Selenium-deficiency cardiomyopathy is a known secondary complication from long-term treatment with a ketogenic diet for medical refractory epilepsy. Our patient, a 5-year-old boy on a ketogenic diet for intractable seizures, had a normal selenium level before starting the diet, but he shortly thereafter developed acute reversible cardiomyopathy and ventricular tachycardia, which was unmasked during a hospitalization for an elective operative procedure. His cardiomyopathy was suspected to be secondary to a selenium-deficient state and was confirmed by way of a markedly low serum selenium level and supported by rapid improvement with the initiation of selenium supplementation and cessation of the ketogenic diet. For patients being initiated on a ketogenic diet, current screening guidelines call for baseline and follow-up selenium levels every 3 months during the first year along with RDA selenium supplementation, which is 30 mcg/day. Most of the new ketogenic diet formulas meet this requirement. Our patient underwent elective surgery before his planned 3-month selenium level check and had potentially preventable complications. Secondary to this experience, we suggest that all patients initiated on a ketogenic diet should have a preoperative electrocardiogram (EKG), an echocardiogram, and selenium level determined before any elective surgery. These steps would prevent unnecessary perioperative morbidity and mortality.

Sarcoidosis and other forms of co-existing granulomatous inflammation have been previously reported to occur along with bronchogenic carcinoma although rare. In addition, sarcoidosis has been reported as an independent risk factor for development of lung cancer. The histological findings of granulomatous inflammation can be misleading in patients with lung nodules and especially with a high pretest probability of lung cancer. We report a case of middle age Caucasian female with smoking history and obstructive lung disease who presented with multiple spiculated pulmonary nodules in both upper lobes. Pretest probability of lung cancer was high in this patient because of smoking history, location (upper lobe), appearance (spiculation) and abnormal Positron Emission Tomography (PET) scan. Initial needle biopsy by interventional radiologist revealed non-caseating granulomatous inflammation without any malignant cells leading to diagnosis of sarcoidosis. But patient underwent surgical lung biopsy because of no response to steroids that revealed the diagnosis of adenocarcinoma. Surgical lung biopsies also revealed coexisting granulomatous inflammation in the vicinity of the malignancy changes. It is difficult to establish whether the sarcoid finding in this case is an immunogenic reaction to malignancy or a precursor for malignancy. Sarcoid like reaction can rarely be seen in bronchogenic carcinoma misleading the diagnosis at times.

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Sarcoidosis and other forms of co-existing granulomatous inflammation have been previously reported to occur along with bronchogenic carcinoma although rare. In addition, sarcoidosis has been reported as an independent risk factor for development of lung cancer. The histological findings of granulomatous inflammation can be misleading in patients with lung nodules and especially with a high pretest probability of lung cancer. We report a case of middle age Caucasian female with smoking history and obstructive lung disease who presented with multiple spiculated pulmonary nodules in both upper lobes. Pretest probability of lung cancer was high in this patient because of smoking history, location (upper lobe), appearance (spiculation) and abnormal Positron Emission Tomography (PET) scan. Initial needle biopsy by interventional radiologist revealed non-caseating granulomatous inflammation without any malignant cells leading to diagnosis of sarcoidosis. But patient underwent surgical lung biopsy because of no response to steroids that revealed the diagnosis of adenocarcinoma. Surgical lung biopsies also revealed coexisting granulomatous inflammation in the vicinity of the malignancy changes. It is difficult to establish whether the sarcoid finding in this case is an immunogenic reaction to malignancy or a precursor for malignancy. Sarcoid like reaction can rarely be seen in bronchogenic carcinoma misleading the diagnosis at times.