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Snapshot
  • A 52-year-old African American woman presents to her primary care physician for worsening cough accompanied by fatigue, fever, and malaise. Physical exam is remarkable for an erythematous, nonulcerated, and tender nodule over the bilateral shins. A chest radiograph is obtained, which demonstrate bilateral hilar adenopathy without any appreciable pulmonary parenchymal infiltrates. 
Introduction
  • Definition
    • a systemic inflammatory disease that is characterized by the presence of non-caseating granulomas
  • Epidemiology
    • incidence
      • the lung is most commonly involved
      • most common in African Americans
  • Etiology
    • unknown
  • Pathogenesis
    • macrophages present antigens to T-cells
      • Th1 cells are recruited and produce IFN-y, TNF, and IL-2
        • results in granulation formation
  • Sarcoidosis staging
    • stage 1
      • bilateral hilar adenopathy 
    • stage 2
      • bilateral hilar adenopathy with parenchymal infiltrates
    • stage 3
      • diffuse parenchymal infiltrates in the absence of hilar adenopathy
    • stage 4
      • pulmonary fibrosis
        • demonstrating honeycombing
  • Associated conditions
    • neurosarcoidosis
    • dilated and restrictive/infiltrative cardiomyopathy
    • myocarditis
    • hypercalcemia
    • erythema nodosum
    • uveitis
    • acute interstitial nephritis
    • lupus pernio
    • restrictive lung disease
    • rheumatoid-lie arthropathy
  • Prognosis
    • generally good in most patients 
Presentation
  • Symptoms 
    • constitutional symptoms (e.g., fever, malaise, and anorexia)
    • dyspnea
    • arthralgias
  • Physical exam
    • erythema nodosum 
    • anterior uveitis
    • cranial nerve VII involvement (worrisome for neurosarcoidosis)
Imaging
  • Chest radiograph
    • indication
      • initial imaging study in the evaluation of sarcoidosis
    • findings
      • hilar adenopathy (hallmark)
      • reticular opacities
      • parenchymal nodules
  • High-resolution CT
    • indication
      • to further evaluate abnormalities demonstrated on chest radiography
Studies
  • Laboratory abnormalities
    • hypercalcemia and hypercalciuria
    • elevated angiotensin-converting enzyme (ACE) levels (~60% of cases)
  • Biopsy of the affected organ
    • non-caseating granuloma 
Differential
  • Lymphoma
    • differentiating factor
      • a biopsy would not demonstrate noncaseating granuloma
Treatment
  • Medical
    • oral corticosteroids 
      • indication
        • considered first-line treatment
Complications
  • Pulmonary fibrosis
  • Pulmonary hypertension
  • Heart failure 

 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PL.17.4686) A 40-year-old woman presents to the clinic for malaise. She has been in her usual state of health until 2 weeks ago, when she noticed weakness and dyspnea upon exertion. She denies any orthopnea, paroxymal noctural dyspnea, or weight loss. She endorses occasional fevers but has not checked her temperature at home. She also reports worsening pain in her eyes that occasionally causes headaches and occasional joint pain. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 70/min, and respirations are 15/min. Physical exam shows injected sclera bilaterally. She denies pain with eye movement. Her lungs are clear to auscultation bilaterally. Cardiac auscultation reveals an S3 with an occasionally split S2. A chest radiograph is obtained and shown in Figure A. Her lower extremities reveal skin findings shown in Figure B. Which of the following is the most likely diagnosis? Review Topic | Tested Concept

QID: 107433
FIGURES:
1

Atypical pneumonia

12%

(32/259)

2

Pulmonary hypertension

9%

(23/259)

3

Rheumatoid arthritis

9%

(23/259)

4

Sarcoidosis

58%

(150/259)

5

Viral pneumonia

9%

(24/259)

L 2 D

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(M2.PL.17.4728) A 30-year-old woman presents to the clinic for evaluation of chronic dry cough of 3-months duration. She denies shortness of breath, hemoptysis, night sweats, or weight loss but does endorse occasional subjective fevers, joint discomfort, and recurrent crops of painful nodules on her legs. Her temperature is 99.2°F (37.3°C), pulse is 60/min, blood pressure is 112/74 mmHg, respirations are 14/min, and oxygen saturation is 98% on room air. Her laboratory test results are shown below:

Leukocyte count: 7,200/mm^3
Hemoglobin: 12.1 g/dL
Platelet count: 400,000/mm^3

Serum:
Na+: 135 mEq/L
K+: 5 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Creatinine: 1.1 mg/dL
Glucose: 105 mg/dL
Ca2+: 11.5 mg/dL
Mg2+: 2.0 mg/dL
Phosphorus (inorganic): 3.2 mg/dL

Which of the following chest radiographs would most likely be present in this patient?
Review Topic | Tested Concept

QID: 108591
FIGURES:
1

Figure A - Chest radiograph 1

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2

Figure B - Chest radiograph 2

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3

Figure C - Chest radiograph 3

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4

Figure D - Chest radiograph 4

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5

Figure E - Chest radiograph 5

12%

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L 2 D

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