QuestionSBA
QuestionChoice
This would occur with obstructive lung diseases such as asthma or chronic obstructive pulmonary disease. This is not likely given the clinical history and the fact she is a non-smoker. Sarcoidosis would typically present with a restrictive picture on lung function testing, although it may also be normal
32186
d
Obstructive pattern on lung function testing
QuestionChoice
This is a test used to detect tuberculosis (TB) infection and would be positive in the context of both latent and active TB. Bronchoalveolar lavage (BAL) may be used in the diagnosis of TB if there are difficulties obtaining induced sputum samples. In TB, BAL is more likely to show caseating (necrotising) granulomas, and cultures would be positive for acid-fast bacilli, which is not the case here
32187
e
Interferon gamma release assay (IGRA) positivity
QuestionChoice
This woman has sarcoidosis, which may present with non-specific respiratory symptoms, polyarthralgia and multiple other extrapulmonary manifestations. BAL is the most specific test for sarcoidosis. It would show non-necrotising granulomas, which are typical of non-infectious interstitial lung disease (ILD), rather than necrotising granulomas, which are usually seen with infections. Other differential causes of non-infectious ILD include drugs, environmental toxins, immunodeficiency, malignancy, vasculitis and inflammation
32183
a
Raised serum angiotensin-converting enzyme (ACE) levels
QuestionChoice
This is most specific for rheumatoid arthritis, which may also present with pulmonary manifestations including interstitial, pleural and airway disease. It does not usually cause granulomatous lung disease
32184
b
Anti-cyclic citrullinated peptide (CCP) antibody positivity
QuestionChoice
Autoimmune vasculitides including granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis, would be possible differentials here given the respiratory symptoms and raised ESR, but it is less likely here given the normal renal function and the raised calcium level
32185
c
Antineutrophil cytoplasmic antibody (ANCA) positivity
Concept
Chapter
# Epidemiology

Around 4,500 people are diagnosed with sarcoidosis in the UK each year representing an annual incidence rate of 7 people per 100,000.

# Definition

Sarcoidosis is a multi-system disease characterised by granuloma formation, resulting in widespread inflammatory changes and complications.

# Acute sarcoidosis features

Acute sarcoidosis: fever, polyarthralgia, erythema nodosum, and bilateral hilar lymphadenopathy. This is also known as **Löfgren syndrome**.

# Chronic sarcoidosis features

- Pulmonary (most common manifestation): dry cough, dyspnoea, reduced exercise tolerance. Examination may reveal crepitations.

- Constitutional: fatigue, weight loss, arthralgia, and low-grade fever. General signs include lymphadenopathy and enlarged parotid glands.

- Neurological: meningitis, peripheral neuropathy, bilateral Bell's palsy.

- Ocular: uveitis, keratoconjunctivitis sicca.

- Cardiac: arrhythmias, restrictive cardiomyopathy.

- Abdominal: hepatomegaly, splenomegaly, renal stones.

- Dermatological: erythema nodosum, lupus pernio.

# Investigation

Tissue biopsy (eg. lung, lymph nodes) is diagnostic, which typically finds non-caseating granulomas. However, other investigations can point towards a diagnosis of sarcoidosis.

- Bloods: Raised ESR, ACE (not specific or diagnostic) and calcium; reduced lymphocytes.

- Chest x-ray or CT:
  - Stage 1 - bilateral hilar lymphadenopathy (BHL)
  - Stage 2 - BHL with peripheral infiltrates
  - Stage 3 - peripheral infiltrates alone
  - Stage 4 - pulmonary fibrosis

# Management

- Bilateral hilar lymphadenopathy alone - usually self-limiting
- Acute sarcoidosis - bed rest, NSAIDs
- Steroid treatment: oral or IV, depending on severity of disease
- Immunosuppressants: in severe disease
1813
2648
Sarcoidosis
Topic
20
Respiratory Physiology
6437
A 50-year-old female presents with shortness of breath, dry cough and fatigue for the past two months. She also has bilateral knee pain. She is a non-smoker, does an office-based job and has no other past medical history of note.


Erythrocyte sedimentation rate (ESR) was raised at 66 mm/hour (normal <20 mm/h). Corrected calcium was 2.85 mmol/L (normal range 2.2-2.6 mmol/L). Blood results for full blood count, urea & electrolytes and liver function testing were all unremarkable.


Chest X-ray: bilateral mid to upper zone reticular opacities


Bronchoalveolar lavage (BAL): Increased lymphocytes, no bacterial growth seen, biopsy showing non-caseating granulomas


Which of the following investigation findings is most likely to correspond with her diagnosis?
a