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Do you want to change your printer?Case report {#s1}
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A 56-year-old woman with no significant past medical history presented to an emergency department with a 1-week history of urinary urgency, dysuria, and suprapubic pressure. Transvaginal ultrasound and voiding cystourethrogram demonstrated a distended urinary bladder with a retention of contrast. A diagnosis of pyelonephritis, cystitis, and urinary retention was made. The patient underwent a cadaveric renal transplant 7 weeks prior to this presentation. Her immunosuppressant regimen included cyclosporine A 3 mg/kg, mycophenolate mofetil 500 mg, and prednisolone 5 mg daily.
The patient was started on nephrostomy placement and broad-spectrum empiric antibiotic treatment. Blood, urine, and dialysate cultures were taken. Six hours after nephrostomy, the patient developed a progressive respiratory distress. Chest X-ray showed bilateral diffuse reticulonodular opacities suggestive of acute respiratory distress syndrome (ARDS) ([figure 1](#F1){ref-type=”fig”}). A transthoracic echocardiogram showed a left ventricular ejection fraction of 55% with increased global systolic function. The patient was treated with bed rest and was placed on non-invasive positive pressure ventilation. She was subsequently intubated and required mechanical ventilation. As the respiratory disease progressed, the reticulonodular opacities worsened and the patient became hypoxemic with a heart failure–organ failure score of 21.
{#F1}
As the diagnosis of pneumonia was considered, a bronchoalveolar lavage (BAL) was performed. The BAL fluid analysis showed a neutrophilic exudate. Gram stain of BAL fluids revealed a chain of coccobacilli ([figure 2](#F2){ref-type=”fig”}).
{#F2}
Fungal infections, such as histoplasmosis or coccidioidomycosis, are often
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