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Diffuse Lung Disease |

Cavitary Sarcoidosis in Remission: Report of Clinical Course

Nada Bader, MD; Ali Saeed, MD
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University of New Mexico, Albuquerque, NM


Chest. 2013;144(4_MeetingAbstracts):447A. doi:10.1378/chest.1704982
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Abstract

SESSION TITLE: Interstitial Lung Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Cavitary sarcoid has rarely been reported in African American females. It is usually a progressive disease requiring prolonged immune suppression. Radiographic resolution of a cavity greater than 6.5cm has rarely been reported in literature.

CASE PRESENTATION: A 29-year-old African American female presented with a 2 month history of intermittent hematemesis and weight loss. She did not have any complaints of shortness of breath, fever, chills, night sweats, chest pain, cough or hemoptysis. Her medical history was significant for diabetes, hypertension and acid reflux. The chest radiograph showed a large cavity in the right mid lung field. CT scan confirmed the presence of a 6.5cm, thick walled cavity involving the right upper and middle lobe with sub-pleural nodules and peri-bronchovascular thickening. Patient was placed on airborne isolation. Three sputum samples for AFB and a basic rheumatology panel came back non diagnostic. Pulmonary were consulted for bronchoscopy. It revealed diffuse mucosal hyperemia and thickening with no endobronchial lesion in the right upper or middle lobe airway. Endobronchial biopsies performed at the primary and secondary carina revealed well-formed non-caseation granulomas with negative AFB and fungal stains. Pulmonary function testing revealed severe reduction in diffusion capacity (25%). She was started on a steroid taper. After 4 weeks she complained of exertional dyspnea and was found to be hypoxic at rest with persistent reduction in diffusion capacity. She was prescribed another steroid taper with 30 mg of prednisone as maintenance. Ventilation perfusion scan was low probability and echocardiogram revealed mild pulmonary hypertension. She returned to clinic after 6 months with significant clinical improvement. Repeat PFT showed normal spirometry and lung volumes. Diffusion capacity remained low at 9.6 ml/min/mmHg. Patient reported discontinuation of prednisone 3 months back because of poorly controlled diabetes. Patient walked a 6 minute distance with no significant desaturation or hemodynamic changes. Repeat CT of chest showed near complete resolution of sarcoid cavity.

DISCUSSION: Cavitary lesions develop in patients with severe and active sarcoidosis. In a large cohort of sarcoidosis patients, only 2% were found to have cavitation on CT scans. Histopathology of a cavitary lesion is found to have ischemic eosinophilic necrosis in the granuloma with vascular involvement of pulmonary veins. The clinical course of cavitary sarcoidosis is variable, with 25% remission and radiographic resolution. Close follow up is required to identify complications and co-infections i.e. Aspergillus.

CONCLUSIONS: Patient is now followed every 6 months with repeat pulmonary function testing. She remains in remission with persistent reduction in diffusion capacity.

Reference #1: Hours et al(2008). Pulmonary cavitary sarcoidosis: clinico-radiologic characteristics and natural history of a rare form of sarcoidosis. Medicine, 87(3),142-151

DISCLOSURE: The following authors have nothing to disclose: Nada Bader, Ali Saeed

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