Dyspnea and a LUL mass

Here's a case from Arenberg:

This is 69-year-old lady with coronary artery disease, diastolic congestive heart failure, and dyspnea on exertion. She came to see me because her cardiologist said she has been experiencing increased dyspnea out of proportion to her normal symptoms for ~3 months. Other than a pacemaker over her left chest, her plain chest x-rays were normal

and her pulmonary function tests were mildly restrictive (FVC ~69%), actually improved from her last testing ~ 4 years prior.

I got a VQ scan that was normal, but only on her second visit (when I actually asked) did I learn that she has had 2 birds as house pets for the last 3 years. She further revealed that she has felt unwell going back about 2-1/2 years. One of the birds was in fact sick, and during this time, she fed the bird from mouth to mouth. Yes, I am serious. She was DEAD SET against getting rid of the birds, so I got a CT scan in anticipation of doing a bronch, to prove she had HP.

The CT showed very subtle changes of ground glass, and was actually read as no evidence of ILD, but surprise surprise, she now had a LUL mass that was not seen on the CXR taken 2 months earlier. The radiologist thought it was likely to be inflammatory. What would you do?

I have more images, and some cool pictures to follow, but I’ll hold onto them until people have a chance to comment.


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UPDATE:
"...good evidence for chronic HP in the form of a patchy chronic
bronchiolitis that includes occasional multinucleated giant cells of the
sort commonly seen in that condition"

Comments from our pathologist.