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Old 12-21-2012
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Lungs Cough and fever after lung transplantation

A 31-year-old man with history of idiopathic pulmonary fibrosis undergoes a successful lung transplant. An immunosuppressive regimen is instituted. Six months following the transplant, the patient presents with cough and low-grade fever. On examination, he is febrile to 38.9°C (102.1°F). His vital signs are heart rate 135/min, respiratory rate 50/min, and blood pressure 145/98 mm Hg. Oxygen saturation is 82% on room air. Lung examination reveals diffuse inspiratory crackles. The remainder of the examination is within normal limits. An xray of the chest shows diffuse bilateral opacities. Following stabilization, what is the next step in terms of appropriate management of the patient?

(A) Expectant therapy with broad-spectrum antibiotics, antivirals, and antifungals
(B) Immediate treatment with high-dose steroids
(C) Pulmonary function tests
(D) Reduction of the immunosuppressive regimen
(E) Transbronchial biopsy
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Old 12-21-2012
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(E) Transbronchial biopsy ---looks like rejection but need to r/o infection.
Also need biopsy as a baseline to assess response to treatment.
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i would think rejection with bilateral lung opacity- start steroids...followed by transbronchial biopsy
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Old 12-25-2012
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The correct answer is E. This patient is likely experiencing an episode of acute rejection. This is an immunologic response to foreign antigens in the graft that leads to bronchiolar lymphocytic inflammation. Acute rejection is experienced by at least 50% of lung transplant patients within the first year posttransplant, and is characterized by cough, low-grade fever, dyspnea, hypoxia, and interstitial infiltrates and edema. It can be treated effectively with highdose steroids and increased immunosuppression. However, the symptoms may mimic those of infections such as cytomegalovirus, so the diagnosis should be confirmed by biopsy.

Answer B is incorrect. Treatment with highdose steroids is indicated once rejection is confirmed. However, because the symptoms of acute rejection may overlap with those of infection, initiating steroid therapy without biopsy confirmation of rejection and the absence of infection is dangerous.
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