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Pulmonology Quiz

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55 yr old in previously good health was seen by his primary care physician complaining of 10 pound weight loss, fatigue and night sweats. Physical exam reveals several enlarged 2 cm cervical lymph nodes. The remainder of the physical exam is unremarkable except for a palpable spleen tip.

A cervical lymph node biopsy is performed. Flow cytometry shows a monoclonal population of lymphocytes marking as CD 5 (+), CD 10 (-), CD 20 (+) dim, CD 23 (+). The final pathology report is small lymphocytic lymphoma. CT scan of the chest, abdomen, and pelvis reveal additional diffuse adenopathy in the mediastinum and retroperitoneum.  Initial blood work reveals a WBC of 45,000, predominantly mature lymphocytes.

The patient is started on allopurinol and then undergoes treatment with fludarabine cytoxan and rituxan chemotherapy.

Following his third cycle of chemotherapy, he presents with low grade fever, cough and shortness of breath. He was seen by his primary care physician was placed on levofloxacin for ten days without improvement in symptoms. Sputum culture obtained prior to antibiotics was negative. Histopathologic stains are negative for pneumocystis.  Chest x ray reveals interstitial infiltrates.



Of the following options, the next best step in the management of this patient is:

  1.  Bronchoscopy with BAL
  2.  Solumedrol
  3.  Lung biopsy to assess for recurrent parenchymal involvement of the lung by lymphoma
  4.  Echocardiogram