Correct!
4. 1 and 3

Here in Arizona coccidioidomycosis (Valley Fever) seems to be in nearly every thoracic differential. A left-sided consolidation and pleural effusion in a patient who has a chronic or subacute process would be compatible with coccidioidomycosis, especially given the eosinophilia. In 2005 Crum and Wallace (1) reviewed 162 cases of coccidioidomycosis and found 28% had peripheral blood eosinophilia (mean 6%, range 0-44%). In 2013 Alzoubaidi et al. (2) found similar results also in 162 patients with an average of 6% eosinophils in patients with coccidioidomycosis. However, in their series 71% had peripheral blood eosinophilia and 53% had having bronchoalveolar lavage eosinophilia.

The elevated NT-proBNP suggests congestive heart failure. Although it is often stated that isolated left-sided pleural effusions are unusual in heart failure, this concept was challenged by Woodring (3). He found that a left-sided pleural effusion is not an atypical finding in congestive heart failure. However, heart failure would not explain the hemoptysis or left-sided focal consolidation. Therefore, it was felt that diuresis was premature until thoracentesis was performed.

Thoracentesis removed 800 mL of yellow fluid. Major findings were as below:

• pH 7.49
• Total protein 2.2 g/dL (serum 6.7)
• LDH 119 U/L (serum 236, normal range 111-222)
• Cell count 700 cells/mL
• Differential
• 22% neutrophils
• 0% eosinophils
• 52% lymphocytes
• 18% macrophages
• Coccidioidomycosis by EIA and PCR negative
• Cytology negative for malignancy

Which of the following should be done next? (Click on the correct answer to be directed to the fifth of sixl pages)

1. Diuresis. No further work up is required.
2. Lung PET scan
3. Pleuroscopy
4. 1 and 3
5. All of the above

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