Correct!
1. Bronchoscopic biopsy
Among the choices listed, bronchoscopic biopsy is the most appropriate, although the transbronchial biopsy diagnostic yield for small airway disorders is inferior to surgical lung biopsy techniques. Percutaneous transthoracic needle and core biopsy is a very useful procedure for obtaining lung tissue for diagnosis, but is typically only employed for focal lung disorders, not diffuse lung diseases. Cervical mediastinoscopy is useful for the evaluation of the mediastinum, particularly inferior to the carina, but would be of little use for a patient with diffuse low attenuation pulmonary parenchyma at HRCT. Medical pleuroscopy would not be useful for this patient as no pleural abnormalities are present. Open surgical lung biopsy would surely establish a diagnosis for this patient but is overly invasive at this point, and could be considered if transbronchial bronchoscopic biopsy is unrevealing and thoracoscopic lung biopsy cannot be performed.
The bronchoscopic transbronchial biopsy revealed non-specific chronic inflammation but was not diagnostic of a particular disorder. The patient subsequently underwent surgical thoracoscopic lung biopsy, and the material retrieved at this procedure showed patchy, peribronchiolar fibrosis surrounding small airways narrowing and obliterating the bronchiolar lumen. The histopathologic features were diagnostic of bronchiolitis obliterans (constrictive bronchiolitis, obliterative bronchiolitis.
Diagnosis: Bronchiolitis obliterans
References