Sarcoidosis in a 65-year-old woman presenting with a lung mass and pericardial effusion: a case report

Abstract

IntroductionSarcoidosis is a multi-systemic disorder of unknown origin and most commonly affects the lungs. Diagnosis relies on the presence of non-caseating granulomas on histologic specimens. In high-resolution computed tomography, the most characteristic findings are peribronchovascular thickening, perilymphatic nodular distribution, and bilateral hilar adenopathy. Confluent nodular opacities or large masses are rare manifestations of the disease. It is well recognized that sarcoidosis can mimic infectious, malignant, and granulomatous conditions. Here, we report a case with a high initial index of suspicion for lung malignancy in terms of clinical, lung imaging, and endoscopic findings.Case presentationA 65-year-old Caucasian woman, lifelong non-smoker with an unremarkable medical history, presented with a 10-month history of progressive breathlessness, dry cough, fatigue, arthralgias, and mild weight loss. The only significant clinical finding was bilateral enlargement of auxiliary lymph nodes. High-resolution computed tomography revealed a soft tissue density mass at the right hilum which was surrounding and narrowing airways and vascular components, nodules with vascular distribution, enlarged mediastinal lymph nodes, and pericardial effusion. Our patient underwent a bronchoscopy, which revealed the presence of submucosal infiltration and narrowing of the right upper bronchus. Endobronchial biopsies showed non-caseating granulomas. As local sarcoid reactions with non-caseating granulomas can be observed near tumors, our patient underwent video-assisted thoracoscopy and surgical removal of an auxiliary lymph node, both of which confirmed the presence of non-caseating granulomas and the diagnosis of sarcoidosis. She was treated with steroids with improvement of clinical and imaging findings. However, while on a maintenance dose, she presented with a pleural effusion, which, after the diagnostic work-up, proved to be sarcoidosis-related. Treatment with initially high doses of steroids plus a steroid-sparing agent led to resolution of the effusion.ConclusionsWe report a case with a high initial index of suspicion for lung malignancy. Clinicians should always be aware that sarcoidosis enters the differential diagnosis of patients presenting with a lung mass that encases and narrows bronchial and vascular structures with associated pericardial effusion. Rarely, pleural effusion can be the presenting symptom of disease relapse despite maintenance treatment.

Case series and literature review of multiple nodular sarcoidosis

“…Two of our patients underwent VATS biopsy and one had a CT-guided lung biopsy. A similar case was reported by Margaritopoulos et al where radiological findings of a soft tissue mass at the hilum with bilateral diffuse lymphadenopathy in a 65 year old Caucasian female was highly suggestive of bronchogenic carcinoma which later turned out to be sarcoidosis [ 16 ]. In one of our patients, lung biopsy showed chronic granulomatous inflammation with central necrosis raising a possibility of necrotising sarcoid granulomatosis (NSG) although histopathology lacked vasculitis.…”

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

“…Because solitary lung masses with mediastinal lymphadenopathy are the hallmarks of lung cancer, obtaining a definitive diagnosis in cases of atypical pulmonary sarcoidosis is diagnostically challenging. Prior case reports described the need for a surgical lung biopsy to obtain sufficient tissue for a definitive diagnosis [ 4 , 6 ], which was the case in our patient. However, the presence of granulomas does not necessarily rule out a malignancy, because non-caseating granulomas have been reported in some instances of small cell lung cancer [ 7 ].…”

“…Common findings include bilateral, symmetric micronodules in a peribronchovascular distribution with upper and middle lung zone predominance accompanied by bilateral, symmetric hilar lymphadenopathy [ 3 ]. However, atypical radiographic patterns of pulmonary sarcoidosis [ 3 ] prove to be diagnostically challenging, particularly in the rare cases of mass lesions, because the associated constitutional symptoms strongly mimic a malignancy [ 4 ]. 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 a rare manifestation of stage II pulmonary sarcoidosis.…”

Sarcoidosis Presenting as a Right Paraesophageal Mass Abutting the Left Atrium

“…One such case of a 65-year-old female presenting with dyspnea, fatigue, and weight loss was evaluated and determined to have probable lung malignancy based on lab work, imaging, and endoscopic evaluation [3]. It was only after biopsy and eventual lymph node resection that lung malignancy was ruled out and sarcoid was determined.…”