Meds before admission: Prograf 0.5 mg every 12 hours, Medrol 2 mg QOD, Pen VK 500 mg b.i.d., Valtrex 500 mg daily, Diflucan 200 mg daily, pentamidine inhalation every four weeks for PCP prophylaxis
In the ICU, his antibitic coverage was broadened to include tobra/vanco/zosyn/voraconazole and PCP-dose IV bactrim. A BAL showed 250 WBC's with 70% PMNs, but no growth and the gram stain was also negative.
ID consult want an open lung biopsy, but when pressed for what they were looking for were unable to give a specifi entity. What are your thoughts and what would you do next?
4 comments - CLICK HERE to read & add your own!:
Wow. Dense air-space Dz, huh?
With 70% PMNs ID causes are way up there for this immunosuppressed patient. PCP (as you are appropriately treating) can have odd patterns on inhaled pentamidine because of the distribution of the drug. I guess fungal disease might be a concern too. GVHD of the lung or post-chemo (if he was on bleo for induction) would be more diffuse. Were ther TBBx done with the bronch?
I didn't want to do a TBBX without fluoro on a vented patient without knowing what I would find that would change management. As you said, non-infectious causes (i.e. things that might be steroid-dependent) would not be limited to the LUL like that, and he is on broad spect antibiotics, antifungals and antivirals. The only thing I could think of would be mucor, but it bothers me that the BAL was negative. But because he is not improving (but radiographically NOT progressing), I got surgery involved for VATS...
Well, we are holding on any biopsy as we cannot think of a diagnosis from the biopsy that would change management. Anyone have any ideas? Muco would be surgical and he's not surgical. Same with a neoplasm...
just got an open lung biopsy. will post answer when i get it...
Post a Commenttest post a comment