Infectious Diseases Question 55

A 35-year-old woman is evaluated for intermittent fever, sweats, fatigue, and dull midchest pain of 2 weeks' duration. Medical history is significant for liver transplantation 6 months ago for primary biliary cirrhosis; she was seronegative for cytomegalovirus and Epstein-Barr virus, and her donor was positive for both. Results of pretransplant testing for tuberculosis were negative. She received valganciclovir prophylaxis for 3 months after transplantation. Medications are tacrolimus, prednisone, mycophenolate mofetil, and trimethoprim-sulfamethoxazole.

On physical examination, temperature is 37.7 °C (99.9 °F), blood pressure is 142/88 mm Hg, pulse rate is 92/min, and respiration rate is 14/min. Oropharynx has whitish plaques on the palate and buccal mucosa. No enlarged lymph nodes are palpable. Cardiopulmonary examination is normal. Abdomen is soft and nontender without hepatosplenomegaly. Extremities are without edema. No skin lesions are noted.

Laboratory studies are significant for a leukocyte count of 5200/µL (5.2 × 109/L) and hematocrit of 33%. Liver and kidney function are normal. Bacterial and fungal blood cultures show no growth.

Chest radiograph shows clear lung fields but left hilar enlargement. Chest CT confirms an enlarged, 3-cm left hilar lymph node; the liver and spleen are unremarkable.

Which of the following is the most likely cause of her clinical findings?

A Cytomegalovirus infection

B Invasive candidal infection

C Posttransplant lymphoproliferative disease

D Reactivation tuberculosis

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