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Extensive microbiology and cytology were negative, PET-CT showed hypermetabolic pulmonary lesions, and biopsy confirmed Kaposi’s sarcoma, highlighting the need to consider oncogenic/lymphoproliferative etiologies in transplant 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. elsevier. es/ora)  \nClinical Image  \nAn Unusual Cause of Pulmonary Nodules  \nLucía Ortega Ruiz a,∗ , Juan Margallo Iribarnegaray a , Begoa Pea del Cura a ,  \nClara Seghers Carreras a , Ana Belén Enguita Vallsb , Alicia De Pablo Gafas a , Rodrigo Alonso Moralejo a , María Teresa Tejedor Ortiz a , Carlos Andrés Quezada Loaiza a  \na Pulmonology Department, Hospital Universitario 12 de Octubre, Madrid, Spain  \nb Pathological Anatomy Department, Hospital Universitario 12 de Octubre, Madrid, Spain  \nFig. 1. (a) Axial slice of a chest CT scan showing bilateral pleural effusion, larger on the right hemithorax, and multiple consolidations, some with air bronchogram and many with a peripheral ground-glass halo (largest nodule in the left lower lobe measuring 22 mm × 23 mm). (b) Axial PET-CT image showing hypermetabolic pulmonary lesions with SUVmax of 10.26 in the left hilar and 8.56 in the right hilar lymph nodes. (c) Histological sections of Kaposi’s sarcoma, hematoxylin–eosin stain ×4. (d) Anti-HHV-8 immunohistochemistry of the same histological section.  \nWe present the case ofa 63-year-old male with a history ofbilateral lung transplantation due to chronic obstructive pulmonary  \n∗ Corresponding author.  \nE-mail address: [lortegar@salud.madrid.org](lortegar@salud.madrid.org) (L.O. Ruiz).  \ndisease, receiving immunosuppressive treatment initially with Basiliximab followed by tacrolimus, mycophenolate, and prednisone, as well as prophylaxis with nebulized amphotericin B and trimethoprim/sulfamethoxazole. The patient had a favorable posttransplant evolution.  \nAt 10 months post-transplant, he experienced a decline in lung function, with a reduction in FEV1 from 3170 ml to 2500 ml  \n[https://doi.org/10.1016/j.opresp.2025.100510](https://doi.org/10.1016/j.opresp.2025.100510)  \n2659-6636/© 2025 Sociedad Espaola de Neumolog y Cirug Torcica (SEPAR). Published by Elsevier Espaa, S.L.U. This is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/)).  \nL.O. Ruiz, J.M. Iribarnegaray, B.P. del Cura et al. Open Respiratory Archives 8 (2026) 100510  \n(−19%) and a fall in FEV1/FVC ratio from 82% to 63%. The patient’s best post-transplant spirometry showed an FVC of 3870 ml and an FEV1 of 3170 ml. A chest X-ray revealed consolidation in the right lower lobe (RLL), coinciding with cytomegalovirus (CMV) viremia of 27,630 IU/ml. At that time, tacrolimustrough levels were 13 ng/ml. During the previous months, immunosuppressant levels had remained stable, ranging between 10 and 16 ng/ml. The target therapeutic range for tacrolimus was approximately 15 ng/ml during the first six months post-transplant and around 10 ng/ml up to the end of the first year. Suspecting CMV pneumonitis, valganciclovir was initiated. Despite this, the patient exhibited clinical (cough, purulent expectoration) and functional deterioration, leading to hospital admission for further diagnostic evaluation.  \nA computed tomography (CT) scan of the chest confirmed central peribronchovascular consolidation in the RLL, with numerous nodular images, some with air bronchograms and others with a surrounding ground-glass halo (Fig. 1a), along with bilateral pleural effusion. Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies revealed a normal endoscopic appearance of the bronchial mucosa. Fungal yeast forms and a colony of Aspergillus niger were isolated from the BAL but the biopsies showed no fungal structures, signs of rejection, or viral infection. Further microbiological studies ruled out infection by VIH, Nocardia, Mycobacterium tuberculosis, Leishmania, and Cryptococcus. Diagnostic thoracentesis revealed a serohematic mononuclear exudate (96%), with negative tumor markers, adenosine deaminase 24 U/l, interferon-gamma 10 pg/ml, and flow cytometry without monoclon","cbCaiklppKZtb0Ba","https://ap.wps.com/l/cbCaiklppKZtb0Ba","pdf",594757,"English","# Case presentation\n## Post-transplant course and symptoms\n## Imaging and diagnostic workup\n## Differential diagnosis and final diagnosis","[{\"question\":\"What patient background preceded the pulmonary nodules?\",\"answer\":\"A 63-year-old man with bilateral lung transplantation for chronic obstructive pulmonary disease, receiving immunosuppressive therapy and prophylaxis.\"},{\"question\":\"Why was CMV pneumonitis initially suspected?\",\"answer\":\"A decline in lung function with consolidation in the right lower lobe coincided with CMV viremia and tacrolimus trough levels.\"},{\"question\":\"How was the final cause of the pulmonary nodules determined?\",\"answer\":\"A PET-CT showed hypermetabolic lesions and a CT-guided biopsy of the largest nodule revealed findings consistent with Kaposi’s sarcoma.\"}]","An Unusual Cause of Pulmonary Nodules - Clinical Image | PDF",1790694596]