A previously healthy 55-year-old woman had a chest computed tomography (CT) scan showing mediastinal lymph node enlargement in September 2015. She denied any symptom of cough, hemoptysis, dyspnea, nasal congestion, wheezing, gastroesophageal reflux, fever and headache. Besides, she also denied being a smoker or drug user, bird or mold exposure, recent travel, or contact with tuberculosis or contagious water. Her family and psycho-social history are not specific. She had not been hospitalized in the past year.
Six months later, without pharmacotherapy, she had an enhanced chest CT scan which revealed multiple mediastinal lymphadenopathy, the largest one being 17 mm x 14 mm (Figure 1(a)). Then, she was admitted into the Department of Thoracic Surgery in our hospital. On admission, her physical examination did not reveal any positive sign. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed to evaluate the mediastinal lymph node size. Furthermore, the biopsy result (Figure 2) revealed the enlarged lymph node was benign but contained non-caseating granulomas. Her brain CT scan was normal. Serological tests for human immunodeficiency virus, viral hepatitis, T cells enzyme-linked immunospot (T-SPOT) and purified protein derivative (PPD) for tuberculosis were all negative. Angiotensin-converting enzyme was 24 U/L. Mediastinoscopy was ordered to fetch biopsy of enlarged lymph nodes, and she was finally diagnosed with sarcoidosis by pathology (Figure 3). Then, she was treated with oral methylprednisolone 24 mg/d from 20 June 2016 to 1 March 2017. On 31 August 2016, another chest CT scan was performed which demonstrated multiple enlarged mediastinal lymph nodes were significantly smaller than before (the largest one was 7 mm x 10 mm). Six months later, she had a third chest CT scan which showed the lymph nodes had totally shrunk. However, multiple small nodules were found in the right upper lobe (Figure 1(b)). Given that she had been treated with glucocorticoid for over 7 months, we ordered a series of tests for opportunistic infections, among which the serum cryptococcal antigen was positive (the titer was 1:5) while her blood culture was negative and her lymphocyte subsets were normal. Since the diagnosis of cryptococcosis was probable which was the most likely cause of her pulmonary nodules, we suggested a lumbar puncture to rule out intracranial infection. However, she rejected it. Then, her corticosteroid was tapered off, and she was treated with oral fluconazole 400 mg/d according to the Chinese expert consensus. The whole clinical course was summarized in Table 1.
During the follow-up, she underwent a fourth chest CT scan on 2 August 2017, which revealed that multiple nodules in the right upper lobe and the lymph nodes were both obviously shrunken. Due to the imaging improvement, she stopped fluconazole on her own terms which was against our recommendation of 6-month course. Since then, she had visited our hospital yearly with annual chest CT scans which indicated the original lesions turned to chronic inflammatory lesions gradually. Besides, she had never complained of any discomfort such as fever, headache, cough and so on during the follow-up.