Presentation
Chronic history of cardiomyopathy.
Patient Data
There are multiple pulmonary nodules scattered bilaterally, predominantly distributed within the upper lobes, and showing irregular or spiculated contours. A few of them are juxta-pleural or cause tenting of the adjacent pleura.
The right apical one measuring now up to 2.4 cm and has increased since the scan one year ago (not shown).
The airways are normal, pleural spaces are clear.
The small mediastinal and hilar lymph nodes are stable. Left-sided single lead pacing/cardioverter device and cardiomegaly. The thoracic cage is preserved, no soft tissue or bony suspicious lesions. The imaged superior abdomen is normal.
Microscopy: Sections show lung tissue that towards one end is alveolated and unremarkable. Elsewhere, the tissue is fibrous, with numerous non-necrotizing discrete granulomas, some of which are peribronchiolar, along with mild predominantly lymphoplasmacytic inflammation. There is no evidence of foreign material, necrosis, vasculitis, dysplasia, or malignancy.
Wade Fite stain and PAS stain for acid-fast bacilli and fungi are negative.
Conclusion: RUL lung core biopsy: Non-necrotizing granulomatous inflammation, consistent with sarcoidosis.
Case Discussion
Having a known history of cardiac sarcoidosis, the multiple bilateral pulmonary nodules are favored to represent nodular sarcoidosis. The fact the one in the RUL has significantly increased in size in a one-year interval scan and has spiculated contours are discordant with the rest of the pulmonary involvement. Concerns for malignancy were raised and further CT-guided lung biopsy was performed confirming sarcoidosis.
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