Sarcoidosis is a multisystem granulomatous disease with variable and often nonspecific clinical manifestations. Suspicion may arise solely from incidental findings on chest imaging.
A 62-year-old male, heavy smoker (2–3 packs/day), with a history of hypertension, benign prostatic hyperplasia, and chronic obstructive pulmonary disease, referred to a Pulmonology consult by his family medicine physician due to abnormalities identified on a chest computed tomography scan. Imaging revealed a 35 mm calcified left hilar lymph node and scattered pulmonary micronodules, raising suspicion of sarcoidosis versus tuberculosis. Due to the suspition, a bronchofibroscopy with bronchoalveolar lavage was performed that showed epithelial cell predominance (77%) and a CD4/CD8 ratio of 1.0. Tuberculosis was ruled out after negative BAAR and PCR results. Bronchial biopsies revealed chronic inflammatory infiltrate without granulomas or malignancy. Angiotensin-converting enzyme level was 6.5 U/L. A presumptive diagnosis of sarcoidosis was considered, and the patient remained under surveillance.
Months later, the patient presented to the emergency department with acute cough, dyspnea, and right pleuritic chest pain. He was hemodynamically stable and afebrile. Chest CT angiography demonstrated pulmonary embolism in segmental branches of the right lower lobe, mild bilateral pleural effusion, left perihilar lymphadenopathy with calcifications, and a large pericardial effusion. A transthoracic ultrasound was performed, revealing pericardial effusion with echographic criteria for "swinging heart" and tamponade. Urgent pericardiocentesis was performed and the collected liquid was sent for study, which revealed positivity for malignant cells suggestive of lung adenocarcinoma. The patient was referred for an urgente bronchofibroscopy biopsy of the suspicious lesion, which confirmed the diagnosis.
This case highlights the diagnostic challenge of differentiating sarcoidosis from other conditions, particularly malignancy, in patients with nonspecific imaging findings. It underscores the importance of maintaining diagnostic vigilance and reconsidering alternative diagnoses when clinical evolution is atypical.