shortness of breath and cough in a kidney-transplant patient august 2005

Shortness of Shortness of breath and cough breath and cough

in a kidney-in a kidney-transplant patienttransplant patient

August 2005August 2005

White 10, Team C – Massachusetts General White 10, Team C – Massachusetts General Hospital,Hospital,

Boston – MA, USABoston – MA, USA

Lorenzo AzzaliniLorenzo Azzalini University of Padua University of Padua Medical School, ItalyMedical School, Italy

History of present illnessHistory of present illness AJMK is a 43 y.o. male with history of ESRD, AJMK is a 43 y.o. male with history of ESRD,

kidney transplant and asthmakidney transplant and asthma Presenting with SOB, cough, headachePresenting with SOB, cough, headache The pt. was in his usual state of health until 2 The pt. was in his usual state of health until 2

weeks prior to admission, when he developed weeks prior to admission, when he developed a cough productive of yellow sputum and a cough productive of yellow sputum and headacheheadache

4 days prior to admission the pt. reports SOB 4 days prior to admission the pt. reports SOB upon 1 flight of stairs (prior to episode, he upon 1 flight of stairs (prior to episode, he was able to walk 3-4 flights of stairs before was able to walk 3-4 flights of stairs before experiencing SOB)experiencing SOB)

The pt. took Tylenol and Robitussin, without The pt. took Tylenol and Robitussin, without improvement of symptomsimprovement of symptoms

He denies fever, nausea or vomiting, but He denies fever, nausea or vomiting, but reports chills, chest tightness and wheezingreports chills, chest tightness and wheezing

History of present illnessHistory of present illness

The pt. reports two episodes of The pt. reports two episodes of pneumonia this year (one in-patient pneumonia this year (one in-patient treatment).treatment).

He was treated with levofloxacin in the He was treated with levofloxacin in the in-patient setting and quickly improvedin-patient setting and quickly improved

The pt. also reports that all three of his The pt. also reports that all three of his children recently had hand-foot-mouth children recently had hand-foot-mouth disease (evident only in throat), but disease (evident only in throat), but reports no other sick contactsreports no other sick contacts

Review of systemsReview of systems

He does report a decrease in He does report a decrease in appetite, which he believes is appetite, which he believes is secondary to decreased renal secondary to decreased renal functionfunction

Past medical historyPast medical history

Membrano-proliferative Membrano-proliferative glomerulonephritis and ESRDglomerulonephritis and ESRD – – Diagnosed with renal disease in 1995 (for Diagnosed with renal disease in 1995 (for casual finding of proteinuria). Began casual finding of proteinuria). Began dialysis in 1997. Right-sided living kidney dialysis in 1997. Right-sided living kidney transplant from his father in 1998, after transplant from his father in 1998, after bilateral nephrectomy. In May 2005, his bilateral nephrectomy. In May 2005, his creatinine increased from a baseline of 3.5 creatinine increased from a baseline of 3.5 to 4.4 mg/dl. He already has a R AV fistula to 4.4 mg/dl. He already has a R AV fistula placed (6/’05) for secondary access in placed (6/’05) for secondary access in emergency.emergency.

Past medical historyPast medical history

CMV infectionCMV infection – May 1998; treated – May 1998; treated with Ganciclovir IVwith Ganciclovir IV

AsthmaAsthma – diagnosed within last year – diagnosed within last year HypertensionHypertension – diagnosed >20 years – diagnosed >20 years

ago; well controlled, with baseline SBP ago; well controlled, with baseline SBP of 120 mmHgof 120 mmHg

Gastro-Esophageal Reflux Disease Gastro-Esophageal Reflux Disease (GERD)(GERD)

DyslipidemiaDyslipidemia

Medications on Medications on admissionadmission

Tacrolimus (Prograf) 2 mg PO Q12HTacrolimus (Prograf) 2 mg PO Q12H Mycophenolate mofetil (CellCept) 500 Mycophenolate mofetil (CellCept) 500

mg PO BIDmg PO BID Valganciclovir (Valcyte) 450 mg PO Valganciclovir (Valcyte) 450 mg PO

