Correct!
1. Bronchoscopy
The thoracic CT scan shows thickening of the posterior wall of the trachea. Empiric treatment with ceftriaxone for epiglottitis is not wrong but bronchoscopy is a better choice. Bronchoscopy is indicated because the disease process appears mostly confined to the posterior wall of the trachea. It is relatively easy to perform biopsy; inspect the trachea; and biopsy under direct vision if necessary, through the bronchoscope. It would be difficult and possibly dangerous to attempt to percutaneously needle biopsy the posterior trachea.
Bronchoscopy was performed and showed creamy white lesions on the posterior wall of the trachea (Figure 2).
Figure 2. View through the bronchoscope from the upper trachea showing creamy white lesions on the posterior trachea consistent with Aspergillosis.
Biopsies from the trachea and epiglottis showed a yeast typical of Aspergillosis. Aspergillus fumigatus was cultured from the biopsy specimens. First-line treatment for invasive aspergillosis is voriconazole (3). The patient was treated with voriconazole and clinically improved.
Diagnosis: Invasive Aspergillus fumigatus tracheitis.
References