kpmle2
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A 31-year-old man with history of idiopathic
pulmonary fibrosis undergoes a successful lung
transplant. An immunosuppressive regimen is
instituted. Six months following the transplant,
the patient presents with cough and low-grade
fever. On examination, he is febrile to 38.9
[font lang="JA" face="Symbol" size="3"]°[/font]C[font lang="JA" face="Symbol" size="3"]°[/font]F). His vital signs are heart rate
(102.1
135/min, respiratory rate 50/min, and blood
pressure 145/98 mm Hg. Oxygen saturation is
82% on room air. Lung examination reveals
diffuse inspiratory crackles. The remainder of
the examination is within normal limits. An xray
of the chest shows diffuse bilateral opacities.
Following stabilization, what is the next
step in terms of appropriate management of
the patient?
(A) Expectant therapy with broad-spectrum
antibiotics, antivirals, and antifungals
(B) Immediate treatment with high-dose
steroids
(C) Pulmonary function tests
(D) Reduction of the immunosuppressive regimen
(E) Transbronchial biopsy
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| ngaybinhyen
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B? just from my gut feeling 
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| wasedf
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To me this seems like PCP in a pat who is on immunosupressive therapy. What is confusing me about the qn is they say following stabilization.... what does that mean? Is it after the acute phase of the illness.
My first response would be to empirically treat.. However, option A sounds cheesy, using all classes of drugs to treat. Option E is used for the definitive diagnosis of PCP. I am torn between A and E.
Any other thoughts,. please share
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| wasedf
Forum Junior
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Why I don't think it is option B- 6 months after the transplant---probably not acute rejection.
Option C and D-- don't seem they will help in the diagnosis or treatment of the current status of the patient.
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| altabban
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i will go with antibiotics.
and by the way, following stabalization means they placed the patient in ICU and started high flow O2 with IV access, meaning "we gave the patient what he is short of".
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| altabban
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i will go with antibiotics.
and by the way, following stabalization means they placed the patient in ICU and started high flow O2 with IV access, meaning "we gave the patient what he is short of".
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| altabban
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another meaning of "after stabalization" is : we gave the patient the first line treatment which in this case is high flow O2
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| nightflight1945
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(E) Transbronchial biopsy
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| kpmle2
Forum Guru
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The correct answer is E.
[font face="ElectraLH-Bold" size="3"]
[/font]
This patient is likely
experiencing an episode of acute rejection.
This is an immunologic response to foreign
antigens in the graft that leads to bronchiolar
lymphocytic inflammation. Acute rejection is
experienced by at least 50% of lung transplant
patients within the first year posttransplant,
and is characterized by cough, low-grade fever,
dyspnea, hypoxia, and interstitial infiltrates and
edema. It can be treated effectively with highdose
steroids and increased immunosuppression.
However, the symptoms may mimic
those of infections such as cytomegalovirus, so
the diagnosis should be confirmed by biopsy.
Answer A is incorrect.
[font face="ElectraLH-Bold" size="3"]
[/font]
Antimicrobial therapy
Answer B is incorrect.
steroids is indicated once rejection is confirmed.
However, because the symptoms of
acute rejection may overlap with those of infection,
initiating steroid therapy without
biopsy confirmation of rejection and the absence
of infection is dangerous.
Treatment with highdose
Answer C is incorrect.
function tests are important maintenance tests
that should be performed periodically on transplant
patients, they are more useful in assessing
chronic rejection than acute rejection.
Although pulmonary
Answer D is incorrect.
infection, reduction of the immunosuppressive
regimen might be warranted; however, reducing
immunosuppression in the case of acute
rejection would be extremely dangerous and
might lead to irreversible graft rejection
If the patient has an
in immunosuppressed patients should be specific
whenever possible. A “shotgun” approach
may promote resistance in this at-risk population.
Because acute rejection is more statistically
likely than infection in this patient, confirmation
by biopsy is warranted before
antimicrobial therapy is initiated. Therefore,
immediate expectant therapy with empiric antimicrobial
therapy is not warranted until an
infectious cause is found.
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| ngaybinhyen
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Nice
Thanks, guys
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| nightflight1945
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| kpmle2
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| altabban
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nice one, thanks....
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