Legionellosis in a lung transplant recipient obscured by cytomegalovirus infection and Clostridium difficile colitis

A 52-year-old-white male underwent double lung transplantation for severe emphysema due to alpha-1-antitrypsin deficiency and heavy tobacco use. Following a postoperative course complicated by renal insufficiency, pulmonary emboli, and Clostridium difficile colitis, he was discharged in stable condition. Two months later, he was admitted to a local hospital with a fever, abdominal pain, diarrhea, nausea, and dyspnea. Computerized tomography (CT) of the chest revealed bilateral pleural effusions. Sigmoidoscopy was grossly normal but biopsy demonstrated cytomegalovirus (CMV) colitis, and the patient was placed on intravenous ganciclovir. Over the next week, he became progressively hypoxemic and was transferred to the University of Pittsburgh Medical Center (post-transplant day 81) for further evaluation. His medications on transfer included: ganciclovir, prednisone, tacrolimus, dapsone, fluconazole, ondansetron, lansoprazole, digoxin, and coumadin.