Demystifying the Presence of a Prominent Hilum: Is It Always Not Sarcoidosis?

Sarcoidosis is a rare condition characterized by the collection of inflammatory tiny cells (granulomas) in body tissue. The most common sites are the lungs and lymph nodes, but it can also affect the skin, eyes, liver, spleen, heart, and other body parts.

The cause of sarcoidosis is unknown, but some experts think it may occur due to the body's immune system responding to certain substances, possibly some infections, dust, or chemicals. It is very difficult for a doctor to make a diagnosis at a very early stage. However, after seeing a prominent hilum in a chest radiograph, a doctor can suspect sarcoidosis.

In this article, we will discuss sarcoidosis, a case presentation, and other conditions.

There is no definitive treatment for sarcoidosis, but many individuals do well without treatment and may remain asymptomatic. In many individuals, it progresses slowly and can lead to organ damage. In some, it progresses very rapidly and also goes away rapidly.

Lung Symptoms

• Persistent or dry cough

• Shortness of breath

• Fatigue

• Wheezing

Heart Symptoms

• Chest pain

• Dyspnea

• Palpitations

• Arrhythmias

• Syncope

• Sometimes symptoms of heart failure

Skin Symptoms

• Nodules below the skin

• Chronic lesions over cheeks, nose, and ears

• Tender rashes over lower limbs (shin of tibia, ankle)

Eye Symptoms

Most patients remain asymptomatic and are sometimes misdiagnosed with allergies and conjunctivitis due to similar symptoms, which include:

• Eye pain

• Redness

• Itching

• Blurred vision

• Photosensitivity

Diagnosis

Chest X-rays, CT scans, and PET-CT are used for diagnosing sarcoidosis. A biopsy is used to confirm the diagnosis as granulomas can be seen microscopically from samples taken through biopsy.

Management

Some experts say not to treat sarcoidosis in the early stages if the patient is asymptomatic and has milder symptoms. Management includes:

• Corticosteroids

• DMARDs (Disease-modifying anti-rheumatic drugs) like Azathioprine, Methotrexate

• Hydroxychloroquine is used to treat skin sarcoidosis.

Case Presentation

A 32-year-old male presented with a complaint of dry cough for one month. He also reported a history of a similar episode of cough six months back that lasted for one month. He did not have fever, night sweats, loss of appetite (LOA), or loss of weight (LOW).

Examination:

• Conscious, alert, afebrile at the time of examination.

• Respiratory: Bilateral normal vesicular breath sounds.

• Cardiovascular system (CVS): Normal S1 and S2, no murmur heard.

• Abdomen (P/A): Soft, non-tender, no hepatosplenomegaly (HSM).

• Bowel sounds (B/S) were also normal.

Investigations:

• Complete hemogram was normal, but ESR was elevated at 80 mm in the first hour.

• Sputum for acid-fast bacilli was negative, and GeneXpert was also negative. The Mantoux report was awaited.

• Chest radiograph showed an enlarged right hilum and blunting of the left costophrenic angle.

  
  

  

  Figure1. Red arrow showing enlarged right Hilum and yellow arrow showing blunting of left CP angle.

  
  

Differential Diagnosis:

• Pulmonary tuberculosis?

• Sarcoidosis?

• Lymphoma?

To approach a diagnosis, HRCT (High-resolution computed tomography) of the chest was advised. It showed mediastinal adenopathy with patchy air space opacities in the right upper lobe, left basal pleural thickening with a few fibrotic bands in the left lower lobe. The HRCT report did not favor any definitive diagnosis.

Figure 2. Showing mediastinal adenopathy and pleural thickening.

TBLB (transbronchial lung biopsy) was considered but not pursued due to the invasiveness of the procedure. The Mantoux report was strongly positive with more than 2 cm of induration. The patient was planned for anti-tuberculosis treatment (ATT) under a clinical diagnosis of pulmonary tuberculosis. After starting treatment, the patient's health significantly improved, and he completed a six-month course of ATT.