SESSION TITLE: Interstitial Lung Disease Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Sarcoidosis and chronic beryllium disease (CBD) share similar histopathologic features, namely the presence of non-caseating granulomas in affected tissue. While a beryllium lymphocyte proliferation test (BeLPT) can distinguish these diseases, a negative blood test does not exclude the possibility of CBD in light of known exposure. We present a rare case of tongue sarcoidosis in a patient with chronic occupational beryllium exposure.
CASE PRESENTATION: A 56 year old female presented for evaluation of pulmonary nodules. She was otherwise healthy and asymptomatic. She was a security guard at a uranium enrichment facility for decades. Physical exam showed no palpable lymph nodes or skin abnormalities. A previous CT scan showed one calcified pulmonary nodule but recent imaging showed new non-calcified nodules and mediastinal nodes, which were hypermetabolic on PET scan (Fig. 1). We performed biopsies of these lymph nodes as well as FDG-avid tongue lesions (Fig. 2). Pathology showed non-caseating granulomas in both specimens. Blood BeLPT was normal. Based on the pathologic findings, she was initiated on prednisone.
DISCUSSION: The etiology of sarcoidosis remains poorly understood. Oral sarcoidosis, particularly tongue involvement, is rare. A relationship between beryllium exposure and sarcoidosis has previously been proposed. Beryllium exposure can cause a hypersensitivity reaction resulting in granulomatous changes in tissue, causing CBD. BeLPT is specific for beryllium sensitization and clinches the diagnosis of CBD when granulomatous changes are present. However, there are concerns about the sensitivity of the test. In one Canadian study, patients with sarcoidosis and known chronic exposure to beryllium all had normal BeLPTs. False negative rates for BeLPT have been reported to be as high as 30% when patients were serially tested. It is therefore recommended that two separate samples be drawn and that testing be repeated serially in patients with ongoing exposure. Studies have suggested that BeLPT on bronchoalveolar lavage (BAL) fluid is more sensitive, as chronically sensitized lymphocytes may migrate to the lung and therefore may not be detected in blood. BeLPT may be initially negative in patients who are the process of being sensitized to beryllium, again highlighting the need for serial testing. Prednisone is the first line therapy for both sarcoidosis and CBD. In addition, CBD patients need to avoid further exposure to beryllium.
CONCLUSIONS: We present a rare case of tongue sarcoidosis in a patient with chronic beryllium exposure. Given the high false negative rate of BeLPT, distinguishing these diseases is challenging and highlights the need for serial testing.
Reference #1: Ribeiro et al. Search for chronic beryllium disease among sarcoidosis patients in Ontario, Canada. Lung. 2011 Jun;189(3):233-41.
Reference #2: Stange et al. The beryllium lymphocyte proliferation test: Relevant issues in beryllium health surveillance. Am J Ind Med. 2004 Nov;46(5):453-62.
DISCLOSURE: The following authors have nothing to disclose: Sindhu Mukku, Jessica Kynyk, Matthew Exline
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