WBR0776

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Author [[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Pulmonology
Prompt [[Prompt::A 52 year old African American diabetic woman presents to the chronic care clinic for indurated nodules on her lower extremities. The patient reports that she noticed them just 2 days ago. The nodules were small at first but have been enlarging since. They seem to be warmer and slightly redder than the rest of the skin, and very tender to touch. Upon further questioning the patient reports a dry cough for the past 2 months and a 20 pound unintentional weight loss in the same time frame. Concerned with the latter findings you decide to order a chest CT scan especially with the family history of lung cancer. A section at the level of the great cardiac vessels is shown below. What would you expect to find on pathology of the observed lesions?

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Answer A AnswerA::Giant cells, granuloma formation with caseating necrosis
Answer A Explanation AnswerAExp::Caseating necrosis within intrathoracic granulomas is usually indicative of a tuberculosis infection.
Answer B AnswerB::Giant cells, non-caseating granuloma formation
Answer B Explanation AnswerBExp::Patients with sarcoidosis have multiple noncaseating epithelioid-cell (giant cell) granulomas.
Answer C AnswerC::Inflammatory reaction with molds branching at acute angles
Answer C Explanation AnswerCExp::Molds branching at acute angles are seen in aspergillomas usually growing in immunocompromised patients with previous cavitary disease colonized by Aspergillus spp.
Answer D AnswerD::Multiplying type II pneumocytes
Answer D Explanation AnswerDExp::Type II pneumocytes are seen in the alveolar spaces and multiply during lung injury to restore parenchymal integrity.
Answer E AnswerE::Nests or cords of uniform cells with central nuclei
Answer E Explanation AnswerEExp::Carcinoid tumors are usually characterized by nests or cords of uniform cells with central nuclei.
Right Answer RightAnswer::B
Explanation [[Explanation::Sarcoidosis is a systemic disease characterized by the development and accumulation of multiple granulomas that may involve virtually any organ but usually most common in the lungs, liver, eyes, and skin. Symptoms include fatigue, night sweats, and weight loss are common. Löfgren's syndrome, a possible presentation of sarcoidosis consists of arthritis, erythema nodosum, and bilateral hilar adenopathy, and can be seen in up to 35% of patients. Although all racial and ethnic groups can have sarcoidosis, African Americans are 3 times more likely than Caucasians to develop the disease. Diagnosis is usually with a combination of clinical and radiologic findings supported by histopathological evidence of noncaseating epithelioid-cell granulomas with absence of any causative organisms or particles. Granulomas classicaly produce angiotensin-converting enzyme (ACE) with 60% of patients having elevated serum levels. Treatment is usually with corticosteroids although therapy is not indicated for everyone. Two thirds of patients recover completely within 10 years of diagnosis.


Educational objective: Sarcoidosis is characterized by the development of multiple noncaseating epithelioid-cell granulomas.


References:

Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357(21):2153-65.
Educational Objective:
References: ]]

Approved Approved::No
Keyword WBRKeyword::Sarcoidosis, WBRKeyword::granuloma
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