Two weeks after undergoing allogeneic stem cell transplant for multiple myeloma, a 55-year-old man develops a severely pruritic rash, abdominal cramps, and profuse diarrhea. He appears lethargic. Physical examination shows yellow sclerae. There is a generalized maculopapular rash on his face, trunk, and lower extremities, and desquamation of both soles. His serum alanine aminotransferase is 115 U/L, serum aspartate aminotransferase is 97 U/L, and serum total bilirubin is 2.7 mg/dL. Which of the following is the most likely underlying cause of this patient's condition?
APreformed cytotoxic anti-HLA antibodies
BProliferating transplanted B cells
CActivated recipient T cells
DDonor T cells in the graft
ENewly formed anti-HLA antibodies
A 55-year-old woman recently underwent kidney transplantation for end-stage renal disease. Her early postoperative period was uneventful, and her serum creatinine is lowered from 4.3 mg/dL (preoperative) to 2.5 mg/dL. She is immediately started on immunosuppressive therapy. On postoperative day 7, she presents to the emergency department (ED) because of nausea, fever, abdominal pain at the transplant site, malaise, and pedal edema. The vital signs include: pulse 106/min, blood pressure 167/96 mm Hg, respirations 26/min, and temperature 40.0°C (104.0°F). The surgical site shows no signs of infection. Her urine output is 250 mL over the past 24 hours. Laboratory studies show: Hematocrit 33% White blood cell (WBC) count 6700/mm3 Blood urea 44 mg/dL Serum creatinine 3.3 mg/dL Serum sodium 136 mEq/L Serum potassium 5.6 mEq/L An ultrasound of the abdomen shows collection of fluid around the transplanted kidney with moderate hydronephrosis. Which of the following initial actions is the most appropriate?
ARe-operate and remove the failed kidney transplant
BContinue with an ultrasound-guided biopsy of the transplanted kidney
CStart on pulse steroid treatment or OKT3
DSupportive treatment with IV fluids, antibiotics, and antipyretics
EConsider hemodialysis
A 72-year-old woman presents to the clinic complaining of diarrhea for the past week. She mentions intense fatigue and intermittent, cramping abdominal pain. She has not noticed any blood in her stool. She recalls an episode of pneumonia last month for which she was hospitalized and treated with antibiotics. She has traveled recently to Florida to visit her family and friends. Her past medical history is significant for hypertension, peptic ulcer disease, and hypercholesterolemia for which she takes losartan, esomeprazole, and atorvastatin. She also has osteoporosis, for which she takes calcium and vitamin D and occasional constipation for which she takes an over the counter laxative as needed. Physical examination shows lower abdominal tenderness but is otherwise insignificant. Blood pressure is 110/70 mm Hg, pulse is 80/min, and respiratory rate is 18/min. Stool testing is performed and reveals the presence of anaerobic, gram-positive bacilli. Which of the following increased this patient’s risk of developing this clinical presentation?
AHypercholesterolemia treated with atorvastatin
BConstipation treated with laxatives
COsteoporosis treated with calcium and vitamin D
DPeptic ulcer disease treated with esomeprazole
ERecent antibiotic use for pneumonia treatment
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