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Pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid: a case report.

Kumagai T, Tomita Y, Inoue T, Uchida J, Nishino K, Imamura F - J Med Case Rep (2015)

Bottom Line: Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated.Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas.Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

View Article: PubMed Central - PubMed

Affiliation: Department of Thoracic Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari-ku, Osaka, 537-8511, Japan. torukumagai@ybb.ne.jp.

ABSTRACT

Introduction: Pleural effusion induced by sarcoidosis is rare, and pleural sarcoidosis is often diagnosed by thoracoscopic surgery. The diagnosis of pleural sarcoidosis using thoracentesis may be less invasive when sarcoidosis is already diagnosed histologically in more than one organ specimen. Here we report the case of a 64-year-old woman with pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis. This case report is important because it highlights the usefulness of the CD4/CD8 lymphocyte ratio in pleural effusion as an indicator of pleural involvement of sarcoidosis.

Case presentation: A 64-year-old Japanese woman visited our hospital with an initial symptom of dyspnea on exertion for a period of 4 months. Chest computed tomography showed bilateral hilar and multiple mediastinal lymphadenopathy, multiple small nodular shadows in her bilateral lungs, small nodular shadows along the interlobar pleura, and bilateral pleural effusion. Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated. Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas. Her bronchoalveolar lavage fluid exhibited a predominance of lymphocytes together with an increase in the CD4/CD8 lymphocyte ratio. The lymphocytic predominance and the increased CD4/CD8 lymphocyte ratio were also detected in the right-sided pleural effusion fluid obtained by thoracentesis. We diagnosed sarcoidosis with pleural involvement. Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

Conclusions: Analysis of the CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis may be helpful for the diagnosis of pleural sarcoidosis when the diagnosis is already made by histological examination of more than one organ specimen.

No MeSH data available.


Related in: MedlinePlus

Chest computed tomography findings after 5 weeks of corticosteroid therapy. a-d The multiple mediastinal and bilateral hilar lymphadenopathy, bilateral pleural effusion, small nodules in the lung and the interlobar pleura, and small subcutaneous nodules have regressed
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Fig5: Chest computed tomography findings after 5 weeks of corticosteroid therapy. a-d The multiple mediastinal and bilateral hilar lymphadenopathy, bilateral pleural effusion, small nodules in the lung and the interlobar pleura, and small subcutaneous nodules have regressed

Mentions: She was discharged 5 weeks after the first visit and was followed up for the spontaneous resolution of the bilateral pleural effusion. However, no improvement was observed and pleural effusion increased (Fig. 1b). The 6-minute walk test revealed that she could walk up to 315 meters with a minimum spO2 of 90%, maximum pulse of 116 beats per minute and the worst modified Borg scale of perceived dyspnea of 4. In addition, her initial symptom, which was induced by walking approximately 100 meters or going up 10 to 20 steps of a staircase, seemed to be severe and was partially improved by frequent thoracentesis. Based on these findings, corticosteroid therapy with a daily dose of 30mg prednisolone was initiated 8 weeks after the first visit. Thirteen weeks later (5 weeks from the initiation of corticosteroid therapy), under a daily dosage of 25mg of prednisolone, a chest radiograph showed decreased pleural effusion (Fig. 1c), and CT revealed regression of multiple skin nodules, mediastinal and bilateral hilar lymphadenopathy, multiple small nodules in her lungs and the interlobar pleura, bilateral pleural effusion, and splenomegaly (Fig. 5a-d). The clinical course of pleural effusions corroborates the diagnosis of pleural sarcoidosis. Three years later, she received 2.5mg of prednisolone per week without any severe adverse events; a chest CT showed only reduced small nodules in her lungs, lymphadenopathy, and subcutaneous nodules and no pleural effusion.Fig. 5


Pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid: a case report.

Kumagai T, Tomita Y, Inoue T, Uchida J, Nishino K, Imamura F - J Med Case Rep (2015)

Chest computed tomography findings after 5 weeks of corticosteroid therapy. a-d The multiple mediastinal and bilateral hilar lymphadenopathy, bilateral pleural effusion, small nodules in the lung and the interlobar pleura, and small subcutaneous nodules have regressed
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4536796&req=5

Fig5: Chest computed tomography findings after 5 weeks of corticosteroid therapy. a-d The multiple mediastinal and bilateral hilar lymphadenopathy, bilateral pleural effusion, small nodules in the lung and the interlobar pleura, and small subcutaneous nodules have regressed
Mentions: She was discharged 5 weeks after the first visit and was followed up for the spontaneous resolution of the bilateral pleural effusion. However, no improvement was observed and pleural effusion increased (Fig. 1b). The 6-minute walk test revealed that she could walk up to 315 meters with a minimum spO2 of 90%, maximum pulse of 116 beats per minute and the worst modified Borg scale of perceived dyspnea of 4. In addition, her initial symptom, which was induced by walking approximately 100 meters or going up 10 to 20 steps of a staircase, seemed to be severe and was partially improved by frequent thoracentesis. Based on these findings, corticosteroid therapy with a daily dose of 30mg prednisolone was initiated 8 weeks after the first visit. Thirteen weeks later (5 weeks from the initiation of corticosteroid therapy), under a daily dosage of 25mg of prednisolone, a chest radiograph showed decreased pleural effusion (Fig. 1c), and CT revealed regression of multiple skin nodules, mediastinal and bilateral hilar lymphadenopathy, multiple small nodules in her lungs and the interlobar pleura, bilateral pleural effusion, and splenomegaly (Fig. 5a-d). The clinical course of pleural effusions corroborates the diagnosis of pleural sarcoidosis. Three years later, she received 2.5mg of prednisolone per week without any severe adverse events; a chest CT showed only reduced small nodules in her lungs, lymphadenopathy, and subcutaneous nodules and no pleural effusion.Fig. 5

Bottom Line: Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated.Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas.Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

View Article: PubMed Central - PubMed

Affiliation: Department of Thoracic Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari-ku, Osaka, 537-8511, Japan. torukumagai@ybb.ne.jp.

ABSTRACT

Introduction: Pleural effusion induced by sarcoidosis is rare, and pleural sarcoidosis is often diagnosed by thoracoscopic surgery. The diagnosis of pleural sarcoidosis using thoracentesis may be less invasive when sarcoidosis is already diagnosed histologically in more than one organ specimen. Here we report the case of a 64-year-old woman with pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis. This case report is important because it highlights the usefulness of the CD4/CD8 lymphocyte ratio in pleural effusion as an indicator of pleural involvement of sarcoidosis.

Case presentation: A 64-year-old Japanese woman visited our hospital with an initial symptom of dyspnea on exertion for a period of 4 months. Chest computed tomography showed bilateral hilar and multiple mediastinal lymphadenopathy, multiple small nodular shadows in her bilateral lungs, small nodular shadows along the interlobar pleura, and bilateral pleural effusion. Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated. Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas. Her bronchoalveolar lavage fluid exhibited a predominance of lymphocytes together with an increase in the CD4/CD8 lymphocyte ratio. The lymphocytic predominance and the increased CD4/CD8 lymphocyte ratio were also detected in the right-sided pleural effusion fluid obtained by thoracentesis. We diagnosed sarcoidosis with pleural involvement. Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

Conclusions: Analysis of the CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis may be helpful for the diagnosis of pleural sarcoidosis when the diagnosis is already made by histological examination of more than one organ specimen.

No MeSH data available.


Related in: MedlinePlus