Presentation
Weight loss, lethargy, and cough over several weeks.
Patient Data
Frontal chest radiograph showing bilateral hilar enlargement. There is also subtle micronodularity throughout both lungs.
CT confirms abnormal lymph nodes – there is bilateral hilar and mediastinal nodal enlargement. The nodes are not calcified. There are small nodules throughout the lungs that have a perilymphatic distribution, causing a subpleural 'pseudoplaque' appearance in some places.
The lymphatics in the lungs follow the pleura and bronchovascular structures, so perilymphatic nodules are subpleural and follow interlobular septa. Look for small nodules causing a ‘beaded’ appearance along the periphery of the lungs, along the fissures, and along the airways and blood vessels. Clusters of subpleural nodules close together can cause a ‘pseudoplaque’ appearance.
The diagnosis was confirmed with an endobronchial ultrasound-guided fine-needle aspiration of the mediastinal nodes, which demonstrated typical non-caseating granulomata.
Case Discussion
Sarcoidosis is an idiopathic disease affecting any tissue with the formation of non-caseating granulomata. Symmetric hilar lymphadenopathy is a characteristic radiographic finding in most patients with thoracic sarcoidosis. On CT, micro-nodules of 2-5mm diameter in a perilymphatic distribution along bronchovascular structures, the interlobular septa, interlobar fissures, and subpleural regions are the characteristic finding of pulmonary sarcoidosis.
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