Correct!
1. Bronchoscopy with bronchoalveolar lavage
2. Surgical lung biopsy
4. 1 or 2

Transthoracic fine needle aspiration biopsy is generally reserved for indeterminate focal lung disorders, such as lung nodules or masses, and not diffuse lung diseases. Usually surgical lung biopsy is required for the diagnosis of indeterminate fibrotic lung disorders, and bronchoscopy with bronchoalveolar lavage is employed principally used to exclude competing diagnoses such as infection. However, in this circumstance, with a clinical history clearly identifying an exposure and serial thoracic CT imaging showing features highly suggestive of hypersensitivity pneumonitis, bronchoscopy with bronchoalveolar lavage showing CD8+ lymphocytosis, particularly if ˃50%, would provide additional sufficient evidence to establish the diagnosis of hypersensitivity pneumonitis for this patient.


Diagnosis: Hypersensitivity pneumonitis progressing to pulmonary fibrosis

References

  1. Hodnett PA, Naidich DP. Fibrosing interstitial lung disease. A practical high-resolution computed tomography-based approach to diagnosis and management and a review of the literature. Am J Respir Crit Care Med 2013;188(2):141-9. [CrossRef] [PubMed]
  2. Hodnett PA, Naidich DP. Reply to Mooney JJ, Koth LL. Surgical lung biopsy over bronchoalveolar lavage in chronic hypersensitivity pneumonitis. Am J Respir Crit Care Med 2014;189(3):372.
  3. Vourlekis JS, Schwarz MI, Cherniack RM, Curran-Everett D, Cool CD, Tuder RM, King TE Jr, Brown KK. The effect of pulmonary fibrosis on survival in patients with hypersensitivity pneumonitis. Am J Med 2004;116:662-8. [CrossRef] [PubMed]
  4. Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM, Drent M, Haslam PL, Kim DS, Nagai S, et al.; American Thoracic Society Committee on BAL in Interstitial Lung Disease. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 2012;185:1004-14. [CrossRef] [PubMed]
  5. Ohshimo S, Bonella F, Cui A, Beume M, Kohno N, Guzman J, Costabel U. Significance of bronchoalveolar lavage for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2009; 179:1043-7. [CrossRef] [PubMed] 

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