It is Tuesday and we have another Radiology Rounds we can’t wait to share with you. Follow along and see if you select the right answer as we go through different presentations of sarcoidosis and pick your answer! What stage is it?!
A middle-aged man presents to you after he was found to have hilar adenopathy on a routine chest x-ray.
A middle-age man presents with dyspnea on exertion, night sweats and weight loss. You see evidence of bilateral apical disease, and fibrosis with evidence of honeycombing on chest CT.
A young woman presents with dyspnea on exertion and was found to have hilar adenopathy with parenchymal disease.
An elderly man presents with dyspnea on exertion and was found to have nodular parenchymal disease without extensive lymphadenopathy.
We have another #RadiologyRounds for you today! You are seeing a new patient in the clinic with dyspnea who brings in prior CT chest imaging. A representative coronal image is shown.
In addition to bullous disease, you see bilateral honeycombing with evidence of fibrosis primarily in the upper lung fields.
As part of your evaluation, an EBUS is performed showing the following representative lymph node tissue pathology.
We had evidence of noncaseating granulomas, evidence of fibrocystic changes on chest imaging, and we excluded other causes of granulomatous disease. Given his symptoms and clinical context, we were concerned about Stage IV pulmonary sarcoidosis which can be categorized below.
Dave Furfaro, Kristina Montemayor, and Ansa Razzaq are back to tackle another pulmonary case! Listen in and solve the case yourself, and we’ll share some diagnostic pearls along the way. Let us know any additional thoughts on Twitter.
The is patient is 57-year-old man with hypertension and asthma who presents with dyspnea and left-sided pleuritic chest pain for 3 weeks. He was in his usual state of health until 3 weeks prior to admission, when he developed dyspnea and sharp left-sided chest pain that worsens with deep breathing. His symptoms are accompanied by unintentional 30-pound weight loss over the past several months as well as an intermittent cough that is nonproductive.
On physical exam, he is mildly tachypneic and saturating well on room air with otherwise normal vital signs. He has decreased breath sounds at the right lung base.
Key Learning Points
**Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below
Physical Exam Pearls
Reasons for decreased breath sounds on physical exam
1. Increased thickness of chest wall
2. Reduced airflow to part of the lung
3. Overinflation to part of the lung
4. Something between the lung and chest wall — air or fluid
Determine bradypnea and tachypnea quickly by matching your breahting rate to the patient’s respiratory rate
1. Is there a compatible presentation (imaging, physical exam)
2. Detection of non-necrotizing granulomatous inflammation in one or more tissue samples
3. Exclusion of other disease that may present similarily
Pulmonary stages of sarcoidosis:
Key to remember that patients don’t always progress through these stages. The system is useful for prognosticating and determining treatment based on the risk for disease progression.
Treatment for pulmonary sarcoidosis
Patients with stage 1, and even many with stage 2, often don’t require treatment
The first-line agent is oral glucocorticoids and the typical starting dose is prednisone 20 – 40 mg by mouth daily. The patient should be evaluated closely, and ideally, this dose can be tapered starting at about 4 – 6 weeks. Following this, the prednisone dose is tapered slowly over 6 months – 1 year while monitoring for symptom recurrence.
Second-line steroid-sparing agents are methotrexate, azathioprine, or mycophenolate. These are often used if the patient relapses, or is on more then 10mg daily for 3 months after the initial taper with intolerance of steroids