A 55-year-old male with a 30 pack-year smoking history presents with a 3-month history of progressive dyspnea and dry cough. He denies fever, night sweats, or weight loss. Vital signs: HR 92/min, RR 22/min, BP 138/86, SpO2 88% on room air, Temperature 37.2°C. Physical examination reveals bilateral hilar lymphadenopathy on chest X-ray. Laboratory studies show serum calcium 11.8 mg/dL (normal 8.5-10.5), ACE level elevated at 68 U/L (normal <30), and normal 24-hour urine calcium. Tuberculin skin test is negative. Lung biopsy demonstrates noncaseating granulomas with multinucleated giant cells. Which of the following best explains this clinical presentation?

1. A)Tuberculosis—caseating granulomas with acid-fast bacilli would be present on histology
2. B)Histoplasmosis—fungal elements would be visible on biopsy and caseating granulomas are typical
3. C)Hypersensitivity pneumonitis—would show lymphocytic infiltration with poorly formed granulomas and requires antigen exposure history
4. D)Chronic beryllium disease—noncaseating granulomas present but requires beryllium exposure history and abnormal beryllium lymphocyte proliferation test
5. E)Sarcoidosis—noncaseating granulomas, negative TST, elevated serum ACE, and hypercalcemia are classic findingsGABARITO