A 64-year-old man with emphysema who had received a double-lung allograft six months previously was admitted to the hospital because of cough, hemoptysis, and abdominal pain.Three days before admission, abdominal pain that was localized to the left lower quadrant developed. Two days before admission, the patient began to have smallvolume hemoptysis (approximately one teaspoon) on awakening. His appetite was poor, but he was able to drink liquids. He did not have diarrhea, melena, hematochezia, shortness of breath, or chest pain. On the evening before admission, fever to 38.3°C developed, associated with shaking chills. The patient vomited once the next morning and came to the transplantation clinic. A chest radiograph revealed a new infiltrate in the right upper lobe, and a test for cytomegalovirus (CMV) antigenemia was positive at 185 cells per two slides. He was admitted to the hospital.The patient had smoked three packs of cigarettes per day for 25 years; he quit 9 years before admission when he started to become short of breath. Over the course of the year after he stopped smoking, his exercise tolerance declined and he was started on home oxygen therapy. Eight years before admission, a lung mass in the left lower lobe was seen on a routine chest radiograph. A thoracoscopic wedge resection and mediastinal lymph-node dissection were performed; pathological examination disclosed a moderately to poorly differentiated squamous-cell carcinoma; the surgical margins and lymph nodes were negative for carcinoma. He received no further treatment for the cancer. Five years before admission, pulmonary-function tests documented findings that were consistent with emphysema with severe obstruction, as defined by a ratio of forced expiratory volume in one second to forced vital capacity of 28 percent, a peak expiratory flow rate of 3.08 liters per second (36 percent of the predicted rate), elevated lung volumes (total lung capacity, 11.1 liters; 176 percent of predicted volume), residual volume of 7.98 liters (327 percent of the predicted volume), and decreased diffusing capacity (15 percent of the predicted capacity).