A 39-year-old man presented with worsening shortness of breath. The patient had a past medical history significant for follicular lymphoma (diagnosed 3 years ago) for which he had completed chemotherapy. He had a relapse of follicular lymphoma, which continued to progress despite chemotherapy with rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone (R-CHOP); eventually received an allogenic stem-cell transplant 1 year ago. The posttransplant course was complicated by graft-versus-host disease of the gastrointestinal tract and skin, cytomegalovirus viremia, BK virus-associated hemorrhagic cystitis, varicella-zoster dermatitis, polymicrobial blood stream infections, and hypogammaglobinemia. He was being treated with oral budesonide, ruxolitinib, and tacrolimus for graft-versus-host disease. The patient was a former smoker with 5 pack-year smoking history with no other primary lung diseases such as chronic obstructive pulmonary disease, bronchiectasis, emphysema, or pulmonary fibrosis. His pulmonary function test showed a normal spirometry and lung volumes with mildly reduced DLCO (carbon monoxide diffusing capacity).
One month prior to this presentation, computed tomography (CT) scan of his chest showed multifocal pulmonary nodules suggesting invasive fungal infection. The patient was started on AmBisome and isuvaconazole and scheduled for bronchoscopy with TBB. Multiple TBB were performed in the lateral-basal segment of the right lower lobe of the lung. The procedure was performed without any complications, but no infectious etiology was identified, and the patient was discharged.
When he presented again to the hospital with worsening shortness of breath, a repeat chest CT was ordered, which in comparison with the CT scan 1 month ago, showed variably changed pulmonary opacities, with new/increased areas of more focal consolidation the right upper lobe (Figure 1A) and left lower lobe (Figure 1B), and with decreased nodular and ground glass opacities elsewhere in the lungs. We repeated the bronchoscopy with TBB:obtaining a total of 7 biopsies from the lateral-basal segment of the left lower lobe of the lung. Chest X-ray (CXR) obtained 35 minutes after the procedure was negative for pneumothorax (Figure 2). Twenty-two hours postprocedure, the patient complained of acute onset of left-sided pleuritic chest pain. CXR revealed a small apical pneumothorax that remained unchanged on serial CXR evaluations and the patient was discharged home. A follow-up CXR performed the following day on an outpatient basis revealed a worsening pneumothorax (Figure 3) and the patient was re-admitted for further management. A 12-French pigtail chest tube was placed under ultrasound guidance that led to the resolution of pneumothorax. The patient was discharged home after a hospital stay of 4 days.