CASE 77
A 36-year-old man was brought to the hospital for complaints of persistent high fever, dry cough, and worsening shortness of breath for a week.
LABORATORY STUDIES
Diagnostic Work-Up
Table 77-1 lists the likely causes of illness (differential diagnosis). Specific diagnosis is difficult owing to the high frequency of asymptomatic and reactivation infections in patients with transplants. Investigational approach for specific microbiologic diagnosis may include a combination of the following tests:
TABLE 77-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Because of their immunocompromised state, transplant patients are at high risk for developing a variety of unusual infections due to bacteria and mycobacteria. Patients with bone marrow transplants are the most immunosuppressed; those with kidney transplants are the least immunosuppressed. A variety of clinical syndromes may be seen, depending on the organ that has been transplanted. Aspergillosis is often seen with prolonged neutropenia and carries a high mortality. Pneumonitis is often caused by Pneumocystis jiroveci in an immunocompromised patient, but Bactrim is a reliable prophylactic drug. CMV is among the most common viral causes of disease in these patients and should always be considered, but adenovirus is also seen.
COURSE
A bronchoscopy was done, and transbronchial biopsy and bronchoalveolar lavage specimens were sent for histopathologic and cytologic examination. Empirical antibiotics were started pending cultures. Routine bacteriologic and mycobacteriologic work-up were all negative. Virus culture was positive for an agent typical of this patient population.
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