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Diffuse Lung Disease |

I Think It's Sarcoid - When Do We Stop Our Workup? FREE TO VIEW

Jamil Taji, MD; Som Chalise, MD; Darla Theobald, APN; Sara Shorter, APN
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Mayo Clinic Health System, Mankato, MN


Chest. 2014;145(3_MeetingAbstracts):211A. doi:10.1378/chest.1835756
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Abstract

SESSION TITLE: ILD Case Report Posters II

SESSION TYPE: Case Report Poster

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

INTRODUCTION: Sarcoidosis is a well described disease that is in the differential of many pulmonary diseases. This case highlights a dilemma where sarcoidosis was strongly suspected despite the unusual presentation but malignancy still had to be aggressively ruled out.

CASE PRESENTATION: A 52 year old nonsmoking white male is referred after an abnormal chest x-ray done as part of a workup of cough with no other symptoms. A subsequent CT confirmed a 1.9 cm right upper lobe spiculated mass, bilateral noncalcified pulmonary nodules, and mediastinal and right hilar adenopathy. A PET CT scan showed significant uptake in all these lesions. It also showed uptake in the right scapula, spine and pelvis. An MRI of the spine revealed disease in C1, C4, C6 and T1 vertebrae. The appearance of the lesions on MRI all favored metastatic disease. Bronchoscopy was performed and biopsies showed noncaseating granulomas. All other workup including infectious was negative. A mildly elevated calcium at 10.6 mg/dL was all that was found. Because of the persistent concern for malignancy, a C6 surgical biopsy was pursued which confirmed noncaseating granulomas and thus Sarcoidosis.

DISCUSSION: Sarcoidosis is a multisystem idiopathic disease that is characterized by the presence of noncaseating granulomas. The most common areas of involvement are the Lungs, with more than 90% of cases involving them, and the lymph nodes. In the skeletal system the prevalence is anywhere from <1% to 13% with this almost always affecting the peripheral skeleton; most commonly the small bones of the hands and feet. Involvement of the axial skeleton is rare. Involvement of the axial skeleton, the scapula and the pelvis is very rare.

CONCLUSIONS: It is well established that Sarcoidosis can be mistaken for malignancy and in this case it also masqueraded as convincing metastatic disease to the bones. As such, despite the bronchoscopic biopsy, further invasive evaluation was undertaken. Cases like this further prove that we don’t really know with certainty how early we can safely diagnose Sarcoidosis with all its many faces.

Reference #1: Talmi D, Smith S, Mulligan ME. Central skeletal sarcoidosis mimicking metastatic disease. Skeletal Radiol. 2008 Aug;37(8):757-61

Reference #2: Moore SL, Kransdorf MJ, Schweitzer ME, Murphy BD, Babb JS. Can Sarcoidosis and Metastatic Bone Lesions Be Reliably Differentialted on Routine MRI? American Journal of Roentenogelogy. 2012;June;198(6):1387-93

Reference #3: Marymont JV, Murphy DA. Sarcoidosis of the axial skeleton. Clin Nucl Med. 1994 Dec;19(12):1060-2.

DISCLOSURE: The following authors have nothing to disclose: Jamil Taji, Som Chalise, Darla Theobald, Sara Shorter

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