Question: Dear Sir / Madam,

A 44 year’s male patient a case of renal transplant recipient on immunosuppressant, BREATHLESSNESS FOR EVALUATION- LRTI VS PULMONARY EDEMA POST RENAL TRANSPLANT WITH ALLOGRAFT DYSFUNCTION ON IMMUNOSUPRESSANT / BA / S/P CLIPPING FOR ANEURYSM.

Patient was admitted with the c/o shortness of breath - about 2 hrs prior to presentation to ER ... insidious in onset and gradually progressed c/o fever..moderate grade - in the evening 0n 14-4-16 relieved with medications (101.5 F at home had taken tab DOLO 650 mg ), not assocaited with chills or rigors c/o cough sinc the past 1 week , initially dry but has been productive since 2 days, whitish sputum , ? blood tinged c/o b/l lower limb swelling since 1 week which has gradually increased , more in the evening and has increased since the last 2 days recent h/o travel in the month of feb 2016 no c/o chest pain/ palpitations, no c/o burning while passing urine / increased frequency of micturition, no c/o dizziness, no othr systemic complaints post renal transplant (June 2015) with allograft dysfunction had recent admission for rising creatinine and acute rejection of graft. Pt was discharged on 09/04/16 with Creatinine of 3.9 /Urea:96.Pt had intermittent h/o tachypnea.Now again readmitted with c/o fever and shortness of breath.In ER pt was tachypnic/tachycardiac,desaturating to unsafe levels on room air. ECG - sinus rhythm Trop-I 0.21 the pateient was started on NIV - in view of pumonary edema -with CPAP - FiO2- 90% - down tirated to 70% peep -9 RR -14 BP - reemained elevated at 190/100 - inj NTG - increased to 20mcg/min inj lasix 40+40 given He was shifted to ICU for further management .

In the ICU , he was optimized by initiating on NIV.CXR:B/L Haziness++.Right Triple lumen Femoral venous cannulation was done. Repeat ABG showing worsening of acidosis.Pt was initiated on HD immediately. He was continued on intermittamnt NIV and other supportive measures .He gradually improved breathing comfortably ,haemodynamically stable.Pulmonology opinion was taken . He was shifted to wards for further management . He was doing well inthe wards. He underwent Cardio-Pulmonary Sleep study - Shows severe OSA with RDI of 95/hr with lowest oxygen saturation of 81% and longest apnea of 46 sec. Lowest HR of 44 and highest HR of 126 was noted during this study. CXR - Shows persisting bil infiltreates inspite of regular MHD He underwent HRCT Chest to r/o primary lung issues- showed Patchy areas of consolidation noted in the left superior, posterobasal, laterobasal segments of the left lung
posterobasal segment of the right lower lobe, and anterior segment of the right upper lobe along the major fissure. Ground glass opacities and nodules tree in bud appearance noted in the anteroposterior segment of the right upper lobe, superior segment of the bilateral lower lobe. Focal consolidation with cavitation in the right upper lobe. He underwent Bronchoscpy and lavage on 25/4/16- to rule out TB/ fungal infection. He was continued on septran and other antibiotics . On 26/4/16, Mr. XXXXXXX Shah was shfted from the ward gasping for breath, tachypneic(RR-52/min), tachycardic(140/min) and hypoxemic (spo2 80%). awake & not able to talk due to breathlessness. Immediately was put on NIV, 100%Fio2.Nephro team have started him on dialysis. He continues to remain breathlesss & tachypneic. remained hypotensive, not breathing well.. Intubated & ventilated. size 8.5, connected to ETT. Cntinued dilaysis. around 15min later, developed bradycardia & hypotension.(HR 38/min) adrenaline boluses given, CPR initiated & patient had ROSC after 2cycles of CPR. family called in, spoke to Yogesh(brother ) about the deterioration XXXXXXX showed AFB- started on Antitubercular drugs along with broad spectrum antibiotics . He remained very critical , remained hypotensive and acidotic despite of all the resuscitative measures .He had sudden cardiac arrest at 9am , could not be revived and declared dead at 9.30am on 27/4/16.

Kindly suggest cause of Death in this case, is it on account of renal transplantation rejection or on account of Tuberculosis.