QODQOD Esomeprazole (Nexium) 40 mg PO QDEsomeprazole (Nexium) 40 mg PO QD Amlodipine (Norvasc) 10 mg PO QDAmlodipine (Norvasc) 10 mg PO QD Labetalol 400 mg PO BIDLabetalol 400 mg PO BID Sodium bicarbonate 2600 mg PO twice Sodium bicarbonate 2600 mg PO twice

QODQOD Montelukast (Singulair) 10 mg PO QDMontelukast (Singulair) 10 mg PO QD

Medications on Medications on admissionadmission

Iron 325 mg PO BIDIron 325 mg PO BID ASA (Aspirin) 81 mg PO QDASA (Aspirin) 81 mg PO QD Fluticasone propionate/Salmeterol Fluticasone propionate/Salmeterol

500/50 mg (Advair diskus 500/50) 1 500/50 mg (Advair diskus 500/50) 1 puff BIDpuff BID

Nasonex sprayNasonex spray Furosemide (Lasix) 40 mg PO BIDFurosemide (Lasix) 40 mg PO BID Atorvastatin (Lipitor) 10 mg PO QPMAtorvastatin (Lipitor) 10 mg PO QPM Multivitamin PO QPMMultivitamin PO QPM Renagel (Sevelamer) 800 mg PO TIDRenagel (Sevelamer) 800 mg PO TID

AllergiesAllergies – NKDA; seafood (itching) – NKDA; seafood (itching) Social historySocial history – He lives with his wife – He lives with his wife

and 3 kids (ages 5, 2, 2). He is a and 3 kids (ages 5, 2, 2). He is a merchandiser for a liquor distributor. merchandiser for a liquor distributor. He denies tobacco, alcohol and illicit He denies tobacco, alcohol and illicit drug use.drug use.

Familial historyFamilial history – He reports diabetes – He reports diabetes in great-grandparents. Mother died at in great-grandparents. Mother died at 57 from MI. HTN reported in siblings.57 from MI. HTN reported in siblings.

Physical examPhysical exam

Vital signs – T 99.7, HR 86, BP 140/66, Vital signs – T 99.7, HR 86, BP 140/66, RR 18, SaORR 18, SaO22 96% RA 96% RA

General – the patient appears his stated General – the patient appears his stated age and is in non-apparent distressage and is in non-apparent distress

HEENT – PERRL, sclera anictericHEENT – PERRL, sclera anicteric Neck – no carotid bruits, JVP 8 cmNeck – no carotid bruits, JVP 8 cm Nodes – no cervical or supraclavicular Nodes – no cervical or supraclavicular

LADLAD CV – RRR, S1 & S2 nl, No m/r/gCV – RRR, S1 & S2 nl, No m/r/g

Physical examPhysical exam

Chest – bilateral ronchi in RLL/LLL, Chest – bilateral ronchi in RLL/LLL, no crackles, dullness to percussion no crackles, dullness to percussion RLLRLL

Abdomen - +BS, NT, ND. No HSM. No Abdomen - +BS, NT, ND. No HSM. No peritoneal signsperitoneal signs

Ext – R AV fistula; 2+ peripheral Ext – R AV fistula; 2+ peripheral edema bilaterally on lower extremity edema bilaterally on lower extremity to just below the kneeto just below the knee

Skin – no rashesSkin – no rashes Neuro – A&Ox3; CN II-XII intactNeuro – A&Ox3; CN II-XII intact

