#Diffuse bilateral pulmonary granulomatous disease.
CXR and CT – chest show diffuse bilateral 1-3mm nodules, consistent with granulomatous disease.
For workup, will order:
-Histoplasma Antigen, urine
-Histoplasma Antigen, blood
-Blastomyces Antibody
-Coccidiodes Antibody.
-HIV screen
-Angiotensinogen I Converting Enzyme (ACE)
-Myeloperoxidase Antibody (C-ANCA specific Antibody)
-ESR, CRP, Procalcitonin.
-MRSA screen culture (Nasal, nares, nurse collect)
-Consult ID in AM. Despite his risk factors for TB, PTB is still unlikely. Will hold off on AFB stain for TB until ID evaluates patient. However, for now, we will keep in isolation until a formal ID evaluation.
-Will need pulmonary consult as well.
-Urine Drug Screen
Sample Board Case:
Male in the mid-30s, smokes 1 pack/day. Is a construction worker with a history of histoplasmosis contracted on a TN farm, s/p treatment and residual granulomas, meth abuse, imprisonment for selling drugs. He presents with a 3 day history of cough, ?hemoptysis, n/v/d, HA, n/v, generalized weakness, fever, chills, and night sweats. In rehab now for drug use. He denies recent travel.
CT chest had shown multiple calcified granulomas which appear chronic and hilar lymphadenopathy but no signs of acute infiltrates especially in the apical area. Out of an abundance of caution, the patient is now in isolation.
How do you work up? As above.