Correct!
4. Thoracentesis
The chest x-ray shows a left lower consolidation and a small left pleural effusion. In a patient with a history of pneumonia the concern would be for an empyema and a thoracentesis is indicated. Bronchoscopy with bronchoalveolar lavage might also be considered. Transbronchial biopsy would not seem to add to the diagnostic yield of bronchoscopy with bronchoalveolar lavage and VATS is overly aggressive at this point. Needle biopsy is usually done for pulmonary nodules.
A thoracentesis was performed and revealed an exudate with negative bacterial cultures. He was treated with an additional course of antibiotics and discharged home. However, he returned in December, 2013 with worsening symptoms.. In addition, he was found to have pancytopenia with the WBC 2.5 million cells/mcL, hemoglobin 8 grams/dL, and platelets 99,000 cells/mcL
A repeat chest x-ray (Figure 2) and thoracic CT scan were performed.
Figure 2. Repeat chest-ray at December 2013 admission.
Figure 3. Representative images from the thoracic CT scan in lung windows.
What should be done next? (Click on the correct answer to proceed to the next panel)