Correct!
5. All of the above
Given the complexity of the patient’s condition, all of the above actions are appropriate choices at this point in the patient’s presentation.
Infectious disease, Neurology, and Rheumatology were consulted, with recommendations including brain and head and neck MRA (given the history of central nervous system vasculitis and recent brain MRI results), repeating the echocardiogram, continuing the corticosteroid therapy but discounting antibiotic therapy to increase the likelihood of finding a causative organism, obtaining blood and sputum cultures, testing for tuberculosis, biopsying the lower extremity rash (now somewhat pruritic and nodular), sampling of the cerebrospinal fluid, and obtaining some additional laboratory data, particularly targeting rheumatological diseases and vasculitis.
Most of the patient’s rheumatological studies, including the patient’s anti-phospholipid antibody levels and cytoplasmic anti-neutrophil cytoplasmic antibody studies were negative, although the anti-nuclear antibody titer was elevated at 1:160, with a speckled pattern. Repeat transthoracic echocardiography confirmed pulmonary hypertension with preserved left ventricular systolic function, but no thrombus was seen within the left atrium or left atrial appendage. Brain and head and neck MRA showed no evidence of vascular abnormalities to suggest plaque or vasculitis; no embolic source was seen. Comparison of the recent brain MRI to a study performed 6 months earlier at an outside institution, however, revealed that some of the changes noted currently were new compared with that previous examination. Cerebrospinal fluid analysis from the lumbar puncture was showed no abnormalities; no evidence of an elevated white blood cell count or pleocytosis was noted in the cerebrospinal fluid. Blood cultures showed no growth at 3 days, testing for tuberculosis was negative, and testing for fungal antigens was also negative.
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 tenth of twelve pages)