Abstract Introduction Sarcoidosis is a multisystem granulomatous disease of unclear etiology that most commonly affects the lungs and intrathoracic lymph nodes. While typical imaging reveals symmetric bilateral hilar lymphadenopathy, alveolar patterns are uncommon and can mimic infection. This case highlights an atypical alveolar presentation of stage III Scadding pulmonary sarcoidosis, illustrating both diagnostic and therapeutic challenges. Case Presentation A 39-year-old Caucasian woman was incidentally found to have multiple lung nodules on abdominal imaging performed for abdominal pain. A follow-up chest CT revealed multifocal bilateral nodular infiltrates, predominantly in subpleural and peripheral regions. She reported persistent low-grade fevers, poor appetite, a 10-pound weight loss, and intermittent violaceous skin lesions for one month. Soon after, she developed a dry cough and progressive dyspnea. Bronchoscopy with bronchoalveolar lavage was negative for malignancy and fungal infection. She was treated empirically for multifocal pneumonia without improvement. Repeat CT imaging showed waxing and waning nodular opacities without hilar or mediastinal lymphadenopathy (Figure 1). Given the fluctuating course, corticosteroids were started for presumed organizing pneumonia, but her symptoms recurred upon tapering. Endobronchial ultrasound-guided transbronchial needle aspiration of the left lower lobe revealed noncaseating granulomas. Acid-fast bacilli stains were negative, and serum ACE level was elevated at 68 U/L. Based on the radiologic pattern patient was diagnosed with alveolar sarcoidosis, a rare radiologic subtype of pulmonary sarcoidosis. She was initially managed with corticosteroids and methotrexate, but developed worsening cough thought to be medication-related. Therapy was switched to azathioprine; however, this was later discontinued after she developed breast cancer, raising concern for a possible association. She was subsequently transitioned to adalimumab 40 mg subcutaneously every two weeks, with clinical and radiographic improvement. Discussion Symmetric bilateral hilar and mediastinal lymphadenopathy, seen in about 75% of patients, was absent here, possibly contributing to initial misdiagnosis. In only 4% of plain films and 15% of CT scans, the disease presents with an alveolar or “pseudoalveolar” pattern. This results from dense aggregation of interstitial granulomas that mimic a true alveolar process. Alveolar sarcoidosis tends to have a more acute onset and may show rapid radiologic changes. Despite this, clinical findings do not differ from those in the more common forms of sarcoidosis. Because of its varied presentation sarcoidosis remains a “great mimicker.” This case emphasizes the importance of considering sarcoidosis even in the absence of lymphadenopathy and recognizing alveolar sarcoidosis as a potential mimic of infection or organizing pneumonia. This abstract is funded by: None
Phirtskhalava et al. (Fri,) studied this question.