A 62-Year-Old Man With Shortness of Breath Years After Heart Transplantation

Shahzad G. Raja, MRCS;  Gilles D. Dreyfus, MD, PhD, FRCS

Disclosures

October 02, 2017

Editor's Note:

The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 62-year-old man presents to the emergency department with a 3-month history of progressively increasing shortness of breath, fatigue, anorexia, and weight loss. The patient underwent orthotopic heart transplantation for ischemic cardiomyopathy 26 months ago.

He received the standard immunosuppression protocol for heart transplantation ("triple therapy" consisting of cyclosporine, azathioprine, and prednisolone). In the immediate postoperative period, he was administered prednisolone at 1 mg/kg orally daily, which was tapered over 3 weeks to 20 mg daily and then continued for 3 months. This was decreased to 10 mg for the following 3 months and, finally, reduced to 5 mg daily for the last 6 months (which concluded a year-long taper). His maintenance immunosuppression regimen includes cyclosporine and azathioprine.

Upon further inquiry, the patient states that he developed a nonproductive cough and left thigh pain that has lasted for the past month. His history includes coronary artery bypass grafting for triple-vessel coronary artery disease (which occurred 8 years ago), hypertension, hyperlipidemia, and intermittent claudication. He has a smoking history of more than 80 pack-years, but he quit smoking at the time of his heart transplantation.

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