Correct!
5. All of the above
The diagnosis at this point is unclear. Since the elevated IgG antibodies to coccidioidomycosis are equivocal, the more specific complement fixation test is indicated (1). Quantiferon is indicated to rapidly evaluate for tuberculosis. Bronchoscopy is indicated to evaluate for cancer as well as to assure adequate cultures. Rheumatologic testing is indicated because of the lung nodules as well as the microscopic hematuria.
On bronchoscopy blood was noted in both mainstem bronchi. A bronchoalveolar lavage (BAL) was performed of the right middle lobe. The return became sequentially bloodier with each aliquot. The coccidioidomycosis complement fixation test was 1:2 (normal < 1:4). Quantiferon was negative. Erythrocyte sedimentation rate was >100 mm/hr (normal < 20), C-reactive protein was elevated 141 mg/dL (normal <6), perinuclear anti-neutrophil cytoplasmic antibody (pANAC) and myeloperoxidase (MPO) antibody were both positive. Creatinine was normal although there was moderate hemoglobin present on repeat UA.
Extractable nuclear antibody (ENA), anti-nuclear antibody (ANA), cytoplasmic ANCA (anti-PR3, cANCA), and anti-glomerular basement membrane (GBM) were all negative.
Which of the following is the most likely diagnosis?