A 43-year-old man comes to the office due to malaise, night sweats, and cough for the past several weeks. He has also lost 4.5 kg (10 lb) over the past 4 months. The patient has no appreciable medical history and has not traveled recently. He has spent the last 10 years working as a respiratory therapist at an urban hospital. Chest x-ray is shown below. A palpable lymph node in the supraclavicular bed is biopsied and pathology reveals well-formed, noncaseating granulomas. Which of the following is the most likely diagnosis?

Question

A 43-year-old man comes to the office due to malaise, night sweats, and cough for the past several weeks.  He has also lost 4.5 kg (10 lb) over the past 4 months.  The patient has no appreciable medical history and has not traveled recently.  He has spent the last 10 years working as a respiratory therapist at an urban hospital.  Chest x-ray is shown below.  A palpable lymph node in the supraclavicular bed is biopsied and pathology reveals well-formed, noncaseating granulomas.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3a1e_53d6_9249_5b2fb31559f1_MD0001_00 This patient with cough, night sweats, and bilateral hilar adenopathy likely has sarcoidosis, a systemic inflammatory disease characterized by noncaseating granulomas (non-necrotic aggregates of epithelioid macrophages frequently with multinucleated giant cells). It typically presents in young adults (women > men) and occurs more commonly in African Americans. Any organ can be affected by sarcoidosis; however, the lungs (eg, reticular/nodular infiltrates), lymph nodes (eg, hilar adenopathy), skin (erythematous rash), and eyes (eg, anterior uveitis) are often involved. In addition to pulmonary symptoms (eg, cough, chest pain, dyspnea), constitutional symptoms (including fever, weight loss, fatigue, night sweats, and arthralgias) are common. (Choice A) Acute HIV infection can present with constitutional symptoms and weight loss; however, noncaseating granulomas are not consistent with isolated HIV infection and suggest sarcoidosis. (Choice B) Hodgkin lymphoma can cause supraclavicular adenopathy and B symptoms (eg, weight loss, fever, night sweats); however, biopsy would demonstrate Reed-Sternberg cells surrounded by an inflammatory infiltrate. (Choices C and D) Adenocarcinoma and squamous cell carcinoma of the lung can cause constitutional symptoms and cough; however, a mass would be expected on imaging. In addition, biopsy of squamous cell carcinoma would show sheets or nests of malignant cells with squamous differentiation (eg, keratinization), whereas adenocarcinoma would show glandular differentiation with atypia. (Choice E) Mycobacterium avium complex can cause similar symptoms with noncaseating (and caseating) granulomas but typically occurs in severely immunocompromised patients. In addition, Mycobacterium avium pulmonary disease typically causes cavitations and pulmonary infiltrates on imaging. (Choice F) Tuberculosis can cause weight loss, cough, and night sweats, particularly in those with risk factors (eg, immunosuppression, imprisonment, immigrants, HIV positive). However, biopsy would typically show caseating granulomas and acid-fast bacilli. Educational objective: Sarcoidosis is an inflammatory disorder characterized histologically by noncaseating granulomas consisting of aggregates of epithelioid macrophages and multinucleated giant cells. Common manifestations include hilar adenopathy, pulmonary infiltrates, skin rash, ophthalmic findings, and constitutional symptoms.

A 43-Year-Old Man Comes to the Office Due to Malaise