Utility of transbronchial lung biopsy in diagnosis of cavitary lung lesion in a patient with HIV infection.

To cite: Shahani L. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015209726 DESCRIPTION A 49-year-old man with advanced AIDS (CD4 count=8 cells/mm; HIV-1 viral load=660 000 copies/mL) was admitted with fever and cough. CT of the chest demonstrated a 3×1 cm cavitary lesion in the right upper lobe. Bronchoscopy with bronchoalveolar lavage (BAL) failed to yield a diagnosis. The patient was non-adherent to medical care and left the hospital against medical advice while on treatment. He was readmitted 3 weeks later and CT of the chest demonstrated interval increase in the cavitary lesion; however, repeat bronchoscopy with BAL failed to yield a diagnosis. Similarly to his previous hospitalisation, the patient left the hospital against medical advice without effective antimicrobial therapy. Consequently, he was readmitted 4 weeks later and CT of the chest demonstrated further increase in size of the cavitary lesion along with newer nodules (figure 1). The patient at this time underwent bronchoscopy with BAL and a transbronchial lung biopsy (TBLB). BAL cultures again did not yield a diagnosis; however, cultures of the TBLB sample yielded Nocardia spp. Nocardiosis commonly presents with airspace opacities and nodules associated with cavitation (60%). Other common aetiologies of cavitary lung lesions in patients with AIDS include Mycobacterium tuberculosis, Mycobacterium avium complex, invasive aspergillosis, malignancy and bacterial lung abscess. TBLB has been shown to provide a diagnostic yield significantly higher than that obtained by BAL in patients with HIV infection (77.3% vs 47.6%; p<0.001). This case highlights the utility of TBLB to increase the diagnostic yield in a patient with HIV infection with cavitary lung lesion.