5. All of the above

In order to determine if his increasing shortness of breath is secondary is secondary to progression of his interstitial lung disease it will be necessary to obtain his baseline data and compare it with his current data.

His pulmonary function testing is shown in figure 1 and his CT scans are shown in figure 2.

Figure 1. Pulmonary function tests from 2011 and 2018.

Figure 2. representative images from thoracic CT scan in 2011 and 2018.
His lung biopsy was requested and mailed, however, only the report was available at that time. The report read “nonspecific interstitial pneumonia pattern with mild interstitial inflammation accompanied by fibrosis.   Differential diagnosis would include drug reaction, systemic autoimmune disease or idiopathic nonspecific interstitial pneumonia.”

Rheumatological work up including rheumatoid factor, anti-nuclear antibody, erythrocyte sedimentation rate, C-reactive protein, anticitrulline antibody, antineutrophil cytoplasmic antibodies, antiglomerular basement membrane were all negative.

What should be done at this time? (Click on the correct answer to proceed to the third of five pages)

  1. Begin pirfenidone or nintedanib
  2. Bronchoscopy with bronchoalveolar lavage to assess for alveolitis
  3. Continue to observe with one-month follow-up
  4. Repeat the lung biopsy
  5. Retreat with prednisone followed by azathioprine