Correct!
1. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
The patient is an immuncompromised host. Most pursue a diagnosis aggressively in these patients since the patients are prone to unusual infections and can decompensate quickly. In our practice bronchoscopy with bronchoalveolar lavage is the usual procedure of choice. Transbronchial biopsy is also done by some. Depending on the hospital and the local expertise VATS could also be considered correct but is more invasive. Repeating the thoracic CT would probably have little utility and a thoracic CT angiogram, usually done for pulmonary emboli, would not seem indicated since that pulmonary embolus is unlikely based on the clinical situation.
The transbronchial biopsy (Figure 2) was interpreted as being negative for malignancy with nonspecific inflammatory changes including organizing pneumonia. Silver, S100 and HMB45 immunohistochmeical stains were negative. Coccidioidomycosis and aspergillus serologies were negative. Gram stain for bacteria and acid-fast stains tuberculosis were also negative.
Figure 2. Transbronchial biopsy. Panel A: low power (H&E stain). Panel B: higher power (H&E stain). Panel C. High power (H&E stain).
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