Case
A 116 cm, 20.9 kg 5-year-old post orthotopic heart transplant for
dilated cardiomyopathy presented with right-sided peripheral pulmonary
opacities on chest CT. She had previously completed intravenous
antifungal therapy for Rhinocladiella similis fungemia acquired
while on left ventricular assist device support. CT revealed the
development of numerous ill-defined, nodular opacities within all lobes
of the right lung and several small areas of calcification in the right
middle and lower lobes (Figure 1). Flexible bronchoscopy with
bronchoalveolar lavage (BAL) was performed, however, broad testing
failed to yield a diagnosis. Oral antifungal therapy was continued with
plans for repeat imaging in 1 month. CT again revealed right-sided
nodules in a similar distribution, but with increased density (-200
versus -450 Hounsfield units). In addition, several left-sided nodules
had developed in the lingula and left upper lobe. Due to the clinical
history and radiographic evolution, tissue biopsy was requested. Because
of the patient’s size and peripheral location of the nodules, biopsy
using the Intuitive IonTM Robotic Bronchoscopy system
was attempted to avoid percutaneous biopsy or video assisted
thoracoscopy.