Sarcoidosis: The Daily PANCE Blueprint
A 32-year-old Black woman has three months of dry cough, mild dyspnea on exertion, and fatigue. She also has tender red nodules on both shins and blurred vision in one eye. Her chest radiograph shows bilateral hilar lymphadenopathy with reticular opacities. Serum calcium is 11.1 mg/dL and ACE level is elevated. A transbronchial biopsy shows noncaseating granulomas, and stains and cultures for acid-fast bacilli and fungi are negative. Which of the following is the most likely diagnosis?
A. Tuberculosis
B. Hodgkin lymphoma
C. Sarcoidosis
D. Silicosis
E. Hypersensitivity pneumonitis
Answer and topic summary
The answer is C. Sarcoidosis
Bilateral hilar lymphadenopathy plus noncaseating granulomas on biopsy is sarcoidosis, a multisystem inflammatory disorder in which activated macrophages and T cells wall off into granulomas without the central necrosis you would see in an infection. The supporting cast here is textbook: erythema nodosum on the shins, uveitis causing the blurred vision, and hypercalcemia — the granulomas themselves convert vitamin D to its active form, driving calcium up. An elevated ACE level supports the diagnosis but is neither sensitive nor specific enough to make it alone. The essential step before treating is excluding tuberculosis and fungal infection, because both produce granulomas and both would be made dramatically worse by the corticosteroids used for sarcoidosis — here the acid-fast and fungal studies are negative, and TB granulomas are classically caseating. Hodgkin lymphoma causes mediastinal adenopathy but shows Reed-Sternberg cells rather than granulomas, and silicosis and hypersensitivity pneumonitis both require an occupational or antigen exposure history that is absent.
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Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
