Friday, March 24, 2006

Sarcoid dilemma

51 yo male with sarcoidosis manifest by low DLCO (some dyspnea with extreme amounts of exertion) and constitutional symptoms (early satiety, abdominal pain and low energy level). Stage II Sarcoid diagnosed with non-caseating granuloma on transbronchial biopsy.
He was started on steroids and plaquenil (the latter by his PCP/rheumatologist) with good resolution of his constitutional symptoms. He was weaned off the steroids over a 6 month stretch. The wean finished about 2 weeks ago.

Initial CT scan in August (conventional CT)



Was seen about 1 week ago after completely weaned off prednisone. Has been having some increased dyspnea over the last 1-2 weeks that is somewhat related to exertion, but not completely.

PFT's: Normal spiro and lung volumes. DLCO ~61% predicted. DLCO in November was ~72% predicted.

Repeat CT chest (this time with HRCT protocol).



The majority of the lung is actually normal. There are a few cuts with the above parenchymal abnormalities.

What would you do?

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

Jennings said...

Let me re-cap before a comment to make sure I understand:

He had dyspnea and constitut sx that improved on steroids. The steroids are off for 2 weeks and he develops increased dyspnea. A f/u spiro shows a DLCO of 61%, down from 72%. An HRCT shows improvement.

Is that correct? Where was he in terms of steroids when the 72% was done? Does the 61% represent a time when he was off steroids? Is the HRCT off steroids? Was he SOB when that HRCT was taken?

Baleeiro said...

I guess one of the questions here is whether he is dyspneic because of the sarcoid despite radiographic improvement or is there a second reason?
His DLCO has decreased even though the lungs look better. It seems the primary Dx of sarcoid is pretty solid with Bxs to seal it.
I might consider looking for other reasons for the change (ECHO, bubble study looking for shunt, TSH, maybe a V/Q, etc.). If there are no obvious cardiac or pulmonary-vascular changes I would probably try a CPET to help identify the source of dyspnea as he may even have a steroid myopathy.

Arenberg said...

I'll be brief. I want to know he doesn't have a PE.

Mike L said...

Jennings recap is accurate.
Nice thoughts.
I did not work him up for a PE as he is pretty active and no recent traumatic injury. His original CT in august was with PE protocol and was negative.
His TSH is normal.
Any other thoughts? Would you still get a V/Q?

Jennings said...

After steroids were stopped his DLCO went from 70% to 62% (but with an HRCT showing radiographic improvement). But a DLCO is still more sensitive for detecting early diffusion abnormalities than HRCT, so if you have ruled out other causes, I would either restart the steroids or consider a steroid-soaring agent at this point.
Other causes to rule out were as Baleeiro and Arenberg stated, namely echo with bubble and maybe a PE-CT: I am sure a V/Q would liklely come back as intermediated and then you'd be stuck.