DIAGNOSING SARCOIDOSIS IN THE EYE OF THE STORM

Abstract

SESSION TITLE: Fellows Diffuse Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Sarcoidosis is a granulomatous disease that typically affects the lungs but can involve all organ systems to a different extent and degree. The diagnosis requires a step wise approach that includes identifying affected organs amenable for biopsy. Up to 30% of patients may present with extra-pulmonary manifestations of sarcoidosis and ocular involvement is seen in up to 25% of these cases. We discuss a case of difficult to diagnose sarcoidosis in a patient with difficult to control asthma that presented with choroidal lesions concerning for ocular lymphoma which prompted additional workup. CASE PRESENTATION: 68 year-old woman with past medical history of difficult-to-treat, severe asthma and obesity with mixed restrictive/obstructive pulmonary functions referred to our institution for a second opinion. She had a long history of asthma since early in childhood that became very difficult to control requiring multiple burst of steroids, use of biologics, and high dose inhaled steroids. She endorsed daily productive cough of white sputum and mild malaise. She denied any other respiratory symptoms. She had undergone an extensive work including serologies and two bronchoscopies with transbronchial and endobronchial biopsies. Chest CT revealed patchy, ill-defined bilateral tree-in-bud opacities without bronchiectasis. Routine exam by her ophthalmologist prompted referral to a regional oncologic ophthalmologist and she was given the presumptive diagnosis of choroidal lymphoma and recommended to undergo choroid biopsy. A PET scan was positive only in the tonsillar beds and biopsy revealed reactive lymphoid hyperplasia. After discussion with ophthalmology the differential diagnosis of choroidal lymphoma, it was decided to proceed to a cryobiopsy of the lung to exclude the possibility of sarcoidosis. She underwent a bronchoscopy and bronchioalveolar lavage revealed 69% lymphocytes with normal flow cytometry. Cryobiopsy revealed non-necrotizing granulomas in a lymphangitic distribution without interstitial inflammation or bronchiolitis. After excluding other causes of granulomatous diseases coupled with eye lesions, patient was diagnosed with systemic sarcoidosis. She was started on oral prednisone with improvement in her respiratory symptoms. DISCUSSION: Sarcoidosis can present with mixed obstructive and restrictive physiology and mimic or exacerbate asthma. It can also present with both anterior and posterior uveitis and is the presenting symptom in 5% of cases. Choroidal and retinal disease can exist without symptoms yet result in blindness. CONCLUSIONS: It is important to recognize this potential presentation of sarcoidosis to start prompt treatment and prevent late complications such as secondary glaucoma and impaired vision. Reference #1: Y. Jamilloux, L. Kodjikian, C. Broussolle, P. Sève. Sarcoidosis and uveitis. Autoimmun Rev. 2014 Aug;13(8):840-9. Epub 2014 Apr 3. Reference #2: B. Bodaghi, V. Touitou, C. Fardeau, C. Chapelon, P. LeHoang. Ocular sarcoidosis. Presse Med, 41 (6 Pt 2) (2012), pp. e349-e354 Reference #3: M. Drent, U. Costabel. European respiratory monograph 32: sarcoidosis. European Respiratory Society (2005) DISCLOSURES: No relevant relationships by Sarah Hackman, source=Web Response No relevant relationships by Jay Peters, source=Web Response No relevant relationships by Jorge Villalpando, source=Web Response