Tiwi, Australia, 3department of gastroenterology, royal darwin hospital, Tiwi, Australia
Biography:
Name: Dr Sivakajani Balakumar
Current work place: Royal Darwin Hospital
Job position: Advanced Trainee-Nephrology since March 2024
Qualifications : MBBS(SL),MD (SL),ESENeph(UK)
Renal interest: I am very much interested in general nephrology and renal transplantation.
Background:
Malakoplakia is an uncommon granulomatous disease linked to impaired macrophage function, primarily affecting the genitourinary tract. Colonic involvement is rare, particularly in immunosuppressed individuals, and can mimic malignancy both clinically and endoscopically. Opportunistic infections such as cytomegalovirus (CMV) and enterococcus may act as cofactors in its pathogenesis.
Case Presentation:
We report a 67-year-old Indigenous male renal transplant recipient who presented with a 12-month history of unintentional weight loss. Immunosuppressed for a decade post-transplant, he was found to have positive faecal occult blood, CMV viremia (2495 copies/mL), and Enterococcus faecalis on urine culture. Colonoscopy revealed caecal lesions suspicious for malignancy, but histopathology confirmed malakoplakia, characterized by Michaelis–Gutmann bodies. He was commenced on valganciclovir and targeted antibiotics, alongside immunosuppression reduction, resulting in clinical improvement. Unfortunately, the patient succumbed to metastatic lung cancer ten years post-transplant.
Discussion:
This case highlights the diagnostic complexity of colonic malakoplakia, particularly in the context of overlapping CMV and bacterial infections. CMV-mediated immune modulation may contribute to defective macrophage clearance, promoting malakoplakia. Timely recognition and a multidisciplinary approach are essential, especially when endoscopic findings suggest neoplasia.
Conclusion:
Colonic malakoplakia, though rare, should be considered in immunosuppressed patients with atypical gastrointestinal symptoms. This case underscores the importance of integrating microbiological, histological, and clinical findings to guide effective management.