A rare presentation of pulmonary sarcoidosis as a solitary lung mass: a case report

Abstract

BackgroundSarcoidosis is a multisystem, chronic granulomatous disease of unknown etiology that predominantly affects the lungs. Pulmonary sarcoidosis classically presents with constitutional symptoms and computed tomographic scan findings of bilateral, symmetric micronodules in a peribronchovascular distribution with upper and middle lung zone predominance accompanied by bilateral, symmetric hilar lymphadenopathy. A solitary lung mass is a rare finding for pulmonary sarcoidosis, and with its associated constitutional symptoms, it strongly mimics a malignancy. We aimed to provide further insight into the broad differential diagnosis of a lung mass by describing our experiences in the care of a patient who presented with clinical and radiographic features of lung cancer who was ultimately found to have an atypical manifestation of stage II pulmonary sarcoidosis.Case presentationA 44-year-old African American woman with a history of childhood asthma and type 2 diabetes mellitus presented with shortness of breath. After being treated for a presumed asthma exacerbation with prednisone, she experienced worsening dyspnea, night sweats, and unintentional weight loss. Further evaluation revealed a large left lower lobe mass and hilar lymphadenopathy. A computed tomography-guided biopsy of the lung mass revealed a multifocal non-necrotizing granuloma with multinucleated giant cells. Although consistent with sarcoidosis, this finding could represent a sarcoid-like reaction secondary to an occult malignancy. A more extensive repeat biopsy via bronchoscopy and mediastinoscopy revealed granulomatous inflammation without evidence of malignancy or infection. These procedures confirmed the diagnosis of pulmonary sarcoidosis, and she was started on treatment with high-dose prednisone. Her treatment course was complicated by hyperglycemia necessitating insulin therapy, but after 3 months of therapy, she reported improvement in her dyspnea, and repeat imaging revealed a significant decrease in the size of the lung mass and lymphadenopathy. Given her clinical and radiographic response, she was continued on a prednisone taper.ConclusionsAtypical manifestations of pulmonary sarcoidosis are diagnostically challenging because the clinical and radiographic features of the disease mimic those of a malignancy. We aimed to illustrate a unique etiology of a lung mass and the importance of maintaining a broad differential diagnosis. Nonetheless, with the possibility of a malignancy, a high index of suspicion is necessary for timely diagnosis and optimal management.

Pulmonary sarcoidosis presenting as hoarseness and mass lesion

“…The nonspecific or atypical radiological findings are seen in 25%-30% of patients [1,2,4]. However, a lung mass, mediastinal lymph nodes without hilar lymphadenopathy and lymph node calcification are rare presentation of sarcoidosis [4,11,12]. Pulmonary sarcoidosis presenting as lung mass on CT chest is a very rare manifestation limited to case reports [11,12].…”

“…The common radiological findings include bilateral, symmetric micronodules in a peribronchovascular distribution with upper and middle lung lobes predominance accompanied by bilateral, symmetric hilar enlarged lymph nodes. However, atypical radiographic patterns of pulmonary sarcoidosis prove to be diagnostically challenging, particularly in the rare cases like mass lesions [4,[10][11][12]. We are presenting a case of pulmonary sarcoidosis with high suspicion of lung malignancy, who was presented with hoarseness for 3 month and mass lesion on chest CECT scan.…”

Atypical presentations of pulmonary sarcoidosis: Three cases report and literature review

“…In order to ascertain diagnose, the patient underwent computed tomography-guided biopsy of the lung mass, and the result revealed a multifocal non-necrotizing granuloma with multinucleated giant cells. Then she was treated with high-dose prednisone, and repeat imaging showed a signi cantly shrinking of lung mass and lymphadenopathy [23] .…”

“…According to the histopathology result, she was con rmed diagnose of sarcoidosis. Then she was treated with high-dose prednisone, and repeat imaging showed a signi cantly shrinking of lung mass and lymphadenopathy [23].…”

“…In order to ascertain diagnose, the patient underwent computed tomography-guided biopsy of the lung mass, and the result revealed a multifocal non-necrotizing granuloma with multinucleated giant cells. Then she was treated with high-dose prednisone, and repeat imaging showed a signi cantly shrinking of lung mass and lymphadenopathy [23] . Andrew Meillier et.al reported a case that a 38-year-old Caucasian female, manifested in chronic cough, fatigue and a loss of appetite for 6 weeks, physic exam showed right facial droop which indicated Bell's palsy syndrome.…”