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.