PMC4748620_01
Chest X-ray (posteroanterior view) shows bilateral diffuse micronodular infiltrates
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F1
C-reactive protein and erythrocyte sedimentation rate. Chest X-ray [Figure 1] displayed micronodular interstitial disease, with diffuse interstitial-alveolar infiltrates.
Computed tomography images demonstrate subcarinal adenopathy (asterisk) and diffuse ground-glass opacities with small nodules (arrows) which tend to be confluent in some areas of the lung (box)
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F2
Chest CT [Figure 2] displayed lung hilar and mediastinal lymphadenopathies (up to 3 cm) associated to diffuse parenchymal opacities (ground glass) and small nodules.
Transbronchial biopsy (TBB) showing granulomas. H and E, assay x100 (a), x200 (b). TBB was mainly characterized by the presence of nonnecrotizing granulomas. Other inflammatory cells were poorly represented, mainly lymphocytes around granulomas. Alveolar septa were overshadowed by granulomatous component. Some central necrosis (b) revealing very active sarcoidosis can be identified. Special stains for fungi (PAS) and mycobacteria resulted negative. Images courtesy of Tironi Andrea MD, Division of Anatomic Pathology, Spedali Civili, Brescia.
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F3
This diagnosis was confirmed by BAL fluid examination which revealed lymphocytic alveolitis with CD4/CD8 ratio 1.2 and TBB was positive for nonnecrotizing granulomas consistent with sarcoidosis [Figure 3].
Computed tomography images show complete resolution of lymphadenopathies and ground-glass opacities; only a few small nodules are detected (arrows)
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F4
Chest X-ray and CT scan, performed 6 and 16 months after the discharge respectively, demonstrated almost complete regression of lymphadenopathies and pulmonary abnormalities [Figure 4].