A 50-year-old man with cirrhosis HCV received steroids, tacrolimus (FK) and mycophenolate mofetil (MMF).
In the first months after transplantation there was a progressive deterioration of renal function and appearance of diabetes related to tacrolimus, being proposed substitution of FK and MMF for rapamicin 2 mg/day.
After 8 days the patient presented asthenia, dry cough and fever.
At that time, plasma rapamicin levels were 25 ng/ml (normal: 9-19).
Chest radiography showed several alveolar infiltrates in the middle lobe and posterior segment of the upper lobe of the right lung associated with ipsilateral pleural effusion.
Treatment with levofloxacin was initiated empirically for suspected bronchopneumonia and the dose was reduced 1 mg/day, with unfavorable evolution with mechanical costal pain, irritative cough, persistence of the fever and appearance.
It was decided to change to piperacillin-tazodone, persistent fever.
Basal arterial gas showed mild hypoxia.
Chest CT revealed basal opacities in both hemothorax, cavitation of both anterior segments of the lower lobes and multiple nodular areas, performing a puncture aspiration with predominance of condensations (PAAF).
The results of FNAC showed negative Ziehl, negative monoclonal antibodies for cysticis carinii and sterile aerobic culture.
Bronchoscopy with bronchioloalveolar lavage (BAL) was performed. Sterile bacilloscopy and culture for bacteria, viruses, mycobacteria or fungicides were performed.
Blood cultures and sputum mycobacteria cultures were negative.
Serology for mycoplasma, Q fever, chlamydia and legion were negative, as well as laymanano, antigenemia and PCR for cytomegalovirus.
Due to the lack of antibiotic response and no microorganisms were isolated, it was decided to discontinue rapamycin.
The clinical picture was favorable, and the asymptomatic patient was found in subsequent revisions, although the radiological lesions prevailed in the control CT scan at 12 weeks, normalizing after 6 months.
