741 - Rapid Response: Chest Pain in Bilateral Orthotopic Lung Transplant

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

PV

Peter D. Vu, MD

Resident Physician
University of Texas Heath Science Center at Houston, TIRR Memorial Hermann
Houston, Texas, United States

Corresponding Author(s)

Nikola Dragojlovic, DO (he/him/his)

Assistant Professor, Residency Program Director
University of Texas Heath Science Center at Houston, TIRR Memorial Hermann
Houston, Texas, United States

Case Diagnosis: Subacute rib fracture in bilateral orthotopic lung transplant (BOLT)

Case Description: A 70-year-old male with pulmonary fibrosis and decannulation post-BOLT presents for inpatient rehabilitation. The patient was admitted in stable condition. Admission physical exam noted healed surgical chest scar with mild tenderness to palpation, intact chest tube sutures, regular heart rate, and clear breath sounds. After his first therapy session, he noted non-radiating 7/10 squeezing chest tightness and dyspnea. Physical exam showed increased chest tenderness to palpation and diminished right breath sounds.

STAT troponins and EKG were negative for cardiac infarction. STAT BMP, CBC, and tacrolimus levels reported no abnormalities. STAT chest radiograph suggested concerns for pneumothorax, prompting STAT CT chest which reported no pneumothorax, pneumoperitoneum, or DVT; it did report diaphragm eventration, intestinal gas, and subacute 4th rib fracture. Scheduled acetaminophen, lidocaine and diclofenac patches, and as-needed acetaminophen-hydrocodone produced great effects. The patient tolerated his pain regimen and continued therapies with improved chest pain.

Discussions: Organ donations are a modern miracle and the enormity is not lost among transplant recipients and their providers. Thus, caring for these patients can be daunting for resident physicians with their medical, transplant, and rehabilitation needs.1 This patient provides a platform to discuss an extensive differential of chest pain in rehabilitation (especially BOLT patients) that includes cardiac, pulmonic, gastric, neurologic, pharmacologic, and musculoskeletal causes.2,3 Rapid diagnosis and management of pain in transplant patients promote improved rehabilitation outcomes and quality of life.4

Conclusions: A broad differential for chest pain in transplant patients should be considered for optimized outcomes.