The Perfect Storm: An Unusual Cause of Intestinal Perforation in a Solid Organ Transplant Patient

Immunosuppressants are used to prevent rejection in transplant patients. Many of these medications commonly cause gastrointestinal (GI) symptoms. We present a 38-year-old kidney and pancreas transplant recipient who had severe ulceration throughout his GI tract leading to perforations of his stomach and cecum, despite early discontinuation of mycophenolate mofetil—the most likely culprit medication. The ongoing injury observed despite holding mycophenolate suggests a possible compounding effect of tacrolimus and everolimus. Both these agents are underrepresented causes of GI injury. This perfect storm of agents may have accounted for the severity and extensive presentation observed in our patient.