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A 43-Year-Old White Man Comes to the Office Due to a 4-Week

question 646

Multiple Choice

A 43-year-old white man comes to the office due to a 4-week history of malaise, profound fatigue, and cough. Over the last 3 days, he has noticed streaks of blood in his sputum. Since childhood, the patient has had mild, intermittent asthma that has been well controlled with as-needed albuterol and has not required hospitalization. Four months ago, the patient experienced pain and blurry vision in the right eye, which spontaneously improved over several days; he did not seek medical attention. The patient has no other medical issues, and family history is negative for cancer and rheumatic disease. He is a lifetime nonsmoker and has not traveled recently.
Temperature is 37.9 C (100.3 F) , blood pressure is 135/70 mm Hg, and pulse is 92/min. BMI is 23 kg/m². Visual acuity is normal and extraocular movements are not restricted. Several small oral ulcerations are present, but there are no skin rashes or lymphadenopathy. Bilateral scattered rhonchi are present on lung auscultation. Heart sounds are normal. Abdominal examination reveals no organomegaly. Laboratory results are as follows:
Urinalysis shows 3+ protein, 30-50 erythrocytes/hpf, and 2-3 leukocytes/hpf. Chest x-ray reveals several ill-defined nodules with cavitation in both lungs.
Which of the following is the most likely diagnosis?

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