Primary Cavitary Sarcoidosis: A Diagnostic Dilemma for the Clinician

SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis is a multisystem granulomatous disease, with lungs being the most commonly affected organ.1 Rarely, pulmonary sarcoidosis can present primarily with cavities and pose a diagnostic dilemma. CASE PRESENTATION: 30-year-old male patient presented with a 6-month history of productive cough, hemoptysis, night sweats, dyspnea and 100-pound weight loss. Exam was unremarkable. Basic metabolic profile and complete blood count were normal. Chest CT revealed bilateral cavities. Figure 1 shows four representative cavities. At this point differentials included malignancy, infections and inflammatory disorders. Sputum was negative for acid fast bacilli (thrice). Tuberculin skin test, urine Histoplasma and Blastomyces antigens, ANA, c-ANCA, p-ANCA and HIV serologies were also negative. Bronchoscopy revealed cystic lesions communicating with airways. Bronchoalveolar fluid cultures were negative for bacteria and fungi. Transbronchial biopsy revealed noncaseating granulomas. Diagnosis of sarcoidosis was established and the patient was started on prednisone and methotrexate. Sustained clinical improvement was noted only after 6 months of treatment. Figures 2 shows significant improvement of the same cavities demonstrated in Figure 1, at 21 months follow-up. Prednisone was tapered however methotrexate was continued for 3 years. Patient is currently doing well, 5 years after his initial presentation. DISCUSSION: Most common radiologic manifestations of pulmonary sarcoidosis include hilar lymphadenopathy, perilymphatic nodules and symmetric peribronchial distortion. Cysts and cavities, when present are mostly related to fibrotic changes with advanced sarcoidosis. However, rarely cavities can be the presenting feature of sarcoidosis, as in our case. This condition is called primary cavitary sarcoidosis and is reported in < 0.6% of cases. Three further aspects of our case made it even more interesting. Firstly, most previous reports of primary cavitary sarcoidosis reported cavities in upper and middle lung zones. However, in our case the largest cavities were in the lower lung zones. Secondly, in previous reports lung cavities were generally associated with nodularity or ground glass opacities in other lung areas. In our case lung cavities were the sole radiographic abnormalities. Thirdly, in most previous reports pulmonary lesions were either incidentally noted or the patient presented with cough and minimal other symptoms. Significant constitutional symptoms, as seen in our patient, are rather unusual. Therefore, in our case we established the diagnosis only after an exhaustive work up. CONCLUSIONS: Primary cavitary sarcoidosis should be considered as a differential diagnosis for lung cavities in the appropriate clinical context. These patients can have cavities in any lung zone and also have significant constitutional symptoms. Reference #1: Valeyre D, Bernaudin J-F, Jeny F, et al. Pulmonary Sarcoidosis. Clin Chest Med 2015;36(4):631-641 DISCLOSURE: The following authors have nothing to disclose: Muhammad Ali, Ferah Ciftci, Divyanshu Mohananey, Ahya Ali No Product/Research Disclosure Information