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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
    • preferred site of biopsy is the lesion that is most superficial 
    • 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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(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? Tested Concept

QID: 107433
FIGURES:
1

Atypical pneumonia

13%

(33/262)

2

Pulmonary hypertension

9%

(23/262)

3

Rheumatoid arthritis

9%

(23/262)

4

Sarcoidosis

58%

(152/262)

5

Viral pneumonia

9%

(24/262)

M 6 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?
Tested Concept

QID: 108591
FIGURES:
1

Figure A - Chest radiograph 1

4%

(1/25)

2

Figure B - Chest radiograph 2

84%

(21/25)

3

Figure C - Chest radiograph 3

0%

(0/25)

4

Figure D - Chest radiograph 4

0%

(0/25)

5

Figure E - Chest radiograph 5

12%

(3/25)

M 6 D

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