A 41-year-old woman presented with 6 weeks history of persistent dry cough, exertional dyspnea, lethargy, a skin rash, and weight loss of 5 kg. She also noticed tender, swollen lumps associated with rash on her shins recently. She was a lifelong nonsmoker.
Physical examination showed that her body mass index was 29, respiratory rate 20/min, and blood pressure 130/70. There was no clubbing or lymphadenopathy. Cardiovascular examination was normal. There were fine crackles at the right lung base. Abdominal examination was normal. Eye and throat examinations were unremarkable. She had erythema nodosum on her shins. Urine dipstick showed mild hematuria and proteinuria.
Biochemical profile showed normal liver function tests and serum calcium. All the hematologic indices were normal. Erythrocyte sedimentation rate (ESR) was 36 (range, 10-20). Her electrocardiogram (ECG) was normal. Serum angiotensin-converting enzyme level was 132 U/L (range, 20-54).