Correct
2. Bronchoscopy with transbronchial biopsy
Bronchoscopy with transbronchial biopsy is the most appropriate next step for the evaluation of this patient among the choices lists above. Surgical lung biopsy would certainly provide tissue sufficient to establish a diagnosis, but is needlessly invasive at this point, given that less invasive methods have not yet been exhausted and may still provide an answer. In general, 18FDG-PET scanning is most useful for the diagnosis and staging of lung cancer metastatic disease, and for the evaluation of focal pulmonary opacities, but not diffuse lung diseases. Similarly, percutaneous transthoracic fine needle aspiration biopsy is not typically employed for diffuse lung diseases, and is instead more commonly used to diagnose focal pulmonary lesions. Finally, mediastinoscopy is useful for diagnosing mediastinal lesions (typically in the middle mediastinum in the pretracheal region), but no such abnormality is present in this patient.
The patient underwent bronchoscopy with transbronchial biopsy without complication. Bacterial, viral, and fungal cultures were negative and endobronchial examination showed no abnormalities. Bronchial lavage showed cell count and differential of 27% polymorphonuclear cells, 5% lymphocytes and 68% monocytes – macrophages. The transbronchial biopsy specimen showed tissue containing islands of erythroid precursors, myeloid series, and both mature and immature megakaryocytes, consistent with extramedullary hematopoiesis.
Diagnosis: Extramedullary hematopoiesis in the lungs
References