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Management of the transplant patient in the emergency department can be divided into 3 general areas: disorders specific to the transplanted organ; disorders common to all transplant patients due to their immunosuppressed state or antirejection medication; and disorders unrelated to their transplant, yet special care is required due to their medications or altered physiology. Disorders specific to the transplanted organ are manifestations of acute rejection, surgical complications specific to the procedure performed, and altered physiology (most important in cardiac transplantation). The most common presentations of transplant patients to the emergency are: infection (39%) followed by noninfectious GI/GU pathology (15%), dehydration (15%), electrolyte disturbances (10%), cardiopulmonary pathology (10%) or injury (8%), and rejection (6%). Before prescribing any new drug for a transplant recipient, the treatment plan should be discussed with a representative from the transplant team.
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Predisposing factors to infections posttransplant include ongoing immunosuppression in all patients and the presence of diabetes mellitus, advanced age, obesity, and other host factors. Table 99-1 lists the broad array of potential infections and the time after transplant they are most likely to occur.
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The initial presentation of a potentially life-threatening infectious illness may be quite subtle in transplant recipients. As many as 50% of transplant patients, with serious infections, will not have fever. A nonproductive cough with little or no findings on physical examination may be the only clue to emerging Pneumocystis jiroveci pneumonia or cytomegalovirus (CMV) pneumonia. Urinary ...