Bryan Christian Gaza Ilagan, Philippines has been granted the Challenging Cases Competition Awards
A 50 year old female, Filipino admitted due to dyspnea. Post-kidney transplantation 2008 for Chronic Glomerulonephritis. No induction, maintained on cyclosporine, mycophenolate mofetil,prednisone with immediate graft function. Baseline creatinine 0.8-1.1mg/dl. Admitted 11/26/2017 for cough and dyspnea. Chest xray showed diffuse interstitial pneumonia mid-upper lungs, consolidation left-lower lung. Meropenem, Fluconazole and Clarithromycin empirically started. Sputum culture,AFB,galactomannan,procalcitonin negative. Had acute kidney injury with creatinine of 2.2mg/dl.CYA trough 77 at 50mg/day. Chest CT scan showed interstitial edema and/or pneumonia and/or tuberculosis left upper-lower lobe. Bronchoscopy with bronchoalveolar lavage(BAL)done. BAL fluid(-) for nocardia, legionella, pneumocystis, cytomegalovirus, tuberculosis, fungi. BAL culture(+) for Pseudomonas aeruginosa. No improvement after 1 week of culture guided antibacterial. Empirically started on Ganciclovir with improvement in dyspnea,slight clearing of left lung infiltrates. Creatinine normalized, 1.0mg/dl. Discharged 12/12/17. BAL cytology showed reactive atypical cells. Readmitted 01/24/18 for dyspnea. Chest Xray showed progression,hazy densities left lung,diffuse interstitial infiltrates.Interstitial lung disease versus tuberculosis considered. 2decho showed massive pericardial effusion. Underwent pericardiostomy, 600cc bloody fluid initially drained. Empiric Rifampicin+Isoniazid+Ethambutol+Pyrazinamide started.Pericardial fluid studies (bacterial, fungal, tuberculosis, TB-PCR,cytology) negative. Intubated 12th hospital day. Had generalized tonic-clonic seizure, cranial CT scan:multiple subcortical-cerebral-cerebellar hyperdensities, septic-microembolic event versus intracranial vasculitis, acute-to-subacute infarctions right frontal-parietal lobes,left centrum semiovale,frontal lobe. Neurologic assessment of systemic vasculitides and septic embolus.Referred to Rheumatology for connective-tissue-disease evaluation. C3, HS-CRP,ESR all elevated. ANA, antidsDNA, ANCA negative. Methylprednisolone pulsing 500mg for 3 days started. CT-guided left lung mass biopsy done. Microbiologic studies negative. Histopathology showed adenocarcinoma of lung primary. Relatives opted palliative care,patient expired 41st hospital day.
