A CURIOUS CASE OF PULMONARY AND EXTRAPULMONARY SARCOIDOSIS IN A PATIENT PRESENTING WITH UNILATERAL PLEURAL EFFUSION

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters 14 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Sarcoidosis is a multisystem granulomatous disorder of unknown etiology characterized pathologically by the presence of noncaseating granulomas in involved organs. Sarcoidosis most frequently involves the lung but up to 30 percent of patients present with extrathoracic manifestations. Pulmonary involvement mostly presents as diffuse interstitial lung disease however less common pulmonary manifestations include pneumothorax, pleural thickening, chylothorax, and pulmonary hypertension. Here, we present a case of sarcoidosis in a 43-year-old male presenting as a large unilateral pleural effusion. CASE PRESENTATION: A 43-year-old male with a history of noninsulin-dependent diabetes mellitus, recent diagnosis of eczema, and anemia of chronic disease with ongoing evaluation of gammopathy came in with progressive shortness of breath with exertion over 5 days. The patient denied any occupational or environmental exposure.He works in a construction company. No history of smoking or lung diseases. Physical examination was significant for dullness to percussion, and decreased breath sounds to the left. Patient also had an erythematous indurated, nontender annular rash on his face and temple. Labs were significant for elevated ESR 129, CRP 8.13, ALP 194, total protein 9.6, and elevated D-dimer 5325. EKG showed sinus tachycardia and low amplitude waves. CTA was negative for pulmonary embolism but showed large left pleural effusion and mediastinal lymphadenopathy with right paratracheal and subcarinal involvement and splenomegaly. Urine streptococcal and legionella antigen, respiratory culture, and a viral respiratory panel including COVID were negative. The patient underwent thoracentesis and a pigtail catheter was placed that drained about 2000 ml of orange cloudy fluid with 73 percent lymphocytes, LDH 262, and protein 7.6. Pleural fluid cultures were negative. Pleural fluid flow cytometry showed lymphocytic predominance with a CD4:CD8 ratio of 15:1. Previous records revealed negative PPD and HIV. ANA came back negative. ECHO revealed normal cardiac function. Finally, the angiotensin-converting enzyme level was elevated at 109. DISCUSSION: The patient underwent an endobronchial evaluation that showed cobblestoning of the bronchial mucosa. Lymph node biopsy revealed non-necrotizing granuloma and endobronchial biopsy revealed squamous metaplasia, chronic inflammation, and two noncaseating granulomas. Fungal and mycobacterial stains on biopsy were negative. The skin lesions appeared to be plaque sarcoidosis and the splenomegaly with anemia and hypergammaglobulinemia also supported the findings. Our patient had compatible clinical and radiographic manifestations with histopathologic evidence, thus establishing the diagnosis of pulmonary and extrapulmonary sarcoidosis. CONCLUSIONS: Pleural effusion is considered to be a rare manifestation of pulmonary sarcoidosis. Studies have shown that a triad of CD4 to CD8 ratio of >4:1, a BAL lymphocyte percentage ≥ 16 percent, and transbronchial biopsy demonstrating noncaseating granulomas were the most specific tests for sarcoidosis. Asymptomatic pleural effusions resolve spontaneously however symptomatic or recurrent pleural effusions may require corticosteroids. Sarcoid pleural effusions can lead to complications like trapped lung requiring invasive procedures. A high index of suspicion must be exercised to diagnose sarcoidosis, monitor for new organ involvement and reduce morbidity associated with the disease. REFERENCE #1: Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med 1997 Jul 10;337(2):139]. N Engl J Med. 1997;336(17):1224-1234. doi:10.1056/NEJM199704243361706 REFERENCE #2: Lower EE, Smith JT, Martelo OJ, Baughman RP. The anemia of sarcoidosis. Sarcoidosis. 1988;5(1):51-55. REFERENCE #3: Huggins JT, Doelken P, Sahn SA, King L, Judson MA. Pleural effusions in a series of 181 outpatients with sarcoidosis. Chest. 2006;129(6):1599-1604. doi:10.1378/chest.129.6.1599 DISCLOSURES: No relevant relationships by Ramachandra Illindala No relevant relationships by Gerald Lawyer No relevant relationships by Kevin Ruiz No relevant relationships by Tejal Shah No relevant relationships by Pooja Shekar No relevant relationships by Natalie Zolotareva