Fever in a lung transplant recipient

A 36-year-old woman presented to the emergency department in June 2019 after experiencing high fevers, chills, nausea, decreased oral intake, and diarrhea for 4 days.Her medical history included cystic fi brosis with resultant exocrine insuffi ciency, and type 2 diabetes mellitus.In addition, she had received a double lung transplant 9 years earlier, for which she was on a long-term immunosuppressive regimen.The donor had been positive for cytomegalovirus (CMV), whereas the patient had been negative for both CMV and Epstein-Barr virus (EBV).The EBV status of her donor was unavailable.However, the patient's EBV serology was negative when tested 6 months before this presentation, and she was also known to be negative for both hepatitis B and hepatitis C.She also had a history of stage 3a proteinuric chronic kidney disease with a baseline serum creatinine level of 1.2 mg/dL, hypertension, and an episode of acute transplant rejection in 2014, which resolved with conservative treatment with glucocorticoids.Her home medications were azathioprine, calcium carbonate, cholecalciferol, ferrous sulfate, insulin neutral protamine Hagedorn, insulin aspart with meals, labetalol, a daily multivitamin, prednisone, tacrolimus, ranitidine, and pancreatic enzyme replacement with meals.She was a lifelong nonsmoker with little alcohol intake, and she said she does not use illicit drugs.She had no recent sick contacts, though she had been hospitalized 4 months earlier for Pseudomonas aeruginosa pneumonia, from which she had fully recovered. ■ INITIAL EVALUATION Physical examinationOn presentation to the emergency department, she was normotensive, febrile with a temperature of 39.5°C (103.1°F), and tachycardic with a heart rate of 133 beats per minute.Jugular venous pulsation was visible 1 cm above the sternal angle, and respiratory examination revealed fi ne crackles in the right upper lobe.There was a soft systolic ejection murmur, grade 2 on a scale of 6, heard best at the right upper sternal border.Her abdomen was nontender on palpation, but her liver could be felt 3 cm below the right costal margin and the spleen at 7 cm below the left costal margin.Palpation of the head and neck revealed small diffuse lymphadenopathy.The patient also had prominent right axillary and inguinal lymphadenopathy. Initial investigationsOn initial testing (Table 1), her serum sodium concentration was 131 mmol/L and her potassium level was 5.6 mmol/L.Her creatinine level was 2.5 mg/dL, up from a baseline of 1.24 mg/dL, consistent with an "acute-on-chronic" kidney injury.She had elevated liver enzymes and bilirubin, as well as neutropenia with an absolute neutrophil count of 0.57 × 10 9 /L.Urinalysis was negative for nitrites, leukocytes, glucose, bilirubin, and protein, with a nonactive sediment on microscopy.Liver enzyme analysis revealed the following levels: aspartate aminotransferase 43 U/L, alanine aminotransferase 33 U/L, lactate dehydrogenase 563 U/L, gamma-glutamyl transferase 342 U/L, and alkaline phosphatase 888 U/L.Ferritin was elevated at 1,983 ng/mL (normal 20-200 ng/mL), and her nonfasting

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