Differential Diagnosis
- Single most likely diagnosis
- C. Proliferation of immortal B cells: This is the most likely cause of the patient's symptoms, given the highly elevated EBV PCR levels and the presence of enlarged lymph nodes. The patient's immunosuppressed state due to maintenance medications after cardiac transplant increases the risk of EBV-related complications, including post-transplant lymphoproliferative disorder (PTLD).
- Other Likely diagnoses
- B. Pneumocystis jiroveci pneumonia: Although the lungs are clear to auscultation, the patient's immunosuppressed state and the presence of scattered bilateral atelectasis on the CT scan make this diagnosis a possibility. Pneumocystis jiroveci pneumonia is a common opportunistic infection in immunocompromised patients.
- A. Graft versus host disease: While less likely, graft versus host disease (GVHD) can occur in solid organ transplant recipients, especially those with a history of fulminant viral myocarditis. However, the clinical presentation and laboratory results do not strongly support this diagnosis.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- E. Transplant rejection: Although the echocardiogram shows normal heart structure and function, transplant rejection is a potentially life-threatening complication that must be considered, especially in an immunosuppressed patient with a history of cardiac transplant.
- D. Recurrent viral myocarditis: While the patient's history of fulminant viral myocarditis and current immunosuppressed state make this diagnosis possible, the normal heart examination and echocardiogram results make it less likely.
- Rare diagnoses
- Other rare infections or malignancies could be considered, but they are less likely given the patient's presentation and laboratory results. Further testing and evaluation would be necessary to rule out these rare diagnoses.