Correct!
5. More than one of the above
A tissue sampling procedure is appropriate at this point as a clear etiology for the chronic, recurrent, and migratory opacities has not been identified. Furthermore, these pulmonary opacities have not resolved on chronic corticosteroid therapy (20 mg/day). Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy may be able to establish a diagnosis and would be the least invasive method for such. Although not mentioned among the choices listed and more invasive than a bronchoscopic approach, cryobiopsy would be a potentially useful procedure. Thoracoscopic surgical lung biopsy, although the most invasive approach should be able to establish the diagnosis with a high degree of certainty. Increasing the dose of immunosuppression could, depending on the diagnosis, result in regression in the pulmonary opacities, but such therapy can be associated with significant complications and should the opacities recur, the impairment in wound healing may result in an increased risk with tissue sampling procedures.
The patient underwent successful thoracoscopic lung biopsy of the right upper, middle, and lower lobes, and bronchioloalveolar lavage of the left lower lobe, which showed areas of patchy aspiration pneumonia and bronchiolectasis with numerous food particles (Figure 6) discretely visualized.
Figure 6. Histopathologic image (Hematoxylin-Eosin, 40X) shows aspirated food particles.
Areas of granulomatous inflammation, organizing lung injury, and airway-centered scarring and patchy areas of alveolar siderosis related to previous hemorrhage were seen. No evidence of vasculitis or capillaritis was noted. No evidence of hypersensitivity pneumonitis or tissue eosinophilia was seen.
Diagnosis: Aspiration pneumonia manifesting as chronic, recurrent, and migratory pulmonary opacity at chest imaging.
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