A 40-year-old male smoker presents with a history of chronic cough.

A 40-year-old male smoker presents with a history of chronic cough. He has had symptoms of an upper respiratory illness for a few months since visiting family in Arizona. Physical exam is normal. CXR is shown below in Fig. below. The next step in management should be:

a. Complete pulmonary function tests
b. Fiberoptic bronchoscopy
c. Percutaneous needle biopsy
d. Observation and repeat CXR in 6 to 8 months

This chest x-ray shows a radiographically dense nodule in the left hilum. Cardiophrenic and costophrenic angles are clear. An 0.8 × 1-cm circular solitary pulmonary nodule with peripheral yet distinct calcification in the superior aspect is seen overlying the 5th posterior rib in the right upper lung zone.

The answer is c. Based on the age of the patient, risk factors, and persistent symptoms, further diagnostic tests are warranted. Observation for 11 months is inappropriate. Due to the peripheral nature of this lesion, a CT-guided needle biopsy would be the best diagnostic strategy and have a better yield than a bronchoscopy. Pulmonary function tests would be helpful if surgery is planned, but would not alter the diagnostic steps. In this case, the CT-guided biopsy revealed coccidioidomycosis. This is caused by a fungus (Coccidioides immitis) in the soil and is seen in desert semiarid climates with a short, intense rainy season. It is endemic in southwestern North America, Mexico, and Central and South America. Most patients are asymptomatic or recover fully after initial flulike illness. The radiographic findings of coccidioidomycosis are variable and depend upon the severity of the disease. Most granulomas are smaller than 2 cm, and almost all are less than 3 cm in size. Besides SPNs, in the early stages of coccidioidomycosis patchy infiltrates may be accompanied by hilar and mediastinal adenopathy and less frequently by pleural effusion. In cases of persistent disease, infiltrates may enlarge.