1. A Rare Case of Sarcoidosis with Bilateral Leg Edema as an Initial Presentation
Yanli Fan, M.D.

2. History 40 y.o. M presents with bilateral leg edema x 7 wks PMH
 DM type 2 SH
 Married with 2 daughter, no smoking or alcohol FH
 strong family history of DM

3. History ROS Medications  (+) Urinary frequency, Nocturia
 (+) Numbness of bilateral lower extremities
Medications
 Glucotrol XL 2.5 mg daily
 Metformin 500 mg QHS
 Neurontin 200 mg Tid

4. PE
BMI 32.6, BP 112/79 mmHg, HR 69
(+) Bilateral leg edema 2+ upper to knees

5. Work Ups for Leg Edema Common Causes of Chronic b/l Leg Edema
Venous insufficiency
Pulmonary HTN
Heart Failure
Idiopathic edema
Lymphedema
Drugs
Premenstrual edema
Pregnancy
Obesity

6. Less Common Causes of Leg Edema

7. Drugs that May Cause Leg Edema

8. Labs BUN/Cr: 18/0.9; GFR: 114 ml/min HbA1C: 10.7
Albumin: 4.2 g/dl, Ca: 9.5 mg/dl
UA: trace of protein

9. Accessory sodium intake
Leg u/s R/O DVT
Renal Function
24 hr urine study
Accessory sodium intake
Hormone (cortisol)
Sleep Study
2d-Echo, MUGA scan for RV EF
Venous insufficiency
Pulmonary HTN
Idiopathic
Obesity, OSA
Pregnancy
Heart failure
Drug
Premenstrual edema
DVT
Renal reasons
1,25 vit D 96, 25-vit D 22, iPTH: 18.2
1-25 dihydroxy-vitamin D ↑
Angiotensin converting enzyme level ↑

10. CT Abdomen and Pelvic
Mildly enlarged inguinal lympho nodes bilaterally.
Largest nodes measures ~ 2 cm

11. CT Chest
Mild mediastinal and bilateral hilar lymphadenopathy compatible with diagnosis of sarcoidosis

12. Bronchial Biopsy, Right Middle Lobe
Chronic bronchitis with focal non-caseating granuloma formation.
- GMS stain fails to reveal any evidence of fungal organisms.
- AFB stain fails to reveal any acid fast bacilli.
- No evidence of malignancy

13. Discussions Work ups for patient present with leg edema Sarcoidosis
Literature review: sarcoidosis and leg edema

14. Discussions – Bilateral Leg Edema
A common challenge for primary care physician is to determine the cause for leg edema of unclear etiology
Most common cause of leg edema in older adults is venous insufficiency
Most common cause in women before menopause is idiopathic edema, known as “cyclic edema”
A common but under-recognized cause is pulmonary HTN, often associated with sleep apnea

16. Discussions – Sarcoidosis
Sarcoidosis is a multisystem granulomatous disease and has variable clinical manifestations
Bilateral lung and hilar node involvement occurs in >90% of cases
Eye and skin lesions are next in frequency
Systemic/Pulmonary: lung involved >90%
Cutaneous: plaques, lupus pernio
Ocular: anterior uveitis is most common
Cardiac: 5%. Various types of heart block, cardiomyopathy later
Neurosarcoidosis: <10%, headache, seizure
Leg edema of lower extremities in an uncommon manifestation of sarcoidosis
Vascular compression by inguinal nodes involvement

17. Literatures Review
There have been five reported cases of sarcoidosis presenting with leg edema
Three cases are women, two were complicated with skin ulceration
Leg edema was attributed to the blockage of lymph flow by systemic lymph node involvement of disease

18. Conclusions
Our case describes a rare case of sarcoidosis in young male which has bilateral leg edema as the initial presentation
Sarcoidosis should be included in the differential diagnosis of leg edema when other common etiologies were ruled out

19. acknoledgement Erdal Sarac, M.D. Bryan Veynovich, D.O.
Walter Passarello, D.O.
David Gemmel, Ph.D.

20. References
Hoover Rd, et al., J. of American Academy of Dermatology 1994
Jobn W., et al., J. Am Board Fam Med 2006
Muller-Quernheim J, et al., Presse Med 2012
O’Regan A, et al., Ann Intern Med 2012
Tomoda F, et al., Am J Med Sci 1999
Sweeney T, et al., Angiology 1980