Labs and studiesLabs and studies

BloodBlood

NaNa++ 136136 (135-145)(135-145) mmol/lmmol/l

KK++ 4.84.8 (3.4-4.8)(3.4-4.8) mmol/lmmol/l

ClCl-- 115 (H)115 (H) (100-108)(100-108) mmol/lmmol/l

COCO22 15.2 (L)15.2 (L) (23.0-(23.0-31.9)31.9)

mmol/lmmol/l

CaCa2+2+ 8.78.7 (8.5-10.5)(8.5-10.5) mg/dlmg/dl

POPO443-3- 4.8 (H)4.8 (H) (2.6-4.5)(2.6-4.5) mg/dlmg/dl

MgMg2+2+ 1.41.4 (1.4-2.0)(1.4-2.0) mEq/lmEq/l


BloodBlood

BUNBUN 63 (H)63 (H) (8-25)(8-25) mg/dlmg/dl

CreatinineCreatinine 6.1 (H)6.1 (H) (0.6-1.5)(0.6-1.5) mg/dlmg/dl

GlucoseGlucose 105105 (70-110)(70-110) mg/dlmg/dl

Total Total proteinsproteins

6.46.4 (6.0-8.3)(6.0-8.3) g/dlg/dl

AlbuminAlbumin 3.2 (L)3.2 (L) (3.3-5.0)(3.3-5.0) g/dlg/dl

Total Total bilirubinbilirubin

0.30.3 (0-1.0)(0-1.0) mg/dlmg/dl

Direct Direct bilirubinbilirubin

refusedrefused (0-0.4)(0-0.4) mg/dlmg/dl


BloodBlood

ASTAST 3636 (10-40)(10-40) U/lU/l

ALTALT 1212 (10-55)(10-55) U/lU/l

ALPALP 5959 (45-115)(45-115) U/lU/l

AmylaseAmylase 4242 (3-100)(3-100) U/lU/l

LypaseLypase 3.03.0 (1.3-6.0)(1.3-6.0) U/dlU/dl


BloodBlood

RBCRBC 3.53 (L)3.53 (L) (4.50-(4.50-5.90)5.90)

·10·1099/mm/mm33

HCTHCT 32.5 (L)32.5 (L) (41.0-(41.0-53.0)53.0)

%%

HbHb 9.8 (L)9.8 (L) (13.5-(13.5-17.5)17.5)

g/dlg/dl

MCVMCV 9292 (80-100)(80-100) flfl

MCHMCH 27.727.7 (26.0-(26.0-34.0)34.0)

pgpg

MCHCMCHC 30.1 (L)30.1 (L) (31.0-(31.0-37.0)37.0)

g/dlg/dl

RDWRDW 15.7 (H)15.7 (H) (11.5-(11.5-14.5)14.5)

%%


BloodBlood

WBCWBC 9.09.0 (4.5-11.0)(4.5-11.0) ·10·1033/mm/mm33

PLTPLT 223223 (150-350)(150-350) ·10·1033/mm/mm33

PTPT 12.312.3 (11.3-(11.3-13.3)13.3)

ss

APTTAPTT 27.927.9 (22.1-(22.1-35.1)35.1)

ss


UrineUrine

Specific Specific gravitygravity

1.0251.025 (1.001-(1.001-1.035)1.035)

kg/l

pHpH 5.05.0 (5.0-9.0)(5.0-9.0)

WBC WBC screenscreen

NegativNegativee

NegativeNegative

NitriteNitrite NegativNegativee

NegativeNegative

AlbuminAlbumin 3+3+ NegativeNegative

GlucoseGlucose TraceTrace NegativeNegative

KetonesKetones NegativNegativee

NegativeNegative


UrineUrine

Occult bloodOccult blood 3+3+ NegativeNegative

Sed-RBCSed-RBC 10-2010-20 (0-2)(0-2) /hpf/hpf

Sed-WBCSed-WBC 0-20-2 (0-2)(0-2) /hpf/hpf

Sed-BacteriaSed-Bacteria FewFew NegativeNegative /hpf/hpf

Hyaline castsHyaline casts 10-2010-20 (0-5)(0-5) /lpf/lpf

Squamous cellsSquamous cells NegativNegativee

NegativeNegative /hpf/hpf

Bladder cellsBladder cells FewFew NegativeNegative /hpf/hpf

Amorphous Amorphous crystalscrystals

ModeraModeratete

NegativeNegative /hpf


MicrobiologyMicrobiology

CMV CMV antigenemiaantigenemia

NegativeNegative

Blood cultureBlood culture No growth after 5 daysNo growth after 5 days

Induced Induced sputumsputum

Few gram –ve rods of mixed Few gram –ve rods of mixed morphologies, few gram +ve morphologies, few gram +ve cocci in pairs/clusters; no cocci in pairs/clusters; no acid fast bacilli; acid fast bacilli; growth of growth of few non-enteric gram –ve few non-enteric gram –ve rodsrods; no growth of ; no growth of microbacteria after 2 days; microbacteria after 2 days; no fungi; no no fungi; no P. CariniiP. Carinii

