SESSION TYPE: Miscellaneous Student/Resident Cases I
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Sarcoidosis is a multisystem noncaseating granulomatous disease of unknown etiology. (2) The lungs with the mediastinal and hilar lymph nodes are the most common sites of involvement.(2) The natural history of sarcoidosis is highly variable with spontaneous remission occurring in 60-70% of all cases.(2) The morbidity and mortality (1-5%) associated with sarcoidosis results primarily from pulmonary involvement.(2)
CASE PRESENTATION: A 53-year-old Caucasian female presents with shortness-of-breath for 1-month. She initially presented with a 4-month history of feeling fatigued and tired with a 60 pound weight loss. She denies fever, chills, night sweats, significant cough, wheezing, or hemoptysis. She has a past medical history of diabetes type II, hypertension, and COPD. Examination revealed bilateral coarse crackles, normal S1-S2 without murmur or pericardial rub, and no edema. Chest x-ray showed diffuse miliary pattern of both lungs. CT-scan showed mediastinal and hilar lymphadenopathy with nodular opacities suggestive of lymphoma or bilateral malignant lymphangitic spread to both lungs. Her laboratory evaluation showed CBC and CMP within normal limits, CA 19-9 of 9 U/mL, and CA-125 of 63 U/mL. She was referred to oncology and diagnostic studies revealed an abnormal PET-scan suggestive of metastases to both lungs. CT-guided periaortic lymph node biopsy was unsuccessful. Bronchoscopy showed irregularity of the lower right and left lung fields. Right middle lobe biopsies revealed noncaseating granulomas with multinucleated giant cells suggestive of sarcoidosis. Bronchoalveolar lavage cytology was negative. No microorganisms were identified with routine, fungal, or AFB stains. Serum angiotensin-converting enzyme was normal. She was diagnosed with miliary sarcoidosis and started on prednisone 60-mg, ipratropium bromide/albuterol inhaled, and oxygen 2-liters.
DISCUSSION: A diagnosis of sarcoidosis depends on the radiology pattern, presence of noncaseating granulomatous inflammation, and negative fungal and AFB cultures. Classic parenchymal abnormalities of sarcoidosis are reticulonodular, acinar, fibrotic, and nodular patterns.(1) A diffuse milliary pattern presents in approximately less than 2% of cases.(1)
CONCLUSIONS: To my knowledge, this case represents a rare presentation of sarcoidosis. The purpose of presenting this case report is to raise awareness amongst clinicians to consider this clinical entity as a differential diagnosis when bilateral miliary-type lesions of both lungs is identified on chest x-ray.
1) Kirks, D.R.; McCormick, V.D.; and Greenspan, R.H. (1989) Pulmonary Sarcoidosis, Roentgenologic Analysis of 150 Patients. Radiology, Vol. 177, No. 4. 777-786.
2) Staton, G.W. and Ingram, R.H. Chronic Diffuse Infiltrative Lung Disease. In: D.C. Dale and D.D. Federman (Eds.) ACP Medicine, 3rd Edition: Volume 2. 2007. New York, NY: WebMD. 2769-2774.
DISCLOSURE: The following authors have nothing to disclose: Kevyn Stroebe, Hassan Haddadin
No Product/Research Disclosure InformationPacific Northwest University of Health Sciences, Yakima, WA