Mass-Like Ground-Glass Opacities in Sarcoidosis

Case Reports in Radiology
14 Jun, 2019 ,

An African American woman presented with neurologic-type symptoms. The appearance of the ground-glass opacities in this case is unique, appearing as discrete well-defined mass-like ground-glass opacities in a peribronchovascular distribution without additional parenchymal findings typically seen in sarcoidosis.

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An African American woman in her mid-30s presented to the emergency room with neurologic-type symptoms. Initial work-up included a chest X-ray which demonstrated multiple bilateral pulmonary masses and right paratracheal lymphadenopathy.

 Further evaluation with chest CT revealed discrete, sharply demarcated, mass-like ground-glass opacities involving all lobes bilaterally. The CT confirmed the right paratracheal lymphadenopathy and also showed bilateral hilar, para-aortic, subcarinal, and prevascular lymphadenopathy. No interstitial opacities or perilymphatic nodules were identified otherwise. The differential diagnosis based on the imaging findings included lymphoma, vasculitis, and atypical pulmonary infection.

The patient did not report any significant respiratory symptoms. An extensive work-up was performed as the clinical differential included inflammatory, infectious, vasculitic, embolic, and neoplastic etiologies. Rheumatologic, serologic, and infectious work-up were negative. Her angiotensin converting enzyme (ACE) was elevated at 57 (reference range 8–52 U/L).

She went on to have bronchoscopy. Cultures from bronchoalveolar lavage were negative for bacterial, fungal, mycobacterial, and viral etiologies. There was no evidence of malignancy. Fine-needle aspiration of an enlarged right paratracheal lymph node and biopsy of the right lower lobe both revealed noncaseating granulomas, consistent with sarcoidosis.

Given the histopathologic findings with the elevated ACE level, the diagnosis was consistent with sarcoidosis and she was started on treatment with corticosteroids.