CRA70 PULMONARY SARCOIDOSIS – MORE THAN MEETS THE EYE

Siti Nabilah Azman, Noor Izyani Zakaria, Shivaanand A/L Letcheminan, Jen Lye Wan

Respiratory Department, Hospital Selayang, Malaysia

Background
Sarcoidosis is a multisystemic non-caseating granulomatous inflammation. Diagnosis often challenging as presentations may vary. We present a case of   middle-aged gentleman and our journey to the sarcoidosis diagnosis.

Case presentation
A 45-year-old ex-smoker, presented with chronic cough, exertional dyspnea, arthralgia and weight loss. He was hypoxic on arrival, requiring 3-litre oxygen upon presentation. Lungs revealed coarse crepitations, with no apparent extrapulmonary sign. Chest radiograph showed bilateral perihilar infiltrates and reticular opacities. Liver enzymes were elevated and Hepatitis C antibody was positive. Autoimmune screening showed positivity for Anti-Nuclear Antibody (ANA), AntiScL-70, Anti-Ro60, Anti-Sm, Anti-RNP, Anti-SS-B, and Anti-centromere. Cultures were negative for infection and other blood investigations were unremarkable. High resolution computed tomography thorax showed bilateral hilar and mediastinal lymphadenopathy with calcification, ground glass with mosaic attenuation and fibrosis. Endobronchial ultrasound and biopsy revealed granulomatous inflammation, negative infections. Hepatitis C treatment initiated with Sofosbuvir and Daclatasvir. Prednisolone 1mg/kg was initiated for lung involvement. A multidisciplinary meeting concluded that he has stage 4 Pulmonary Sarcoidosis with fibrosis. He showed clinical and radiological improvement and returned to work. He achieved Hepatitis C serological conversion. Mycophenolate Mofetil was started as steroid sparing agent but replaced with Methotrexate due to intolerance. On further history, he experienced multiple uveitis in his twenties, managed with topical steroid. He was on Prednisolone 2.5mg once daily during current presentation for at least a year.

Conclusion
Sarcoidosis may mimic other diseases and requires thorough assessment. This patient’s autoimmune positivity, deranged liver enzymes and imaging features required differentiation from autoimmune-related interstitial lung disease, sarcoidosis and hypersensitivity pneumonitis. Mosaic attenuation may indicate small airway granulomatous involvement. Therefore, histology and multidisciplinary discussion are very important.