Case 29-2020: A 66-Year-Old Man with Fever and Shortness of Breath after Liver Transplantation

Abstract

T h e ne w e ngl a nd jou r na l o f m e dicine Pr esentation of C a se Dr. Matthew B. Roberts: A 66-year-old man who had undergone orthotopic liver trans-plantation because of end-stage liver disease was admitted to this hospital because of fever and cough during the pandemic of coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Two days before this admission, fever, chills, and diffuse myalgias developed. The patient also noted a dry cough and nausea and that he had reduced his fluid intake. On the day of admission, the patient learned that his sister had received a diagnosis of Covid-19, and he was concerned that his symptoms might also be caused by infection with SARS-CoV-2, prompting him to present to a neighborhood health center. At the health center, the patient reported mild dyspnea. He appeared comfortable , with unlabored breathing. The temperature was 37.8°C, the pulse 125 beats per minute, the blood pressure 127/78 mm Hg, the respiratory rate 18 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. Aus-cultation of the lungs revealed normal breath sounds. Further evaluation in the emergency department of this hospital was recommended. On arrival at the emergency department, the patient reported ongoing cough and nausea but no chest pain, abdominal pain, vomiting, or diarrhea. He had a history of hypertension, diabetes, hyperlipidemia, obesity, peripheral neuropathy, chronic kidney disease, and end-stage liver disease due to alcohol use disorder and hepatitis B virus infection. Twenty-two months earlier, renal replacement therapy had been initiated for worsening renal function due to the hepatorenal syndrome, and shortly after, the patient had undergone orthotopic liver transplantation. Combined liver and kidney transplantation had been planned, but the donor kidney was