Contributed by Maurice R. Grant, MD, A. William Pasculle, ScD, and James Shaeffer, MS
Published on line in July 2002
Chief concern: fever, chills, and shortness of breath
This is a 60-year-old white male with a past medical history significant for a single left lung transplant in November of 2001 secondary to emphysema. His postoperative course has been complicated by multiple episodes of both high-grade rejection requiring high-dose corticosteroid therapy and infection requiring antibiotic therapy. He was recently readmitted to the hospital with symptoms of fever, shaking chills, and productive cough. A complete blood count on admission showed a total white count to be 3,800 (77% neutrophils, 7% bands, 1% lymphocytes, and 15% monocytes), hemoglobin 7.9 gm/dL, hematocrit 24.1%, and platelet count of 294,000. A chest radiograph revealed an interval increase in areas of nodular consolidation in both the transplanted left lung and native right lung (Figure 1). The patient had blood and urine cultures drawn, and empiric intravenous antibiotic therapy was initiated.
A computed tomography (CT) of the chest was compared to a previous scan and revealed an interval increase in the size of the left lower lobe superior segment solid nodule and innumerable new solid and cavity nodules throughout both lungs in a bronchovascular distribution (Figure 2). It was noted in the report that these findings were suspicious for an opportunistic infection. The patient had a bronchoalveolar lavage and transbronchial biopsies performed and samples were sent to pathology to rule out rejection versus infection. Also during the course of this hospitalization, the patient was noted to have a swollen elbow. An aspirate was obtained from the joint and sent for cultures.
The patient's culture results from blood culture bottles revealed many gram-positive bacilli with a filamentous and branching arrangement (Figures 3 and 4). During the course of this hospitalization, the patient had a blood culture on admission, pleural fluid, joint fluid, and sputum cultures that were all positive for Nocardia farcinica