case_images: PMC10540203_01
case_images: PMC10540203_02
case_images: Immunosuppressive therapy and immune cell counts after lung transplant and a timeline depicting the disease course of the patient. (A) The immunosuppressive therapy of the case after lung transplant and the trends of immune cell counts of CD3+/CD4+ and CD33+/CD8+. (B) The immunosuppressive therapy of the case after lung transplant and the trends of immune cell counts of CD19+ and CD56+/CD16+. (C) The immunosuppressive therapy of the case after lung transplant and the trends of immune cell counts of CD45+ and CD3+. (D) The timeline illustrates the different events in the course of the patient's treatment and disease progression. CD3+ T cells (reference range 797-2370), CD3+/CD4+ helper T cells (reference range 432-1341), CD3+/CD8+ cytotoxic T cells (reference range 238-1075), CD19+ B cells (reference range 86-594), CD56+/CD16+ NK cells (reference range 127-987), CD45+ absolute lymphocyte count (reference range 800-594).
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case_images: Postoperatively, the recipient was treated with conventional immunosuppressive agents such as tacrolimus (target trough concentration 10-12 ng/mL) and prednisolone (0.5 mg/kg/d for 1 week, followed by a gradual reduction to 0.25 mg/kg/d) ( Figures 1A-C ). Monitoring of immune function indicators showed that his T-cell counts were below normal, with the numbers of helper and cytotoxic T-cells being 123 and 150 cells/ul, respectively ( Figures 1A-C ). He went back to the lung transplantation unit on postoperative day 85, receiving continuous mechanical ventilation, as shown in the timeline in  Figure 1D . The total lymphocyte count was extremely low ( Figures 1A-C ).
case_images: Lung CT and serum EBV/CMV monitoring after lung transplantation. (A) Lung CT scan showing that dense nodular shadows were seen in both lower lungs on August 18th, then larger and more nodular and patchy dense shadows were seen on October 3rd and 23rd. (B) EBV-DNA was negative at the beginning, then was detected in the blood on postoperative day 15, with an increase in viral load in the late stage. (C) CMV-DNA was negative at the beginning, then was positive on postoperative day 36.
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case_images: A lung CT scan on day 98 showed multiple dense nodular shadows in both lower lungs ( Figure 2A ). Moreover, lung CT ( Figure 2A ) showed progressively larger and more nodular and patchy dense shadows in his lungs, but the patient and his family refused lung tissue biopsy. Viral loads of EBV and CMV were monitored weekly ( Figures 2B, C ), with the results suggesting that the patient was initially negative for EBV-DNA and CMV-DNA; his blood concentration of EBV-DNA was 1840 copies/ml on day 15 and his blood concentration of CMV-DNA was 5440 copies/mL on day 36, at which time antiviral therapy (ganciclovir 250 mg bid) was started.
case_images: Antifungal therapy after lung transplant. All antifungal drugs received by the patient after lung transplant; the X-axis represents treatment time.
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case_images: A. fumigatus, EBV, and CMV, but bone marrow tests showed no tumor cells. Although his antifungal therapy was changed ( Figure 3 ) based on the NGS results, the patient's condition continued to deteriorate, and he was treated with continuous renal replacement therapy for acute kidney injury.
case_images: Next-generation sequencing and histologic evaluation of puncture samples from right lung masses. (A) mNGS result of nucleotide sequences distributed along the genome of EBV in the case (the X-axis represents the full-length reference genome and the Y-axis represents the distribution of detected sequences at different locations in the reference genome). (B) Tissue biopsy shows an aggregation of abnormal lymphocytes (HE x200 and x400), and an immunohistochemical examination of these cells revealed a positive reaction to CD20 (x200 and x400), Ki-67 (x200 and x400), and Mum1 (x200 and x400).
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case_images: NGS of the lung tissue sample revealed EBV ( Figure 4A ), and the tissue biopsy showed PTLD (B cell, monomorphic), with a tendency to develop diffuse large B cell lymphoma ( Figure 4B ).