Correct!
5. More than one of the above
Bronchoscopy with biopsy may be the optimal approach to obtain a tissue diagnosis for the patient’s thoracic abnormalities, although transthoracic needle biopsy could also be performed. Pulmonary function testing may prove valuable at some point in the course of this patient’s care, but at this point efforts must be directed towards obtaining a diagnosis for the lung and mediastinal abnormalities. 68Ga-PET Dotatate PET scan may prove useful if the patient is subsequently diagnosed with neuroendocrine malignancy, but is premature at this point; the chest CT findings are consistent with possible neuroendocrine malignancy, but are certainly not specific for this diagnosis.
The patient underwent percutaneous transthoracic needle mediastinal lymph node biopsy (Figure 4).
Figure 4. Prone CT during percutaneous needle biopsy of the right paratracheal lymphadenopathy.
The biopsy showed non-necrotizing granulomatous inflammation but no evidence of malignancy. Bronchoscopy with endobronchial ultrasound and biopsy of the right paratracheal lymphadenopathy was also performed and showed similar histologic findings; no coccidioidomycosis spherules were identified. The patient then underwent testing for coccidiomycosis, which showed immunodiffusion testing positive for IgM antibodies, suggesting acute infection. Coccidioidomycosis complement fixation was positive at 1:32. The patient was started on fluconazole.
The patient was continued on antifungal therapy which was switched from fluconazole to itraconazole due to the lack of appropriate decrease in complement fixation titers assessed at follow up. The patient continued to complain of inability to gain the weight he lost (approximately 45 lbs. over a number of months) as well as fatigue. Repeat complete blood count showed a normal white blood cell count at 4.5 x109/L (normal, 3.4 – 9.6 x109/L). The absolute neutrophil count was 1.08 x109/L (normal, 1.56 – 6.45 x109/L). His hemoglobin and hematocrit values were 8.1 gm/dL (normal, 13.2 – 16.6 gm/dL) and 23.5% (normal, 38.3 – 48.6%). 6% blasts were noted. The platelet count was normal at 166 x 109/L (normal, 135 – 317 x 109/L).
Which of the following represents the most appropriate next step for the patient’s management? (Click on the correct answer to be directed to the eighth of fourteen pages).