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3. Bronchoscopy with bronchoalveolar lavage

There is still no established diagnosis. Since infection is still a leading possibility, bronchoscopy with bronchoalveolar lavage is reasonable. VATS is also reasonable depending on the expertise available and the clinical judgment of the clinician. Empiric treatment is not appropriate without an established or presumptive diagnosis. There are no enlarged lymph nodes on the CT scan.

Bronchoscopy with bronchoalveolar lavage was performed and the results are below:

• Normal bronchial anatomy
• Bronchoalveolar lavage differential

• 95% neutrophils
• 1 % lymphocytes
• 4 % alveolar macrophages

• Methicillin sensitive Staphylococcus aureus (MSSA)
• Candida albicans
• Aspergillus antigen 0.583 (normal < 0.5)
• No hemosiderin laden macrophages
• No malignant cells

Clinically it was thought that the MSSA, Candida and Aspergillus were all unlikely to explain the patient's overall picture although the patient was begun on methicillin and voriconazole. There was no clinical response.

What is the most likely diagnosis? (Click on the correct answer to proceed to the fourth of five panels)

1. Acute hypersensitivity pneumonia
2. Acute interstitial pneumonia (Hamman Rich syndrome)
3. Adult respiratory distress syndrome
4. Lupus pneumonitis
5. Mycoplasma pneumonia

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