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A3242 - Recurrent Pleural Effusion: A Rare Manifestation of Sarcoidosis
Author Block: D. Zhang, H. J. Patel; Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical School, Dallas, TX, United States.
The clinical spectrum of sarcoidosis is wide, but recurrent massive pleural effusions is a rare presenting manifestation of this disease. A 35-year-old woman presented to the hospital with subacute dyspnea on exertion and was found to have a pleural effusion on chest roentgenogram. Chest CT revealed innumerable pulmonary nodules along with a moderate to large right pleural effusion and both mediastinal and hilar adenopathy. Laboratory testing was unrevealing and physical exam revealed mild end expiratory wheezing on pulmonary auscultation as well as numerous subcutaneous skin nodules. Dermatology was consulted, and skin biopsies were obtained but were inadequate. Over a liter of pleural fluid was drained with fluid characteristics revealing an exudative lymphocyte predominant fluid with negative acid fast and fungal cultures, negative cytology, and normal adenosine deaminase levels. Noninvasive testing for rheumatoid arthritis, fungal infections, and mycobacterial disease including tuberculosis was negative. A bronchoscopy with transbronchial biopsies was attempted, but due to patient intolerance only a bronchoalveolar lavage was performed. Lavage fluid characteristics revealed a 39% lymphocyte fluid with negative cultures. Patient left against medical advice due to a death in the family but was readmitted two weeks later with recurrence of a large right pleural effusion. A repeat thoracentesis was performed which again showed a lymphocyte predominant effusion with negative cultures and cytology. Patient again underwent bronchoscopy but this time with anesthesia and endobronchial ultrasound. Transbronchial biopsies and mediastinal lymph node biopsies were obtained revealing non-necrotizing granulomas. Patient was diagnosed with sarcoidosis and discharged with prednisone with but continued to have dyspnea prompting another readmission for dyspnea and recurrence of a right sided pleural effusion. Repeat thoracentesis was performed with additional testing showing no chylomicrons and flow cytometry with a CD4:CD8 ratio of 3.7:1. Cardiothoracic surgery was consulted for a pleural biopsy which was performed showing numerous non-necrotizing granulomas with negative stains for organisms. Patient was diagnosed with granulomatous pleuritis from sarcoidosis with recurrent massive pleural effusions. Patient was followed up in sarcoidosis clinic, started on methotrexate with stability of her pleural disease. This case underscores the challenges of diagnosing pleural sarcoidosis given the rarity of pleural effusion as a primary manifestation of the disease. Thorough investigation of a concomitant pleural effusion in a patient with newly diagnosed sarcoidosis is warranted given its rarity, and disease mimics such as malignancy or tuberculosis need to be ruled out.