Correct!
5. All of the above
The patient was treated with steroids with a prolonged taper. Follow-up in clinic two months later showed almost complete resolution of his consolidation and effusion (Figure 5).
Figure 5. Repeat chest radiograph taken in February 2014. Note clearing in the left lung (red arrow).
He felt better but not great and his pancytopenia had not improved. A hematology consult was ordered as an outpatient.
He was again seen in clinic after two months. He felt "terrible". He had quit taking the corticosteroids due to “bruising easily”. His chest radiograph was worse (Figure 6).
Figure 6. Chest radiograph taken in April 2014. Note reappearance of consolidation and effusion in the left lung (red arrow).
He was admitted to the hospital with worsening leukopenia and neutropenia, severe anemia and thrombocyopenia. A hematology/oncology consult was obtained and a peripheral blood leukemia/lymphoma panel was ordered and was normal. He was transfused PRBCs and the corticosteroids were restarted and he is discharged the following day with outpatient hematology follow up.
He comes to the emergency room 2 months later with worsening weakness and pancyotpenia and is admitted to the intensive care unit. His chest x-ray and CT scan are again worse (Figure 7).
Figure 7. Chest radiograph and representative image from the thoracic CT scan done in June 2014.
What should be done at this time? (Click on the correct answer to proceed to the next panel)