A 56-year-old woman with COPD was referred to the pulmonary clinic for the evaluation of multiple pulmonary nodules. One month prior, a routine chest radiograph (Fig 1
) revealed a left upper lobe nodule. She denied cough, fevers, shortness of breath, weight loss, night sweats, or chest pain. She had a long history of dyspnea on exertion that was unchanged from her baseline values. Three years prior, COPD had been diagnosed based on the results of pulmonary function tests and a CT scan of the chest showing moderate-to-severe emphysema. No nodules were seen at that time. She had no other significant medical history, and was receiving only fluticasone, nasal budesonide (Rhinocort; AstraZeneca; Wilmington, DE), and hormone replacement therapy. The patient was a 30-pack-year tobacco smoker and had quit 8 years prior. She reported a 10-year history of heavy marijuana use and continued to smoke marijuana cigarettes daily. The findings of a recent Papanicolaou smear as well as a mammogram had been negative. She denied any occupational exposures, recent travel, or HIV risk factors. The findings of a review of her physiologic systems were negative for symptoms suggestive of collagen vascular disease.