Correct!
5. All of the above
Correct!
5. All of the above
Compared to her previous chest x-ray in figure 1 the pleural effusions are smaller, however, there is a new right upper lobe density. A thoracic CT scan was performed (Figure 3).
Figure 3. Representative axial images from thoracic CT scan in lung windows.
The patient is an immunocompromised host aggressive pursuit of a diagnosis is appropriate. Given the right upper lobe density likely represents a pneumonia. Most advise bronchoscopy with bronchoalveolar lavage as an initial step (3). A coccidioidomycosis serology is appropriate given the frequency of Valley Fever in Arizona.
A bronchoscopy was performed which showed no endobronchial masses with areas of bronchial erythema (Figure 4).
Figure 4. View of the main carina showing some areas of bronchial erythema.
Results of the bronchoalveolar lavage are shown in Table 1.
Table 1. Bronchoalveolar lavage results
In addition, a urinary antigen for Legionella was negative. The patient was started on meropenem, levofloxacin, and fluconazole. She was continued on tacrolimus and amiodarone. However, she continued to have fever and repeat chest x-ray was performed two days after the bronchoscopy (Figure 5).
Figure 5. Repeat chest x-ray two days after the bronchoscopy.
What should be done at this time? (Click on the correct answer to proceed to the fourth and final panel)