Correct!
1. The thoracic CT shows interlobular septal thickening, pleural and pericardial effusions, and lung nodules
Thoracic CT shows a moderate-to-large right pleural effusion, a moderate pericardial effusion, mediastinal lymph node enlargement, right lung nodules, and multifocal, right-sided liner opacities representing interlobular septal thickening. There is no evidence of features suggesting fibrotic lung disease- such as architectural distortion, traction bronchiectasis, or honeycombing- to suggest either a fibrotic interstitial pneumonia or post-inflammatory scarring. While the interlobular septal thickening may appear slightly nodular in some areas, and larger right lung nodules are evident, a “miliary” pattern is not present. Importantly, no left lung nodules are seen, and a random dissemination pattern should show fairly diffuse, and certainly bilateral, abnormal findings. Perilymphatic nodules, often seen in patients with sarcoidosis, appear as small nodules along the central and peripheral bronchovascular interstitium as well as studding the visceral pleural surfaces; such a pattern in not evident on this CT scan.
A thoracic CT performed at an outside institution 3 months earlier (Figure 4) was obtained.
Figure 4. Static representative axial thoracic CT images displayed in lung windows performed 3 months prior to CT obtained at presentation (Panels A-D). Lower panel: movie of CT scan performed 3 months prior to presentation in lung windows.
This examination showed abnormalities similar to what was noted at the presentation thoracic CT (Figure 3), although these abnormalities were less pronounced. No tissue diagnosis was attempted at this time.
Which of the following represents the next most appropriate step for the evaluation of this patient? (Click on the correct answer to proceed to the next panel)