Correct!
1. Consult general surgery for biopsy of a metabolically active lymph node
Starting or re-starting immunosuppressive biologic therapy would be inappropriate given the lingering question of undiagnosed infection. Mediastinoscopy could access one of the metabolically active right paratracheal lymph nodes, but may be needlessly invasive given that other more superficially located metabolically active lymph nodes are present. While repeating the retroperitoneal lymph node biopsy could potentially retrieve material for diagnostic testing, a technically adequate retroperitoneal lymph node biopsy has already been performed and did not successfully establish a diagnosis; therefore, a different target for repeat intervention may stand a better chance of obtaining the material needed to establish the correct diagnosis.
The liposomal amphotericin therapy was stopped. Cardiothoracic surgery was consulted for mediastinoscopy but deferred, noting that the 18FDG-PET scan showed abnormalities for intervention that could be targeted in a less invasive fashion. General surgery declined repeat biopsy of a retroperitoneal lymph node, citing that a diagnosis was unlikely for such a procedure as the interventional radiology procedure properly sampled an enlarged retroperitoneal lymph node yet failed to retrieve material harboring a diagnosis. However, general surgery did agree to biopsy one of the enlarged, metabolically active supraclavicular lymph nodes, and hematology / oncology continue to recommend obtaining tissue to establish the etiology of the imaging findings. Tissue obtained during the flexible sigmoidoscopy showed cytomegalovirus, and ganciclovir therapy was initiated. Multidrug anti-tuberculous therapy with ethambutol, rifampin, pyrazinamide, and INH was initiated.
General surgery performed an excisional biopsy of an enlarged left supraclavicular lymph node approximately 6 days following bronchoscopy. The histopathology of this lymph node showed granulomatous inflammation with necrosis. The acid-fast smear was negative, but two days later the acid-fast stain was positive for Mycobacterium tuberculosis.
Diagnosis: Disseminated Mycobacterium tuberculosis as result of biologic treatment with a tumor necrosis factor therapy
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