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Weekly Chest CasesCases by Disease Category

Case No : 1379 Date 2024-03-26

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  • Courtesy of Bo Mi Gil / Bucheon St. Mary
  • Age/Sex 59 / M
  • Chief Complaintsputum and weight loss
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Diagnosis With Brief Discussion

Diagnosis
(Miliary) Sarcoidosis
Radiologic Findings
Figure 1. Initial chest PA shows Numerous tiny nodular opacities in B lung field
Figure 2. Chest CT(lung setting) shows diffuse fine nodules and miliary nodules and smooth interlobular septal thickening in the entire lung, with upper lobar predominance.
Figure 3. on the Mediastinal settings, there is no abnormal enlarged LNs in the mediastinum and neck.


Sarcoidosis was suspected on the images, but as there was a history of tuberculosis diagnosed with LN biopsy at another hospital, 5years ago, tuberculosis medication was started in clinical practice. After 3months, the disease had progressed as following images. A biopsy was performed on the Lt. inguinal LN, and sarcoidosis was diagnosed.

Trans-bronchial lung biopsy(TBLB) shows chronic granulomatous inflammation.
The result of TB culture and PCR of TB/NTM are negative
Brief Review
Miliary sarcoidosis is a rare manifestation of sarcoidosis, accounting for less than 1% of cases. It mainly affects older individuals and is characterized by scattered small lung nodules, unlike the typical sarcoidosis pattern. It can be challenging to differentiate from other lung conditions like military tuberculosis. HRCT scans may show a miliary pattern, but it's usually a subtle perilymphatic pattern. True miliary patterns are linked to prominent perivascular granulomas.

Patients with miliary sarcoidosis are typically older and symptomatic, requiring treatment upon diagnosis. There may be cases where "miliary" sarcoidosis develops after tuberculosis treatment, making it difficult to distinguish between the two conditions, resulting in a "tuberculo-sarcoid" presentation.
References
1) Khanal S, Murali S, Ghimire P, Chu A. Seeds in the Lungs: A Pseudo-Miliary Pattern of Sarcoidosis. Cureus. 2022 Jan 24;14(1):e21569. doi: 10.7759/cureus.21569. PMID: 35228928; PMCID: PMC8866100.
2) Liendo A., RAapista N., Song K., Park M. Pulmonary sarcoidosis masquerading as military TB: radiographic patterns offer valuable clues. CHEST. 2020 Oct 158;4. DOI: https://doi.org/10.1016/j.chest.2020.09.126
3) Rajagopala S, Sankari S, Kancherla R, Ramanathan RP, Balalakshmoji D. Miliary Sarcoidosis: does it exist? A case series and systematic review of literature. Sarcoidosis Vasc Diffuse Lung Dis. 2020;37(1):53-65. doi: 10.36141/svdld.v37i1.7837. Epub 2020 Mar 15. PMID: 33093769; PMCID: PMC7569537.
Keywords

No. of Applicants : 75

▶ Correct Answer : 17/75,  22.7%
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - , Senegal AXEL MBUYU KAYEMBE
  • - , Korea (South) JIN YOUNG LEE
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - , Korea (South) KANGHWI LEE
  • - Uniyersity of Yamanashi , Japan TAKAAKI HASHIMOTO
  • - University of Yamanashi , Japan HIROAKI WATANABE
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Mie university , Japan SHIKO OKABE
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - , Algeria SAMIR SALAH AIECH
  • - Fukuoka university , Japan KEISUKE SATO
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - , Korea (South) JIN WOO YOON
  • - Juntendo University , Japan YUTAKA IKENOUCHI
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 34/75,  45.3%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - medical scanning , Japan HIROAKI ARAKAWA
  • - The University of Tokyo Hospital , Japan JUN KANZAWA
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Kyoto University , Japan AKIHIKO SAKATA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Oita university , Japan AYUMI KAMEI
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - , Korea (South) DONG-HO BANG
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Other , Korea (South) SEONGSU KANG
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
  • - , Japan YUKIKO USUI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Nankai medical center , Japan NORITAKA KAMEI
  • - , Japan KENTARO KOTANI
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan SHUNJIRO NOGUCHI
  • - Tokyo Medical and Dental University , Japan MIKIYA FUJII
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Shiga General Hospital , Japan YUSAKU MORIBATA
  • - Kyoto university , Japan HIROKAZU SAWAMURA
  • - TB centre kasaragod. , India rikhy krishnan
  • - Kyoto University , Japan SHO KOYASU
  • - Kantou Rousai Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Matsunami General Hospital , Japan TARO TAKEDA
  • - University of Yamanashi , Japan TAKUMI YAMAMOTO
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
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