Correct!
5. Video-assisted thorascopic lung biopsy
Percutaneous transthoracic needle biopsy is typically employed for solid pulmonary, pleural, or chest wall targets; in the lungs, nodules are the typical target of this procedure. Cavities may be targeted in selected cases, but uniformly thin-walled cysts are not an appropriate target for this procedure. 18FDG-PET scan is a useful technique for the evaluation of focal pulmonary lesions and malignancy staging, and can be useful for selecting a target for tissue sampling when multiple indeterminate lesions are present, but would not provide management-altering information for this patient at this point of the patient’s evaluation. Pleuroscopy can be useful for evaluating pleural space abnormalities, but such abnormalities are lacking in this patient. This patient’s lesions reside within the lung, and therefore a lung-tissue sampling procedure is required. Catheter pulmonary angiography is useful for assessing right cardiac and pulmonary artery pressures as well as the pulmonary vasculature for thromboembolic disease, arteriovenous malformations, and / or vasculitis, but these disorders are not relevant considerations for this patient’s cystic lung disorder. VATS has the ability to obtain enough pulmonary parenchymal tissue to allow a confident histopathologic diagnosis for the pulmonary abnormalities in this patient.
Further clinical course: The patient underwent video-assisted thoracoscopic (VATS) lung biopsy, which showed tissue characterized by large cystic spaces lined by moderately thickened fibrotic walls with chronic and follicular bronchiolitis , as well as mild patchy follicular interstitial hyperplasia, establishing the diagnosis of lymphocytic interstitial pneumonia. Given the patient’s history of psoriasis treated with Enbrel (etanercept), the possibility of Enbrel (Etanercept)-induced Sjögren syndrome was entertained. This drug was discontinued and the patient was started on Imuran® (azathioprine) and prednisone to treat her combination of lymphocytic interstitial pneumonia and psoriatic arthritis. Her symptoms of shortness of breath and chest pain, as well as her psoriatic arthritis symptoms, greatly improved on therapy.
Diagnosis: Lymphocytic interstitial pneumonia.
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