Correct!
5. More than one of the above
The persistence of the left-sided lung opacity and pleural effusion both present targets for obtaining diagnostic tissue and sampling of either or both sites are appropriate. Testing for fungal infection, which would explain the persistence of lung opacities despite appropriate broad-spectrum antibiotic therapy, is also reasonable. Finally, repeat imaging to assess the evaluation of the pulmonary findings is also reasonable.
Testing for coccidioidomycosis was negative. Bronchoscopy with bronchioloalveolar lavage and transbronchial biopsy was unrevealing- adequate tissue was obtained, but no features diagnostic of a particular disorder was evident. Diagnostic thoracentesis with removal of 750 mL cloudy, orange fluid was performed and showed 559 µL nucleated cells (normal, ˂500 cells µL) with 82% lymphocytes, LDH= 146 (serum = 130 U/L, normal serum = 100-190 U/L), total protein= 3.6 gm/dL (serum = 6.8 gm/dL), glucose = 126 mg/dL (serum = 103 mg/dL), and pH >7.5. Testing for vasculitis, including anti-nuclear antibodies (ANA), anti-neutrophil cytoplasmic antibodies (ANCA), and other auto-antibodies, was negative. Testing for inflammation, including C-reactive protein, while elevated at 18.9 mg/dL (normal, ≤8 mg/dL), was decreased from 27.1 mg/dL one year earlier. The erythrocyte sedimentation rate was 5 mm/hr (normal, 0-29 mm/hr), also decreased from one year earlier (13 mm/hr). A respiratory viral panel was completely negative, and testing for acid-fast bacilli and other pathogens, including Rickettsia and Legionella, was also negative.
The possibility of organizing pneumonia was considered, although the presence of the pleural effusion and intermittent hemoptysis was considered atypical for that diagnosis. Combined corticosteroid and azithromycin therapy were begun, and repeat chest CT (Figure 6) was performed several weeks into this new regimen.
Figure 6. Left: Representative images from repeat axial unenhanced chest CT. Right: video of chest CT in lung windows.
Which of the following represents an appropriate interpretation of this chest CT? (Click on the correct answer to be directed to page 8 of 10 pages)