ChestChestX-RayX-Ray

Chest X-RayChest X-Ray

Interval development of Interval development of right lower right lower lobe pneumonialobe pneumonia and and small right small right pleural effusionpleural effusion. Follow-up films to . Follow-up films to resolution are suggested.resolution are suggested.

ChesChest CTt CT

Chest CTChest CT

Multifocal air space opacifications Multifocal air space opacifications and tree-in-bud opacities as above and tree-in-bud opacities as above may represent inflammatory change, may represent inflammatory change, aspiration, or aspiration, or pneumoniapneumonia..

Bilateral hilar and mediastinal Bilateral hilar and mediastinal lymphadenopathy, likely reactive in lymphadenopathy, likely reactive in nature.nature.

Assessment and planAssessment and plan AJMK is a 43 y.o. male with history of AJMK is a 43 y.o. male with history of

ESRD and recurrent lower respiratory tract ESRD and recurrent lower respiratory tract infections, presenting with SOB, cough infections, presenting with SOB, cough productive of yellow sputum and headache.productive of yellow sputum and headache.

1)1) SOB/CoughSOB/Cough SOB/Cough productive of yellow SOB/Cough productive of yellow

sputum/headache/chills – suggestive of sputum/headache/chills – suggestive of pneumonia. PE ronchi bilaterally. PA & pneumonia. PE ronchi bilaterally. PA & LA CXR: RLL infiltrate and small right LA CXR: RLL infiltrate and small right pleural effusion. Preliminary sputum pleural effusion. Preliminary sputum gram stain revealed rare gram –ve rods; gram stain revealed rare gram –ve rods; respiratory and blood cultures pending.respiratory and blood cultures pending.

Assessment and planAssessment and plan

Asthma – While SOB could be related to Asthma – While SOB could be related to asthma, the acute onset along with cough asthma, the acute onset along with cough productive of yellow sputum and chills productive of yellow sputum and chills suggests infectious cause.suggests infectious cause.

Heart disease – HD could produce SOB and Heart disease – HD could produce SOB and chest tightness; cardiac ultrasound on chest tightness; cardiac ultrasound on 7/19/’05 showed normal valve structure; 7/19/’05 showed normal valve structure; trace MR, AI and TI; dilated LA and LV trace MR, AI and TI; dilated LA and LV hypertrophy; EF=66%. Diastolic heart hypertrophy; EF=66%. Diastolic heart failure may play a role in the patient’s failure may play a role in the patient’s shortness of breath and peripheral edema. shortness of breath and peripheral edema. Diuresis may help with symptoms.Diuresis may help with symptoms.


PlanPlan Treatment: Treatment: VancomycinVancomycin 1g IV for coverage 1g IV for coverage

of resistant gram +ve, and of resistant gram +ve, and CefepimeCefepime 2g IV 2g IV for gram –ve coverage, in for gram –ve coverage, in immunosuppressed patient with multiple immunosuppressed patient with multiple recent pneumoniasrecent pneumonias

Await final sputum gram stain, respiratory Await final sputum gram stain, respiratory and blood culturesand blood cultures

Chest CT ordered to evaluate pleural Chest CT ordered to evaluate pleural effusion and consolidationeffusion and consolidation


2)2) Membrano-proliferativeMembrano-proliferative glomerulonephritis and ESRDglomerulonephritis and ESRD

