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Cleveland Clinic Journal of MedicineDyspnea and Cough in a Lung Transplant Recipient

Comprehensive Evaluation and Management of Dyspnea and Cough in a Lung Transplant Recipient: Clinical Implications for Transplant Care

A 62-year-old woman with a history of bilateral lung transplantation presented with sudden onset dyspnea, dry cough, and fatigue, accompanied by a new opacity on chest radiography. This case study explores the broad differential diagnosis and management strategies for such symptoms in lung transplant recipients, emphasizing the need for early and thorough evaluation to guide appropriate treatment, particularly in immunocompromised patients.

Key Points:

  • Patient Presentation: A 62-year-old lung transplant recipient presented with acute dyspnea, dry cough, fatigue, and a decrease in home spirometry values.
  • Medical History: Bilateral lung transplantation six years ago for chronic respiratory failure due to usual interstitial pneumonitis; both patient and donor were positive for Epstein-Barr virus and cytomegalovirus.
  • Current Medications: Low-dose aspirin, trimethoprim-sulfamethoxazole, azithromycin, and immunosuppressants (tacrolimus, prednisone, mycophenolate).
  • Initial Examination: The patient was hemodynamically stable with an oxygen saturation of 97%, normal heart, lung, and abdomen examinations, and a transient fever of 38.1°C (100.6°F).
  • Laboratory Results:
    • White blood cell count: 10.6 × 10^9/L
    • Procalcitonin: <0.06 ng/mL
    • Tacrolimus: 4.3 ng/mL
    • Negative for human leukocyte antigen class I and II antibodies, Aspergillus antigen, Epstein-Barr virus, and cytomegalovirus viral load.
  • Radiographic Findings: New ill-defined opacity superior to the right hilum on chest radiography.
  • Differential Diagnosis: Broad differential includes respiratory tract infection, pulmonary embolism, lung transplant rejection/dysfunction, and posttransplant lymphoproliferative disorder.
  • Diagnostic Focus: In immunocompromised patients, consider opportunistic infections, lymphoma, and iatrogenic injury from immunosuppressive therapy.
  • Infection Workup: Strong suspicion for respiratory tract infection due to immunocompromised status; initial tests included a viral respiratory pathogen panel, sputum Gram stain and cultures, and blood cultures.
  • Empiric Treatment: Started on broad-spectrum intravenous antimicrobials (cefepime and vancomycin) due to history of allergy to fluoroquinolones and penicillin.
  • Bronchoscopy and Biopsy: Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy performed after initial workup; samples tested for various pathogens.
  • Diagnosis: Positive for human metapneumovirus (HMPV) from bronchoalveolar lavage samples, leading to a diagnosis of HMPV bronchitis.
  • Management: Transition to oral antibiotics (high-dose azithromycin) to prevent secondary bacterial pneumonia; continued immunosuppressive therapy; supportive care.
  • Follow-Up: Routine follow-up included complete blood count, metabolic panel, viral load testing, and pulmonary function testing, all of which were stable.

Lung transplant recipients (LRs) have a reduced median 5-year survival of approximately 55% primarily due to chronic lung allograft dysfunction (CLAD). (Clinical Transplantation)

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