PMC6925795_01
Chest, abdomen, and pelvis computed tomography. (a) Mediastinum with multiple lymph node enlargements in the paratracheal chains. (b) Micronodules in the pulmonary parenchyma with bilateral perilymphatic distribution and enlarged lymph nodes in the pulmonary hilum. (c) Liver and spleen with increased dimensions, and prominent lymph nodes in retroperitoneal and external iliac chains. (d) Kidneys of normal size with nonobstructive calycinal microlithiasis.
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Abdominal computed tomography (CT) showed multiple retroperitoneal and iliac lymphadenopathy, enlarged liver with heterogeneous attenuation, and splenomegaly, as well as multiple nonobstructive renal micro calculi and a normal pancreas (Figure 1). Despite the absence of respiratory symptoms, a chest CT scan showed micronodular infiltrates with perilymphatic distribution and mediastinal and hilar lymphadenopathy (Figure 1), corroborating the hypothesis of sarcoidosis.
Macroscopic and microscopic appearance of the liver. (a) Multiple white lesions on the liver surface. (b) Well-formed epithelioid granulomas without necrosis (H&E 40x). (c) Epithelioid granuloma with epithelioid macrophages and pooled multinucleated giant cells with interposed lymphocytes (H&E 100x). (d) Detail of multinucleated giant cells with asteroid bodies within the cytoplasm (H&E 1000x), provided by the pathology service of HUCAM-UFES.
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Diagnostic laparoscopy was indicated for retroperitoneal lymph node biopsy; however, intraoperatively it was decided for the performance of liver biopsy since this organ had multiple white lesions (Figure 2(a)). The histopathological study showed epithelioid granulomas without caseous necrosis, with the presence of asteroid bodies, highly suggestive of sarcoidosis (Figures 2(b)-2(d)).
PMC6925795_02
(a and b) Magnetic resonance imaging of the left knee demonstrating an important degenerative process, with bilateral thinning of the articular cartilage and narrowing of the tibiofemoral joint space, bone remodeling, diffuse osteochondral lesions, and intense knee synovitis. (c and d) Wrist radiograph showing the presence of bone demineralization, important diffuse reduction of the interline/joint space, carpal and radial erosions, and diffuse intracarpal ankylosis.
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At the age of 34, a magnetic resonance imaging study of the knees was performed, showing an important degenerative process, with bilateral thinning of the articular cartilage and narrowing of the tibiofemoral joint space, bone remodeling, and diffuse osteochondral lesions, as well as intense left knee synovitis (Figures 3(a) and 3(b)). During the current hospitalization, wrist radiography showed bone demineralization, significant diffuse reduction of joint space, carpal and radial erosions, and diffuse intercarpal ankylosis (Figures 3(c) and 3(d)).