AN UNUSUAL CASE OF SARCOIDOSIS PRESENTING AS A LUNG MASS AND CARDIAC TAMPONADE

Abstract

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Sarcoidosis is a multisystem granulomatous disease whose etiology remains elusive yet nevertheless has classic pulmonary and extrapulmonary findings that may aid in the diagnosis. The proceeding case demonstrates however the difficulty in diagnosing this masquerader when rare presentations instead form the clinical picture. CASE PRESENTATION: We present a 63-year-old male with a history of treated active tuberculosis who presented with abdominal pain and incidentally found to have innumerable bilateral pulmonary nodules accompanying a right hilar mass with confluent lymphadenopathy (Figs 1&2). Despite these findings, he denied cough, hemoptysis, dyspnea, fevers, chills, night sweats, and weight loss. He had a notable history of particulate exposure as a contractor but was otherwise a lifetime non-smoker. Diagnostic bronchoscopy with endobronchial ultrasound guidance revealed both necrotizing and non-necrotizing granulomata but no evidence of malignancy. Before additional studies could be performed, the patient was hospitalized at an outside facility for dyspnea and found to be in cardiac tamponade requiring a pericardial drain. Microbiology from his initial bronchoscopy grew Cryptococcus prompting empiric fluconazole at the outside facility. His parenchymal findings and dyspnea persisted however and with an interval discovery of pulmonary emboli (Fig 3), therapy was switched to prednisone and anticoagulation leading to near-resolution of his pulmonary nodularity and asymmetric lymphadenopathy. DISCUSSION: Pulmonary sarcoidosis generally manifests as symmetric, bilateral, hilar lymphadenopathy with micronodules along the peribronchovascular bundle and interlobular septa or in the upper and middle lobes when parenchymal involvement is present. Extrapulmonary sarcoidosis occurs much less frequently, often involving extrapulmonary lymphatics or presenting with dermatologic, ophthalmologic, and hepatic findings. Our patient's pulmonary sarcoid was unique in both its appearance as a basilar predominant nodularity seemingly randomly distributed with areas of confluence mimicking a malignant mass with hematogenous dissemination as well as the presence of asymmetric hilar lymphadenopathy without significant mediastinal involvement. Furthermore, the development of cardiac tamponade and unprovoked pulmonary embolism hints at highly atypical cardiac sarcoid and sarcoid-related thromboembolic disease that is only just gaining recognition in the nascent literature. CONCLUSIONS: In the correct epidemiologic and clinical context alongside radiographic and pathologic correlation, sarcoidosis can be diagnosed after the exclusion of etiologies like malignancy, infection, or autoimmune disease. However, as this case demonstrates, clinical suspicion remains the most powerful tool when synthesizing seemingly discordant data from rarely seen presentations of the disease. REFERENCE #1: Criado E, Sanchez M, Ramirez J et al. Pulmonary sarcoidosis: typical and atypical manifestation at high-resolution CT with pathologic correlation. Radiographics. 2010;30(6):1567-1586. REFERENCE #2: Ungprasert P, Crowson CS, Matteson EL. Association of sarcoidosis with increased risk of VTE: a population-based study, 1976-2013. CHEST. 2017;151(2):425-430. REFERENCE #3: Ungprasert P, Ryu JH, Matteson EL. Clinical manifestations, diagnosis, and treatment of sarcoidosis. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):358-375. DISCLOSURES: No relevant relationships by Christine Choi, source=Web Response No relevant relationships by Julien Nguyen, source=Web Response No relevant relationships by Janine Vintch, source=Web Response