Correct!
1. Needle biopsy
3. VATS
4. 1 or 3
Really any are reasonable, although having failed twice before, repeating a bronchoscopy with EBUS for a third time seems unlikely to result in a diagnosis. A needle biopsy with CT guidance was performed. The histology showed acute inflammation with necrosis and granulation tissue (Figure 4).
Figure 3. Needle biopsy of the lung. A: H&E staining low power. B: H&E staining high power.
No malignancy was identified and acid fast bacilli and Grocott's methenamine silver stain (GMS) were negative.
Because a definitive diagnosis was not made, the patient was referred for VATS biopsy. The histology again was nondiagnostic showing necrotizing and cavitating granulomatous inflammation surrounded by hyalinizing fibrosis (Figure 5).
Figure 5. VATS biopsy of the lung. A: H&E staining low power. B: H&E staining high power.
At about this time a complement fixation test for histoplasmosis yeast returned positive at 1:16. The complement fixation against histoplasmosis mycelia and a histoplasmosis antibody test were negative.
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