Thursday, June 23, 2005

Pleuritic Pain and Fatigue Follow-up

This is the follow up to the young woman with pleuritic pain and pulmonary nodules on CT.

F/U labs revealed normal Calcium and comp as well as normal CBC. ACE level was normal.
Bronchoscopy w/ BAL and TBBX was performed. Cultures negative as well. Path on tissue revealed epitheloid granulomas. Fungal and AFB stains negative.

Her airway exam and BAL was unremarkable except for the following findings throughout the airways:



Unfortunately, endobronchial Bx's were not performed in this case. But, I thought it would be a good point of discussion. The literature suggests that, in addition to TBBXs, endobronchial Bx can increase your yield for diagnosis of sarcoid, more so if there is gross mucosal nodularity as shown in the image below from Mehta's review on this particular subject(Curr Opin Pulm Med 2003;9:402-407). However, a diagnosis can still be made by biopsy of normal mucosa.




This patient's pain and nephrolithiasis were attributed to sarcoid so she was placed on prednisone. I'll give you f/u when I get news from her caregiver.

6 comments - CLICK HERE to read & add your own!:

Jennings said...

Cool case and first bronch picture of the blog. Did she have hilar adenopathy? What do you think the earier diagnosis of asthma was all about (if anything)?

Mendez said...

No adenopathy which makes her stage III. Her most recent spiro and exam are normal, but airway hyperreactivity is not uncommon so I'm not surprised about the earlier asthma Dx.

Mike L said...

It is actually fairly common for patients with submucosal sarcoid in the bronchi to wheeze. This, along with decreased PEFR's were the probable etiology of her "asthma" diagnosis.
Also, PFT's with obstruction are also relatively common with submucosal granulomas.
Although there is no data to suggest efficacy, JPL III often taught of using inhaled corticosteroids in patients with symptomatic submucosal disease.
Actually, if her CXR is normal, she has stage 0 disease. The sarcoid staging, to the best of my knowledge, is based exclusively on CXR imaging. However, this is probably why all patients with stage I disease do not behave similarly (i.e. their CT's may "upstage" them)

Mendez said...

Right... I forgot to mention that her CXR did have infiltrates - this was a new development compared to CXR from four years ago.

Baleeiro said...

Cool case. I would also try ICS for the wheezing/bronchial involvement.

Tom said...

The nodules appear to be associated with the patients cartilagenous rings. I suspect that these are not granulomas but related to spurs of her tracheal cartilage.