Correct!
4. 1 and 3
The next diagnostic step is probably bronchoscopy. Coccioidomycosis was thought to be unlikely although still within the diagnostic possibilities. Beginning fluconazole would not necessarily be wrong. A rheumatology consult was ordered and a number of serologic tests were ordered. Scl-70 and anti-nuclear antibody were positive, however, the consultant thought rheumatologic disease was unlikely. A bronchoscopy with transbronchial biopsy was performed. No organisms were seen on Gram, acid-fast, or silver stains. The biopsy was interpreted as showing “cryptogenic organizing pneumonia”. Cryptogenic organizing pneumonia (COP), formerly known as bronchiolitis obliterans organizing pneumonia (BOOP), is an inflammation of the bronchioles (bronchiolitis) and surrounding tissue in the lungs (4). It should not be confused with bronchiolitis obliterans, a form of non-infectious pneumonia. It is often a complication of an existing chronic inflammatory disease such as rheumatoid arthritis, dermatomyositis, or it can be a side effect of certain medications such as amiodarone.
Which of the following should be done next? (Click on the correct answer to be directed to the fifth of seven pages)