From the Research
The most appropriate biopsy for a patient with ground glass opacities on CT, petechial rash, elevated CRP, and peripheral eosinophilia would be a transbronchial lung biopsy. This procedure allows for direct sampling of lung tissue while being less invasive than surgical options. The constellation of findings suggests an eosinophilic lung disease such as eosinophilic pneumonia or possibly a vasculitic process with pulmonary involvement. The transbronchial approach is preferred because it can access the areas of ground glass opacities seen on CT while providing adequate tissue for histopathological examination, including special stains to identify eosinophilic infiltration. Bronchoalveolar lavage should also be performed during the bronchoscopy to analyze cell counts and differentials, which can further support the diagnosis by demonstrating increased eosinophils in the lavage fluid, as seen in cases of eosinophilic pneumonia 1.
Some studies have reported atypical presentations of sarcoidosis with predominant ground glass opacity on high-resolution CT scans, which can be confirmed only based on pathological examination of the resected tissue 2. However, the presence of peripheral eosinophilia and petechial rash in this patient makes eosinophilic lung disease a more likely diagnosis. The procedure is typically performed under moderate sedation and carries less risk than surgical lung biopsies. If the transbronchial biopsy yields insufficient tissue or inconclusive results, a surgical lung biopsy via video-assisted thoracoscopic surgery (VATS) may be necessary as a second-line approach to obtain larger tissue samples. It is also important to consider other potential causes of ground glass opacities, such as malignancy, and to rule out these conditions with appropriate diagnostic testing, as seen in a case report of breast cancer metastasis to the lung presenting with ground glass opacities 3.
In terms of prioritizing morbidity, mortality, and quality of life, a transbronchial lung biopsy is a relatively safe procedure that can provide a definitive diagnosis and guide treatment, potentially improving patient outcomes. The most recent and highest quality study supporting this approach is from 2019, which highlights the importance of considering eosinophilic lung disease in patients with ground glass opacities and peripheral eosinophilia 1. Overall, a transbronchial lung biopsy is the most appropriate initial biopsy procedure for this patient, given the clinical presentation and potential diagnoses.