Lung

• Presentation: cough, dyspnea and other pulmonary symptoms are common; nonpulmonary presentations often include skin or eye lesions
• Acute presentations may display fever, arthralgia and painful skin lesions
• May be discovered incidentally following chest radiographs which often show hilar adenopathy and reticular opacities
• Lungs
  • Reticular opacities on chest radiograph may be evident
  • High resolution CT may show multiple subcentimeter nodules with a perilymphatic distribution
  • Most cases will be associated with hilar lymphadenopathy
  • Pulmonary involvement in the absence of lymphadenopathy portends a worse prognosis
• Lymph nodes
  • The vast majority of patients show hilar or mediastinal lymphadenopathy
  • Involved lymph nodes may be calcified or sclerotic
• Cardiovascular
  • Symptomatic cardiac involvement is rare but autopsy studies have shown that > 50% of cases may show subclinical cardiac involvement
• Liver
  • A subset of patients display liver involvement, often accompanied by hepatomegaly
  • Cirrhosis is a rare complication
• Skin
  • Skin involvement in ~25%
  • Findings can include erythema nodosum or presence of numerous skin colored papules, especially on the face / nose
• Eye
  • Common manifestations include uveitis and keratoconjunctivitis
• References: JAMA 2022;327:856, Intern Emerg Med 2018;13:325, Ann Am Thorac Soc 2016;13:1244, EClinicalMedicine 2021;37:100966

Images hosted on other servers:

Contributed by @AKhannaMBBS on Twitter


Images hosted on other servers:

Contributed by Aliya N. Husain, M.D. and @AKhannaMBBS on Twitter

• Berylliosis:
  • Diagnosis requires clinical history of exposure
• Infectious causes (fungi, atypical mycobacteria):
  • GMS and AFB should be routinely performed on all pulmonary biopsies with granulomas
    • Tissue cultures increase sensitivity for infectious agents
    • If clinical suspicion for infectious etiology is high and tissue cultures are negative, RNA sequencing should be considered
• Foreign body granulomas:
  • Polarization can aid in identifying foreign bodies; however, polarizing material may occasionally be present in giant cells of sarcoidosis

A 55 year old woman with clinically suspected sarcoidosis undergoes biopsy of mediastinal lymph nodes and wedge biopsy of involved lungs. Which of the following findings are most consistent with sarcoidosis?

1. Lungs with poorly formed granulomas along the bronchovascular structures and lymph nodes with granulomatous lesions containing refractile material
2. Lungs with poorly formed interstitial granulomas and lymph nodes with granulomatous lesions containing refractile material
3. Lungs with well formed granulomas along bronchovascular structures and pleura and lymph nodes with well formed granulomas
4. Lungs with well formed interstitial granulomas with refractile material and lymph nodes with reactive changes

C. Lungs with well formed granulomas along bronchovascular structures and pleura and lymph nodes with well formed granulomas. Answers A, B and D are incorrect because sarcoid associated granulomas tend to be well formed and typically do not contain foreign material including refractile particles.

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Reference: Sarcoidosis

The image above shows a mediastinal lymph node biopsy in a patient whose CT findings include mediastinal and hilar opacities as well as micronodularity of perilymphatic and bronchocentric distribution. What is the most likely diagnosis and which stains should be performed on the biopsy prior to signout?

1. Diagnosis: infectious process; stains: Gram stain, AFB
2. Diagnosis: infectious process; stains: trichrome, Gram stain
3. Diagnosis: sarcoidosis; stains: AFB, GMS
4. Diagnosis: silicosis; stains: AFB, GMS

C. Diagnosis: sarcoidosis; stains: AFB, GMS. This section demonstrates a lymph node with multiple well formed, nonnecrotizing granulomas as well as fibrosis. These findings are characteristic of sarcoidosis. Answer D is incorrect because no fine particulate is seen, which makes silicosis less likely. Answers A and B are incorrect because the differential for granulomatous inflammation also includes infectious processes including fungal and atypical mycobacterial infections and GMS and AFB should be performed on all pulmonary / mediastinal lymph node specimens with granulomas. Negative special stains do not rule out this possibility; if clinical suspicion is high and special stains and cultures are negative, RNA sequencing may be considered to more definitively rule out infectious etiology. Remember that sarcoidosis is a diagnosis of exclusion.

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Reference: Sarcoidosis