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A6535 - Sarcoidosis a Radiographic Chameleon
Author Block: V. Garvia1, M. Rives2, A. Niroula2, P. Putthapiban1, A. Mora1, J. Stempel1, J. Sta Cruz2; 1Internal Medicine, Einstein Healthcare Network. Philadelphia, PA, Philadelphia, PA, United States, 2Pulmonary Critical Care, Einstein Healthcare Network. Philadelphia, PA, Philadelphia, PA, United States.
Sarcoidosis is an enigmatic disease that can affect almost every organ but has a preference for the lungs. The incidence of sarcoidosis varied widely, however in the United States is 11 in 100,000 people per year. Early diagnosis and treatment is associated with decrease morbidity and mortality. We present a 47-year-old female with a past medical history of hypertension and non-toxic goiter who presented to her primary care physician’s office with 2 weeks of coughing associated with meals and bilateral painful ankle edema. She is non-smoker and no family history of pulmonary disease. Vital signs and physical exam only remarkable for edema around ankles. Laboratory data was normal. Chest X-Ray was significant for parasternal and aortopulmonary lymphadenopathy, unilateral haziness of lateral right lung base with possible sub-pleural involvement. Subsequent computed tomographic imaging of the chest demonstrated multiple bilateral hilar and mediastinal lymph nodes, and a 5.8 x 1.8 cm sub pleural ovoid opacity in the right lower lobe. Given differential diagnosis biopsy of sub pleural-lung base mass was performed and it showed non-caseating granulomatous inflammation and a mass forming consolidation of granulomas. No malignant cells were seen. Acid-fast and fungal cultures were negative. The patient was started on steroids and improvement of symptoms achieved. Sarcoidosis is a multisystem disease of unknown origin characterized by granulomatous inflammation. It can arise at any age, but usually presents in the second or third decade of life with a higher female predominance. It affects all ethnicities but in the USA prevalence is higher in African Americans. Clinical presentation consists of but not limited to cough, fatigue, erythema nodosum and weight loss. Diagnosis is usually made by the combination of clinical presentation and radiologic findings, and confirmed by tissue biopsy. CXR typically shows bilateral mediastinal lymph nodes, predominantly in the upper lobes for which Scaddings classification is use. Most physicians are familiar with the typical presentations of pulmonary sarcoidosis; however, atypical presentations are often missed. 20-30% of patients with sarcoidosis will present with atypical imaging findings, such as the one described in our case. Lung masses are present in approximately 10% of patients, and these generally are seen bilaterally. Although, it is essential to rule out other diagnosis such as pulmonary tuberculosis and malignancy, when encountering a lung mass, we aim to highlight this atypical presentation of pulmonary sarcoidosis, high index of suspicion especially in high-incidence population could lead to early diagnosis and treatment.