Correct!
2. Bronchoscopy
Bronchoscopy is the best choice for the evaluation of this patient. Percutaneous transthoracic needle biopsy could be considered, but biopsy of cavitary lesions can be problematic and result in complications. Video – assisted thoracoscopic surgical biopsy would certainly be capable of establishing the etiology of the cavity, but is needlessly invasive and may be difficult, short of an actual lobectomy, given the size of the lesion. Extended cervical mediastinoscopy is occasionally employed to sample left mediastinal lymph nodes, most commonly in the context of staging primary malignancy in the left lung, to establish or exclude N2 / mediastinal disease; however, this patient has no left-sided lesion to target with this procedure. 18FDG-PET scan would provide little useful information in this patient- lack of tracer utilization would not allow the lesion to be managed conservatively, and elevated tracer uptake within the lesion would be non-specific and not distinguish among the myriad of infectious and non-infectious diagnostic considerations for this lesion.
The patient underwent bronchoscopy with bronchial lavage directed into the left lower lobe. At bronchoscopy, purulent secretions were noted emanating from the superior segment left lower lobe bronchus. Numerous white blood cells were noted in the bronchial lavage fluid. Testing of the bronchial lavage fluid showed normal respiratory flora, moderate gram + cocci and bacilli, few gram – bacilli and Moraxella catarrhalis. Polymerase chain reaction testing for Pneumocystis jirovecii, Epstein-Barr virus, coccidioidomycosis, Legionella, cytomegalovirus, and Mycobacterium tuberculosis were negative. No evidence of Nocardia spp. was noted on smear. Aspergillus antigen (0.876) was detected. The patient was placed on broad-spectrum antibiotics and additional antifungal therapy was instituted. His symptoms continued to worsen, with increasing shortness of breath and recurrent hemoptysis noted. Repeat thoracic CT (Figure 3) was performed.
Figure 3. Panels A-F: Representative static repeat axial enhanced thoracic CT displayed in lung windows. Right panel: video of repeat thoracic CT in lung windows.
Regarding this examination, which of the following is correct? (Click on the correct answer to proceed to the sixth of eight panels)