Case Presentation: Patient is a 26 year old African American female with a history of asthmapresenting with acute left flank pain and severe shortness of breath. Chest x ray on admission discovered a large left pneumothorax with evidence of tension. Immediate chest tube was placed.Prior to admission she had several months history of worsening shortness of breath on exertion and cough. She presented to the ER two and one month prior to admission with similar complaints. Chest x ray at that time showed diffuse bilateral airspace opacities, most pronounced in perihilar regions. Findings highly suspicious for infection. No effusion or significant pneumothorax. She was diagnosed with community acquired pneumonia and mild asthma exacerbation, given azithromycin and albuterol. Patient finished the course of antibiotics at that time without relief.On day two of the admission, the pulmonary team performed flexible bronchoscopy with endobronchial and transbronchial biopsies. RLL BAL and endobronchial biopsy, LLL brushings and transbronchial biopsies were obtained. EBUS- TBNA was performed on station 7.Infectious workup was grossly negative including HIV, aspergillus antibody, beta-d-glucan, histoplasma antigen,TB- quantiferon gold, blastomycosis antigen, MAC antibody. Bronchial brushings with AFB smear negative three times, negative fungus culture, negative for bacteria, HSV and viral panel. Of note Mycoplasma IgG was positive and she finished a 5 day course of azithromycin. Rheumatologic workup was also negative including ANA, anti-dsDNA, P-ANCA, C-ANCA, rheumatoid factor, anti-CCP, Anti-Jo.On hospital day six pathology of RLL and LLL transbronchial brushings showed non-necrotizing granulomas. A diagnosis of sarcoidosis highly suspected. Patient was started on prednisone 1mg/kg daily. Given lack of complete resolution of pneumothorax with continued chest tube requirement along with increased risk of recurrence of secondary pneumothorax, on hospital day five thoracic surgery proceeded with surgical pleurodesis and wedge biopsy. Pathology results of wedge excisions also with multiple non-caseating granulomas. On discharge our patient was continued on prednisone and will follow with pulmonology.
Discussion: In such a young patient it was prudent to carefully exclude other more common causes of secondary pneumothorax, primarily infectious and rheumatologic etiologies Two separate sets of biopsies were obtained from on different days. Both consistent with non-caseating granulomas allowed for a strong suspicion for pulmonary sarcoidosis. Furthermore, prompt improvement of patient’s symptoms with prednisone clarified the clinical picture and she was able to be discharged home with a new diagnosis of pulmonary sarcoidosis.
Conclusions: Prompt improvement of patient’s symptoms with prednisone clarified the clinical picture and she was able to be discharged home with a new diagnosis of pulmonary sarcoidosis.