• Daniel Loeb, Charles Spear, and Don Hayes.
• Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Electronic address: Daniel.Loeb@cchmc.org.
• Chest. 2022 Mar 1; 161 (3): e149-e152.

Case PresentationA 27-year-old man with a history of bronchiolitis obliterans caused by a severe viral illness during early childhood that necessitated lung transplantation who was receiving tacrolimus therapy presented with rapidly worsening mental status. Prior to his change in mental status, his postoperative course was complicated by severe primary graft dysfunction and acute renal failure due to acute tubular necrosis that required continuous renal replacement therapy (CRRT). The patient had a prolonged intubation that required periodic BAL for mucous plugging. He ultimately was weaned to high-flow nasal cannula and subsequently 2 L/min by nasal cannula to maintain oxyhemoglobin saturations at >90%. On the night before mental status change, the patient experienced day/night inversion. After arousing that morning, the patient became combative, violent, and confused. This altered mentation progressed throughout the day to somnolence and lethargy, necessitating endotracheal intubation for airway protection. The patient experienced subsequent hypotension that necessitated low-dose epinephrine and vasopressin infusions.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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