This document describes the case of a 35-year-old male kidney transplant recipient who presented with swelling of the lower limbs and shortness of breath for the past 3 months. He has a history of renal transplantation for unknown causes 2 years ago and is on immunosuppressive medications. On examination, he had generalized edema, decreased breath sounds, and elevated kidney function tests. Tests found a high CMV viral load. He was admitted for further management and treatment of CMV infection with pneumonitis and electrolyte imbalances.

1. Dr . Eslam Osama Ibrahim Sabri
Resident doctor of nephrology
NMGH

2. Khalid Hamad Mourad 35 years old ,
male patient from Kafer Al shaihk,
clothes dealer, married and have 2
children with no special habits of
medical importance.

3. Swelling of his lower limbs for 3 month &
shortness of breath

4. The condition started about 3 month
ago with gradual onset and
progressive course of edema of his
lower limbs , for the last 3 week
condition associated with dyspnea
grade 3 generalized odema, cough
with whitish expectoration and
recurrent vomiting
..

5. Renal transplantation on may 2010 “non
relative donor” for unknown cause.
Hypertension for 2 year.
No past history of similar condition .
AVF created in 2009 with 2 HD session prior
to transplantation.

6. No similar family history
-VE consanguinity

7. Cyclosporin for 2 year then tacrolimus 1 mg 2x1 am &
1x1 pm
Cellecept 750 mg BID
Metolazone 5 mg OD
Torseretic 5 mg 2x1
Calmag 2x2
Pulse steroid “Solumedrol 500 mg “ for 3 days before
admission (11-13/03) at home.

8. General examination
Patient was fully conciouss, alert ,
oriented cooperative, puffy face
Over weight “generlized odema”
Neck examination : normal JVP, no
palpable mass

9. Vital signs:
BP: 160/90mmhg
PR: 76/min
RR: 18/min
Temp: 36.9 c

10. Local examination:
Chest vesicular breathing with decrease bilateral
air entry and diffuse crepitation.
normal S1 & S2 no murmurs or added soundsHeart
Abdomen Lax & soft & no graft tenderness & no
organomegally.

11. LOCAL EXAMINATION:
CNS normal reflexes , power , tones and cranial
nerves, no other neurological deficit
Lower limbs bilateral LL pitting odema above knee,
intact peripheral pulsations.

13. Protein/Creat. Ratio 5960
Tacrolimus trough level 4 ng/ml
C3 :99.9 mg/dl
C4: 39.4 mg/dl
Urine analysis : albumin +2 & pus 1-3
RBC : 2-4 HPF
CRP : 48-84.8
CMV (lgm)-Ve
CMV (PCR) 40840 viral load
Virology (HCV&HBV&HIV)-VE

14. Abdominal Ultrasound
Liver : average size, noemal texture , no focal lesion
normal intrahepatic radicle and CBD
Kidneys : normal shape graft kidney normal vascularity
and echogenicity, minimal free fluid in hepatorenal
pouh.

16. On 24/2/2018
.membranoproliferative pattern of GN
No evidence of acute cellular or antibody mediated
.rejection
.Hypertensive changes

19. The patient has been admitted to nephrology
department On 14/3/2018 in isolation room for furthur
investigation & management .
cellecept was holded to control infection with low UOP
on the following ttt :.
Solupred 20mg OD
Ceftriaxone 1 gm IV /24 h
Epilate 20 mg oral BID
Zantaz 150 mg BID
Lasix 40 mg TiD
Actyle cystein sachet TID

20. .On 16/3 UOP increased to 3250 ml / day
O n 18/3 patient became more dyspneic X rays showed
pneumonic patch , started on Cefipime 1 gm/ 24 ct
chest is requested , Solupred increase to 60 mg OD .
.UOP 2150 ml/day
On 19/3 duplex US on transplanted kidney was normal
UOP decreased to 350 ml /day
On 20/3 patient became severly dyspneic ,oliguric and
overloaded RT IVJ catheter was inserted and (1 st )
session received with UF of 3 litre UOP350 ml/day

21. On 21/3 2 nd session with UF 3.5 liter

On 22 /3 3nd session with UF 4 liter , seen by start on
Levofloxacin , Mereponem and Tamiflu .
At night patient became severely respiratory distressed
With RR 38 min patient tranferred to ICU.
On 24/3 patient slightly improved with increase UOP to
1500 ml/day recived HD with UF 2.5 liter.
On 26/3 became stable no more hyspnea lost about 10
kg of his weight and shifted back to our departmet ,Uop
1000 ml/ day and lasix
holded.

22. On 28/3 satable general condition but decreased UOP
to 650 ml/day , tamiflu sttoped .
On patient became oligurice 300 ml/day with rising
S.creat to 7.5 then 8.4 mg/dl on 30/3.
On 01/4 result for CMV (PCR) 40840 viral load Cmv
( IgM) –Ve
On 2/4 Ganciclovir 450 mg/48h ,
Tienam changed to Meroponem 500mg/12h
UOP 650 ml/day .

23. CMV infection with pneumonitis
Elecrolytes imbalance “hyponatremia”
chronic kidney disease