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Diagnosis of Sarcoidosis
10
Atlas of Sarcoidosis
inclusions does not imply that a foreign body granulomatous reaction has occurred. The size of these inclusions
is even larger than those capable of being inhaled, and
they do support the diagnosis of sarcoidosis.2
11
Lungs
Tuberculosis
Atypical mycobacteriosis
Mycoplasma infections
Fungal granuloma (aspergillosis, histoplasmosis,
cryptococcosis, coccidioidomycosis, blastomycosis)
Drug reactions
Aspiration of foreign material
Hypersensitivity pneumonitis
Pneumoconiosis (beryllium, aluminium, titanium)
Lymphocytic interstitial pneumonia
Necrotising sarcoid granulomatosis (NSG)
Pneumocystis carinii
Wegeners granulomatosis
Brucellosis
Toxoplasmosis
Cat scratch disease
Sarcoid-like reactions in regional lymph nodes to carcinoma
Hodgkins disease
Non-Hodgkins lymphoma
Granulomatous histiocytic lymphadenitis
(Kikuchis disease)
Granulomatous lesions of unknown signicancethe
GLUS syndrome
FIGURE 3.7 Composite of four pictures that demonstrate various inclusion bodies that may be
seen in sarcoid granulomas. It is important to appreciate that these inclusions are not diagnostic of
sarcoidosis because asteroid and Schaumann bodies are also observed in tuberculosis and occupational lung diseases.19
FIGURE 3.8 Granuloma with caseous necrosis. The sample was taken from a patient with chronic
caseous tuberculosis. (Figure courtesy of Vesna Cemerikic, MD, PhD, Pathology Department, Clinical Center, Belgrade, Serbia.)
FIGURE 3.9 Composite picture showing some unusual cause of granulomatous inammation. (A)
Hypersensitivity pneumonitis granuloma in a patient with farmers lung disease. (B) Granulomatous
inammation due to coccidioidomycosis spherule. (C) Granuloma surrounding a Strongyloides stercoralis larva. (D) Talc-induced granuloma in an intravenous drug addict.4
A
FIGURE 3.10 Brucella abortus infection. Note these granulomas are poorly formed and lack the
elegance of compact, noncaseating sarcoid granulomas.6 (A) Low power, HE -50. (B) High power,
HE -100.
FIGURE 3.11 The composite showing granulomatous inammation seen in patients with
hypogammaglobulinemia.7 (A) Liver biopsy showing a collection early granulomatous response. (HE
stain, -50). (B) Lymph node biopsy in the same patient showing a dense granuloma with mixed cell
population (HE stain, -100).
14
Atlas of Sarcoidosis
DIAGNOSIS OF SARCOIDOSIS
The following are all clinical and/or radiological patterns
of sarcoidosis.2,3,14
A patient with a typical Lofgrens syndrome (fever,
erythema nodosum, arthralgias, and bilateral hilar
adenopathy);
A patient with Heerfordts syndrome (Fever, parotid
gland enlargement, facial palsy, and anterior uveitis);
Panda sign (lachrymal and parotid uptake) on a total
body 67 GA scan, combined with Lambda pattern
(right azygos and bilateral hilar thoracic uptake); and
Asymptomatic patients with bilateral hilar adenopathy and no pulmonary inltrates.
Other conditions are possible but most unlikely with
sarcoidosis2,14:
No evidence of extrapulmonary disease (chronic
berylliosis, other possible granulomatous lung
disease);
No thoracic lymphadenopathy on radiographic
studies (hypersensitivity pneumonitis, other granulomatous lung disease); and
The patient with the very low likelihood of having
sarcoidosis (i.e., young age).
Granulomatous Lesions of
Unknown Signicance
Granulomatous lesions of unknown signicance (GLUS
syndrome) is described clinically as prolonged fever with
epithelioid granulomas in liver, bone marrow, spleen, and
lymph nodes. It has a benign course and a tendency for
recurrence.
The difference between extrapulmonary sarcoidosis
and GLUS syndrome is:
The Kveim skin test is always negative.
Elevated angiotensin converting enzyme (ACE) levels
have never been detected.
Hypercalcemia has never been found.
The immunotyping of the T-cells in the granulomas
is different from those in sarcoidosis granulomas.
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