40 year old female presents for shortness of breath and cough, worsening over the last few months. She reports a history of bilateral breast implants which she is hoping to have removed due to concerns about rupture. Her symptoms recently worsened last month with fevers and increased cough, for which she received a Z pack after which she felt better and her fevers resolved. A chest X-ray at that time demonstrated "bilateral diffuse fluffy infiltrates with an area of consolidation in the right lung base". She is a never smoker and denies any fume exposures. She works from home in IT and has no pets. She denies any family history of lung disease. Her physical exam is only notable for soft bibasilar crackles. Blood tests demonstrate a normal complete blood count, complete metabolic panel, and brain natriuretic peptide.
Due to persistent symptoms she underwent a non-contrast CT chest, which demonstrated "bilateral patchy ground glass in regions of septal line thickening with crazy paving appearance". She also underwent a transthoracic echocardiogram demonstrating left ventricular ejection fraction of 65%, no wall motion abnormalities, normal diastolic dysfunction, normal appearing chambers and valves.
She next underwent bronchoscopy and bronchoalveolar lavage, which resulted in recovery of "milky appearing fluid". Periodic-Acid Schiff stain was requested which was positive.
What is the next best step?
77 year old male presents for increasing dyspnea on exertion and increasing cough. He reports that he was previously active and walked around a park every day, but over the last few weeks has been unable to walk more than a block. He reports a history of heart disease, atrial fibrillation, an unspecified arrhythmia, and high blood pressure for which he is taking amiodarone, diltiazem, apixaban, and losartan. His cardiologist has told him he is doing well on this regimen and that his arrhythmias are well controlled. He has been taking amiodarone 200mg daily for several years. He has never smoked but previously worked in a shipyard decades ago. He has no pets but until last year kept chickens. His brother died of lung cancer in his 60s but was a longtime chain smoker.
His physical examination is notable only for bibasilar crackles.
His PCP sent him for lab work and a non-contrast CT scan of his chest which demonstrated "patchy bilateral ground glass opacities throughout both lungs with traction bronchiectasis bilaterally".
Due to these findings, he is sent to Pulmonology for further evaluation.
During that time, a complete blood count, complete metabolic panel, and brain natriuretic peptide return with all values in normal range. A respiratory culture he provided grows normal flora.
Pulmonary function tests before initiating amiodarone were within normal range.
New PFTs are within the normal range except the following changes:
TLC 80% of predicted
DLCO 65% of predicted
He undergoes bronchoscopy with bronchoalveolar lavage and transbronchial biopsies.
Initial results from the lavage are negative for infectious organisms and fungal blood markers come back negative.
Pathology results from transbronchial biopsies demonstrate "intra-alveolar and interstitial macrophage collections with atypical lipid-laden or 'foamy' appearance".
Which of the following is false?
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