SESSION TYPE: ILD Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Sarcoidosis, an immune-mediated granulomatous disease of uncertain etiology, is often a diagnostic challenge. While typical radiographic features such as reticulonodular opacities and hilar adenopathy may aid the clinician, confirming the diagnosis frequently requires tissue demonstrating noncaseating granuloma and exclusion of the other myriad causes of granulomatous disease. Oftentimes typical radiographic features are absent, contributing to the challenges clinicians face in confirming a diagnosis.
CASE PRESENTATION: A 53 year old African American man with no significant past medical history presented to his primary physician's office for evaluation of sudden onset chest pain and minimal dyspnea following a cough. He was sent to the Emergency Department where a chest x-ray demonstrated a left-sided pneumothorax; a chest tube was inserted. He was afebrile and normotensive. His heart rate was 94 beats per minue. His oxygen saturation was 96% breathing room air. There was no evidence of subcutaneous emphysema. The chest tube was in place and there were crackles and reduced air entry on the left side. The remainder of his exam was normal. A computed tomography (CT) scan demonstrated bilateral upper lobe cavitary opacities and reticulonodular opacities distributed along the bronchovascular bundles bilaterally. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was performed in the left upper lobe. Smears for acid-fast bacilli and fungal elements were negative. Pathology revealed well formed non-caseating granulomas. Given his demographics, exclusion of infectious etiologies and typical pathologic findings, a diagnosis of sarcoidosis was made.
DISCUSSION: It is important to include sarcoidosis in the differential diagnosis of a cavitary opacitiy identified on CT chest. While more typical of infectious etiologies such as tuberculosis and fungal disease, cavitation certainly does not exclude noninfectious etiologies such as sarcoidosis. A proposed mechanism of cavitation is ischemic necrosis with extrusion of hyaline material from conglomerate sarcoid granulomas. In the appropriate clnical-radiographic context, i.e. young African American person, associated reticulonodular opacities along the bronchovascular bundles and along they lymphatic chains, we have learned that sarcoidosis can present with cavitary opacities.
CONCLUSIONS: In the appropriate clinical and radiographic context, sarcoidosis can present with cavitation and pneumothorax; the finding of reticulonodular opacities along the bronchovascular bundles and lymphatic chains in this setting should alert the clinician of a possible non-infectious etiology of the presenting complaints.
1) Criado et al. Pulmonary Sarcoidosis: Typical and Atypical Manifestations at High-Resolution CT with Pathologic Correlation. RadioGraphics 2010; 30:1567-1586.
2) Brauner et al. Pulmonary sarcoidosis: evaluation with high-resolution CT. Radiology. 1989 Aug;172(2):467-71.
DISCLOSURE: The following authors have nothing to disclose: Ahmad Abdelwahed, Vishal Patel, Lavanya Irugulapati, Jeremy Weingarten
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