A 48-year-old gentleman presented with fatigue for two weeks. There was no history of night sweats, weight loss or fever. He did not smoke, did not raise pets, abuse alcohol or drugs and did not report exposure to occupational dusts. Physical examination was normal. Renal function tests, urine microscopy and hemogram were normal. Serum calcium was elevated (1.43 mg/dL, normal 1.1-1.3). Chest radiographs showed miliary nodules (Figure 7, left). ACE levels were elevated (76 U/mL, normal 8-53). Tuberculin skin testing was negative. CT-Chest showed upper lobe predominant random micronodules and lower-lobe interlobular septal thickening (Figure 8, left & right). FOB was done with BAL and TBLB; BAL was negative for mycobacterial cultures and Xpert MTB/RIF. TBLB showed prominent perivascular non-necrotizing epitheloid granulomas with asteroid bodies (Figure 7, right). A diagnosis of miliary sarcoidosis was made and steroids were initiated. His symptoms and hypercalcemia resolved by four weeks and steroids were tapered over the next nine months. He remains asymptomatic on follow-up.
Composite image of the HRCT image of Patient 4 showing. upper lobes) random nodules with perilymphatic predominance, beading of the right oblique fissure, and ,perivascular nodules, and.