• Ashraf Omar, Pradnya D Patil, Sami Hoshi, Jasmine Huang, Earle Collum, and Tanmay S Panchabhai.
• Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
• Chest. 2018 Jun 1; 153 (6): e153-e157.

Case PresentationA 68-year-old man presented to our ED with shortness of breath, weakness, and a 25-lb unintentional weight loss. He had undergone bilateral lung transplantation (cytomegalovirus [CMV]: donor+, recipient+; Epstein-Barr virus: donor+; recipient+) for idiopathic pulmonary fibrosis (IPF) 18 months prior. His posttransplant course was fairly unremarkable until 1 month earlier, when he was admitted for breathlessness and weakness. CT of the chest during that admission revealed mild intralobular and interlobular septal thickening. A bronchoscopy with BAL and transbronchial biopsies did not show acute cellular rejection, but the BAL fluid was positive for coronavirus. His cortisol level was undetectable; he was diagnosed with adrenal insufficiency and fludrocortisone was initiated. He was taking prednisone, tacrolimus, and everolimus for immunosuppression and valganciclovir, itraconazole, and trimethoprim-sulfamethoxazole for antimicrobial prophylaxis. His 25-lb weight loss occurred over the span of just one month.Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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