Correct!
5. No presumptive diagnosis can be offered
The only data on which a diagnosis could be suggested is the presence of the persistent right upper lobe nodular consolidation. The bronchoscopy with transbronchial biopsy procedure did not provide any specific diagnosis, therefore, this procedure should be regarded as non-contributory. Primary malignancy (bronchogenic, lymphoproliferative) remains a consideration. Coccidioidomycosis is probably unlikely, given that two separate serological assessments for this infection were unrevealing, but the diagnosis is not excluded, and the nodular character of the right upper lobe opacity does raise the possibility of a granulomatous process. For these same reasons, sarcoidosis, while unlikely (particularly since the process appears unilateral), is also not excluded.
Based on the notes in the electronic medical record, the patient was considered to have organizing pneumonia, likely cryptogenic, and corticosteroid therapy with a planned 3-4-week taper was instituted, as was azithromycin, with the intention of following the patient clinically and with repeat thoracic CT. Several weeks following bronchoscopy, the patient reported an episode of severe abdominal pain, which woke him from sleep. He was advised to go to the Emergency Room, but instead he presented to his primary care physician several days later with complaints of dizziness and weakness, feeling “terrible,” and was found to be tachycardic with orthostatic hypotension on physical examination. His prednisone and azithromycin were discontinued because the patient indicated he always feels “terrible” when taking these medications. The orthostatic hypotension was attributed to the patient’s aortic stenosis and some of the medications he was taking (Terazosin taken for hypertension and benign prostatic hypertrophy). The patient continued to periodically see his internal medicine physician, whose notes indicated a working diagnosis of cryptogenic organizing pneumonia. Repeat thoracic CT Images not shown), now 5 months following his most recent CT (Figure 14) was read as progression in the right upper lobe process. The patient continued to see his pulmonary medicine physician, who advised enhanced pulmonary toilet with follow up thoracic CT. The follow up thoracic was performed 7 months following this most recent CT scan (Figure 15).
Figure 15: Upper panels: Representative images from axial unenhanced thoracic CT now with a small focus of cavitation (yellow arrow in detail image). Lower panel: video of thoracic CT.
Which of the following represents the most accurate assessment of the thoracic CT findings? (Click on the correct answer to proceed to the seventeenth of nineteen pages)