Post on 22-Jan-2018
• 71 year old male
• Manual laborer
• Dyspnea – increased over 1 month
• Cough
• Multiple Joint pain
• Past history –
DOE – 3yrs , Polyarthralgia , Hypertensive
No DM / CAD / PTB
• Personal history –
LOW + LOA+
Ex smoker SS- 600
Examination………
• Moderately built and nourished
• PR- 88 , BP – 140/90 mmHg
• Spo2 – 95 % , RR – 18/min
• Clubbing +
• No pallor / icterus / cyanosis / lymphadenopathy / pedal odema
• URT - wnl
• Shape of chest – normal
• Trachea – central
• Apex – 5th left intercostal space 1cm medial to midclavicular line
• Movements – equal bilaterally
• B/l resonant note obtained
• Bilateral scattered fine late inspiratory crackles
• CVS
• CNS normal
• GIT
• Musculoskeletal system – swelling both knee joint , tender , decreased range of movements
• Randomly distributed nodules , interlobular septalthickening and GGO noted involving bilateral lung fields .
• Fibrosis with traction bronchiectasis & paraseptalemphysematous changes noted
• Few enlarged mediastinal lymph nodes –aortopulmonary window LN – 6.4 mm , L peribronchial 10mm , R paratracheal 9mm
• Unclassified interstitial lung disease
Atypical presentations of sarcoidosis - Elderly
• Multisystem idiopathic granulomatous disease
• Adults aged between 20 years and 40 years.
• Rare among elderly patients.
• Diagnosing sarcoidosis in an elderly patient remains a challenge.
• An indolent decline in general health with asthenia, anorexia, and weight loss.
• In 60%–70% of patients, the characteristic feature is enlarged hilar and paratracheal lymph nodes, with or without concomitant parenchymal changes
• Imaging findings are nonspecific or atypical in 25%–30% of patients, and in another 5%–10%, no abnormalities are seen at thoracic imaging
Elderly onset sarcoidosis (EOS)
• 1) Clinical features of sarcoidosis – not typical
• 2) Age ≥65 years at diagnosis
• 3) Absence of any known history of sarcoidosis
• 4) Biopsy analysis revealed noncaseating granuloma
• 5) And exclusion of other possible causes, including
other granulomatous disorders.
TYPICAL FEATURES IN HRCT
• Lymphadenopathy: hilar, mediastinal (right paratracheal), bilateral, symmetric, and well defined
• Nodules: micronodules (2–4 mm in diameter; well defined, bilateral); macronodules (≥5 mm in diameter, coalescing)
• Lymphangitic spread: peribronchovascular, subpleural, interlobular septal
Typical features……
• Fibrotic changes: reticular opacities, architectural distortion, traction bronchiectasis, volume loss
• Bilateral perihilar opacities
• Predominant upper- and middle-zone locations of parenchymal abnormalities
ATYPICAL FEATURES
• Lymphadenopathy: unilateral, isolated, anterior and posterior mediastinal
• Airspace consolidation: masslike opacities, conglomerate masses, solitary pulmonary nodules, confluent alveolar opacities (alveolar sarcoid pattern)
• Ground-glass opacities
• Linear opacities: interlobular septal thickening,
intralobular linear opacities
• Fibrocystic changes: cysts, bullae, blebs, emphysema, honeycomb-like opacities with upper- and middle-zone predominance
• Miliary opacities
• Airway involvement: mosaic attenuation pattern, tracheobronchial abnormalities, atelectasis
• Pleural disease: effusion, chylothorax, hemothorax, pneumothorax, pleural thickening, calcification , Pleural plaquelike opacities
• Although the prognosis for sarcoidosis is life threatening , organ involvement does not seem to be more severe in the older subjects.
• The disease course is generally similar to that of young subjects, and stage IV intrathoracic forms and some types of organ involvement remain difficult to treat.
• In older patients, suitable treatment leads to improvement or stabilization of the disease in > 80% of cases.
CONCLUSION• Thoracic sarcoidosis - “the great mimic”; -manifests
with various patterns at radiologic imaging, necessitating an initially broad differential diagnosis
• Presents with nonspecific features among Elderly patients.
• An alteration of general health is the major sign
• Once the very particular clinical signs of the disease are recognized, the older patient can benefit from treatment and improved quality of life.