Correct!
1. Bronchoscopy
In our view bronchoscopy is the next logical choice. Switching antibiotics or adding amphotericin would not seem appropriate with the patient becoming afebrile and a decreasing WBC. Steroids for amiodarone toxicity is not wrong but this is a diagnosis of exclusion and other causes have not been totally excluded. Lung biopsy is not wrong but does seem overly aggressive since not all less invasive procedures have been performed.
Bronchoscopy showed purulence noted at the left lower lobe orifice. Bronchoalveolar lavage was performed of the right middle lobe (due to the CT findings) and washings were performed of the left lower lobe.
All the cultures were negative. Cytology revealed no malignancy, fungi or viral inclusions.
Because the diagnosis was still unclear a video-assisted thorascopic (VATS) biopsy was performed (Figure 4).
Figure 4. VATS showing organizing acute lung injury; prominent foci of organizing pneumonia; and prominent foamy alveolar macrophages. Special stains for organisms were negative.
Which of the following explain the patient’s clinical picture?