Correct!
2. Ventilation-perfusion scintigraphy evaluation for pulmonary embolism
The patient’s presentation, and the rapidly progressive pulmonary opacities, are not suggestive of pulmonary embolism. Furthermore, in the setting of suspected pulmonary embolism, ventilation-perfusion scintigraphy would stand a substantial chance of providing non-diagnostic results when performed for patients with extensive lung opacities. Assessment for data supporting or refuting the diagnosis of community-acquired pneumonia is appropriate, as is consideration for other causes of an acute lung injury pattern, such as hypersensitivity pneumonitis. While left ventricular dysfunction is relatively unlikely in a young patient, particularly when some clinical features suggest infection, the chest radiographic pattern is consistent with pulmonary edema and therefore assessment of left ventricular function has some value. Checking the patient’s coagulation parameters is appropriate as pulmonary hemorrhage could present with the pattern presented in Figures 1 - 3. Similarly, pulmonary vasculitis may present with diffuse lung opacities, often representing hemorrhage, and assessment for pulmonary vasculitis is appropriate.
No source of infection could be identified. No antigenic sources or environmental insults were discovered. The patient’s coagulation studies were normal, and no antibodies or other laboratory data suggesting pulmonary vasculitis were found. Left ventricular function was normal.
On her third hospital day, more profound oxygen destauration was noted, the patient’s level of consciousness deteriorated, she became hypotensive; repeat chest radiography (Figure 4) was performed.
Figure 4: Frontal chest radiograph performed on third hospital day shows progressive bilateral peripheral air-space consolidation.
Subsequently, the patient was transferred to the intensive care unit and intubated. Thoracic CT (Figure 5) was then performed.
Figure 5. Three representative cuts from the thoracic CT performed on the third hospital day show progressive symmetric, bilateral, diffuse air-space consolidation and ground-glass opacity compared to the previous thoracic CT. Symmetric bilateral pleural effusions are again seen.
Click here for a movie of the thoracic CT scan
Which of the following would be an appropriate next step in this patients’ evaluation?
