A 34-year-old African American man comes to the office due to 2 months of fatigue and nonproductive cough. During this time, the patient has also had mild achiness of the joints, a feverish feeling, and night sweats but is most bothered by the constant feeling of tiredness. He has had no change in appetite or weight. The patient served in Iraq and Afghanistan as a United States Marine and was discharged after a combat-zone trauma. He underwent multiple surgeries after the injury and received blood transfusions. While serving, he was also found to have a positive tuberculosis skin test and received treatment for latent tuberculosis. He has no other medical problems and takes no medications. The patient is in a monogamous relationship and does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits. Physical examination reveals a well-built man in no acute distress. There is no scleral icterus, lymphadenopathy, mucosal lesions, or skin rash. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender with no masses or hepatosplenomegaly. Neurologic examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits. Chest imaging reveals right paratracheal and bilateral hilar lymphadenopathy with no parenchymal opacities.
Which of the following is the most appropriate next step in management of this patient?

Question

A 34-year-old African American man comes to the office due to 2 months of fatigue and nonproductive cough.  During this time, the patient has also had mild achiness of the joints, a feverish feeling, and night sweats but is most bothered by the constant feeling of tiredness.  He has had no change in appetite or weight.  The patient served in Iraq and Afghanistan as a United States Marine and was discharged after a combat-zone trauma.  He underwent multiple surgeries after the injury and received blood transfusions.  While serving, he was also found to have a positive tuberculosis skin test and received treatment for latent tuberculosis.  He has no other medical problems and takes no medications.  The patient is in a monogamous relationship and does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits.  Physical examination reveals a well-built man in no acute distress.  There is no scleral icterus, lymphadenopathy, mucosal lesions, or skin rash.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender with no masses or hepatosplenomegaly.  Neurologic examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits.  Chest imaging reveals right paratracheal and bilateral hilar lymphadenopathy with no parenchymal opacities.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's isolated mediastinal (hilar) adenopathy, systemic symptoms, and African American descent strongly suggest sarcoidosis. However, he may have lymphoma, pulmonary infection, or other pulmonary or systemic disease (eg, pneumoconiosis, vasculitis). The diagnosis of sarcoidosis requires: Compatible clinical and radiologic manifestationsExclusion of other diseases with similar presentationHistopathologic evidence of noncaseating granulomas Compatible clinical and radiologic manifestations Exclusion of other diseases with similar presentation Histopathologic evidence of noncaseating granulomas Diagnostic tissue sampling should usually be obtained from the most accessible site of suspected disease involvement (eg, lymph nodes, skin lesions), with the notable exception of erythema nodosum, which does not demonstrate noncaseating granulomas even when occurring in association with sarcoidosis. For mediastinal lymph node sampling, endobronchial ultrasound (EBU) with nodal aspiration is the preferred initial method; it would be the most appropriate next step in this patient. (Choice A) Some infectious diseases (eg, histoplasmosis, active tuberculosis) can present similarly to sarcoidosis; therefore, exclusion of these etiologies or histopathologic confirmation of sarcoidosis is required prior to the initiation of glucocorticoids. (Choice C) Mediastinoscopy with excisional lymph node biopsy is more invasive than EBU with nodal aspiration and is typically reserved for suspected mediastinal lymphoma (due to the need for full lymph node architecture for diagnosis). The absence of other lymphadenopathy makes sarcoidosis more likely in this patient; mediastinoscopy with excisional biopsy is an appropriate second-line diagnostic method if EBU with nodal aspiration fails to confirm sarcoidosis. (Choice D) Peripheral blood flow cytometry is used in the diagnosis of leukemia. The absence of abnormalities in this patient's complete blood count makes leukemia unlikely. In some cases, lymphoma evaluation includes flow cytometry analysis performed on tissue samples rather than peripheral blood. (Choice E) Positron emission tomography (PET) detects cells with high metabolic activity and may help differentiate pathologic lymph nodes from those that are nonpathologic. However, this patient's systemic symptoms suggest a pathologic nature to his mediastinal lymphadenopathy, and tissue sampling is indicated. Sarcoidosis often causes positive PET results; therefore, the test cannot differentiate sarcoidosis from lymphoma. Educational objective: The diagnosis of sarcoidosis requires compatible clinical and radiologic manifestations, exclusion of other diseases with similar presentation, and histopathologic evidence of noncaseating granulomas. Endobronchial ultrasound with nodal aspiration is the preferred initial method of mediastinal lymph node sampling in patients with suspected sarcoidosis. __________ References: Pulmonary manifestations of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/22579234) Sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/22032436)

A 34-Year-Old African American Man Comes to the Office Due