WHAT IS YOUR DIAGNOSIS? PULMONARY NODULAR LESIONS IN A RENAL TRANSPLANT RECIPIENT

WHAT IS YOUR DIAGNOSIS? A 54 year-old diabetic man, who had received a renal transplant two years ago due to diabetic nephropathy, was referred to our center. The allograft had a good function and creatinine level was normal. He was febrile since 2 months ago and had non-productive cough. He was admitted and evaluated in another center. No abnormality was found in his chest x-ray at that time and the fever subsided with empirical treatment consisting of vancomycin, imipenem and ganciclovir without any definite diagnosis. After discharge, the fever recurred with shaking chills and productive cough and pulmonary nodular lesions were found in the new chest x-ray (Figure 1). He received immunosuppressive regimen consisting of cellcept 500 mg, twice daily, prednisolone 10 mg daily and cyclosporine 225 mg daily in divided doses. Serologic studies for HIV, HCV and HBV as well as the PPD test were negative at the time of transplantation but anti-CMV and anti-EBV IgG antibodies were positive. We did not find any abnormality except for macular purple lesions in distal part of extremities. The results of laboratory tests were: Total leukocyte count: 8,200 cell/μl with normal differentiation, hemoglobin: 10.3 gr/dl, platelet count: 320,000 cell/μl and normal liver function tests, biochemistry and electrolytes. PPD test, multiple blood and urine cultures and plasma CMV-PCR were negative. Anti-nuclear antibody (ANA), anti-ds DNA and (C-P) ANCA were negative. Sputum smears for acid fast bacilli and culture for routine bacteriology were negative. Lung CT-Scan was also performed (Figure 2).(Tanaffos 2009; 8(1): 85-87)