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Sarcoidosis – clinical club

Sarcoid club cd1

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Sarcoidosis – clinical club

• 71 year old male

• Manual laborer

• Dyspnea – increased over 1 month

• Cough

• Multiple Joint pain

• Past history –

DOE – 3yrs , Polyarthralgia , Hypertensive

No DM / CAD / PTB

• Personal history –

LOW + LOA+

Ex smoker SS- 600

• Family history– Nil

• Treatment history – on Ayurvedic medications & analgesics for joint pain

Examination………

• Moderately built and nourished

• PR- 88 , BP – 140/90 mmHg

• Spo2 – 95 % , RR – 18/min

• Clubbing +

• No pallor / icterus / cyanosis / lymphadenopathy / pedal odema

• URT - wnl

• Shape of chest – normal

• Trachea – central

• Apex – 5th left intercostal space 1cm medial to midclavicular line

• Movements – equal bilaterally

• B/l resonant note obtained

• Bilateral scattered fine late inspiratory crackles

• CVS

• CNS normal

• GIT

• Musculoskeletal system – swelling both knee joint , tender , decreased range of movements

• Interstitial lung disease – IPF

Medications

CTD associated

• Occupation related

• Malignancy

Investigations

• Hb 12.7

TC– 8200

DC – P60 L 32

ESR -110

RBS – 106

RFT , LFT , SE - wnl

• RA factor – neg

• Anti – CCP – neg

• ANA – neg

• PFT – Restrictive pattern

• Randomly distributed nodules , interlobular septalthickening and GGO noted involving bilateral lung fields .

• Fibrosis with traction bronchiectasis & paraseptalemphysematous changes noted

• Few enlarged mediastinal lymph nodes –aortopulmonary window LN – 6.4 mm , L peribronchial 10mm , R paratracheal 9mm

• Unclassified interstitial lung disease

• Miliary TB

• Sarcoidosis

• Sputum AFB – Neg

• S.calcium – 11.8

• S.ACE – 137.5

• Opthalmology consultation - normal

• FOB – Normal study

• TBLB – Non caseating granuloma consistent

with Sarcoidosis

Diagnosis

• Sarcoidosis stage 2 , Hypertension

Atypical presentations of sarcoidosis - Elderly

• Multisystem idiopathic granulomatous disease

• Adults aged between 20 years and 40 years.

• Rare among elderly patients.

• Diagnosing sarcoidosis in an elderly patient remains a challenge.

• An indolent decline in general health with asthenia, anorexia, and weight loss.

• In 60%–70% of patients, the characteristic feature is enlarged hilar and paratracheal lymph nodes, with or without concomitant parenchymal changes

• Imaging findings are nonspecific or atypical in 25%–30% of patients, and in another 5%–10%, no abnormalities are seen at thoracic imaging

Elderly onset sarcoidosis (EOS)

• 1) Clinical features of sarcoidosis – not typical

• 2) Age ≥65 years at diagnosis

• 3) Absence of any known history of sarcoidosis

• 4) Biopsy analysis revealed noncaseating granuloma

• 5) And exclusion of other possible causes, including

other granulomatous disorders.

TYPICAL FEATURES IN HRCT

• Lymphadenopathy: hilar, mediastinal (right paratracheal), bilateral, symmetric, and well defined

• Nodules: micronodules (2–4 mm in diameter; well defined, bilateral); macronodules (≥5 mm in diameter, coalescing)

• Lymphangitic spread: peribronchovascular, subpleural, interlobular septal

Typical features……

• Fibrotic changes: reticular opacities, architectural distortion, traction bronchiectasis, volume loss

• Bilateral perihilar opacities

• Predominant upper- and middle-zone locations of parenchymal abnormalities

ATYPICAL FEATURES

• Lymphadenopathy: unilateral, isolated, anterior and posterior mediastinal

• Airspace consolidation: masslike opacities, conglomerate masses, solitary pulmonary nodules, confluent alveolar opacities (alveolar sarcoid pattern)

• Ground-glass opacities

• Linear opacities: interlobular septal thickening,

intralobular linear opacities

• Fibrocystic changes: cysts, bullae, blebs, emphysema, honeycomb-like opacities with upper- and middle-zone predominance

• Miliary opacities

• Airway involvement: mosaic attenuation pattern, tracheobronchial abnormalities, atelectasis

• Pleural disease: effusion, chylothorax, hemothorax, pneumothorax, pleural thickening, calcification , Pleural plaquelike opacities

• Although the prognosis for sarcoidosis is life threatening , organ involvement does not seem to be more severe in the older subjects.

• The disease course is generally similar to that of young subjects, and stage IV intrathoracic forms and some types of organ involvement remain difficult to treat.

• In older patients, suitable treatment leads to improvement or stabilization of the disease in > 80% of cases.

CONCLUSION• Thoracic sarcoidosis - “the great mimic”; -manifests

with various patterns at radiologic imaging, necessitating an initially broad differential diagnosis

• Presents with nonspecific features among Elderly patients.

• An alteration of general health is the major sign

• Once the very particular clinical signs of the disease are recognized, the older patient can benefit from treatment and improved quality of life.