Clinical Cases

HomeProfessionalsClinical ResourcesClinical Cases ▶ 60-Year-Old Man with Non-resolving Pneumonia
60-Year-Old Man with Non-resolving Pneumonia

Case Editor - Judd Flesch

Reviewed By Critical Care Assembly

Submitted by

Nicholas C. James, MD

Department of Pulmonary and Critical Care Medicine

Lahey Hospital & Medical Center

Burlington, Massachusetts

Timothy N. Liesching, MD

Department of Pulmonary and Critical Care Medicine

Lahey Hospital & Medical Center

Burlington, Massachusetts

Submit your comments to the author(s).


A 60 year-old man with a past medical history for coronary artery disease requiring four vessel coronary artery bypass grafting, hypertension, hyperlipidemia, nephrolithiasis and cirrhosis related to alcohol abuse was deemed a liver transplant candidate after complications of several episodes of hepatic encephalopathy and esophageal variceal bleeding. He remained abstinent from alcohol.

He underwent a living donor liver transplant using the right hepatic lobe graft donated by his son. His immunosuppression regimen included sirolimus, mycophenolate, and prednisone. Valgancyclovir and trimethoprim/sulfamethoxazole included his prophylactic therapy. There were no peri-operative complications noted. Post-operatively, the patient noted mild dyspnea and a non-productive cough. His postoperative course was complicated by cholangitis secondary to biliary stricture necessitating percutaneous trans-hepatic cholangiography (PTC) and biliary dilation.  Work up for his cholangitis included an abdominal CT that incidentally demonstrated a dense pulmonary infiltrate of the right middle lobe (RML) (Figure 1). He also developed acute renal insufficiency, but did not require renal replacement therapy. It was determined by the surgical team that the patient had pneumonia and was treated amoxicillin/clavulanate. His respiratory symptoms resolved and followed up in clinic.

As an outpatient, the patient required one additional biliary dilation procedure for biliary stricture. A follow up chest CT (Figure 2) 7 weeks after initial imaging demonstrated a persistent RML infiltrate. The patient was completely without respiratory complaint at the time.  A pulmonary consultation is requested. 

Physical Exam

Physical examination revealed the patient to be afebrile with an oxygen saturation of 99% on room air. The remaining vitals were also unremarkable. The patient was not in acute distress and could talk in complete sentences.  Auscultation of the lungs was clear throughout and cardiac examination revealed a 3/6 systolic murmur. The extremities were void of edema and there was no clubbing.

Figure 1

Figure 1: CT chest showing right middle lobe dense consolidation with associated ground glass opacities

Figure 2

Figure 2: Persistent, more consolidated right middle lobe infiltrate with increased ground glass opacities

Question 1

What would be the next best diagnostic approach for this patient’s non-resolving opacity?


  1. Fishman, JA. Infection in Solid-Organ Transplant Recipients. NEJM. 2007;357:2601-14.
  2. Garzoni C. Multiply resistant gram-positive bacteria methicillin-resistant, vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (MRSA, VISA, VRSA) in solid organ transplant recipients. Am J Transplant. Dec 2009;9 Suppl 4:S41-9.
  3. Preiksaitis, JK, Keay, S. Diagnosis and Management of Psttransplant Lymphoproliferative Disorder in Solid-Organ Transplant Recipients. Clin Infect Dis. 2001; 33 (1): S38-46.
  4. Johnson, PC, Hogg, KM, Sarosi, GA. The rapid diagnosis of pulmonary infections in solid organ transplant recipients. Semin respir infect. 1990; 5(1): 2-9.
  5. Tuna, T., Ozkaya, S., Dirican, A. et al. Diagnostic Efficacy of Computed Tomography-guided Transthoracic Needle Aspiration and Biopsy in Patients with Pulmonary Disease. Onco Targets Ther. 2013;6: 1553-57.
  6. Wiener, RS, Schwartz, LM, Woloshin, S. et al. Population-Based Risk Complications After Transthoracic Needle Lung Biopsy of a Pulmonary Nodule: An Analysis of Discharge Records. Ann Intern Med. 2011; 155(3): 137-44.
  7. Rano, A., Agusti C., Jimenez, P., et al. Pulmonary infiltrates in non-HIV imunocompromisesd patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax. 2001; 56: 379-387.
  8. Yale, SH, Limper, AH. Pneumocystis carinii Pneumonia in Patients without Acquired Immunodeficiency Syndrome: Associated Illnesses and Prior Corticosteroid Therapy. Mayo Clin Proc. 1996; 71(1): 5-13.
  9. Green, H, Paul, M, Vidal, L, Leibovici, L. Prophylaxis of Pneumocystis Pneumonia in Immunocompromised Non-HIV-Infected Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc. 1996; 82(9): 1052-1059.
  10. Ewig, S, Bauer, T, Schneider C, Pickenhain, A et al. Clinical characteristic and outcome of Pneumocystis carinii pneumonia in HIV-infected and otherwise immunosuppressed patients. Eur Respir J. 1995;8: 1548-1553.
  11. Matsumura, Y, Shindo, Y, Iinuma, Y, Yamamoto, M et al. Clinical characteristics of Pneumocystis pneumonia in non-HIV patients and prognostic factors including microbiological genotypes. BMC Infect Dis. 2011;11:76-84.
  12. Chan, ED, Morales, DV, Welsh, CH, et al. Calcium Deposition with or without Bone Formation in the Lung. Am J Respir Crit Care Med. 2002; 165:1654-69.
  13. Yousem, SA. The Surgical Pathology of Pulmonary Infarcts: Diagnostic Confusion with Granulomatous Disease, Vasculitis, and Neoplasia. Mod Pathol. 2009;22:679-85.
  14. Thomas, CF and Limper, AH. Pneumocystis Pneumonia. NEJM. 2004;350:2487-98.
  15. Bartlett, MD and Smith, JW. Pneumocystis carinii, and Opportunist in Immunocompromised Patients. Clin Microbiol Rev. 1991;4(2):137-49.
  16. Bein, ME, Lee, DBN, Mink, JH, et al. Unusual Case of Metastatic Pulmonary Calcification. AJR. 1979;132:812-816.
  17. Wechsler, RJ, Feld, R, Munoz, SJ, et al. Suprahepatic Circumcaval Ring: CT Finding After Orthotopic Liver Transplantation. AJR. 1992; 183:545-48.