Disorders of the Mediastinum: Pleura and Chest Wall |

Massive Pleural Effusion as an Initial Manifestation of Sarcoidosis FREE TO VIEW

Khalid Sherani, MD; Ahmed Alnuaimi, MD; Abhay Vakil, MD; Kelly Cervellione, MSHP; Umma Kulsum, MBBS; Artur Shalonov, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A225. doi:10.1016/j.chest.2016.02.233
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SESSION TITLE: Pleura and Chest Wall

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: The presence of pleural effusion in the patients with sarcoidosis is extremely rare with an estimated prevalence of 2-3%. We report the case of a 51-year-old male presenting with dry cough and dyspnea. Imaging studies showed massive left-sided pleural effusion with splenomegaly and hilar lymphadenopathy, highly suspicious for malignancy. Histopathological examination of the lymph nodes revealed non-caseating granulomas suggestive of sarcoidosis.

CASE PRESENTATION: A 51-year-old non-smoker African-American male was referred to clinic for evaluation of chronic dry cough and worsening dyspnea. He denied fever, night sweats, chest pain or weight loss. He was hemodynamically stable on presentation. Physical examination revealed decreased left-sided air entry with dullness to percussion and decreased tactile vocal fremitus on the left. Imaging studies showed massive left-sided pleural effusion with mediastinal shift (Fig. 1a and b), splenomegaly and hilar as well as mediastinal lymphadenopathy, highly suspicious for malignancy. Thoracentesis revealed lymphocyte-predominant exudative fluid using protein criteria with a negative cytology for malignant cells. Histopathological examination of the hilar and mediastinal lymph nodes revealed non-caseating granulomas (Fig. 1c) with a negative fungal and AFB stain, suggestive of sarcoidosis. Subsequent ACE level was 90 micrograms/L (normal < 40 micrograms/L). Once infectious etiology was ruled out, the patient was started on oral steroids with rapid resolution of his symptoms as well as radiologic findings.

DISCUSSION: Pleural effusion as the initial manifestation of sarcoidosis is extremely rare. In patients with known sarcoidosis only 1% of pleural effusions are caused by sarcoid involvement of the pleura. There by, it should not be assumed that pleural effusion in sarcoid patients is secondary to sarcoidosis and other infectious, malignant and inflammatory causes of effusion should be ruled out. A lymphocyte-predominant exudative effusion with discordance between pleural fluid total protein and lactate dehydrogenase levels favor sarcoidosis-related pleural effusion. Pleural biopsy is rarely needed to confirm the diagnosis. An exacerbation of pulmonary sarcoidosis is not an independent risk factor for the development of sarcoid-related pleural effusion. Most of such effusions resolve with steroid therapy and rapid steroid taper is associated with recurrence. Pleurodesis is ineffective for recurrent pleural effusions.

CONCLUSIONS: Sarcoid-related pleural effusions are lymphocyte-predominant exudative effusions and are extremely rare, responding well to steroid therapy. Other causes of exudative effusions, particularly malignancy should be ruled out before establishing the diagnosis.

Reference #1: Huggins JT et al. Pleural effusions in a series of 181 outpatients with sarcoidosis. Chest. 2006 Jun;129(6):1599-604.

DISCLOSURE: The following authors have nothing to disclose: Khalid Sherani, Ahmed Alnuaimi, Abhay Vakil, Kelly Cervellione, Umma Kulsum, Artur Shalonov

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