A 32-year-old man comes to the office due to right-sided facial weakness for 3 days. He has had no fever, headache, vision disturbances, or extremity weakness or numbness but has been extremely fatigued over the past several months. The patient has no prior medical conditions and takes no medications. He drinks alcohol occasionally and does not use tobacco or illicit drugs. The patient lives in coastal California and has not traveled recently. Vital signs are within normal limits. Physical examination reveals right-sided facial droop with flattening of the nasolabial fold. He is unable to elevate the right eyebrow or close the right eye completely. Upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal on both sides. There is no neck rigidity. The lungs are clear on auscultation, and heart sounds are normal. Hepatosplenomegaly is present. The cervical, axillary, and inguinal lymph nodes are multiple, firm, and nontender. No skin rash or extremity edema is present. The joints are not swollen or tender. A week later, the patient returns to the office for follow-up. His facial weakness is improving with oral glucocorticoids, and he has had no new symptoms. Laboratory results from the previous visit are as follows: Chest x-ray reveals bilateral hilar adenopathy and interstitial infiltrates. Which of the following is most appropriate to confirm the diagnosis?

Question

A 32-year-old man comes to the office due to right-sided facial weakness for 3 days.  He has had no fever, headache, vision disturbances, or extremity weakness or numbness but has been extremely fatigued over the past several months.  The patient has no prior medical conditions and takes no medications.  He drinks alcohol occasionally and does not use tobacco or illicit drugs.  The patient lives in coastal California and has not traveled recently.  Vital signs are within normal limits.  Physical examination reveals right-sided facial droop with flattening of the nasolabial fold.  He is unable to elevate the right eyebrow or close the right eye completely.  Upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal on both sides.  There is no neck rigidity.  The lungs are clear on auscultation, and heart sounds are normal.  Hepatosplenomegaly is present.  The cervical, axillary, and inguinal lymph nodes are multiple, firm, and nontender.  No skin rash or extremity edema is present.  The joints are not swollen or tender. A week later, the patient returns to the office for follow-up.  His facial weakness is improving with oral glucocorticoids, and he has had no new symptoms.  Laboratory results from the previous visit are as follows:  Chest x-ray reveals bilateral hilar adenopathy and interstitial infiltrates.  Which of the following is most appropriate to confirm the diagnosis?

Quizplus · Accepted Answer

Explanation: This patient's chest x-ray evidence of bilateral hilar lymphadenopathy and interstitial infiltrates supports the diagnosis of sarcoidosis. Other common findings include elevated calcium, erythrocyte sedimentation rate, and alkaline phosphatase (if the liver is involved). Angiotensin-converting enzyme levels are also increased in approximately 75% of cases, but this test has poor diagnostic sensitivity/specificity and cannot be used for confirmation (Choice A). Suspected cases are typically confirmed when the following occurs: Diseases causing similar symptoms (eg, tuberculosis) are excluded. Biopsy reveals noncaseating granulomas. Biopsy should be performed on the involved location that is easiest to assess, which is usually a palpable lymph node or skin lesion. If no superficial lesion is present or the diagnosis remains uncertain after initial biopsy, bronchoscopy with transbronchial biopsy is often performed (Choice B). This patient with peripheral lymphadenopathy (eg, cervical, axillary, inguinal) should undergo excisional lymph node biopsy for confirmation. (Choice D) All patients with pulmonary sarcoidosis should undergo pulmonary function testing to evaluate for respiratory impairment, but this test cannot confirm the diagnosis. (Choice E) Liver biopsy cannot easily distinguish noncaseating granulomas due to sarcoidosis from other hepatic granulomatous diseases. As such, liver biopsy is usually reserved for cases in which other biopsies have failed to establish a diagnosis. Educational objective: Patients with clinical and radiographic features consistent with sarcoidosis are usually diagnosed after other diseases with similar symptoms (eg, tuberculosis) have been excluded and biopsy demonstrates noncaseating granulomas. Biopsy should be performed on the involved location easiest to assess, which is usually a palpable lymph node or skin lesion. When there is no easily accessible lesion, fiberoptic bronchoscopy with transbronchial lung biopsy is often performed. References: The clinical and radiologic features of nodular pulmonary sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/18843518)

A 32-Year-Old Man Comes to the Office Due to Right-Sided