Nodular sarcoidosis is a rare presentation of pulmonary sarcoidosis. It usually presents with multiple pulmonary masses that tend to be peripheral and are associated with mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsies has high diagnostic yield. Despite its ominous presentation, nodular sarcoidosis has favorable prognosis.

BackgroundSarcoidosis is a chronic disease with different phenotypic manifestations. Health-related quality of life is an important aspect in sarcoidosis, yet difficult to measure. The objective of this study was to identify clinical markers predictive of poor quality of life in sarcoidosis patients that can be followed over time and targeted for intervention.MethodsWe assessed the quality of life of 162 patients with confirmed sarcoidosis in a prospective, cross-sectional study using the Sarcoidosis Health Questionnaire (SHQ) and Short Form-36 Health Survey (SF-36). We evaluated the validity of these questionnaires and sought to identify variables that would best explain the performance scores of the patients.ResultsOn multivariate regression analyses, the very best composite model to predict total scores from both surveys was a model containing the distance-saturation product and Borg Dyspnea Scale score at the end of a 6-min walk test. This model could better predict SF-36 scores (R2 = 0.33) than SHQ scores (R2 = 0.24). Substitution of distanced walked in 6 min for the distance-saturation product in this model resulted in a lesser ability to predict both scores (R2 = 0.26 for SF-36; R2 = 0.22 for SHQ).ConclusionsBoth the SHQ and SF-36 surveys are valuable tools in the assessment of health-related quality of life in sarcoidosis patients. The best model to predict quality of life among these patients, as determined by regression analyses, included the distance-saturation product and Borg score after the 6-min walk test. Both variables represent easily obtainable clinical parameters that can be followed over time and targeted for intervention.

A non-smoking 45-year-old white man presented with a globus sensation worsened by lying down, with no complaints of hoarseness or dysphonia. He denied fever, fatigue, cough, chest pain, sweats, weight loss, reflux, arthralgias, myalgias and rash. He also denied exposure to asbestosis, beryllium, silica, HIV or tuberculosis, but he reported a recent cat bite. Physical examination revealed normal vital signs, no cervical or supraclavicular lympadenopathy and a normal cardiorespiratory system. He was referred to the otolaryngology department. Laryngoscopy revealed right vocal cord paralysis. A CT scan of the neck/chest identified diffuse mediastinal lymphadenopathy without parenchymal changes (figures 1 and 2).A purified protein derivative test was negative. Endobronchial ultrasound (EBUS)-directed transbronchial needle aspirations (TBNA) were performed of the paratracheal and subcarinal lymph nodes (figure 3). Diagnostic bronchoscopy revealed no endobronchial lesions or mucosal abnormalities. Acid-fast bacilli studies were negative and flow cytometry detected no monoclonal lymphocytes. Bacterial and fungal cultures, cryptococcal/ histoplasma antigen, HIV and Bartonella serology were negative. ACE was 31 U/l (reference range 9e67 U/l). Pulmonary function testing revealed mild decreased diffusion capacity but was otherwise normal. Empirical steroid therapy failed to provide benefit and mediastinoscopic right paratracheal lymphadenectomy was subsequently conducted (figure 4). QUESTION What is the diagnosis?See page