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Diffuse Lung Disease |

Sarcoidosis Presenting as Bilateral Leg Lymphedema: A Case Report FREE TO VIEW

Viral Patel, MD; Abhay Vakil, MD; Punit Jariwala, MD; Kelly Cervellione, PhD; Artur Shalonov, MD
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Jamaica Hospital Medical Center, Jamaica, NY


Chest. 2014;145(3_MeetingAbstracts):229A. doi:10.1378/chest.1826517
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Abstract

SESSION TITLE: ILD Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Sarcoidosis, a multisystem granulomatous disorder, has variable clinical presentations. Though most of the diagnosed cases are asymptomatic or present with pulmonary, ocular, cardiac or neurologic manifestations, there have been fewer than dozen cases reported, initially presenting with lower leg edema. We report the case of a patient presenting with bilateral leg edema and generalized lymphadenopathy without any pulmonary symptoms. Lymph node biopsy revealed non-caseating granulomas consistent with sarcoidosis.

CASE PRESENTATION: A 26-year-old African-American male, with no medical history, presented with bilateral lower leg swelling and pain for 3 weeks. He denied having cough, fever, difficulty breathing or any recent illness. He reported heavy smoking and had multiple sexual partners. He was afebrile with saturation of 98% on room air. Physical examination revealed generalized lymphadenopathy and 3 +, non-tender, non-pitting bilateral lower extremity edema. Laboratory studies including calcium level were within normal limits. Peripheral blood smear was reported to be normal. HIV test was negative. Imaging studies showed diffuse mediastinal and inguinal lymphadenopathy with scattered nodular opacities in both lungs. Chest X-ray showed bilateral hilar lymphadenopathy. CT chest showed diffuse mediastinal and inguinal lymphadenopathy with scattered nodular opacities in both lungs.(Image 1) Excisional biopsy of the inguinal lymph node showed diffuse confluent non-necrotizing granulomas consistent with sarcoidosis.(Image 2) The patient was treated with oral steroids, showing improvement in leg edema.

DISCUSSION: To the best of our knowledge, only 8 cases of sarcoidosis presenting initially with bilateral lymphedema have been reported, with 6 cases (75%) being in men and 5 cases (63 %) being of African-American ethnicity. Common obstructing lymph nodes in the reported cases include those in the inguinal (88%) and retroperitoneal (12%) regions. With steroids being the main therapy for sarcoidosis, 40 mg prednisone for 1 month has shown to cause marked improvement in edema symptoms. However, 6 month therapy has been recommended, as dose reduction often leads to recurrence.

CONCLUSIONS: This case illustrates the importance of including sarcoidosis in the differential diagnoses of patients presenting with unexplained lower leg edema. Such patients require at least 6 month steroid therapy for complete resolution of edema symptoms.

Reference #1: A rare case of sarcoidosis with bilateral leg lymphedema as an initial symptom. Am J Med Sci 1999;318(6):413-414.

Reference #2: Nathan MP, Pinsker R, Chase PH, Elguezabel A. Sarcoidosis presenting as lymphedema. Arch Dermato 1974;109(4):543-544.

Reference #3: Sweeney T, Ramsby G, Keohane M. Edema of the lower extremities secondary to obstructive sarcoidosis. Angiology 1980;31(1):69-71.

DISCLOSURE: The following authors have nothing to disclose: Viral Patel, Abhay Vakil, Punit Jariwala, Kelly Cervellione, Artur Shalonov

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