Pulmonary sarcoidosis

Case contributed by Aneta Kecler-Pietrzyk


A farmer referred by his GP with ongoing shortness of breath especially on exertion, chest pain on inspiration, ongoing cough, fatigue and weight loss. History of exposure to hay on farm. On examination finger clubbing and skin nodules on his hands. On auscultation bibasal crepitations.

Patient Data

Age: 30
Gender: Male

Extensive bilateral interstitial opacification with a predilection for the upper zones, and sparing of the bases. No pleural effusion. Tenting of the left hemidiaphragm suggestive of volume loss.

Small right pneumothorax, best seen on expiration view. No mediastinal shift.


Severe bilateral symmetric upper lobes peribronchovascular nodularity and traction bronchiectasis with superior retraction of the hila in keeping with fibrosis. Peripheral increased interstitial markings also seen in the upper lobes. Relative sparing of the lung bases seen however scattered peribronchovascular nodules are also present in the lower lobes.

The pneumothorax demonstrated on the chest radiograph has resolved. No pleural effusion.

Mediastinal and bilateral hilar lymphadenopathy is present. No axillary lymphadenopathy.

Partially visualized upper abdomen demonstrates splenomegaly.

Overall findings highly suspicious for sarcoidosis.

Case Discussion

Upper lobe pulmonary fibrosis has a wide differential - see upper lobe pulmonary fibrosis (mnemonic)

In this case non-caseating epithelioid granulomas were histologically-confirmed via biopsy of the hand nodules confirming sarcoidosis. Also, the patient's serum ACE levels were extremely high. 

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