October 2015 Critical Care Case of the Month: A Moldy But Gooey

Jennifer M. Hall, DO

Banner University Medical Center Phoenix

Phoenix, AZ

History of Present Illness

A 45-year-old man with a history of a kidney transplant in 2011 was admitted with subjective fevers, nausea, abdominal pain, chest pain and recurrent renal failure. Cardiac workup was negative for ischemia and intermittent hemodialysis was initiated. CT of chest and abdomen was significant for a new cavitary pulmonary lesion. Leading up to this admission, he had been on immunosuppressive agents including tacrolimus, mycophenolate and prednisone, and the day of presentation had been doing quite well, actually was bear hunting in the mountains near Flagstaff, Arizona.

Past Medical History

• Donor kidney transplant in 1999, which failed in 2011, prompting a second kidney transplant
• Failed pancreas transplant
• Coronary artery disease, with percutaneous cardiac intervention in 2001
• Diabetes mellitus type I
• Chronic anemia
• History of total parathyroidectomy
• History of C5-C7 cervical fixation

Physical Examination

• Vital signs stable
• Appeared to be pale, no apparent distress
• Cardiac exam unremarkable
• Chest exam with fine crackles in left base / otherwise clear
• Abdomen slightly tender in left lower quadrant, but without guarding, rebound or peritoneal signs; small dime-sized area of ecchymosis, where lovenox injections had been administered
• No peripheral edema or clubbing

Laboratory Evaluation

• WBC 17,900 cells/mcL with 96% segmented neutrophils, hemoglobin 8.9 g/dL(after transfused 2 units prior to transfer), PLT 232,000 cells/mcL,
• INR 1.3
• Blood urea nitrogen (BUN) 74 mg/dL, serum creatinine 2.32 mg/dL, electrolytes within normal limits, albumin 3.2 g/dL, aspartate aminotransferase (AST) 24 IU/L, alanine transaminase (ALT)81 IU/L.
• NT-proBNP 6841 pg/ml (normal < 300 pg/ml)
• Hemoglobin A1C 7.2%
• Lactate 0.7 mmol/L

Imaging

A thoracic CT scan was performed (Figure 1).

Figure 1. Panels A-D: representative static views from the CT scan in lung windows. Note the cavitary lesion in the right lung (red arrow), the right pleural effusion (blue arrow) and the left lower lobe consolidation (yellow arrow) with a pleural effusion. Lower panel: video of the thoracic CT scan in lung windows.

Which diagnosis is least likely in this patient’s differential diagnosis for the cavitary pulmonary lesion? (Click on the correct answer to proceed to the second of five panels)

1. Aspergillosis
2. Coccidioidomycosis
3. Invasive mucormycosis
4. Metastatic malignancy
5. Nocardiosis
6. Pulmonary Infarct

Cite as: Hall JM. October 2015 critical care case of the month: a moldy but gooey. Southwest J Pulm Crit Care. 2015;11(4):136-43. doi: http://dx.doi.org/10.13175/swjpcc130-15 PDF