Case

A 58-year-old never-smoker man developed dyspnoea, cough, fevers, weight loss and tremulousness over 4 weeks. He had a brief history of asbestos exposure. Significant medical history included autosomal-dominant polycycstic kidney disease (APKD) and renal transplantation 7 years previously. He took mycophenolate mofetil and tacrolimus immune-suppressants. Examination revealed tachypnoea, a fine right arm tremor, bronchial breathing on the right and a superficial 1×2 cm non-fluctuant lump over the abdomen. Lymph nodes were impalpable.

Screening blood tests showed values of c reactive protein 115 mg/l (NR <6.0), urea 25.8 mmol/l, creatinine 254 umol/l (post-transplant baseline 220–230) and tacrolimus 25.5×µg/l (NR 5–10). Autoimmune profile was negative. PCR detected cytomegalovirus (CMV) levels at 31 338 copies/ml. Plain chest radiography showed right upper lobe consolidation (figure 1A). An abdominal ultrasound scan revealed a normal transplanted kidney. Intravenous empirical antibiotics and oral valganciclovir, subsequently changed to intravenous …