Correct!
4. 1 and 3
Correct!
4. 1 and 3
Coccidioidomycosis is endemic in Arizona and causes as much as 24% of community-acquired pneumonia (1). This patient's serology was negative but it is important to remember that serology can be falsely negative especially early in the course of disease (1). The absence of fever and other symptoms such as productive cough and dyspnea suggests that this may be something other than typical pneumonia. A course of antibiotics is not unreasonable but the patient responded minimally to the therapy. Subsequently, he underwent bronchoscopy and needle biopsy. Cytology showed atypical lymphoid cells. Flow cytometry expressed CD-19 and CD-20, lambda light chains, and weak BCL-2. Diagnosis was established as marginal zone mucosa associated lymphoid tissue (MALT) lymphoma. Five weeks of rituximab had no effect on tumor size. He had since been observationally followed with routine thoracic CT scans, with his lymphoma remaining stable and asymptomatic.
Eleven years after his initial presentation he was seen complaining of dyspnea and new-onset palpitations. His physical examination showed stable vital signs with decreased breath sounds in the right chest. Troponins and electrocardiography were unremarkable. A chest radiograph was performed (Figure 2).
Figure 2. Portable chest x-ray taken 11 years after his initial presentation.
What of the following should be done next? (Click on the correct answer to proceed to the fourth of five panels)