A 53‐year‐old African American woman presented with 2 weeks of productive cough not responsive to antibiotics and 1 week of fever, headache, night sweats, and lightheadedness. She also reported a 25‐pound weight loss over 2 months, but she denied dyspnea and chest pain. She had a 15‐pack‐year smoking history and was febrile, tachycardic, and tachypneic. Her lungs were clear, and she had no skin lesions. Chest radiograph revealed a 5 × 3–cm triangular pleural‐based opacity and bilateral hilar fullness. CT of the chest with contrast revealed multiple pulmonary nodules with a dominant right middle lobe mass (5 × 4 × 3 cm) with abnormal mediastinal and bilateral hilar lymphadenopathy, concerning for a neoplastic process. Angiotensin‐converting enzyme was normal. Pulmonary function testing revealed decreased FEV1, FVC, and ratio suggestive of mixed restrictive and obstructive abnormality. She was treated for community‐acquired pneumonia and ultimately underwent bronchoscopy. Fine‐needle aspiration revealed the presence of nonnecrotizing epithelioid granulomas, negative for malignancy, acid‐fast bacilli, or fungus. She was diagnosed with nodular sarcoidosis with postobstructive pneumonia and treated with prednisone and moxifloxacin.
Lung masses are a common diagnostic challenge, and clinicians should be aware of nodular sarcoidosis when faced with this challenge. Sarcoidosis is a multisystem disease that peaks between ages 20 and 39 and affects African Americans 3 times more frequently than whites. Granulomas form in response to an unclear inciting event that leads to IL‐2, interferon‐gamma, and TNF‐alpha production. Clinically, fatigue, night sweats, and weight loss are common. Two‐thirds of patients experience remission within a decade. Fewer than 5% of patients die from sarcoidosis, usually from pulmonary fibrosis or cardiac or neurological involvement. Sarcoidosis is diagnosed based on typical radiological, clinical, and histological features. Biopsy of the affected organ should be obtained. Sarcoid granulomas have no unique features; therefore, stains for acid‐fast bacilli and fungi must be obtained. Sarcoid granulomas produce angiotensin‐concerting enzyme (ACE); levels are only elevated in 60% of cases and are not diagnostic. Pulmonary sarcoid generally presents with a restrictive pattern on pulmonary function testing. Pulmonary hypertension is often a complication. Radiographic findings show bilateral lymphadenopathy. CT chest typically reveals micronodules in a perilymphatic distribution.
Nodular (alveolar) sarcoidosis is a variant of sarcoid that presents in 1%–4% of patients as multifocal bilateral ill‐defined nodules mimicking airspace disease. Radiography and CT reveal multiple nodules (<3 cm) and/or masses that resemble metastatic cancer. This variant generally presents in female smokers with cough and shortness of breath. Patients with nodular sarcoidosis have a favorable prognosis with complete resolution of the masses with steroids.
To cite this abstract:Oncale M, Boswell E, Hefler H. Sneaky Sarcoidosis or a Metastatic Masquerade?. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 250. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/sneaky-sarcoidosis-or-a-metastatic-masquerade/. Accessed April 2, 2020.