Correct!
4. 1 and 3
The patient is an immunocompromised patient presenting with non-specific and vague symptoms raising the possibility for underlying infection, particularly centered in his chest given his CT chest findings. It would be very reasonable to obtain serologic and culture data to help narrow the differential diagnosis as well as perform a bronchoscopy with bronchoalveolar lavage with transbronchial biopsy to obtain samples directly from the site of interest. Assuming worsening of RA ILD and treating with empiric corticosteroids is wrong because of the high risk for an infection.
Sputum, blood, and urine cultures were obtained which were negative. Serum beta 1,3 glucan and galactomannan were obtained and negative. A bronchoscopy was performed, and BAL was performed which was sent for cell count, bacterial, AFB, and fungal culture which showed a no significant growth of organism in 5 days of growth. A transbronchial biopsy was also performed at the time of bronchoscopy which showed non-caseating granulomas with stains negative for bacterial or fungal elements.
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