Anchoring bias in a kidney transplant recipient with persistent fever and urinary symptoms

A case report.

Abstract

Introduction: Infections are a leading cause of morbidity and mortality among kidney transplant recipients. In endemic areas, tuberculosis can present with atypical extrapulmonary manifestations that mimic common bacterial infections, potentially leading to diagnostic delays. We present a case illustrating how anchoring bias—stemming from a urinary tract infection—hindered the timely recognition of disseminated tuberculosis.

Case report: We report the case of a 64-year-old man who underwent deceased-donor kidney transplantation for chronic kidney disease secondary to diabetes mellitus and arterial hypertension. Pre-transplant protocols, including infection screening, yielded negative results. A retrospective review was conducted of his medical history, hospital course, microbiological studies, imaging, and pathological findings.

Results: During post-transplant follow-up, the patient experienced delayed graft function, a lymphocele, and choledocholithiasis. He required multiple hospitalizations for fever and lower urinary tract symptoms, which were treated as urinary tract infections with various antibiotic regimens despite repeatedly negative urine cultures. Persistent urinary frequency, urgency, and dysuria, followed by rectal tenesmus, led to the decision to perform a prostatectomy, during which a prostatic abscess was identified. Subsequently, the patient developed neurological deterioration and seizures. Polymerase chain reaction (PCR) testing for *Mycobacterium tuberculosis* in the cerebrospinal fluid confirmed disseminated central nervous system tuberculosis. A prostate biopsy confirmed the diagnosis of tuberculosis. Treatment with an RIPE regimen and corticosteroids was initiated, requiring close monitoring of immunosuppressive therapy due to drug-drug interactions.

Conclusions: In kidney transplant recipients, persistent fever and urinary symptoms in the absence of microbiological confirmation should prompt a diagnostic re-evaluation. In endemic regions, extrapulmonary tuberculosis should be considered early to avoid anchoring bias toward urinary tract infection and to reduce delays in diagnosis and treatment.