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Zachary Creech
Creighton University School of Medicine, Medical Student
Creighton University School of Medicine
Omaha, NE
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Regan Denny, B.S.
Medical Student
Creighton University School of Medicine
Omaha, Nebraska, United States
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Shraddha Narechania, MD
Physician
Creighton University School of Medicine, Department of Pulmonary, Critical Care, and Sleep Medicine, United States
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TitlePulmonary Sarcoidosis: The Grand Impersonator
Introduction: The definitive diagnosis of pulmonary sarcoidosis, a rare granulomatous disease, can sometimes pose a challenge due to its shared clinical and radiologic presentation with other conditions. The typical radiologic findings of sarcoidosis include bilateral symmetric paratracheal and hilar lymphadenopathy or mid to upper lung zone predominant fibrotic changes with pulmonary micronodules in a perilymphatic distribution. We present a case of sarcoid with atypical radiologic findings.
Case Description: A 34-year-old female with a history of tobacco abuse, polysubstance abuse, anxiety, and recent admission for pneumonia presented to the emergency department with shortness of breath and worsening back and chest pain. The patient was alert with no signs of respiratory distress. Significant laboratory values included an elevated white blood cell count with neutrophil predominance and decreased albumin. A chest x-ray was performed, which displayed patchy bilateral airspace opacities suggestive of multifocal pneumonia. A high-resolution computed tomography (HRCT) revealed extensive multifocal centrilobular ground-glass opacities with a mid to upper lung prevalence, along with multifocal consolidative opacities. Centrilobular nodules often suggest a bronchiolitis pattern, and given the patient’s smoking history, respiratory bronchiolitis was thought to be one of the differentials. Atypical multifocal pneumonia and hypersensitivity pneumonitis were also thought to be possible causes. The patient was treated with several courses of antibiotics; however, she returned one month later with persistent cough and dyspnea on exertion. Given the circumstances, a bronchoscopy was performed, which revealed non-caseating granulomas consistent with sarcoidosis. Staining was negative for fungal and mycobacterial organisms. The patient was started on a prolonged prednisone taper and had improvement in her symptoms.
Discussion: A conclusive diagnosis of pulmonary sarcoidosis requires histopathological confirmation unless clinical and radiologic findings are typical. Sarcoidosis can mimic several other illnesses, including atypical infections, hypersensitivity pneumonitis, and other interstitial lung diseases. A broad differential, thorough evaluation, and a diagnosis-of-exclusion approach are crucial to prevent misdiagnosis.