Correct!
2. Biopsy of the left axilla
3. Bronchoscopy with bronchoalveolar lavage
Biopsy of the left axilla is indicated because the PET scan showed increased uptake. This could either represent residual tumor or infection. Bronchoscopy with bronchoalveolar lavage is indicated because it is unclear what lung pathology is present and there are multiple possibilities in an immunocompromised host. Three sputum specimens for AFB and Tb culture is not entirely wrong, but in this case with an immunocompromised host, it would probably take too long. Bronchoscopy with bronchoalveolar lavage is probably more sensitive at detecting tuberculosis and faster. Empiric treatment with amphotericin B is not entirely wrong, but in our view, bronchoscopy with bronchoalveolar lavage is probably a better answer and may well detect any fungal disease. Open lung biopsy is probably over aggressive at this point.
Biopsy of the left axilla showed recurrent Hodgkin’s disease. Bronchoscopy with bronchoalveolar lavage was Influenza A positive by both shell vial and PCR.
All the other cultures were negative. Transbronchial biopsy was non-diagnostic.
She was treated with tamiflu and sent home 3/13, but was readmitted 3/23 with dyspnea and chest pain. Work up for pulmonary embolism was negative and sputum cultures and smears were negative. A repeat CT scan was unchanged.
What should be done now?