Correct!
5. More than one of the above
The axial unenhanced chest CT shows basal, peripheral predominant ground-glass opacity and consolidation, and all of the listed diagnostic possibilities can, or characteristically, show a peripheral predominance of findings at CT. Aspiration often shows a dependent distribution, and some of the opacities are located in a dependent distribution. Non-specific interstitial pneumonia often presents with peripheral ground-glass opacity, which is present in this case; consolidation may be seen less frequently, but may occur. The lack of clearly fibrotic features at CT is less common in patients with non-specific interstitial pneumonia, but when the disorder shows a primarily cellular histopathological pattern, CT features of fibrosis may be quite inconspicuous. Both organizing pneumonia and chronic eosinophilic pneumonia often show areas of peripheral consolidation at CT. While chronic eosinophilic pneumonia may more commonly show more upper lobe predominant abnormalities, and the lack of peripheral eosinophilia is atypical for this diagnosis, the consideration of the possibility of chronic eosinophilic pneumonia remains appropriate.
A neurology consult was requested which disclosed possible submandibular gland enlargement as well as symmetric lower extremity reflexes but with absent ankle jerks bilaterally. Toe walking was abnormal bilaterally and vibratory sense in the great toes was absent bilaterally as well. Lower extremity muscular weakness was found, and relative atrophy of the right calf was confirmed. The patient also underwent a stress echocardiogram which did not show features suggesting flow-limiting coronary atherosclerosis, although the study was suboptimal given that the workload was insufficient. The echocardiogram (Figure 4) also showed moderate left ventricular muscular hypertrophy and grade 2/4 diastolic dysfunction, and longitudinal strain was reported at =14% (normal, ˂-18%).
Figure 4. 4-chamber echocardiogram shows left ventricular muscular thickening (line shows thickened interventricular septum.
Which of the following represents an appropriate test for this patient given the information so far? (Click on the correct answer to be directed to the seventh of nine pages)