Correct!
3. Examine the bronchoalveolar lavage fluid cells and transbronchial biopsy

CMV is rather common and the presence of the virus does not necessarily indicate infection (3). The transbronchial biopsy was examined (Figure 5).

Figure 5. Panel A: low power view of transbronchial biopsy (H&E). Panel B: Higher power view. Panel C: High power view showing viral inclusion (arrow).

After viewing the biopsy our patient was begun on ganciclovir and eventually foscarnet. Her viral load was 18,600 copies/ml (>10,000 usually indicates infection). Unfortunately, she continued to do poorly and eventually died after being placed on comfort care only.

Cavitary lesions are unusual with CMV pneumonia although they have been reported (4,5). It seems more likely she developed pneumonia surrounding areas of emphysematous lung.

References

1. Bell DJ, Gaillard F. Pulmonary cavity (mnemonic). Radiopedia. Available at: https://radiopaedia.org/articles/pulmonary-cavity-mnemonic (accessed 3/27/18). 
2. Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin Proc. 2003 Jun;78(6):744-52. [CrossRef] [PubMed]
3. Mann M, Shelhamer JH, Masur H, et al. Lack of clinical utility of bronchoalveolar lavage cultures for cytomegalovirus in HIV infection. Am J Respir Crit Care Med. 1997 May;155(5):1723-8. [CrossRef] [PubMed]
4. Moon JH, Kim EA, Lee KS, Kim TS, Jung KJ, Song JH. Cytomegalovirus pneumonia: high-resolution CT findings in ten non-AIDS immunocompromised patients. Korean J Radiol. 2000 Apr-Jun;1(2):73-8. [CrossRef] [PubMed]
5. Najjar M, Siddiqui AK, Rossoff L, Cohen RI. Cavitary lung masses in SLE patients: an unusual manifestation of CMV infection. Eur Respir J. 2004 Jul;24(1):182-4. [CrossRef] [PubMed]

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