How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?

In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system involvement of other diagnoses such as sarcoidosis, which could mandate treatment as well as cultures for atypical mycobacterial or other granulomatous infections. Potential noninfectious etiologies of noncaseating granulomas with giant cells include sarcoidosis or sarcoid-like reactions due to drugs, immunodeficiency, and cancer. Heavy metal granulomatosis, berylliosis, and allergic alveolitis due to silicosis are other possibilities, so a deta...

Agree with this approach. High CCP may not sway me either, but if it were an ILD case, I would then approach her as an IPAF (interstitial Pneumonitis with Autoimmune Features).