Figure 1
Chest radiograph
Chest radiograph, PA-view shows multiple pulmonary nodules with a diameter of up to 3 cm predominantly in the lower zones of both lungs. The nodules are well-defined and non-calcified.
Clinical History
Complaints of chest pain and non-productive cough. Symptoms had become apparent five weeks before. Personal history of the patient disclosed insulin-dependent diabetes. Clinical examination and extensive laboratory investigations, including renal function tests, were normal. Tuberculin reaction was negative.
Imaging Findings
The patient was admitted to the hospital with complaints of chest pain and non-productive cough. Symptoms had become apparent five weeks before. A general practitioner made the diagnosis of common cold. Personal history of the patient disclosed insulin-dependent diabetes. Clinical examination and extensive laboratory investigations, including renal function tests, were normal. Tuberculin reaction was negative. Chest radiography and CT scan of the lungs were performed. Based on the findings, a percutaneous needle aspiration of one of the pulmonary lesions was carried out under CT guidance. This procedure was repeated twice but yielded only a non-diagnostic, serosanguilent fluid. Finally, a video-thoracoscopic resection of a peripheral lesion was performed, followed by microscopic examination of the specimen.
Discussion
Most patient with necrotizing sarcoid granulomatosis (NSG) are middle aged. A varying female predominance is seen. The disease usually presents with a specific symptoms, such as dry cough, chest pain and fatigue.
NSG has to be differentiated from pulmonary sarcoidosis. Massive necrosis and vasculitis, which are typical findings in NSG, are very uncommon in sarcoidosis. Moreover, T- and B-cell activity, as well as the angiotensin converting enzyme levels in serum and tissue are normal in this disease.
On chest radiographs, NSG is characterized by presence of a solitary, or more often, multiple pulmonary nodules. The latter image may be mistaken for malignancy. Pleural effusion and mediastinal lymphadenopathy are uncommon.
Differential diagnosis of NSG includes pulmonary sarcoidosis, being the most important, and pulmonary tuberculosis, Wegener’s granulomatosis, and lymphomatoid granulomatosis.
The final diagnosis of NSG is made histologically. Pathohistologic hallmarks of NSG are necroziting, angiocentric, confluent granulomas with epitheloid and giant cells, as well as focal destructive vasculitis of small to medium sized vessels.
The prognosis of NSG is usually good, with mostly complete response after corticosteroid therapy.
Differential Diagnosis List
Necrotizing sarcoid granulomatosis
Final Diagnosis
Necrotizing sarcoid granulomatosis
References
[1] Churg A, Carrington CB, Gupta R. Necroziting sarcoid granulomatosis. Chest 1979; 76: 406-413. (PMID: 477427)
[2] Koss MN, Hochholzer DS et al. Necroziting sarcoid-like granulomatosis: clinical, pathologic and immunopathologic findings. Hum Pathol 1980; 11: 510-519. (PMID: 6776027)
[3] Pertschuk LP, Silverstein E, Friedland J. Immunohistologic diagnosis of sarcoidosis. Am J Clin Pathol 1981; 75:350-354. (PMID: 6259928)
Case information
| URL: | https://eurorad.org/case/919 |
| DOI: | 10.1594/EURORAD/CASE.919 |
| ISSN: | 1563-4086 |
Figure 2
CT scan of the lungs
CT scan of the lungs, section at the level of the lower lobes confirms multiple pulmonary nodules of varying size. CT scan showed neither evidence for pleural effusion nor for mediastinal lymphadenopathy (not shown).
Figure 3
Microscopy of a resected pulmonary module
Microscopy of a resected pulmonary nodule shows the presence of multiple confluent granulomas with central necrosis. Pathohistologic examination of the resected specimen revealed necrotizing sarcoid granulomas.
Chest radiograph
Chest radiograph, PA-view shows multiple pulmonary nodules with a diameter of up to 3 cm predominantly in the lower zones of both lungs. The nodules are well-defined and non-calcified.
CT scan of the lungs
CT scan of the lungs, section at the level of the lower lobes confirms multiple pulmonary nodules of varying size. CT scan showed neither evidence for pleural effusion nor for mediastinal lymphadenopathy (not shown).
Microscopy of a resected pulmonary module
Microscopy of a resected pulmonary nodule shows the presence of multiple confluent granulomas with central necrosis. Pathohistologic examination of the resected specimen revealed necrotizing sarcoid granulomas.