SARCOIDOSIS OF THE PLEURA

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sarcoidosis is a multisystem disease characterized by the involvement of noncaseating granulomas that classically affects the pulmonary system by causing diffuse interstitial lung disease. Though parenchymal lung disease is common from sarcoidosis, involvement of the pleura is rare. Here, we present the case of a patient with recurrent pleural effusions who was diagnosed with sarcoidosis of the pleura. CASE PRESENTATION: A 66-year-old male with past medical history of heart transplant 8 months prior and a chronic, lymphocytic predominant, exudative left sided pleural effusion presented to the hospital with shortness of breath and exertional dyspnea. Initial CT of the chest revealed a new right-sided pleural effusion and subcarinal, right hilar, and upper abdominal lymphadenopathy that were not present previously. As he was immunocompromised on post-transplant immunosuppression, the concern for infection causing reactive lymphadenopathy was high. Video-assisted Thoracoscopic Surgery (VATS) was performed for effusion drainage and biopsy of lymph nodes and pleura. Right-sided pleural fluid studies showed a lymphocytic predominant, exudative effusion and cytology was normal. All culture data from blood, pleural fluid, and sputum were within normal limits. Repeat right heart catheterization for routine heart transplant workup was unremarkable for any disease to explain the new effusion. Within a few days, the station 7 lymph node biopsy and pleural biopsy pathology revealed several non-necrotizing granulomas, concerning for a new diagnosis of sarcoidosis. With this data, the most probable diagnosis for his recurrent effusion was primary sarcoidosis of the pleura complicated by pleural effusion. He was placed on a steroid taper and his effusion and symptoms improved. DISCUSSION: The prevalence of sarcoidosis in the United States is approximately 0.06%1. Although lung disease from sarcoidosis is common, the prevalence of sarcoidosis with pleural involvement is rare, occurring in approximately 3% of all cases2. Though this patient had no previous diagnosis of sarcoidosis, his chronic effusion raises the concern that he did have sarcoidosis-associated effusion prior to this second effusion. This case highlights the rare and multifactorial presentation of sarcoidosis of the pleura. CONCLUSIONS: Sarcoidosis involving the pleural space and pleura is a rare manifestation of the disease that should be considered in patients with biopsy proven sarcoidosis with respiratory symptoms. REFERENCE #1: Baughman RP, Field S, Costabel U, Crystal RG, Culver DA, Drent M, Judson MA, Wolff G. Sarcoidosis in America. Analysis Based on Health Care Use. Ann Am Thorac Soc. 2016 Aug;13(8):1244-52. doi: 10.1513/AnnalsATS.201511-760OC. PMID: 27509154. REFERENCE #2: Soskel NT, Sharma OP. Pleural involvement in sarcoidosis. Curr Opin Pulm Med. 2000 Sep;6(5):455-68. doi: 10.1097/00063198-200009000-00012. PMID: 10958239. DISCLOSURES: No relevant relationships by Pranay Arora, source=Web Response No relevant relationships by James Dugan, source=Web Response No relevant relationships by Claire Irons, source=Web Response No relevant relationships by Patrick Kramer, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Soud Sediqe, source=Web Response No relevant relationships by Pallavi Sharma, source=Web Response