Abstract
IntroductionSarcoidosis is a multi-systemic disorder of unknown origin and most commonly affects the lungs. Diagnosis relies on the presence of non-caseating granulomas on histologic specimens. In high-resolution computed tomography, the most characteristic findings are peribronchovascular thickening, perilymphatic nodular distribution, and bilateral hilar adenopathy. Confluent nodular opacities or large masses are rare manifestations of the disease. It is well recognized that sarcoidosis can mimic infectious, malignant, and granulomatous conditions. Here, we report a case with a high initial index of suspicion for lung malignancy in terms of clinical, lung imaging, and endoscopic findings.Case presentationA 65-year-old Caucasian woman, lifelong non-smoker with an unremarkable medical history, presented with a 10-month history of progressive breathlessness, dry cough, fatigue, arthralgias, and mild weight loss. The only significant clinical finding was bilateral enlargement of auxiliary lymph nodes. High-resolution computed tomography revealed a soft tissue density mass at the right hilum which was surrounding and narrowing airways and vascular components, nodules with vascular distribution, enlarged mediastinal lymph nodes, and pericardial effusion. Our patient underwent a bronchoscopy, which revealed the presence of submucosal infiltration and narrowing of the right upper bronchus. Endobronchial biopsies showed non-caseating granulomas. As local sarcoid reactions with non-caseating granulomas can be observed near tumors, our patient underwent video-assisted thoracoscopy and surgical removal of an auxiliary lymph node, both of which confirmed the presence of non-caseating granulomas and the diagnosis of sarcoidosis. She was treated with steroids with improvement of clinical and imaging findings. However, while on a maintenance dose, she presented with a pleural effusion, which, after the diagnostic work-up, proved to be sarcoidosis-related. Treatment with initially high doses of steroids plus a steroid-sparing agent led to resolution of the effusion.ConclusionsWe report a case with a high initial index of suspicion for lung malignancy. Clinicians should always be aware that sarcoidosis enters the differential diagnosis of patients presenting with a lung mass that encases and narrows bronchial and vascular structures with associated pericardial effusion. Rarely, pleural effusion can be the presenting symptom of disease relapse despite maintenance treatment.
Highlights
Sarcoidosis is a multi-systemic disorder of unknown origin and most commonly affects the lungs
We report a case with a high initial index of suspicion for lung malignancy
Clinicians should always be aware that sarcoidosis enters the differential diagnosis of patients presenting with a lung mass that encases and narrows bronchial and vascular structures with associated pericardial effusion
Summary
It is well recognized that sarcoidosis can mimic infectious, malignant, and granulomatous conditions and may predispose patients to the development of lung cancer [12]. We report a case with a high initial index of suspicion for lung malignancy in terms of clinical, lung imaging, and endoscopic findings. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. Authors’ contributions GAM performed the physical examination of the patient, analyzed clinical and laboratory findings, and was a major contributor in writing the manuscript. EL performed the pathologic review of the lung and auxiliary lymph node specimens. Author details 1Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Panepistimiou Avenue, Voutes, 71110, Heraklion, Crete, Greece. Author details 1Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Panepistimiou Avenue, Voutes, 71110, Heraklion, Crete, Greece. 2Department of Pathology, Medical School of the University of Crete, Panepistimiou Avenue, Voutes, 71110, Heraklion, Crete, Greece. 3Department of Radiology, University Hospital of Heraklion, Panepistimiou Avenue, Voutes, 71110, Heraklion, Crete, Greece
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