Correct!
3. The PFTs show restrictive disease and the CT scan shows a reticulonodular pattern

The PFTs show a reduced FVC and FEV1 with an elevated FEV1/FVC; reduced TLC; and a reduced DLCO. These changes are consistent with restrictive disease. Obstructive disease is characterized by a reduced FEV1 and FEV1/FVC and usually associated with emphysema on CT scanning.

A rheumatology consult was obtained and felt that the most likely diagnosis was limited systemic sclerosis. Given the uncertain diagnosis to explain her lung findings and the atypical findings for scleroderma-associated ILD, discussed doing another lung biopsy. A decision was made to perform a cryobiopsy and the histology is shown in Figure 4.

Figure 4. Panel A: Low power view of lung biopsy. Panel B: Higher power view showing a small granuloma.

The pathology report was described as “Patchy mild airway-centered fibrosis with vague non-necrotizing granulomas in airspaces and focally increased eosinophils”.

What should be done next? (Click on the correct answer to be directed to the fourth of six pages)

1. Begin anti-reflux therapy for presumptive chronic aspiration
2. Begin anti-tuberculosis therapy
3. Begin fluconazole for presumptive Valley Fever
4. A or C
5. None of the above

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