Unveiling the great mimicker: a rare case of sarcoidosis

Sarcoidosis is a multisystem granulomatous disease with a wide range of clinical and radiographic manifestations.¹ Cavitation is rare in sarcoidosis.²

A 27-year-old man from Ukraine presented to the emergency department with hemoptysis. A CT scan showed extensive thin-walled cavities and multiple enlarged mediastinal and hilar lymph nodes (Figure 1A-C). The patient had been evaluated two years earlier, and a chest CT scan performed at that time revealed a diffuse perilymphatic micronodular pattern (Figure 1D). However, he was lost to follow-up.

Figure 1
In A, B, and C, chest CT scans showing extensive, irregular, thin-walled cavities bilaterally, predominantly in the upper lobes and perihilar region, reaching 9 cm in diameter and associated with architectural distortion of the lung parenchyma. In D, chest CT scan performed two years earlier, showing extensive perilymphatic and subpleural micronodules associated with areas of densification of the lung parenchyma in the perihilar region, forming fibrotic masses/clusters. In E, photomicrograph (H&E; magnification, ×200) showing a giant cell with intracytoplasmic Schaumann body (yellow arrow).

Laboratory test results showed elevated serum levels of angiotensin-converting enzyme and normal serum levels of Aspergillus-specific IgG. Analysis of BAL fluid revealed lymphocytic alveolitis (lymphocytes: 36%; CD4/CD8 ratio, 5.2), being negative for malignant cells and microbiology (including mycobacteria and fungi). No CD1a-positive cells were identified. A PET scan showed increased uptake in the mediastinal, hilar, and right supraclavicular lymph nodes, as well as in the spleen and lung cavity walls. An excisional biopsy of the right supraclavicular lymph node revealed noncaseating granulomas with giant cells and Schaumann bodies (Figure 1E).

After a multidisciplinary team discussion, a diagnosis of stage IV sarcoidosis was established. The patient was started on corticosteroids and methotrexate, with clinical and functional improvement.

REFERENCES

• ¹
  Llanos O, Hamzeh N. Sarcoidosis. Med Clin North Am. 2019;103(3):527-534. https://doi.org/10.1016/j.mcna.2018.12.011
  » https://doi.org/10.1016/j.mcna.2018.12.011
• ²
  Handa A, Dhooria S, Sehgal IS, Agarwal R. Primary cavitary sarcoidosis: A case report, systematic review, and proposal of new diagnostic criteria. Lung India. 2018;35(1):41-46. https://doi.org/10.4103/lungindia.lungindia_225_17
  » https://doi.org/10.4103/lungindia.lungindia_225_17

Publication Dates

• Publication in this collection
  17 Nov 2023
• Date of issue
  2023