Correct!
5. Pulmonary angiography shows no change in the pulmonary parenchymal findings seen at the unenhanced chest CT (Figure 2)
The CT pulmonary angiogram shows no evidence of acute or chronic thromboembolic disease, although features of increased right heart pressures, evidenced by straightening of the interventricular septum and enlargement of both the main pulmonary artery and right ventricle, are present. The randomly distributed, branching nodular opacities noted throughout the lung parenchyma remain unchanged.
The patient underwent lower extremity venous ultrasound examination, which was normal. Review of the outside facility bronchoscopy with transbronchial biopsy showed a few non-specific granulomas, and only one washing showed Actinomyces israelii and it was felt therefore that this organism may simply be a contaminant. The patient’s erythrocyte sedimentation rate and C-reactive protein levels were elevated at 50 mm/h (normal, <10 mm/h), and 23 mg/L (normal, <5 mg/L), respectively. The patient underwent repeat brain MRI (Figure 5), which showed subcortical abnormalities in both the supratentroial and infratentorial compartments suggesting embolic infarction.
Figure 5. Axial T2-weighted (A), fluid sensitive (aka “FLAIR,” B), and contras-t-enhanced T1-weighted brain MR just cranial to the lateral ventricular system, shows subcortical areas of T2-hyperintensity (arrow, A) that are also hyperintense on fluid-sensitive imaging (arrowheads and arrow, B), with subtle areas of enhancement (arrow, C).
At this point, which of the following represents the most appropriate step in this patient’s management? (Click on the correct answer to proceed to the ninth of twelve pages)