September Case of the Month

Clinical History: A 21-year-old asymptomatic woman developed pulmonary lesions in the setting of recent liver transplantation. The opacities were discovered on abdomino-pelvic CT performed for nausea 2 months post transplantation. The patient’s initial liver transplantion was at the age of 1 for biliary atresia, but she required re-transplantation 20 years later for cirrhosis, and then most recently a 3rd transplant due to thrombosis of the inferior vena cava and splenic vein. She remained in hospital for several weeks following the most recent transplant. She did not smoke tobacco but did smoke marijuana twice a week, and occasionally drank alcohol.

A dedicated thoracic CT scan demonstrated multifocal bilateral consolidations with anterior predominance (Figure 1) without evidence of pulmonary embolism. Blood tests were significant for anemia, and CMV, EBV, and coronavirus screening tests were negative. The clinical differential diagnosis included organizing pneumonia, post-transplant lymphoproliferative disorder, and atypical infection in the setting of immunosuppression. A transthoracic biopsy was performed. Representive images are shown in Figures 2, 3 and 4 (H&E) and Figure 5 (HPS). No microorganisms were detected on special stains.

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