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A 78-year-old white female with a past medical history significant for hypertension and end-stage renal disease secondary to nephrosclerosis underwent cadaveric renal transplantation. She had an uneventful postoperative course, attaining normal renal function. Her medications included cyclosporin (6 mgukg), prednisone (25 mg) on a tapering schedule and mycophenolate mofetil (2000 mguday). Approximately 3 months after transplant, she presented with fever of 101.68F, dyspnea, and hypoxia (oxygen saturation 86% on room air). Physical examination revealed an elderly female in distress. She was pale, her jugular vein was flat, and she had oral thrush. There was no evidence of lymphadenopathy. Examination of the lungs demonstrated equal air entry with scattered rales. She continued to deteriorate and was subsequently intubated. The chest X-ray revealed a diffuse reticulonodular pattern greater on the right than the left, without parenchymal calcifications or cavitary lesions (Figure 1). The patient then began to develop palpable purpura on the trunk (Figures 2 and 3). A skin biopsy was subsequently performed which revealed numerous multinucleated giant cells (Figure 4). Over the next 48 h, the purpura evolved into haemorrhagic vesicles of the face, trunk, back, and extremities.

Giant cells and pneumonia in a transplant patient. What is the link?