What's Your Diagnosis? Management of Pediatric Transplant Patients in the Emergency Department

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Terrestrial Envenomations in Pediatric Patients: Identification and Management in the Emergency Department right.

Case Presentation: Management of Pediatric Transplant Patients in the Emergency Department

An 11-year-old boy who received a heart transplant 8 months ago presents to the ED for evaluation of fever…

He has had a mild cough and rhinorrhea for the past 2 days and developed a fever to 38°C this morning. He received his heart transplant for hypoplastic left heart syndrome and has been doing well on his maintenance immunosuppression medications. He sees his transplant physician every 2 months and has had no complications. There are no sick contacts at home, but the child does attend school.
Given the boy’s history of transplantation, he was triaged as a high-acuity case. His vital signs are: temperature, 38.6°C; heart rate, 185 beats/min; respiratory rate, 25 breaths/min; blood pressure, 105/82 mm Hg; oxygen saturation, 95% on room air. On physical examination, you note crackles at the lung bases bilaterally.
Knowing this patient is immunocompromised, you are worried about a lower respiratory tract infection, but you are also concerned this could be an episode of acute rejection manifesting as early congestive heart failure. As you consider the possible diagnoses, you think about your next steps. Which laboratory tests would be most helpful? Which antibiotics does he need? Should corticosteroids be started to treat possible rejection?

Case Conclusion

You obtained a CBC, CMP, urinalysis, blood culture, fungal culture, urine culture, CMV PCR, EBV PCR, and BNP. After the lab studies were drawn, he was given IV vancomycin and cefepime for broad-spectrum antimicrobial coverage. Given the crackles on his examination, you did not immediately give IV fluids. Although he was tachycardic, it was likely exacerbated by his fever, and his blood pressure was stable. You obtained an ECG, which showed a right bundle branch block, though it appeared to be consistent with his previous ECG from 2 months ago. You ordered a chest radiograph that showed bilateral pleural effusions.

The laboratory results returned and showed an elevated BNP and leukocytosis. With these findings, you determined it was most likely that his symptoms were due to acute rejection rather than a lower respiratory tract infection. Prior to initiating any further treatment, you called the patient’s transplant physician, who recommended admission to the cardiac intensive care unit for an urgent echocardiogram and high-dose corticosteroid treatment for likely acute graft rejection.