Correct!
1. Hematogenous (“miliary”) infection
The small nodules present are very non-specific, and, while their distribution is somewhat random, the nodules are not the typical size associated with hematogenous dissemination of infection, also often referred to as “miliary” disease. “Miliary” nodules are typically about 2 mm in size, far more profuse in number, and more widely distributed throughout the lungs (Figure 4), whereas the nodules in Figure 3 are far fewer in number and somewhat spare the bases.
Figure 4. High-resolution chest CT (A-D) of hematogenously disseminated nodules, or “miliary” disease- numerous small nodules ranging in size from 1-3 mm equally distributed throughout the lungs (upper, mid, and lower lobes, centrally and peripherally) bilaterally. E, photograph of millet seeds.
Some of the nodules are subpleural and the nodules are upper lobe predominant, and therefore sarcoidosis does merit some consideration. Viral bronchopneumonia may present in a wide variety of ways, often as a more clear-cut bronchopneumonia pattern, but occasionally as non-specific smaller nodules. Similarly, lymphocytic interstitial pneumonia (LIP) may present in a very non-specific fashion. Typically the diagnosis of LIP is often associated with multiple, bilateral, thin-walled cysts, but LIP may present in numerous ways, including areas of ground-glass opacity, which may be centrilobular, as mild septal thickening, or small nodules that may be perifissural or peribronchovascular in distribution; these presentations are very non-specific. Langerhans cell histiocytosis often presents as upper lobe predominant “bizarre-shaped” cysts that evolve from nodules that cavitated, so, while non-specific, the nodules on the thoracic CT in Figure 3 could be consistent with that diagnosis.
At this point, which of the following represents the most appropriate step in this patient’s management? (Click on the correct answer to proceed to the eighth of ten pages)