An x-ray of a lung suggested consolidation in the right upper lobe and the patient has been put on a broad spectrum antibiotic for two weeks on suspicion of pneumonia. Subsequent to the antibiotic course, another x-ray was taken which showed no improvement in the lung condition. No final diagnosis could be made even after CT scan and Bronchoscopy. How can such conditions be diagnosed further and what could be the course of treatment in the present situation?
First, Is there an old X-ray or Imaging study of the area of concern, and if available compare to see if these findings are old or new.
If these findings are new or no previous image of concerned area is available for comparison, then next step would be to do a biopsy - either CT guided or VATS, mini-thoracotomy.
Biopsy of the sample was done with the sample picked up during bronchoscopy and there are no such cells suggesting malignancy. Old x-ray image is however not available.
The question is, was there enough tissue for assessment with Bronchoscopic biopsy. If the tissue was not enough then requires open biopsy with VATS or minithoracotomy.
The other thing would be the density of this mass on CT and the radiologist based on the CT density may be able to narrow the possibilities.
Dr Parmar, here is the summary of the reports, in case if it of some help in getting some direction in diagnosis.
1. Histopathology: Specimen - TBLB - Right Upper Lung - Anterior segment; Collected as multiple tiny tan brown soft tissue pieces measuring 0,3 x 0.2 x 0.1 cm in aggregate.
Diagnosis: Biopsy showing no significant pathology.
2. Microbiology:
Specimen Source - Bronchoalveolar Lavage
Result: Culture - negative; AFB - not detected in the slide; Fungal elements not detected.
3. Bronchoscopy observation: Right upper lobe anterior segment mucosa was oedematous. Recommendation: lobular biopsy of right upper limb apical segment.
4. CECT Chest:
Study reveals dense consolidation of anterior segment of right upper lobe. Multiple calcific foci are seen within this on unenhanced study. Mild loculated pleural effusion is seen anteriorly. There are few discrete subcentimeter sized mediastinal lymph nodes seen.
Impression: features are suggestive of infective aetiology. However, the spiculated lesion in the lingular merits histopathological response to rule out mitotic aetiology.
Hope the above details may provide some lead.
It seems like that the bronchoscopist also recommended a biopsy of RUL apical segment and so the CT Chest. The tissue obtained by bronchoscopy is small and fragmented and doesn't rule out a neoplasti pathology completely. Also, what about cytology on bronchial washings or sputum if any?
Microbiological examination of sputum was done, which showed regular microflora. Cytology of bronchial washing was not done. In the meantime patients was put on anti-allergic drug for a week and has shown good improvement in his condition. Should the patient undergo an chest x-ray (5th in the past one month) or RUL apical segment biopsy has to be done anyway.
Try to repeat the bronchoscopy, this time do a transbronchial biopsy to rule out organizing pneumonia and cultures to rule out TB should be done too.
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