PMC3600993_01
A frontal chest x-ray showing changes consistent sarcoidosis. There is bilateral bulky hilar and paratracheal lymphadenopathy together with extensive, confluent reticulonodular opacities with a characteristic distribution in the mid and upper zones.
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F1
Chest x-ray showed bulky hilar lymphadenopathy with extensive reticulonodular and mass like opacities in both lungs with a middle zone predominance (Figure 1).
Selected axial (A) and high resolution coronal (B) reformats from a non-contrast helical CT shows striking bilateral bulky hilar and mediastinal adenopathy. Mass-like fibrosis is encasing the hila and central bronchi causing traction bronchiectasis. There are several partially calcified hilar lymph nodes. There are also extensive perivascular and perilymphatic nodules throughout both lobes with relative sparing of the lower zones and right upper lobe bullae.
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F2
A non-contrast computed tomography (CT) scan of the thorax demonstrated numerous nodules in a perilymphatic distribution (subpleural and peribronchovascular) together with perihilar conglomerate masses (Figure 2).
Histology H&E images, original magnifications 200x (A) and 400x (B), of specimen from the transbronchial lung biopsy. It identified numerous well-formed, non-necrotising epithelioid granulomas (arrows) at both low (A) and intermediate (B) power.
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F3
Histopathology of a transbronchial lung biopsy showed numerous well-formed, non-necrotising epithelioid granulomas (Figure 3), but tests for bacilli, fungi and tuberculosis were negative.
Functional (cine) cardiac magnetic resonance images in the four-chamber image plane in diastole (A) and systole (B). The images show poor contraction of the right ventricle (RV) free wall (arrows in A and B), but normal contraction of the left ventricle (LV).
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F4
A cardiac magnetic resonance (CMR) scan confirmed a dilated RV with impaired systolic function (Figure 4), RV ejection fraction (EF) was 34% (normal 44-63%).
Delayed enhancement cardiac magnetic resonance images in the four-chamber (A) and short axis (B) image plane. The images show a patchy pattern of delayed enhancement (arrows) in the subepicardial and mid-wall of the right ventricle free wall, interventricular and interatrial septum. The myocardium of the left ventricle free wall is normal.
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F5
Extensive, patchy delayed gadolinium enhancement was observed in the RV free wall, as well as subtle mid-wall delayed enhancement in the interventricular and the interatrial septum (Figure 5).