Pulmonary Sarcoidosis (Stage II)

Ugur Topal, MD
Robert D Pugatch, MD

May 24, 1996

Presentation

Imaging Findings

Posteroanterior (PA) and lateral radiographs show prominence of both hila (arrow), widening of the right paratracheal stripe (arrow), and obliteration of the aortopulmonary window (arrow). Multiple small nodules are visible in both lungs. The lung volumes are decreased.

High resolution computed tomography (HRCT) confirms miliary-like nodules in a subpleural, perihilar, and bronchovascular distribution. Fissures are thickened. Paratracheal (arrow), bilateral hilar (arrow) and subcarinal (arrow) lymph nodes are also demonstrated.

Differential Diagnosis

• Infections (tuberculous, fungal)
• Sarcoidosis
• Metastasis
• Pneumoconiosis
• Hypersensitivity lung disease

Diagnosis

Discussion

• Stage 0: Normal chest radiograph
• Stage I: Hilar and mediastinal lymph node enlargement
• Stage II: Lymphadenopathy and parenchymal disease
• Stage III: Parenchymal disease only
• Stage IV: Pulmonary fibrosis

Intrathoracic lymphadenopathy is the most common finding in sarcoidosis occurring in over 85% of patients. The most common pattern is right paratracheal and bilateral hilar adenopathy (the "1,2,3 sign"). Unusual patterns of lymph node enlargement occasionally occur. While not common, paratracheal, subcarinal, aortopulmonary window, and other mediastinal lymph node groups can be involved in the absence of hilar disease.

The radiographic appearance of parenchymal disease can be fine nodular, reticulonodular, acinar and very rarely focal (solitary nodule or mass). Acinar opacities in sarcoidosis may coalesce to give the appearance of the so-called alveolar form of sarcoidosis.

Computed tomography (CT) is more sensitive than chest radiography in the detection of adenopathy and subtle parenchymal disease. High resolution CT (HRCT), by demonstrating fine anatomic detail, can show the distribution of the granulomas. HRCT findings include areas of ground-glass appearance, subpleural and perivascular nodules, irregular thickening of bronchovascular bundles, and thickening of interlobular septa. Although nodular thickening of interlobular septa (so-called "beaded septa sign") is more commonly described in lymphangitic spread of tumor, it can also be seen in sarcoidosis.

References

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