A puzzling pulmonary nodule in a renal transplant recipient.

A 52 year old gentleman; jeweller by profession, residing in rural Goa, was admitted to our institution in March 2013 with complaints of chest pain, fever and dry cough for 2 weeks prior to admission. He was admitted to a hospital in Goa for two days prior to the present admission where he was found to have a raised WBC count of 18000/cm3 with a neutrophilic predominance. Chest x-ray showed a right upper zone para-tracheal nodular opacity (Figure 1). An HRCT chest revealed a 5.5 cm x 4.6 cm well-defined, dense, rounded mass of uniform density in the anterior segment of the right upper lobe with a few tiny, surrounding nodules (Figure 2). He was started empirically on IV piperacillin tazobactam and levofloxacin. The patient had undergone a living-related renal transplant (mother-donor) in September 2009 following which he was on immunosuppression with tacrolimus, mycophenolate mofetil and deflazacort. In August 2012, he developed proteinuria and renal biopsy r e v e a l e d a c u t e c e l l u l a r rejection. He received 3 doses of methylprednisolone 1g IV at th is t ime. A month la ter he was re -admit ted w i t h c h r o n i c d i a r r h o e a , persistent proteinuria and a rise in serum creatinine from A Puzzling Pulmonary Nodule in a Renal Transplant Recipient