Correct!
2. Bone marrow aspiration and biopsy
The pulmonary diagnosis seems well established although the patient could have a superimposed pneumonia. A repeat bronchoscopy with bronchoalveolar lavage was performed but was negative for infection. Following Sutton's law the money appears to be in the bone marrow which was diagnostic of acute myelogenous leukemia. A repeat peripheral blood leukemia/lymphoma panel was ordered and returned about a week later showing 2% blasts detected suggestive of low grade myelodysplastic syndrome (highlighting how inaccurate this test can be compared to bone marrow biopsy). However, the patient was now so weak he elected for hospice and no therapy and subsequently passed away.
Although rare, his leukemia was probably "driving" his organizing pneumonia (2). In retrospect, the assumption that the diagnosis of COP was sufficient was wrong and the search for an underlying disease was not aggressively pursued early on in the patients course. Eventually the fact that a serious illness was underlying the organizing pneumonia became very evident, but unfortunately was too late. For COP, a physician's job is not done until an underlying disease has been excluded.
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