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Pulmonology Quiz

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35 year old with recent diagnosis of acute myelogenous leukemina is treated with induction chemotherapy with idarubicin and cytarabine.  3 weeks after induction chemotherapy he develops cough, dyspnea, hypoxemia, and fever with temperatures to 101.5. 

Physical exam reveals a few crackles in the R lung, but is otherwise unremarkable.

Chest x-ray reveals a focal infiltrate in the R lung.

Routine sputum C/S is negative.  4 sets of blood C/S are negative.  Patient is still febrile after 3 days of cefepime and vancomycin.

Laboratory testing is as follows:

WBC: 0.2

Hb: 9.2 gm/dl

Platelets: 33,000

LFTS: Total protein: 4.9 TB: 0.8, Alk Phos 123, ALT 34, AST 27

Na: 137, K: 3.9, HCO3: 16 Cl: 118, BUN: 22, Cr: 0.9, Glucose: 98, Calcium 8.9


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

  1.  Bronchoscopy with broncoalveolar lavage (BAL)
  2.  Sputum fungal cultures and sensitivity
  3.  Voriconazole
  4.  Fluconazole