A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia. Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia. All the episodes were successfully treated with intravenous antibiotics. Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar. The scar was not noted on the chest x-ray prior to the episodes of pneumonia. He has a 50-pack year history of smoking. He quit smoking 10 years ago. Which of the following is the most likely to definitively confirm the diagnosis in this patient?

Question

A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia.  Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia.  All the episodes were successfully treated with intravenous antibiotics.  Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar.  The scar was not noted on the chest x-ray prior to the episodes of pneumonia.  He has a 50-pack year history of smoking.  He quit smoking 10 years ago. Which of the following is the most likely to definitively confirm the diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: This patient would benefit the most from a flexible bronchoscopy for the confirmation of the diagnosis. Flexible bronchoscopy is a simple, invasive test that will definitivelydiagnose the cause of this patient's recurrent pneumonia, since it will enable the physician to visualize the actual endobronchial lesion, and take a tissue biopsy at the same time. It is relatively easy to perform, and has a low risk of complications, thus making it the procedure of choice for obtaining tissue samples and lavage fluid to confirm the diagnosis. It also has a better yield for diagnosing certain other infections, such as fungal infections or tuberculosis. (Choice A) Obtaining sputum samples for AFB staining and cytology has a low yield, and is not very helpful in patients suspected of having endobronchial obstruction. (Choice B) Hemosiderin laden macrophages are seen in diffuse alveolar hemorrhage syndromes (granulomatosis with polyangiitis, anti-GBM disease, and other systemic vasculitides). (Choice D) Checking for immunoglobulin deficiencies would not be helpful in this patient. (Choice E)High resolution CT scan (HRCT) can diagnose interstitial lung disease, and can also help in characterizing the persistent "scar" seen on chest x-ray. However, it would not provide a definitecause of this patient's lesions and recurrent pneumonia. Educational objective: Flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving pneumonia or pulmonary infiltrates (HRCT scan is an alternative, but it does not provide confirmatory information). *The best diagnostic test for endobronchial obstructive lesions is flexible bronchoscopy. If the question had asked for the next best step in management, then the answer would have been CT scan.

A 60-Year-Old Caucasian Man Is Admitted to the Hospital with an Episode