Correct!
1, 3, 4 or 5
A diagnosis can be unclear making the direction to proceed uncertain. This appears to be one of those situations. Granulomata are a nonspecific finding seen with many diseases including infectious diseases (tuberculosis, Valley Fever) and noninfectious diseases (sarcoidosis, aspiration pneumonia). The biopsy really does not establish a diagnosis and treatment for presumptive Valley Fever in the Southwest US or aspiration would not be wrong. The risks of anti-tuberculosis therapy outweigh the chances of her disease proving to be tuberculosis in my opinion. A decision was made to follow the patient. She continued her treatment with azathioprine and was placed on anti-reflux therapy. After 6 months she returned and was feeling increasingly short of breath and her CT scan was repeated (Figure 5).
Figure 5. Representative images in lung windows from repeat thoracic CT scan.
The scan was interpreted as showing an increase in the number of nodules. There was some nodularity along pleura and fissures. Some of the nodules contained internal air bronchograms.
Which of the following should be done? (Click on the correct answer to be directed to the fifth of six pages)