Correct!
4. Metastatic malignancy
Metastatic malignancy is not likely given an isolated cavitary lesion. Certainly one may find cavitary lesions associated with certain primary pulmonary malignancies, such as squamous cell carcinoma, primary lymphoma and lymphomatous granulomatosis, but with metastatic secondary malignancies, these characteristically present as hematogenous spread with multiple solid nodules. The other choices are within the differential, especially infections, and given his immunosuppressed state, one must consider fungal, atypical, mycobacterial and other opportunistic infections. There are other considerations including infarcts, septic embolic phenomena, autoimmune diseases, granulomatous processes, parasitic infections and some less common entities. But, in our patient, we were primarily focused on infections given his immunocompromised status.
The patient underwent bronchoscopy with bronchoalveolar lavage as well as endobronchial ultrasound and biopsy of an enlarged mediastinal lymph node. A chest tube placed for the left-sided pleural effusion. All of the serologies and cultures were negative, and pleural fluid was a neutrophilic-predominant exudative effusion, but with negative work up otherwise. Empirically he was started on fluconazole to cover for coccidioidomycosis, and then later in his course, voriconazole was added for the possibility of aspergillosis.
Clinically he had a gradual decline over the next couple of weeks including rising WBC, persistent fevers, worsening abdominal pain with distention and shortness of breath, prompting his transfer to the ICU. A CT of the abdomen and pelvis was obtained (Figure 2).
Figure 2. Panels A-C: selected images from the abdominal CT scan. Lower panel: video of abdominal CT scan.
There were no abscesses on the exploratory laparoscopy and also no evidence of perforation. The donor kidney was explanted, without evidence of infectious process, but revealing necrosis.
What would be the next best step in evaluation for patient’s organ infarcts? (Click on the correct answer to proceed to the third of five panels)