Is this BOOP, Y-J?

41 yo male who works for a satellite dish installation company presented with progressive dyspnea over a couple of months. An urgent care CXR was (+) for a nodule in the R mid lung field, and he was referred to his PCP; he received no intervention at that time. He was lost to f/u and ultimately presented with progressive symptoms one month later. His PCP obtained a CT (see below) and he was sent to be admitted. Upon seeing him, he look chronically ill, but not toxic.









I bronched him, and it was non-diagnostic. I sent him for a surgical biopsy.
The report was read as BOOP with an microscopic sulfur granules c/w actinomycosis.

I started him on Augmentin and saw in the office in 3 weeks.
He was no better. Spiro was c/w were moderate restrictive vent defect.

So, I started him on steroids at 40 mg/day of prednisone x 3 weeks then 30 mg/day.
I saw him 4 weeks later (about 1 week into his 30 mg/day) without any clinical improvement.
His full PFT's are c/w mild obstruction with air trapping and impaired gas exchange (DL ~70% predicted). He is a smoker, and is still smoking about 1/2 ppd.

I had his biopsy reviewed by Jeff Myers at U of M (profoundly smart and helpful- wish he would have joined the faculty 5 years sooner), but he thought the original interp was correct.

Now what?