A 60-year-old female on prednisone 60 mg daily for a medical history of unspecified rheumatologic disorder was suspected to have interstitial lung disease seen on computed tomography scan of the chest [Figure 1]. She underwent bronchoscopy with bronchoalveolar lavage and TBLC. Her steroids were not held before the procedure. Bronchoalveolar lavage was done in the right upper lobe posterior segment, with 150 mL instilled and 120 mL recovered. A biopsy was obtained with the cryoprobe from the superior segment of the right lower lobe. One sample was obtained with one pass, complicated only by mild bleed that resolved after administration of cold saline and 3 mL epinephrine. She was discharged home several hours later without further complication.
Nine days later, the patient was admitted to the hospital with right upper quadrant abdominal pain, fever, and leukocytosis with a white blood cell count of 31,000. Computed tomography scan of the chest revealed right lower lobe cavitary lesion measuring 2.6 cm x 3.5 cm x 4 cm in the superior segment where the cryobiopsy was taken [Figure 2]. This lesion was new compared to imaging from 2 weeks prior. The patient was empirically placed on vancomycin and piperacillin-tazobactam with continuation of steroids. The fungal culture from prior bronchoscopy grew Fusarium species, and cryobiopsy tissue revealed only sparse chronic inflammation.
After consultation with infectious disease, antimicrobial therapy was narrowed to voriconazole to cover fungal species. A steroid taper was started to allow for healing and clearance of suspected abscess. Repeat bronchoscopy performed during hospitalization revealed only mild erythema of airways and small old blood in the anterior distal trachea.
Computed tomography chest showing cavitation in the right lower lobe with an air-fluid level that measures 2.6 cm x 3.2 cm, highly suggestive of lung abscess.