대한흉부영상의학회 Weekly Chest Cases

Case No : 1226 Date 2021-04-20

Courtesy of Yoon Joo Shin, Su Yeon Ahn, Jeong Geun Yi / Konkuk University Medical Center
Age/Sex 25 / M
Chief ComplaintCough, sputum (2MA)

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Diagnosis With Brief Discussion

Diagnosis: Sarcoidosis
Radiologic Findings: Fig. 1. Chest posteroanterior radiograph showing increased haziness in the right hilar area, diffuse interstitial thickening especially in the right lung field, widening of the left and right paratracheal stripes, and right pleural effusion.
Figs. 2–4. Axial computed tomography (CT) images showing ill-defined mass-like consolidations in the right hilum and multiple conglomerated mediastinal lymphadenopathy with numerous tiny perilymphatic and fissural nodules. Small pleural nodules on both sides and right pleural effusion are also seen. A few osteolytic lesions can be seen in the manubrium.
Fig. 5. Coronal CT images showing an ill-defined right hilar mass and multiple lymphadenopathies in the lower neck, axilla, mediastinum, and cardiophrenic and upper abdominal areas.
Brief Review: Bronchoscopy revealed mucosal irregularity in both bronchi, and transbronchial lung biopsy (TBLB) of the spur mucosa was performed. Endobronchial ultrasound (EBUS) biopsy was performed for 4R, 7, and 10R lymphadenopathy. Noncaseating granulomatous inflammation was found in both TBLB and EBUS biopsy, and the angiotensin-converting enzyme level was elevated (125 U/L).
Because the patient was almost asymptomatic at the time, the clinician decided to perform observation without any treatment. Two months later, follow-up posteroanterior chest radiography showed mild improvement in hilar haziness, lymphadenopathy, and right pleural effusion.

Sarcoidosis is a multisystem granulomatous disorder characterized by the development of noncaseating granulomas in various organs. The clinical features are often nonspecific (e.g., cough, dyspnea, and chest pain) and can be seen in 9%–19% of cases.
Thoracic involvement is common and accounts for most of the morbidity and mortality associated with the disease. Pulmonary sarcoidosis may manifest various radiologic patterns, with bilateral hilar lymph node enlargement being the most common finding, followed by interstitial lung disease. On high-resolution computed tomography, the most typical findings of pulmonary involvement are micronodules with perilymphatic distribution, fibrotic changes, and bilateral perihilar opacities. Atypical manifestations, such as mass-like or alveolar opacities, honeycomb-like cysts, miliary opacities, mosaic attenuation, tracheobronchial involvement, and pleural disease, and complications such as aspergillomas may also be seen.
Pleural plaque-like opacities are pulmonary opacities that simulate pleural plaques. Formed by multiple coalescent micronodules (granulomas), these lesions usually have well-defined irregular margins. They are bilaterally seen in regions contiguous with the pleura, mostly in the upper and middle lung zones, sometimes with associated pleural effusion.
Bone involvement is rare (approximately 5%) in sarcoidosis, and vertebral involvement is uncommon. Although sarcoidosis can involve any bones in the axial and appendicular skeleton, small bones of the hand (particularly the distal and middle phalanges of the second and third digits) are more commonly involved. On radiography, a lace-like pattern of osteolysis with thickened trabeculae and a thin cortex are characteristically seen in the small bones of the hands and feet.
Given the high probability of spontaneous resolution in patients with newly diagnosed early-stage pulmonary sarcoidosis, it may be preferable to monitor the condition without applying any specific treatment in the early stages. Patients showing progression of symptoms, worsening radiographic appearance, or decreasing pulmonary function should be considered for treatment. Systemic corticosteroids are the mainstay of treatment for sarcoidosis.
Please refer to: KSTR Imaging conference 2010 Summer Case 14 ,
KSTR Imaging conference 2009 Summer Case 6,
References: 1. Criado E, Sánchez M, Ramírez J et al. Pulmonary sarcoidosis: typical and atypical manifestations at high-resolution CT with pathologic correlation. RadioGraphics 2010;30(6):1567–1586.
2. Ganeshan D, Menias CO, Lubner MG, et al. Sarcoidosis from head to toe: what the radiologist needs to know. Radiographics 2018; 38:1180–1200.
Keywords

No. of Applicants : 86

▶ Correct Answer : 17/86, 19.8%

- Other , Korea (South) HYEJIN YANG
- CHCB , France LE GUEN RAPHAEL
- Other , Korea (South) SEONGSU KANG
- Samsung Medical Center , Korea (South) JUHYUN KIM
- Chungnam National University Hospital , Korea (South) HYUN JAE LIM
- Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
- Kyeongpook National University Hospital , Korea (South) HYEONJUN JANG
- Yeungnam University Medical Center , Korea (South) JONGSOO PARK
- Osaka City General Hospital , Japan SHU MATSUSHITA
- Seoul Veterans Hospital , Korea (South) JANG SEONG WON
- , Saudi Arabia RAWAN AHMED ALJEFRI
- Fortis hospital , Mohali , India SHALEEN RANA
- Chonbuk National University Hospital , Korea (South) MINJEE KIM
- Seoul National University Bundang Hospital , Korea (South) JUNWOO KIM
- Tokyo Metropolitan Bokutoh Hospital , Japan TOMOKI WADA
- Columbia asia radiology group , India VIKHYATH SHETTY Y
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 19/86, 22.1%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Mayo Clinic , United States AKITOSHI INOUE
- Chonnam National University Hwasun Hospital , Korea (South) INWOO CHOI
- Chonbuk National University Hospital , Korea (South) MINGI SHIN
- , Japan YUSUKE UTSUNOMIYA
- , Italy PAOLO BALDASSARI
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Gifu University Hospital , Japan Yo Kaneko
- Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Seoul National University Hospital , Korea (South) SE WOO KIM
- , Japan HIROAKI ARAKAWA
- Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
- The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
- Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
- Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- algeria , Algeria ZAKARIA CHERAGA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1226 Date 2021-04-20

Discussion

No. of Applicants : 86