Abdominal gas is not always bowel associated: lessons from an allograft recipient

A 39-year-old female, who underwent renal transplantation 2 years earlier, was referred to our unit with a 2 week history of high-grade fever and graft dysfunction. She was on an immunosuppressive regime containing cyclosporin, azathioprine and prednisolone. Six months post-transplantation she developed hyperglycaemia and was treated with insulin. Nine months later she developed disseminated tuberculosis and received antituberculous therapy. At the time of referral, apart from immunosuppressives, she was on isoniazid 200mg and ethambutol 400mg, daily. Her serum creatinine ranged between 1.5 and 1.8mg/dl in the past year. On examination she was febrile, normotensive and complained about vague abdominal discomfort. The abdomen was distended with no tenderness guarding or rigidity, but bowel sounds were absent. She was anuric with anasarca and had fine basal crackles. She was disoriented but without focal neurological deficits. Investigations revealed a serum creatinine of 3.9mg/dl and arterial blood gas analysis showed metabolic acidosis (pH 7.195, pCO2 24.1mmHg, pO2 87.8mmHg, HCO3 14mmol/l, ABE 9.4mmol/l, sO2 96.4%). She had a platelet count of 12 000/mm, white blood cell count of 36 900/dl with 90% polymorphs and a blood sugar of 343mg/dl. An X-ray of the abdomen in the erect position (Figure 1) was taken followed by an ultrasonogram. A few hours later, she developed pulmonary oedema and hypotension with a blood pressure of 90/60mmHg. While on ionotropic support she received haemodialysis.