The Second Greatest Masquerader? Sarcoidosis Presenting as a Nodular Lung Mass Mimicking Malignancy

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis is a systemic granulomatous disease that involves the lungs in 90% of cases. Pulmonary Sarcoidosis can present with the classic pattern of hilar adenopathy and parenchymal ground glass opacities, but also with a wide range of more unusual patterns. We present the case of a young female patient with a lung mass on CT scan that was initially concerning for malignancy but was ultimately found to be Sarcoidosis. CASE PRESENTATION: A 44 year old African American woman with a past medical history of diabetes, obesity, and asthma presented with shortness of breath for one month. She had been treated with Prednisone for a presumed asthma exacerbation; her breathing improved initially but deteriorated after being tapered off Prednisone. She ultimately came to our facility as her respiratory status worsened and she developed night sweats and unintentional weight loss. Chest radiograph revealed a mass-like opacity in the left lower lobe. CT Chest revealed a left lower lobe mass and diffuse hilar lymphadenopathy, which was concerning for malignancy. Initial CT-guided biopsy of the lung mass revealed granulomatous disease consistent with Sarcoidosis and without evidence of malignancy, fungal infection, or infection with acid fast bacilli. However, given the atypical presentation and ongoing concern for malignancy, bronchoscopy and then mediastinoscopy were performed. These both confirmed the diagnosis of Sarcoidosis. Prednisone was initiated but management has been challenging due to frequent episodes of hyperglycemia requiring insulin therapy. Given her robust response, Prednisone has been continued despite poor glucose control. Repeat imaging after 3 months shows a significant decrease in the size of the left lower lobe lung mass. DISCUSSION: Sarcoidosis is known to mimic neoplastic, infectious, or other granulomatous conditions, but dominant nodular mass-like lesions resembling neoplasm are a rare manifestation. Such an atypical presentation requires thorough investigation to rule out other causes. Repeated biopsy on two non-contiguous sites is recommended. In our patient there was initially a high clinical suspicion for malignancy, so the team did not feel comfortable relying on a single biopsy result. After two additional biopsies of other sites the diagnosis of Sarcoidosis was confirmed. Because Sarcoidosis can masquerade as so many conditions, it may be overlooked or disregarded in the search for alternative diagnoses. It is therefore imperative for physicians to keep a high clinical suspicion for Sarcoidosis to prevent delay in diagnosis and treatment. Steroid-sparing agents such as Rituximab can also be considered if patients are intolerant to first-line steroid therapy. CONCLUSIONS: Sarcoidosis can present with a wide range of unusual patterns and a high clinical suspicion is important to prevent delay in management. Reference #1: Baughman RP, Culver DA, Judson MA. A Concise Review of Pulmonary Sarcoidosis, Am J Respir Crit Care Med.2011;183:573-81 DISCLOSURE: The following authors have nothing to disclose: Wing-Tai Kong, Changwan Ryu, Afshin Ahoubim, Christopher Erb No Product/Research Disclosure Information