5. Chest radiography shows numerous small nodular opacities

The frontal and lateral chest radiograph shows multiple, small, bilateral mid- and lower lung predominant nodular opacities, possibly with a faint branching configuration, but no pleural effusion or mediastinal or peribronchial lymph node enlargement is present. Lung volumes appear normal and no basal predominant reticulation to suggest fibrotic lung disease is seen. The hear is upper normal in size, but marked cardiomegaly is not present. While nodular opacities are evident in the lungs bilaterally, no cavitary lesions are seen.

The patient’s prior medical records were obtained, and it was learned that the biopsy of lower extremity erythema nodosum grew Actinomyces israelii. At this time in another institution she underwent bronchoscopy for complaints of worsening shortness of breath, with negative results for Pneumocystis, but culture results were still pending.

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 third of twelve pages)

  1. 18FDG-PET scan
  2. Chest CT
  3. Repeat bronchoscopy with transbronchial biopsy
  4. Surgical lung biopsy
  5. Thoracic MRA