BILATERAL INGUINAL LYMPHADENOPATHY AS THE EXTRAPULMONARY PRESENTATION OF PULMONARY SARCOIDOSIS: A RARE CLINICAL PRESENTATION

Abstract

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sarcoidosis is a multi-systemic granulomatous disorder of unknown etiology and is characterized pathologically by the presence of non-caseating granulomas in involved organs; particularly in the lungs, hilar lymph nodes, skin, and eyes. Sarcoidosis affects individuals of any age, sex and race but it commonly affects young to middle-aged, Black American adults. The diagnosis of sarcoidosis is made on the basis of clinical features with compatible radiological findings and is further supported by the histological evidence non-caseating granulomas in affected organs, and the exclusion of other disorders that may present similarly. Biopsy is usually recommended for all patients that are suspected of having sarcoidosis with the exception of Lofgren's syndrome, Heerfordt syndrome and Lupus Pernio. Extra-pulmonary lymph nodes are present in 15% of patient's at the time of diagnosis. We present a young female who presents with bilateral inguinal lymphadenopathy as the first sign of sarcoidosis CASE PRESENTATION: A 32 year old female presented with complaints of bilateral, non-tender, inguinal swellings that progressively enlarged over a two week period. This was accompanied by a five pounds weight loss which she attributed to decreased appetite due to personal stressors. She had no associated fever, chills, vaginal discharge, dyspnea, cough, arthralgia or rashes. Physical examination revealed multiple, palpable, non-tender, mobile inguinal lymph nodes of varying sizes bilaterally with no associated overlying skin changes. She had no hepatomegaly, splenomegaly or uveitis. The erythrocyte sedimentation rate was 34 mm/hr (<25 mm/hr), 25 hydroxy-vitamin D was 13.5 ng/mL (30.0-80.0 ng/mL) and serum angiotensin converting enzyme level was 259 U/L (9.0-47.0 U/L). Abdomen and pelvic computed tomography showed bilateral inguinal lymphadenopathy measuring up to 1.6 cm on short axis. Chest computed tomography showed bulky mediastinal and bilateral hilar adenopathy with bilateral axillary lymphadenopathy. There were multifocal clusters of peri-lymphatic lung nodules in bilateral lungs. Excisional biopsy of the right inguinal lymph node revealed non-caseating granulomatous lymphadenitis. Acid fast bacilli (AFB) stain was negative for acid fast organisms. DISCUSSION: While extra-pulmonary manifestations of sarcoidosis are common, inguinal lymphadenopathy remains a rare presenting complaint with few documented cases. This finding suggests that biopsy of peripheral lymph nodes in an effort to establish the presence of granulomas, with the appropriate radiographic findings and clinical presentation, remains a viable and minimally invasive method of diagnosing sarcoidosis. CONCLUSIONS: The differential diagnosis for inguinal lymphadenopathy should include systemic conditions such as sarcoidosis. REFERENCE #1: Baughman, RP, Teirstein, AS, Judson, MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 2001; 164: 1885–1889. REFERENCE #2: Monnet P, Thevenon J. Sarcoidosis with clinically isolated mediastinal adenopathy; diagnosis confirmed by biopsy of inguinal & right pre-scalenic lymph nodes. Lyon Med 1959;91:191-5. REFERENCE #3: Iannuzzi MC, Rybicki BA, Teirstein AS (2007) Sarcoidosis. N Engl J Med 357(21):2153–2165. DISCLOSURES: No relevant relationships by Sai Achi, source=Web Response No relevant relationships by Raji Ayinla, source=Web Response No relevant relationships by Janet Joseph, source=Web Response No relevant relationships by Richard Sheppard, source=Web Response