MyPACS.net: Radiology Teaching Files > Case 62158935

Last visited 09/06/2012 Stage 4 pulmonary sarcoidosis
Contributed by: chris atkinson, Resident, Wilford Hall Medical Center, Texas, USA.
Patient: 55 year old female
History: 55 year old female with unintentional weight loss and chronic cough.
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Findings: TECHNIQUE: Multiple helical CT images of the chest were acquired without intravenous contrast, using high-resolution protocol.

FINDINGS:
The thyroid gland is unremarkable. No pathologically enlarged supraclavicular or axillary lymph nodes. The visualized trachea and esophagus are unremarkable.

The heart is of normal size, without pericardial effusion. Few stable subcentimeter, nonpathologic mediastinal lymph nodes are seen.

Intra- and interlobular septal thickening, along with ground glass opacities and traction bronchiectasis is again seen within the predominantly right greater than left lung apices, not significantly changed in appearance. Similar appearing interstitial thickening with associated glass opacities are seen to a lesser extent scattered throughout the remainder of the bilateral lungs. Several pulmonary nodules measuring 4 mm within the right lung apex, 8 mm within the left lung apex and 6 cm within the left upper lobe. No pneumothorax or pleural effusion.

Limited noncontrast evaluation of the visualized upper abdomen is unremarkable.

Multilevel degenerative changes of the spine, without evidence of fracture.

IMPRESSION:

1. Diffuse, apically predominant ground glass opacities with interstitial thickening and traction bronchiectasis, not significantly changed in appearance from prior examinations, consistent with grade IV sarcoidosis.
2. Upper lobe pulmonary nodules, with the largest measuring up to 8 mm stable since 2010.
Diagnosis: Stage 4 Sarcoidosis
Discussion: GENERAL:
Multiorgan widespread noncaseating granulomas. More frequent in African-Americans, tends to occur from ages 20-40 and affects women more often than men. Most commonly present with fatigue, weight loss, fever, dyspnea, dry cough.

90 % of patients with sarcoid will have pulmonary involvement, which resolves or can progress to cause pulmonary fibrosis. Most common findings are symmetric hilar and mediastinal lymphadenopathy. Patients can often develop reticulnodular opacities in the upper lungs. Lymph nodes may calcify, sometimes in eggshell pattern. Lung disease often worsens with nodal regression. Disease progression can lead to pulmonary fibrosis with upper lobe cyst formation (honeycombing) and traction bronchiectasis with severe disease. Pulmonary function tests are typically restrictive pattern with interstitial lung disease, but may be obstructive pattern in those with bronchiectasis. Major complications include respiratory failure from fibrosis, mycetomas, hemorrhage, and cor pulmonale.
The progression of disease occurs in 4 stages.

Stage 0: Normal chest radiograph (50%, at presentation)
Stage 1: Lymphadenopathy (45-65%)
Stage 2: Lymphadenopathy and lung opacities (30-40%)
Stage 3: Lung opacities (10-15%)
Stage 4: Fibrosis with or without lymphadenopathy (5-25%)

IMAGING:
CT Findings
Bilateral hilar and mediastinal lymphadenopathy. Nodal calcification (egg shell).
Micronodules (1-5mm), centrilobular, perivascular, perilymphatic, bronchovascular bundles, subpleural, often extends in a swath from the hilum to lung periphery.

Thickened interlobular septa. Ground-glass opacities, nodular or lobular in size may precede or coexist with nodules. Progressive massive fibrosis, architectural distortion, honeycombing, cysts, bullae and traction bronchiectasis.

TREATMENT:
Up to 50% are treated with steroids or immunosuppression.
References: Koyama T et al: Radiologic manifestations of sarcoidosis in various organs. Radiographics. 24(1):87-104, 2004.

Miller BH et al: Thoracic sarcoidosis: radiologic-pathologic correlation. Radiographics. 15(2):421-37, 1995.

Traill ZC et al: High-resolution CT findings of pulmonary sarcoidosis. AJR Am J Roentgenol. 168(6):1557-60, 1997.
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Additional Details:

Case Number: 62158935Last Updated: 2012-09-06
Anatomy: Chest   Pathology: Non-Infectious Inflammatory Disease
Modality: CTAccess Level: Readable by all users
Keywords: sarcoid

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