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60-Year-Old Man with Non-resolving Pneumonia

Reviewed By Critical Care Assembly

Submitted by

Nicholas C. James, MD

Department of Pulmonary and Critical Care Medicine

Lahey Hospital & Medical Center

Burlington, Massachusetts

Timothy N. Liesching, MD

Department of Pulmonary and Critical Care Medicine

Lahey Hospital & Medical Center

Burlington, Massachusetts

Submit your comments to the author(s).

History

A 60 year-old man with a past medical history for coronary artery disease requiring four vessel coronary artery bypass grafting, hypertension, hyperlipidemia, nephrolithiasis and cirrhosis related to alcohol abuse was deemed a liver transplant candidate after complications of several episodes of hepatic encephalopathy and esophageal variceal bleeding. He remained abstinent from alcohol.

He underwent a living donor liver transplant using the right hepatic lobe graft donated by his son. His immunosuppression regimen included sirolimus, mycophenolate, and prednisone. Valgancyclovir and trimethoprim/sulfamethoxazole included his prophylactic therapy. There were no peri-operative complications noted. Post-operatively, the patient noted mild dyspnea and a non-productive cough. His postoperative course was complicated by cholangitis secondary to biliary stricture necessitating percutaneous trans-hepatic cholangiography (PTC) and biliary dilation.  Work up for his cholangitis included an abdominal CT that incidentally demonstrated a dense pulmonary infiltrate of the right middle lobe (RML) (Figure 1). He also developed acute renal insufficiency, but did not require renal replacement therapy. It was determined by the surgical team that the patient had pneumonia and was treated amoxicillin/clavulanate. His respiratory symptoms resolved and followed up in clinic.

As an outpatient, the patient required one additional biliary dilation procedure for biliary stricture. A follow up chest CT (Figure 2) 7 weeks after initial imaging demonstrated a persistent RML infiltrate. The patient was completely without respiratory complaint at the time.  A pulmonary consultation is requested. 

Physical Exam

Physical examination revealed the patient to be afebrile with an oxygen saturation of 99% on room air. The remaining vitals were also unremarkable. The patient was not in acute distress and could talk in complete sentences.  Auscultation of the lungs was clear throughout and cardiac examination revealed a 3/6 systolic murmur. The extremities were void of edema and there was no clubbing.

Figure 1

Figure 1: CT chest showing right middle lobe dense consolidation with associated ground glass opacities

Figure 2

Figure 2: Persistent, more consolidated right middle lobe infiltrate with increased ground glass opacities

Question 1

What would be the next best diagnostic approach for this patient’s non-resolving opacity?

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