Authors
Max Martin, M.D.1, Kelly Pennington, M.D.2, Jay H. Ryu M.D.2
1Division of General Internal Medicine and 2Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
Case
A 31-year-old female nurse presents with a 4-month history of progressive, exertional dyspnea. Her only associated symptoms are mild, nonproductive cough. She denies fevers, chills, weight loss, joint pains, odor sensitivity, seasonal variation, or skin changes. She previously smoked for about 1 year in her early 20s. She denies any relevant environmental exposures including molds, birds and hot-tubs. She has no family history of pulmonary disease including asthma.
Her medical history is notable only for endometriosis requiring laparoscopic vaginal hysterectomy. Her postoperative course has been complicated by recurrent urinary tract infections requiring multiple treatments of antibiotics. For the last 6 months, she has been receiving a daily suppressive antibiotic.
On exam, she is afebrile and hemodynamically stable. She is in no distress. Her cardiac exam is unremarkable. Her lungs are clear to auscultation. She has no rashes or synovitis of the large or small joints.
Complete pulmonary function tests are normal. Chest x-ray demonstrates bilateral, patchy opacities prompting further imaging. Representative images from her high-resolution chest CT is shown below:
Question
What additional information is most likely to provide the diagnosis?
A. Bronchoscopy with bronchoalveolar lavage
B. Extractable nuclear antigen antibody panel
C. Methacholine challenge test
D. Review of medication list
