Correct!
1. Bronchoscopy with bronchoalveolar lavage and/or transbronchial lung biopsy
The differential diagnosis for cavitary lung disease is large (Table 1) (1).
Table 1. Differential diagnosis of cavitary lung disease
Noninfectious
- Neoplasm (11% CXR)(SCC)
- Embolism w/ infarction
- Vasculitis (Wegener’s, Sarcoidosis)
- Bullae/Cysts
- Bronchiectasis
- Empyema with an air-fluid level
Infectious
- Bacteria
- Mycobacteria
- Fungi
Many of these causes can also result in brain abscesses. Usually rejection does not cavitate. Because the differential is large, empiric therapy could be started but should be followed with efforts to establish a cause. Of the options listed, most would select a bronchoscopy as the lease invasive. Most favor aggressive pursuit of a diagnosis rather than empiric therapy in the immunocompromised host (1). Many pulmonary infections in this situation can be diagnosed with bronchoalveolar lavage. Aspergillosis with its characteristic 45º branching chains (Figure 4) may be absent on BAL.
Figure 4. Silver stain showing numerous intraparencymal hyphae with acute angle branching consistent with invasive aspergillosis (From Shostak E, Liesching T, Wener K. A young woman with respiratory failure after a visit to compost station. American Thoracic Society. Available at: http://www.thoracic.org/professionals/clinical-resources/clinical-cases/a-young-woman-with-respiratory-failure-after-a-visit-to-compost-station.php)
A BAL with transbronchial biopsy was performed with the results as below:
A presumptive diagnosis of invasive aspergillosis was made. Which of the following is the drug of choice for invasive aspergillosis? (Click on the correct answer to procee to the fourth and last panel)