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A 58-year-old man with hypercholesterolaemia was admitted for acute coronary syndrome with ST-segment elevation in inferior ECG derivations and ST-segment depression in antero-lateral ECG derivations ( Panel A ) . The patient underwent emergency coronary catheterization. Subtotal occlusion of the third segment of the right coronary artery (RCA) (Supplementary data online, Movie …

A 64 year-old man, who received a renal transplant in 1988 for end-stage renal disease due to chronic pyelonephritis, developed persistent dry cough, progressive dyspnoea, fatigue and fever, 2 weeks after he was shifted from cyclosporine to sirolimus for recurrent squamous cell carcinomas. Physical examination was unremarkable except for mild fever. Moderate acute phase reaction (CRP: 5.2 mg/dl) was present and sirolimus trough level was 6 ng/ml. A left lower infiltrate was noted on chest radiograph. He was treated with a course of moxifloxacin without improvement. High-resolution CT scan of the lungs revealed bilateral heterogeneous ground-glass opacities predominant in the lower lung zones (Figure 1A), associated with mild interlobular septal thickening. Bronchoalveolar lavage (BAL) disclosed 63% macrophages, 11% lymphocytes and 26% neutrophils. Specific stainings and culture of BAL fluid samples were negative for bacteria, mycobacteria, viruses, fungi and parasites. Serological tests for Chlamydia pneumoniae, C. psittaci, Mycoplasma pneumoniae, Coxiella burnetti and Legionella pneumoniae as well as cytomegalovirus antigenemia remained negative. Sirolimus was discontinued and the patient improved gradually, with complete disappearance of the symptoms and normalization of CRP level within 2 weeks. High-resolution thoracic CT scan returned to normal 4 months later (Figure 1B). Sirolimus is a potent immunosuppressive drug, increasingly used in solid-organ transplantation for its nephrotoxicsparing and antitumour effects. Interstitial pneumonitis fol