| الوصف: |
(CHEST 2001; 120:1394–1398) A 48-year-old man with end-stage renal disease due to bilateral hydronephrosis had undergone a cadaveric kidney transplantation in April 1990, after 3 years of hemodialysis. His maintenance immunotherapy consisted of cyclosporine, 150 mg/d; prednisolone, 7.5 mg/d; and azathioprine, 125 mg/d. In August 1999, cyclosporine-associated arteriopathy and chronic rejection led to progressive graft failure, and he was evaluated for retransplantation. Unexpectedly, the chest radiograph revealed bilateral confluent alveolar opacities, with a nodular, fluffy appearance observed on high-resolution CT (Fig 1, 2). The patient denied fever, cough, weight loss, night sweats, or dyspnea. Results of pulmonary function testing and arterial blood gas analysis were normal; only a metabolic acidosis was noticed. Physical examination detected hypertension (BP, 184/97 mm Hg), obesity (body mass index, 30), a grade 2/6 aortic ejection murmur, and edema of the legs. Results of chest and abdominal examination were normal. Lymph nodes were not enlarged, and no skin lesions could be seen. Laboratory findings were as follows: erythrocyte sedimentation rate, 64 mm/h; C-reactive protein, 4 mg/L (normal range, 5 mg/L); hemoglobin, 9.9 g/dL; WBC count, 9 10 cells/ L; platelet count, 163 10 cells/ L; creatinine, 3.9 mg/dL (normal range, 1.3 mg/dL); urea, 90 mg/dL (normal range, 20 mg/dL); sodium, 144 mEq/L; potassium, 5.7 mEq/L; calcium, 9 mg/dL (normal range, 9 to 10.5 mg/dL); phosphate, 6.8 mg/dL (normal range, 3 to 4.5 mg/dL); intact parathyroid hormone, 627 pg/mL (normal range, 10 to 65 pg/mL); and albumin, 3.1 g/dL (normal range, 4.0 to 5.0 g/dL). Flexible bronchoscopy revealed an acute bronchitis, but no pathogen could be isolated. BAL showed normal cellularity and results were negative for routine bacterial Gram’s stain and cultures, including acid-fast bacilli, fungi, Pneumocystis carinii, and viruses. To define the exact etiology and relevance of the radiologic findings, thoracoscopic wedge biopsy of the left upper lobe was performed. |
