1. History: 58 year-old male with 6 months of progressive breathlessness Case of the Month 10 April 2016

2. Case of the Month 10

3. What is your diagnosis ?

5. Case of the Month 10 Question : What are the key findings on the CXR?

6. Case of the Month  Bilateral symmetrical ground-glass opacification  Multiple micronodules  Upper/Mid zone predominance  No CXR evidence of lymph node enlargement  No pleural thickening/effusions

7. Question: What is shown on the CT images? Case of the Month 10

8.  Multiple micronodules  Ground-glass opacification and dense bronchocentric parenchymal opacification  Upper/Mid zone predominant

9. Case of the Month 10 Diagnosis What is your diagnosis ?

10. Case of the Month 10 Diagnosis Sarcoidosis Differential Diagnosis - Tuberculosis - Tuberculosis - Fungal infection - Fungal infection - Silicosis - Silicosis - Chronic hypersensitivity pneumonitis - Chronic hypersensitivity pneumonitis Authors: M Zagura, S Tran, SR Desai London

11. Case of the Month 10 Discussion  Sarcoidosis is a systemic disorder of unknown aetiology characterised non-caseating granulomatous inflammation  Granulomas have characteristic distribution in the peribronchovascular space, subpleural space and in the interlobular septa  Common symptoms of sarcoidosis include dyspnea, cough, chest pain, fatigue, weight loss, night sweats and erythema nodosum  Thoracic involvement can lead to extensive fibrosis (20-25% of cases), lung volume reduction, bronchial stenosis, pulmonary hypertension and mycetoma formation

12. Case of the Month 10 Discussion CHEST RADIOGRAPHY  Reticulonodular opacities in upper and mid zones  Bilateral hilar and mediastinal lymph node enlargement  Coarse linear pattern and upward displacement of the hila HIGH-RESOLUTION CT  Innumerable perilymphatic nodules predominantly in upper and mid zones  Bilateral symmetrical hilar and mediastinal lymph node enlargement  Architectural distortion and traction bronchiectasis  " Icing sugar " pattern of lymph node calcification  Atypical features include: consolidations, ground- glass opacities, presence of cysts or bullae, pleural disease

13. Case of the Month 10 Further Reading SARCOIDOSIS 1) Prabhakar HB et al. Imaging features of sarcoidosis on MDCT, FDG PET, and PET/CT. AJR Am J Roentgenol 2008; 190: S1-S6 2) Hoang DQ et al. Sarcoidosis. Semin Roentgenol 2010; 45: 36-42 3) Nishino M et al. The spectrum of pulmonary sarcoidosis: variations of high- resolution CT findings and clues for specific diagnosis. Eur J Radiol 2010; 73: 66-73. 4) Valeyre D et al. Sarcoidosis. Lancet 2014; 383: 1155-1167 5) Spagnolo P et al. Imaging aspects of the diagnosis of sarcoidosis. Eur Radiol 2014; 24: 807-816