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HIV
15%
7/47
IV drug use
Medication
9%
4/47
Transplant rejection
43%
20/47
Tuberculosis
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This patient has a history of a kidney transplant (thus she must be on immunosuppressive medications to not reject the transplant) and is presenting with imaging findings of interstitial infiltrates and ground glass opacities which is concerning for Pneumocystis jirovecci pneumonia (PJP). This infection is likely secondary to the immunosuppressive drugs she is on for her kidney transplant. Immunosuppressive drugs are essential for many clinical conditions but are known to have many important side effects. Immunosuppressive medications can include cyclosporine, tacrolimus, azathioprine, and mycophenolate among many others. Patients with transplanted organs must be on immunosuppressive drugs in order to not reject the transplanted organ. For this reason, any patient with a transplant is at high risk for infection, including opportunistic infections that may only be seen in conditions like HIV. For this reason, the differential must be expanded when considering the infectious etiologies of a patient presenting with a transplanted organ. Figure A is a chest radiograph demonstrating interstitial infiltrates. Figure B is a CT scan demonstrating ground glass opacities suggesting of PJP. Incorrect Answers: Answer 1: HIV with a CD4 count < 200/mm^3 is the common predisposing condition for PJP; however, this patient has no known history of HIV (other than her risk factors including IV drug use and work as a commercial sex work) but certainly must be on immunosuppressive agents given her kidney transplant and normal kidney function (meaning she is not rejecting her kidney). Answer 2: IV drug use may predispose patients to endocarditis which presents with a fever and a murmur (usually of the tricuspid valve). Septic emboli may be formed and travel to the lungs leading to a pneumonia; however, radiography would demonstrate these focal infectious collections rather than diffuse interstitial infiltrates. Answer 4: Transplant rejection is unlikely given this patient's creatinine which is near her baseline. Answer 5: Tuberculosis would present with fever, night sweats, weight loss, and chills in addition to a cough and lung infiltrates with cavitary lesions on radiography. Bullet Summary: Transplant patients are typically on immunosuppressive drugs which predispose them to opportunistic infections.
3.4
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