GENERALIZED LYMPHADENOPATHY IN A PATIENT WITH DIFFUSE BILATERAL PULMONARY FIBROSIS

Purpose: To present an unique and atypical case of sarcoidosis and lessons learned from it. Methods: Medical charts, Diagnostic studies, Imaging studies, and Laboratory studies, Consultant notes and referral notes. Results: The patient had 4 lymph noded present throughout his body(left posterior nec, right antecubital fossa, and 2 in the groin) which were nontender, firm, and mobile. He was afebrile and did not have leukocytosis. Chest x-ray revealed diffuse bilateral pattern of micronodular disease with interstitial fibrotic changes within both lungs. CT angiogram revealed diffuse mediastinal, hilar, and upper abdominal retroperitoneal adenopathy. FNA of the lump node in the neck revealed no diagnostic value. HIV status was negative. RPR nonreactive. ANA screen normal. ACE level was elevated. AFP and b-HCG were normal. Echocardiogram revealed an EF of 50-55%. Broncho gram stain, bronchial lavage, and culture were negative. Culture showed no growth at 3 weeks. Fungus smear showed no yeast, no fungal elements seen at 3 weeks. Right Arm Lymph node biopsy showed abudant, back-to-back granulomas with prominent multinucleated giant cells; while the majority of the granulomas are non-caseating, granulomas with central necrosis were not difficult to find. With all the test results back, along with the clinical presentation, physicians were able to diagnose an atypical case of sarcoidosis after ruling out other differential diagonis such as Hodking lymphoma. Conclusions: This case is a great learning experience about expecting the unexpected, and understanding that while most disease processes follow a specific pattern and presentation there will be be cases that are atypical. This case reminds us as clinicians that some cases follow an unusual pattern despite a typical diagnoses.