We present the case of a young male who visited the emergency room with progressive dyspnea and left sided chest pain. A chest X-ray was performed which showed a pattern of diffuse nodular and reticular opacities. The diagnosis of Necrotizing Sarcoid Granulomatosis (NSG) was made by histopathological examination of a lung biopsy specimen and by excluding other causes of granulomatous disease. He was treated with corticosteroids. Because of persistent extrapulmonary (ocular) involvement a maintenance dose of prednisone was needed. Necrotizing Sarcoid Granulomatosis is a granulomatous disease with necrosis and vasculitis of unknown cause. The resemblance between NSG and (nodular) sarcoidosis is strong, but subtle differences exist. The prognosis is good and therapy is usually not necessary. However in some cases there is a need for therapy with corticosteroids, depending on the involved organs and/or the degree of impairment.Keywords: Necrotizing Sarcoid Granulomatosis; Sarcoidosis; Extrapulmonary Involvement; Computed Tomography; Pathology CASE PRESENTATIONA 21 year old non-smoking male was presented at the emergency department of our hospital. He suffered from pain in his right shoulder and on the left side of his chest, with progressive shortness of breath for two days. He had a productive cough with clear blank sputum. There was no haemoptysis, nor were there constitutional symptoms like fever or night sweats. There were no complaints that could be related to a vasculitis-like disease, e.g. vision problems, joint aches, skin problems or abdominal discomfort. He had a blank history, and didn't use any medication.Our patient was tachypnoeic with an oxygen saturation of 98% with 3 litres of supplemental oxygen per minute. His blood pressure was 110/70 mmHg with a regular pulse of 115/minute. He had a low grade fever, with a temperature of 38,2 o C. There were no palpable lymph nodes. Chest examination revealed wheezing on both sides and crackles at the bases. There were no other abnormalities at the physical examination.The posteroanterior view of the chest X-ray showed diffuse reticular and nodular opacities of both lungs (Figure 1). A computed tomography of the chest and upper abdomen (Figure 2) showed mediastinal and right hilar lymphadenopathy. Diffusely dispersed alveolar opacities were present in both lungs, which were more pronounced in the lower lobes.Laboratory findings showed an elevated erythrocyte sedimentation rate. The C-reactive protein and white cell counts were both minimally elevated. The serum angiotensin converting enzyme (ACE) level was low. Antinucleair antibodies (ANA) and anti-neutrophil cytoplasmatic antibodies (ANCA) were both negative. Analysis of his urine showed no abnormalities. Pulmonary function tests showed a restrictive pattern (TLC = 53% of reference) with a diminished diffusion capacity (D L CO = 48%). Arterial blood gas analysis (ABGA) breathing room air showed a mild hypoxemia (pO 2 9.6 kPa), with normocapnia (pCO 2 5.1 kPa).We performed extensive microbiological test...
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