More data on "Abnormal CxR"

This is the 64-year-old man with progressive, worsening dyspnea described below.
Initial blood cultures and sputum culture were non-revealing. His ESR was 75 with a positive ANA screen but essentially negative titers (<1:40); U/A was unimpressive, renal function was normal, initial CBC had mild anemia (Hgb 12.6) but normal WBC (7.6 with 90% PMNs) and normal platelets.
What other tests/info would you like next?

Abnormal CxR

This is a very pleasant, 64-year-old man with progressive worseningdyspnea over the past couple of months. He states that up until maybe six months ago he had been in his usual state of health and had no persistentdyspnea. For the past 3-4 months he has had insidious onset of dyspnea on exertion, which has been worsening. He has had no associated cough, no chest pain, no fever, no chills and no night sweats. He denies any significant paroxysmal nocturnal dyspnea, though he does have some component of orthopnea. He has never had hemoptysis. His weight has been stable. He actually has gained some weight in the past couple of years. He has had no previous label of severe chronic lung disease.

PAST MEDICAL HISTORY: Significant for some hypertension.He had been diagnosed with mediastinal and hilar adenopathy some 15 yearsago, according to the patient. He actually underwent a bronchoscopy atthat time, but was not found to have any significant evidence ofmalignancy. He has never had a sleep study. The films and reports on his adenopathy are in a Mississippi and not available...
SOCIAL HISTORY: He used to smoke, but quit about 15 years ago when he was diagnosed with the mediastinal and hilar adenopathy. He worked in freight mostly at docks and driving transport. No alcohol abuse, no illicit drug use. He used to live in Mississippi (now here in TN). He has no exposure to sick contacts. He lives with his wife and they have no pets. No alcohol abuse, no illicit drug use.
FAMILY HISTORY: Is remarkable for his sister having pulmonary fibrosis, but we are not sure as to what type. She apparently is on oxygen 24/7.
REVIEW OF SYSTEMS is otherwise fairly unremarkable.
PHYSICAL EXAMINATION: Afebrile. Only pertinent positives are some faint right basilar crackles which actually cleared withcough. He has slightly diminished breath sounds at the bases. I could not appreciate any wheezing. He has no edema, no clubbing and no cyanosis.
CxR and CT as below. What do you think and how would you work him up?

Hemoptyis and bilateral infiltrated UPDATE

The case below was posted last week. Since that time I obtained a high res CT and autoimmune panel. The ANCA and ANA were normal. The BAL (clear non-bloody) was negative for any infection. The cell count of about 500 was predominantly macrophages. He is still short of breath (mostly on exertion but to a lesser extent at rest). He has no fevers or other constitutional symptoms. No more hemoptysis.

CT (no hilar adenopathy, by the way):


63 year old man with one week of hemoptysis. The hemoptysis is described as streaks of blood with the underlying sputum being slighltly light green or white. No malaise. Just some shortness of breath. No fevers or night sweats. No anorexia or weight loss. He feels pretty well except for the mild increase in SOB.
He is a 48 pack year smoker now quit. No significant exposure or travel history. For what its worth (if anything), he was cleaning out his gutters about a week before the symptoms. Lots of decayed leaves etc.

On exam he is WNWD and NAD. Vitals and pulsox are normal. No LAD and the lungs are clear to auscultation.

His WBC is 14 and in June it was 7.
His xray from 3 years ago:




The xray from today is seen here:



He has persistent dyspnea despite a course of azithro for presumed mycoplasma. The BAL was negative for virus or fungi.
His new cxr is here:


What is your differential dx?

TB pericarditis

Submitted by IS:

What are your opinions regarding the use of adjuvant steroids for presumed TB pericarditis? Do you think a pericardial biopsy is a must if we have a positive PPD, negative cytology of fluid, low glucose on fluid studies, and good clinical history? Thanks.