Abstract

SESSION TITLE: Medical Student/Resident Transplantation Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Unilateral pulmonary edema in lung transplant is a unique entity that requires a broad differential including evaluation for infection, acute graft rejection, cardiovascular, and pulmonary vascular pathology. CASE PRESENTATION: A 74-year-old male with history of right single lung transplant in 2011 for severe emphysema, chronic kidney injury, and avascular necrosis of the hip underwent uncomplicated left total hip arthroplasty. On post-operative day 1, he developed acute hypoxemic respiratory failure requiring high-flow nasal cannula. He was otherwise afebrile and normotensive on arrival. Physical examination revealed crackles in the right lung and bedside lung ultrasound demonstrated diffuse unilateral B-lines in the right lung. Labs were unremarkable other than NT-pro BNP level of 2200 pg/mL. ECG was unremarkable, and chest x-ray showed diffuse interstitial airspace opacities on the right. He was started on antibiotics for possible aspiration pneumonia. Review of post-operative fluid balanced revealed he was net positive 3.5 L since the admission. Ventilation and perfusion scan from 2 months prior demonstrated dominant right lung perfusion at 91% compared to 9% to the left lung. Echocardiogram showed ejection fraction of 54% without significant valvular pathology. Overall, his presentation was thought secondary to volume overload presenting as unilateral pulmonary edema secondary to selective perfusion of his transplanted lung. Diuretic therapy was started, and over the next day, the patient was weaned off supplemental oxygen entirely. The following day, his antibiotics and diuresis were discontinued and his unilateral pulmonary edema had completely resolved (Figure 1). DISCUSSION: The differential diagnoses for single lung interstitial infiltrates include infection, pneumonitis, and pulmonary edema from acute mitral regurgitation, pulmonary artery hypoplasia, or pulmonary vein stenosis (reference 1-2). Additionally, lung transplant patients require thorough evaluation for infection and acute graft rejection, which necessitate an invasive procedure, such as bronchoscopy with transbronchial biopsy. This case demonstrates the importance of the considering vascular etiologies, as it avoided an unnecessary invasive procedure. A case study by Akindipe et al. described 3 cases of single lung transplant patients presenting with unilateral pulmonary edema (reference 3). Two of these cases occurred in the context of acute renal failure and the other after acute mitral regurgitation. In our patient, no evidence of acute on chronic renal injury, coronary disease, or valve pathology was noted. CONCLUSIONS: We believe this is a unique, but often unrecognized case of unilateral pulmonary edema in a single lung transplant patient with asymmetric pulmonary perfusion. Reference #1: Attias David et al. Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema. Circulation 122, 1109–1115 (2010). Reference #2: Handagala, R., Ralapanawa, U. & Jayalath, T. Unilateral pulmonary edema: a case report and review of the literature. J. Med. Case Reports 12, (2018). Reference #3: Akindipe, O., Fernandez-Bussy, S., Staples, E. D. & Baz, M. Late Unilateral Pulmonary Edema in Single Lung Transplant Recipients. J. Heart Lung Transplant. 27, 1055–1058 (2008). DISCLOSURES: No relevant relationships by Samuel Falde, source=Web Response No relevant relationships by Hiroshi Sekiguchi, source=Web Response No relevant relationships by Yosuf Subat, source=Web Response

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