Correct!
5. All of the above
The CT chest/abdomen was interpreted as showing mediastinal and hilar adenopathy with calcification, diffuse interstitial and airspace disease, small pleural effusions, and splenomegaly. Calcification of mediastinal lymph nodes occurs in sarcoidosis and increases with time. Calcification occurs in 3% of patients after 5 years and in 20% after 10 years (1).
Overall the patient seems to be getting worse. Transfer to the ICU is appropriate for observation and further management. The increasing confusion is worrisome and arterial blood gases are indicated both because of his increasing respiratory distress as well as his confusion. The arterial blood gases showed adequate oxygenation on supplemental oxygen without an increased pCO2 and BiPAP was instituted.
Lumbar puncture is indicated because of the increasing confusion without an adequate explanation. It revealed 2 WBC, glucose 59 mg/dL, protein 56 mg/dL. Gram stain and stains for fungi were negative.
Bronchoscopy with BAL is indicated because of the worsening clinical situation in a patient who appears to have pneumonia. The BAL demonstrated yeast (Figure 3) that was later identified as Candida.
Figure 3. Smear of BAL demonstrating a yeast that proved to be Candida.
Which of the following is indicated?