Correct!
2. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
The CT abnormalities are clearly worsening and therefore expectant management is not appropriate, particularly given the patient’s worsening symptoms. Thoracoscopic lung biopsy could obtain an accurate diagnosis for the lung parenchymal abnormalities but is unnecessarily invasive given that fiberoptic bronchoscopy may also be capable of establishing the diagnosis. The findings at CT are not suggestive of a steroid-responsive condition, and hence presumptive corticosteroid therapy is not advisable. The patient’s anti-fungal therapy appears effective given the improvement in nodular lung disease in the medial right upper lobe as well as the initial regression, and now stability of, mediastinal lymphadenopathy.
Given the presence of fever and the patient’s chemotherapy regimen, broad-spectrum antibiotic therapy was begun. The patient underwent flexible fiberoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy in the right upper lobe as well as endobronchial ultrasound-guided biopsy of the right paratracheal lymph nodes. The bronchoalveolar lavage fluid appeared cloudy and showed 44% lymphocytes, 22% neutrophils, 14% macrophages, and 20% eosinophils. The transbronchial biopsy material stained strongly with periodic acid-Schiff (PAS). The diagnosis of secondary pulmonary alveolar proteinosis in the context of myelodysplastic syndrome was established. Pulmonary medicine felt that the lack of significant milky return at fiberoptic bronchoscopy indicated that whole-lung lavage would not be necessary and instead treatment of the underlying myelodysplastic syndrome would be more appropriate.
Diagnosis: Secondary pulmonary alveolar proteinosis in the context of myelodysplasia with multilineage dysplasia.
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