Contributed by Scott M Kulich MD, PhD and William A Pasculle ScD
Published on line in April 1998
The patient is a 68-year-old male retired carpenter with a history of long standing diabetes mellitus who underwent an orthotopic heart transplant 9 month prior to admission (PTA) for ischemic heart disease. His post-operative course was complicated by moderate multifocal acute cellular rejection (grade 3A) 5 months PTA for which he was treated successfully with a course of intravenous methylprednisolone. He was maintained on an immunosupressive regimen of tacrolimus, prednisone, and azathioprine without recurrent episodes of rejection. Two weeks PTA he began experiencing fevers, chills, and an associated non-productive cough. Four to five nights PTA he began experiencing night sweats, shaking chills, a sore throat, and dyspnea on exertion. He also reported weight loss of approximately 4 pounds over this time period. When seen as an outpatient for a routine endomyocardial biopsy, given his history over the preceeding 2 weeks, chest x-rays (Images 01 and 02) and a CT scan (Images 03 and 04) were obtained which showed mediastinal and right hilar lymph node enlargement and a focal, pleural-based, mass-like consolidation of the right lower lobe with focal cavitation. He was admitted for further evaluation.
The day after admission, a CT-guided fine needle aspiration of his right lower lobe mass was performed and sent for culture and cytology. Cytologic examination of the fluid was non-contributory and a gram-stain was negative for microorganisms. Three days into his hospitalization, he became acutely ill with temperatures spiking to 39.5 0C. Blood cultures were drawn and a bronchoscopy with multiple Wang needle biopsies of the precarinal lymph nodes and brochoalveolar lavage was performed.