Review Question - QID 108591

The chest radiograph (Figure B) showing bilateral hilar lymphadenopathy would fit best in this patient with non-productive cough, arthralgias, and painful lower extremity subcutaneous nodules suggestive of sarcoidosis.

Sarcoidosis is a disease characterized by formation of non-caseating granulomas within various tissues of the body. It most commonly affects young to middle-aged African American women and classically presents with hilar lymphadenopathy causing non-productive cough. Other clinical features of sarcoidosis include arthralgias and erythema nodosum (painful subcutaneous nodules of the lower extremities). However, sarcoidosis may affect any organ system and may have protean manifestations. The triad of hilar lymphadenopathy, arthralgias, and erythema nodosum is known as Löfgren’s syndrome and is a good prognostic indicator. Patients with sarcoidosis may have hypercalcemia due to increased production of calcitriol (1,25-OH-vitamin D) by the macrophages associated with the granulomas (this may also be seen in other granulomatous disorders). In addition, serum levels of angiotensin-converting enzyme (ACE) may be elevated. Treatment of sarcoidosis is dependent on the burden of disease, with systemic corticosteroids being the mainstay of therapy and other immunosuppressants/immunomodulators including hydroxychloroquine, methotrexate, and cyclophosphamide as second-line options.

Figure A shows a normal chest radiograph without hilar lymphadenopathy. Figure B shows a chest radiograph with fullness in the hilar region consistent with hilar lymphadenopathy. Figure C shows a chest radiograph with a lobar opacity consistent with consolidation of the lobe (i.e., filling of the alveoli with pus as in pneumonia, water/serum in pulmonary edema, or blood in alveolar hemorrhage). Figure D shows a chest radiograph with many thin lines forming a net-like or reticular pattern in the lungs consistent with pulmonary fibrosis. Figure E shows a chest radiograph with patchy opacification of the apical right upper lobe with circular areas of cavitation consistent with reactivation of pulmonary tuberculosis.

Incorrect Answers:
Answer 1: Figure A is a normal chest radiograph without prominence of the hilar region.

Answer 3: Figure C shows a lobar consolidation that would be consistent with pneumonia. Wedge-shaped opacities without significant shift of surrounding structures on chest radiograph suggests dense material (water, blood, pus) filling the alveoli. Atelectasis of a lobe can also present with opacification on chest radiograph, but it would also result in pulling in of surrounding structures.

Answer 4: Figure D shows an interstitial pattern of pulmonary disease, which could represent pulmonary fibrosis. Sarcoidosis can present with pulmonary fibrosis, however, this is typically seen in later stages of the disease and would present with progressive shortness of breath.

Answer 5: Figure E shows a patchy opacification of the apical right upper lobe with areas of cavitation suggestive of reactivated pulmonary tuberculosis (TB).

Bullet Summary:
Sarcoidosis is most commonly seen in young to middle-aged African American women and classically presents with arthralgias, erythema nodosum, and bilateral hilar lymphadenopathy (this triad is known as Löfgren’s syndrome). Patients may have hypercalcemia due to increased production of calcitriol (1,25-OH-vitamin D) by macrophages within granulomas.