Sarcoidosis — The eternal diagnostic challenge

Abstract

Sarcoidosis is a systemic granulomatous of unknown etiology which affects mostly young adults. The clinical presentation is variable but nearly 90% have pulmonary involvement. Diagnosis is based on clinical and radiological presentation, confirmed by the presence of noncaseating granulomas and the exclusion of other granulomatous diseases. Evolution is also variable, from acute outset with spontaneous resolution to cronical disease, namely pulmonary fibrosis. Clinical case: Man, 64 years old, smoker in the past, with severe coronary artery disease, heart failure, type 2 diabetes mellitus, arterial hypertension, dyslipidemia. Hospitalized for recurrent atypical chest pain. Chest radiography — bilateral diffuse micronodular pattern. CT scan: micronodular pattern in upper lung fields, mediastinal and hilar lymphadenopathy; clinical analysis with no significant changes, serum calcium and urinary ACE and ADA normal; HIV negative. Intradermal reaction anergic, fiberoptic bronchoscopy without lesions, sputum and bronchoalveolar lavage (BAL): bacteriological and mycobacteriological (direct and culture) negative; BAL: CD4/CD8 lymphocyte ratio: 2.3; cytology negative for neoplastic cells, bronchial biopsies with nonspecific alterations. Normal spirometry and plethysmography; slight decrease in diffusion capacity of carbon monoxide. Transbronchial biopsies: aggregates of histiocytic cell type granuloma, giant cells multinucleated, compatible with sarcoidosis. Ophthalmic examination without significant changes. Started corticosteroid therapy with good clinical response. Comments: The diagnosis of Sarcoidosis remains a challenge for the doctor, being fundamental the exclusion of other diseases, including tuberculosis. The treatment is based on corticosteroid therapy in selected patients depending on the organ involvement, with difficult monitoring and uncertain prognosis.