Labs and exam consistent with MPGN: UA-Labs and exam consistent with MPGN: UA-occult blood 3+, UA-Sed-RBC 10-20, UA-occult blood 3+, UA-Sed-RBC 10-20, UA-Hyaline casts 10-20, UA-Albumin 3+ Hyaline casts 10-20, UA-Albumin 3+ (nephrotic characteristic seen in MPGN); (nephrotic characteristic seen in MPGN); peripheral edema, HTNperipheral edema, HTN

NaNa++ nl, K nl, K++ nl, Phos 4.8 mg/dl nl, Phos 4.8 mg/dl Plasma COPlasma CO22 15.2 mmHg – levels have been 15.2 mmHg – levels have been

chronically low, suggesting the kidney’s chronically low, suggesting the kidney’s inhability to make HCOinhability to make HCO3

-- and handle acid and handle acid loadload


Transplant 1998; Immunosuppression: Transplant 1998; Immunosuppression: Tacrolimus (Prograf) 2 mg PO Q12H; Tacrolimus (Prograf) 2 mg PO Q12H; Mycophenolate mofetil (CellCept) 500 Mycophenolate mofetil (CellCept) 500 mg PO BIDmg PO BID

Suspect transplant rejection Suspect transplant rejection kidney kidney function: Cre 6.1 (from 4.1 on function: Cre 6.1 (from 4.1 on 5/27/’05); BUN 63 (from 62 on 5/27/’05); BUN 63 (from 62 on 5/27/’05). Continue to monitor Cre and 5/27/’05). Continue to monitor Cre and BUN.BUN.


PlanPlan Monitor electrolytesMonitor electrolytes Diet: low KDiet: low K++ and low Phos and low Phos Renagel (Sevelamer)Renagel (Sevelamer) 800 mg PO TID 800 mg PO TID Immunosuppression: Immunosuppression: TacrolimusTacrolimus (Prograf) 2 (Prograf) 2

mg PO Q12H; mg PO Q12H; Mycophenolate mofetilMycophenolate mofetil (CellCept) 500 mg PO BID(CellCept) 500 mg PO BID

Consult renal team and discuss indication to Consult renal team and discuss indication to start dialysis (not urgent)start dialysis (not urgent)


3)3) Volume overloadVolume overload The patient is thought to be volume-The patient is thought to be volume-

overloaded due to JVP 8 cm, renal overloaded due to JVP 8 cm, renal disease, BP 140/66 and peripheral disease, BP 140/66 and peripheral edema.edema.

PlanPlan Furosemide (Lasix)Furosemide (Lasix) 40 mg PO BID 40 mg PO BID


4)4) AnemiaAnemia HCT 32.5 (from 25.4-29 on 5/'05-6/’05), HCT 32.5 (from 25.4-29 on 5/'05-6/’05),

possibly secondary to decreased possibly secondary to decreased erythropoietin production by kidney. No erythropoietin production by kidney. No plan to transfuse at this time as patient plan to transfuse at this time as patient is hemodynamically stableis hemodynamically stable

PlanPlan Pt. on Pt. on EpogenEpogen 20,000 units 2/week at home 20,000 units 2/week at home


5)5) CMVCMV The patient had a CMV infection in May The patient had a CMV infection in May

1998, which was treated with 1998, which was treated with Ganciclovir IV.Ganciclovir IV.

PlanPlan Send CMV antigenemia assay to assess Send CMV antigenemia assay to assess

activity of CMVactivity of CMV Valganciclovir (Valcyte)Valganciclovir (Valcyte) 450 mg PO QOD 450 mg PO QOD Involve Transplant ID, as specific Involve Transplant ID, as specific

management questions arise regarding CMV management questions arise regarding CMV and management of pneumoniaand management of pneumonia

ConclusionsConclusions

Await final sputum gram stain, Await final sputum gram stain, respiratory and blood cultures to respiratory and blood cultures to guide treatment of pneumoniaguide treatment of pneumonia

Consult Transplant ID team toConsult Transplant ID team to Evaluate the possibility of resuming Evaluate the possibility of resuming

dialysisdialysis Discuss about CMV- and pneumonia-Discuss about CMV- and pneumonia-

related issuesrelated issues

shortness of breath and cough in a kidney-transplant patient august 2005

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