She was seen in clinic in 2004 because of increasing shortness of breath and dry cough. Chest imaging at that time showed areas of centrilobular nodules and tree-in-bud opacities in the right upper lobe, right middle lobe, and lingula, as well as indeterminate nodules in the right lower lobe, lingula, and left lower lobe. Bronchoscopy was performed, and culture findings were positive for both Mycobacterium avium complex and Exophiala jeanselmei. Transbronchial biopsies showed mild chronic inflammation; however, there was no evidence of granulomas or fibrosis. Laboratory workup at that time was significant for an elevated rheumatoid factor (RF); however, routine chemistries, CBC count, erythrocyte sedimentation rate, urinalysis, and other serologies (complement levels and antibodies to antigens double-strand DNA, Smith, ribonucleic protein, Sjogren syndrome A, Sjogren syndrome B, centromere, cardiolipin, proteinase-3 [PR3], and myeloperoxidase were all negative).