A 5-year-old girl was admitted to the hospital with lethargy and increasing jaundice. At age 18 months, she had undergone an orthotopic liver transplantation for extrahepatic biliary atresia and had subsequently developed chronic graft rejection. Other medical problems included nutritional deficiency, renal dysfunction, episodes of gastrointestinal hemorrhage, seizures, anemia secondary to chloramphenicol toxicity, developmental delay, and hypoxemia.
Physical examination revealed a dehydrated, lethargic, jaundiced, and cushingoid-appearing girl who was small for her age. Her weight and height were 13.7 kg and 93 cm, respectively. On auscultation, breath sounds were harsh but there were no rales or rhonchi. She developed persistent hypoxemia and her arterial