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The Boiling Patient: A Rare Presentation of Sarcoidosis FREE TO VIEW

Anthony Cucci*, MD; Khalil Diab, MD; Aliya Noor, MD
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Indiana University, Indianapolis, IN

Chest. 2012;142(4_MeetingAbstracts):985A. doi:10.1378/chest.1390282
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SESSION TYPE: Miscellaneous Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is an idiopathic multi-systemic disease in which the underlying pathology is characterized by the formation of non-caseating granulomas within various organs. Clinical presentation can vary markedly and symptoms typically are associated with the pattern of organ involvement. Such symptoms range from dry cough and dyspnea to vague constitutional symptoms including fatigue, malaise, and low-grade fevers. We describe a rare case of sarcoidosis in which our patient’s presenting symptom was persistent high grade fevers for seven weeks in the absence of any localizing symptoms.

CASE PRESENTATION: A 40-year old caucasian male presented to our hospital with a seven week history of high grade fevers and 35-pound weight loss. His temperature was noted to be as high as 105° F on a few occasions. The fevers persisted in spite of multiple courses of empiric antibiotics in the outpatient setting. Other than extreme weakness, poor appetite, and relentless fever, our patient had no other localizing symptoms . His examination was impressive only for a temperature of 103° F. Initial labs were impressive for a white count of 1,600 cells/mL, hemoglobin of 9.2 g/dL, and platelet count of 121,000/µL; along with an elevated Angiotensin Converting Enzyme (ACE) level of 122 units/L. Chest CT was impressive for precarinal lymphadenopathy, diffuse nodular infiltrates with interlobular septal thickening, and hepatosplenomegaly. He subsequently underwent lung, liver, and bone marrow biopsies. Pathology showed non-caseating granulomas from all three sites. Acid fast and periodic acid-Schiff staining on all biopsy specimens failed to reveal any mycobacteria, yeast, or other fungal elements. Further work-up with fungal serologies and antigens, along with T-spot testing were negative. The diagnosis of sarcoidosis was made and he was started on high dose methylprednisolone. His fevers subsequently subsided and his treatment was eventually transitioned to oral prednisone at the time of discharge.

DISCUSSION: Sarcoidosis can vary in presentation, duration, and severity of symptoms. Though low grade fevers can be a relatively common symptom, our patient presented with fevers as high as 105° F for over seven weeks. To our knowledge there have been very few cases describing isolated high grade fevers as a presenting feature of sarcoidosis.

CONCLUSIONS: In conclusion, sarcoidosis should always be considered in the differential for patients with high grade fevers of unknown etiology. It must be emphasized that patients with non-caseating granulomas must be ruled out for presence of mycobacterial infection and disseminated fungal disease before the diagnosis of sarcoidosis is made.

1) Nunes H, Soler P, Valeyre D. Pulmonary Sarcoidosis. Allergy 2005; 60: 565-582

DISCLOSURE: The following authors have nothing to disclose: Anthony Cucci, Khalil Diab, Aliya Noor

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Indiana University, Indianapolis, IN




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