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Weekly Chest CasesArchive of Old Cases

Case No : 329 Date 2004-02-14

  • Courtesy of Jeong Joo Woo, M.D. / Nowon Eulji Hospital, Seoul, Korea
  • Age/Sex 41 / M
  • Chief ComplaintNo pulmonary symptom. Skin nodule
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Pulmonary sarcoidosis
Radiologic Findings
Chest radiographs show poorly defined patchy nodular opacities in the both lung fields.
HRCT images show numerous small nodules along the bronchovascular bundles, adjacent to interlobular septa and subpleurally.
There is no mediaistnal or hilar lymph node enlargement.
Patient had a skin nodule on back. Biopsy from skin nodule and TBLB were done and sarcoidosis was confirmed. The nodular lesions were markedly resolved without any treatment after one year.
Brief Review
Sarcoidosis is a systemic disorder of unknown cause characterized histologically by the presence of noncaseating granulomatous inflammation. It may spontaneously resolve, generally in less than 2 years, or may evolve to pulmonary fibrosis in 20-25% of cases.

This case was stage 3 sarcoidosis (diffuse pulmonary disese unassociated with node enlargement). In one survey, only 20% with Stage 3 disease showed resolution of the radiographic findings. But the staging system of the sarcoidosis is only a means to describe the radiographic findings and patients do not necessarily progress sequentially from one stage to the next.

HRCT findings of pulmonary sarcoidosis
1) Nodules: Nodules are the most common abnormality in sarcoidosis. Most nodules are 2 mm to 1cm in diameter and have irregular margins. Nodules occur predominantly in a perilymphatic distribution. Beaded appearance of bronchovascular bundles, a perihilar concentration of abnormalities, and associated lobular distortion all typify sarcoidosis, as compared with lymphangitis carcinomatosa. Large parenchymal nodules (>1cm in diameter) are seen less frequently and this large nodule often shows so-called "sarcoid-galaxy sign".

2) Ground-Glass Attenuation
3) Alveolar Sarcoidosis: Large opacities with air bronchograms were seen in three of 44patients with sarcoidosis in one study. Peripheral distribution is common. The characteristic assocication with mediasitnal LAP and small nodules are seen.
4) Reticular opacities: Irregular reticular opacities are likely to represent early mainfestations of fibrosis.
5) Distortion, Cystic air spaces, and traction bronchiectasis: Usually shown by posterior displacement of the main or upper lobe bronchus.
6) Air Trapping: Narrowing of small airways occurs as a result of peribronchiolar granulomas.
7) Complication of Sarcoidosis: mycetoma formation of bullous disease in pulmonray sarcoidosis

Among the lesions described above, nodules, irregularly marginated nodules, and alveolar or pseudoalveolar consolidations were reversible. While septal or nonseptal lines with parenchymal distortion, honeycomb cysts, and traction bronchiectasis never decreased.
References
1. Brauner MW, Lenoir S, Grenier P, et al. Pulmonary sarcoidosis: CT assessment of lesion reversibility. Rdiology 1992; 182:349-354
2. Traill ZC, Maskell GF, Gleeson FV. High-resolution CT findings of pulmonary sarcoidosis. AJR 1997; 168:1557-1560
3. Muller NL, Fraser RS, Lee KS, Johkoh T. Diseases of the lung. Radiologic and Pathologic Correlations. 2003, Lippincott Williams & Wilkins 352-362
Keywords
Lung, Interstitial lung disease, Sarcoidosis, ILD,

No. of Applicants : 29

▶ Correct Answer : 24/29,  82.8%
  • - Annecy Hospital, France Gilles Genin
  • - Armed Forces Capital Hospital, Korea Chang Hyun Lee
  • - Centre d'imagerie Jacques Callot, Nancy, France Lionel Cannard
  • - CH Lyon sud, France Xavier Riviere
  • - CHU Nancy-Brabois, France Denis Regent
  • - Chungju Hospital, Konkuk University, Korea Chang Hee Lee
  • - CIM Saint Dizier, France JC Leclerc
  • - Clinic 1, Moscow, Russia Lepikhina Dasha
  • - Escola Paulista de Medicina, Fleury, Sao Paulo - Brazil Gustavo Meirelles
  • - Ewha Woman's University Hospital, Korea Yoo Kyoung Kim
  • - Hangang SacredHeart Hospital, Korea Eil Seong Lee
  • - Homs National Hospital, Homs, Syria Rami Abou Zalaf
  • - Hospital Donostia, Spain Aitor Tilla
  • - Incheon Sarang Hospital, Korea Jung Hee Kim
  • - Jeju hanmaeum hospital, korea Kwon Hyoung Kim
  • - Kangbuk Samsung Hospital, Korea Hyon Joo Kwag
  • - Maimonides Medical Center, N.Y., USA Naomi Twersky
  • - Mallinckrodt Institute of Radiology, USA Jin Mo Goo
  • - National Taiwan University Hospital, Taiwan Tan Che Kim
  • - Samsung Medical Center, Korea Sung Shine Shim
  • - Shin Kong Wu Ho-Su Memorial Hsopital, Taipei, Taiwan Chen-Chun Lin
  • - Social Security Hospital, Ankara, Turkey Meric Tuzun
  • - Sunlin Hospital, Korea Won Hyuk Shin
  • - University Hospital of Ghent, Belgium De Cuyper Kristof
▶ Semi-Correct Answer : 4/29,  13.8%
  • - Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
  • - Gwangmyoung Sung-Ae Hospital, Korea Jiyong Rhee
  • - Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
  • - Pingtung Christian Hospital, Taiwan JunJunYeh
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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