A 54-year-old male patient was diagnosed with psoriasis vulgaris 20 years ago. He received methotrexate treatment for 6 months in 2005. However, the treatment was discontinued due to elevated liver function tests. Following exacerbation of his skin lesions, he received cyclosporine treatment for 4 months in February 2008. Again, the treatment was discontinued due to elevated liver function tests and severe enteritis. After 3 months, he received etanercept (ETN) treatment due to exacerbation of his disease. The ETN treatment was discontinued after 59 cycles due to elevated carbohydrate antigen 199 levels in the follow-up examinations. The patient was scheduled for infliximab (IFX) therapy due to increased symptoms in March 2010. There was no sign of infiltration in the chest x-ray (Figure 1), and the lung examination was normal. Besides, there were no symptoms regarding organs except for the skin, and abdominal ultrasonography and colonoscopic evaluations were normal. The patient's anti-HBs, anti-HCV, and anti-HIV antibodies were negative, while C-reactive protein, procalcitonin, whole blood count, and liver and kidney function tests were at the normal levels. The patient was started on anti-TNF treatment. The patient received isoniazid prophylaxis for 9 months (1 x 300 mg/day) after a tuberculin skin test (ppd = 16 mm), and chest x-ray and physical examinations were normal until August 2012. At that date, bilateral hilar swelling and a reticulonodular appearance at the bilateral middle and lower zones were detected during bilateral chest x-ray (Figure 2). The patient was prediagnosed with sarcoidosis and tuberculosis, and a high-resolution thorax computed tomography (CT) was planned. The following parameters were detected in the 24-hour urine sample: calcium, 383 mg/24 h (100-300 mg/24 h); serum calcium, 9.5 mg/dL (8.2-10.6 mg/dL), angiotensin-converting enzyme level was high, and ppd was 15 mm. There were no significant signs of sarcoidosis and tuberculosis involvement in the eyes. The following results were found in diffusion respiratory function test: forced expiratory volume in 1 second (FEV1) 2860 cc 87%; forced vital capacity (FVC) 3370 cc 83%; FEV1/FVC 85%; diffusing capacity for carbon monoxide 77%; DLCO/alveolar volume (VA) 112; RV (residual volume) 130%; TLC (total lung capacity) 99%; and VC (vital capacity) 85%. High-resolution CT revealed peribronchovascular nodules in the bilateral upper and middle zones that were centrally located (Figures 3-5); hilar and mediastinal lymphadenopathies were also detected (Figures 6 and 7).
The patient underwent fiberoptic bronchoscopy. Bronchoalveolar lavage (BAL) was obtained from the anterior segment of the upper left lung. Mucosal biopsy specimens were obtained from the upper left lung and tracheal carinas of the upper left lung. Transbronchial biopsy (TBB) specimen were obtained from the anterior segment of the upper left lung. Fifty-five percent lymphocytes, 40% macrophages, and 5% neutrophils were detected in the BAL specimen, and non-necrotizing granulomatous lesions were detected in the TBB specimens. During histopathological examination of the biopsy specimens, Ehrlich-Ziehl-Neelsen and Kinyoun-specific microorganisms were not detected. The tuberculosis culture from the tissue biopsy was negative. The examination of histopathological and microbiological specimens did not yield any fungal elements or microorganisms including histoplasmosis. The BAL panfungal polymerase chain reaction was negative for the fungi. As no cases of histoplasmosis have been reported in our center, we did not specifically study histoplasmosis.
Considering the radiological and pathological findings, the patient was diagnosed with stage 2 sarcoidosis and was suggested to discontinue anti-TNF treatment. After discontinuation, the patient had been followed for 4 months without any treatment and showed no symptoms. Thereafter, we observed regression in the control chest x-ray and high-resolution CT (Figures 8-11), and the patient is now on topical treatment for psoriasis without any treatment for sarcoidosis.