case study
Dr. Jaron Lee: A 55-year-old man was admitted to this hospital with fatigue, weight loss, and new pulmonary nodules 7 months after kidney transplantation.
The patient had been in normal health until 1 week before this admission, when severe fatigue and general weakness developed. He lost 4.5 kg last month after choosing a healthier diet. However, he had also noticed discomfort in his abdomen and decreased appetite.
Over the next week, the patient could barely eat or drink and lost an additional 4.5 kg. I felt more tired and weak and almost bedridden. He had several episodes of lightheadedness, gait unsteadiness, and falls while walking to the bathroom. He had new dysphagia, dysphagia, and nausea.
On the day of admission, the patient was evaluated at this hospital’s kidney transplant clinic prior to the scheduled belatacept infusion. During fresh air breathing, body temperature was 37.3°C, blood pressure was 70/50 mm Hg, heart rate was 98 beats/min, respiratory rate was 35 beats/min, and oxygen saturation was 96%. He looked cachectic and lethargic. He was taken by ambulance from his clinic to the emergency department of this hospital.
In the emergency department, the patient reported feeling tired and without energy or strength. Lightheadedness and gait instability persisted. System review noted persistent shortness of breath, dark urine, anorexia, nausea, dysphagia, dysphagia, and abdominal discomfort. He reported no chills, night sweats, cough, chest pain, vomiting, blood in the stool, rectal bleeding, or difficulty urinating.
The patient had a history of sarcoidosis. Nine years before this admission, nephrocalcinosis had caused end-stage renal disease. Hemodialysis was started and this treatment continued until a deceased kidney transplant was performed 7 months before his admission. Routine serological tests performed before transplantation were positive for Epstein-Barr virus (EBV) IgG and cytomegalovirus (CMV) IgG.Interferon-γ release assay Mycobacterium tuberculosis was negative. Donor serology was also positive for EBV IgG but negative for CMV IgG. Induction immunosuppressive therapy with antithymocyte globulin was started. Maintenance therapy included prednisone, mycophenolate mofetil, and tacrolimus.
Six months before the current admission, pathological examination of biopsy specimens from transplanted kidneys revealed donor-derived vascular disease and acute tubular injury, although T-cell-mediated or antibody-mediated There was no evidence of refusal. Treatment with tacrolimus was discontinued and belatacept was started. Prednisone and mycophenolate mofetil therapy was continued.
One month before the current admission, pathological examination of another biopsy specimen from the transplanted kidney revealed vaguely granulomatous, ruptured tubular and interstitial Tamm-Horsfall protein (as uromodulin). (also known as There was no evidence of allograft rejection.
Table 1. Inspection data. 
Figure 1. Imaging of the chest obtained on admission. 
Figure 1. Imaging of the chest obtained on admission. Frontal radiograph (panel A) shows multiple small pulmonary nodules (arrows) scattered throughout both lungs in a miliary pattern. Coronal (panel B) and axial (panel C) images from a CT of the pulmonary window show new numerous small bilateral nodules (yellow arrows) compared to images obtained 6 months earlier. The nodule distribution is random, a feature suggestive of a hematogenous origin. There is a small right pleural effusion (panel C, blue arrow). A coronal CT image (panel D) obtained in the soft tissue window shows enlarged bilateral hilar and carinal lymph nodes that are partially calcified (arrows). These findings are consistent with the known history of chronic sarcoidosis. Figure 2. CT of abdomen and spleen. 
Figure 2. CT of abdomen and spleen. Abdominal coronal sections obtained in the soft-tissue window from CT performed 6 months before admission (i.e., baseline) (Panel A) and at admission (Panel B) without the administration of intravenous contrast. image is shown. He had advanced splenomegaly and had a spleen size of 16 cm on admission. A small amount of new perihepatic ascites is also present (arrow).
Two weeks prior to the current admission, laboratory tests revealed a blood creatinine level of 2.31 mg/dL (204.2 μmol/L; reference range, 0.60–1.50 mg/dL). [53.0 to 132.6 μmol per liter]); routine laboratory tests revealed similar creatinine levels over the past 6 months. Other laboratory test results are table 1.
The patient also had a history of hypertension, hyperlipidemia, and gout. Current medications included aspirin, atorvastatin, labetalol, nifedipine, trimethoprim-sulfamethoxazole, valganciclovir, prednisone, mycophenolate mofetil, and belatacept. There were no known drug allergies. The patient lived with her mother in an urban New England area and had never traveled outside of that area. He works as an administrator and has never been homeless or imprisoned. He had no sexual partners and did not smoke, use illegal drugs, or drink alcohol.
On the day of evaluation in the emergency department, the temperature was 36.7°C, the blood pressure was 80/50 mmHg, the heart rate was 100 beats per minute, the respiratory rate was 24 beats per minute, and the oxygen saturation was 92%. The patient was breathing ambient air. His body mass index (weight in kilograms divided by his square of height in meters) was 20.5. The patient was lethargic and spoke in sentences of 3-4 words. The mucosa was dry and the throat could not be evaluated due to nausea. There was no cervical lymphadenopathy. Auscultation of the lungs revealed diffuse inspiratory crackles. Neurological examination was limited, but her 4/5 exercise intensity in arms and legs was notable.
The blood level of creatinine was 5.05 mg/dl (446.4 μmol/l) and the calcium level was 13.1 mg/dl (3.3 mmol/l; reference range, 8.5–10.5 mg/dl). [2.1 to 2.6 mmol per liter]), lactate level 4.4 mmol/liter (39.6 mg/deciliter; reference range, 0.5–2.0 mmol/liter) [4.5 to 18.0 mg per deciliter]), with a hemoglobin value of 6.6 g per deciliter (reference range, 13.5–17.5). A blood culture was obtained. Other laboratory test results are table 1.
Dr. Mark C. Murphy: Computed tomography (CT) of the chest, abdomen, and pelvis was performed without intravenous contrast agent. Chest CT (Figure 1) revealed new myriad bilateral miliary pulmonary nodules compared with a CT scan acquired 6 months earlier. Nodules were in a random distribution suggesting a hematogenous origin. Minimal bilateral pleural effusions were present, as was calcified mediastinum and bilateral hilar adenopathy. Lymphadenopathy appeared unchanged from previous imaging. CT of the spleen (Figure 2) revealed a new splenomegaly. There was a new mild enlargement of the renal collecting system of the transplanted kidney in the lower right quadrant of the abdomen.
Dr. Lee: The temperature rose to 39.6°C while the patient was being evaluated in the emergency department. Intravenous fluids and an intravenous infusion of phenylephrine were administered. Empiric treatment with vancomycin, cefepime, metronidazole, levofloxacin, doxycycline, and micafungin was initiated. Trimethoprim-sulfamethoxazole and valganciclovir were continued. Treatment with prednisone and mycophenolate mofetil was discontinued and hydrocortisone therapy was initiated. The patient was admitted to the intensive care unit.
Within 24 hours of admission, oxygen saturation had dropped to 84% and the patient was breathing ambient air. Administering oxygen through a nasal cannula at a rate of 2 liters per minute increased his oxygen saturation to 94%. Continuous intravenous infusion of phenylephrine was continued and norepinephrine was added to maintain mean arterial pressure above 65 mmHg. Two units of packed red blood cells were transfused. The creatinine value decreased to 3.82 mg/dl (337.7 μmol/l), the lactate value to 1.6 mmol/l (14.4 mg/dl) and the calcium value to 8.9 mg/dl (2.2 mmol/l). Treatment with levofloxacin and micafungin was discontinued. Isavuconazole was started.
question
what is the diagnosis? please vote.
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