Correct!
4. 1 or 3
Most likely she has had a recurrence of her radiation pneumonitis when the corticosteroids were tapered. If there was a suspicion of another process bronchoscopy could be performed. Tacrolimus is generally not used for radiation pneumonitis (1). She was again started on prednisone with clinical improvement. She was tapered off prednisone in January, 2016, but her symptoms of dyspnea and cough returned. She was referred for a second opinion.
In addition to the thymic carcinoid tumor, she has a past medical paroxysmal atrial fibrillation, hypertension, and hypothyroidism. Her medications included
apixaban, levothyroxine, and diltiazem. She had a minimal smoking history of 5 pack years having quit in 1974. Her physical exam showed a few crackles on right but was otherwise unremarkable. Laboratory evaluation revealed a normal complete blood count with a normal differential and an elevated C-reactive protein.
A repeat thoracic CT scan was obtained (Figure 4).
Figure 4. Two views in lung windows from the repeat thoracic CT scan.
What should be done at this time? (Click on the correct answer to proceed to the fifth of six pages)