Sarcoidosis presenting with massive pleural effusion and elevated serum and pleural fluid carbohydrate antigen-125 levels

Abstract

A 55-year-old woman was admitted for an elevated serum carbohydrate antigen-125 (CA-125) level, and a left pleural effusion, which were detected at a routine health examination. Computed tomography of the chest was performed upon admission, revealing extensive bilateral paratracheal and mediastinal lymph node enlargement with a massive left-sided pleural effusion. Subsequent analysis of the pleural fluid demonstrated consistency with an exudate, no evidence of malignant cells, and a normal adenosine deaminase. However, the pleural fluid and serum CA-125 levels were 2,846.8 U/mL and 229.5 U/mL, respectively. A positron emission tomography did not reveal any primary focus of malignancy. Finally, a surgical mediastinoscopic biopsy of several mediastinal lymph nodes was performed, revealing non-necrotizing granulomas, consistent with sarcoidosis. After a month of treatment of prednisolone, the left pleural effusion had resolved, and after 2 months the serum CA-125 level was normalized.

Keywords: CA-125 Antigen; Pleural Effusion; Sarcoidosis.

Figure 1

(A) The initial chest X-ray showed a left-sided massive pleural effusion, which disappeared after 2 months of medication with oral prednisolone (B).

Figure 2

(A) The initial chest computed tomography showed a left-sided pleural effusion and mediastinal lymph nodes enlargement. (B) The ¹⁸F-fluorodeoxyglucose-positronemission tomography revealed intense uptake on the bilateral paratracheal, hilar, and supraclavicular lymph nodes.

Figure 3

(A) The fiberoptic bronchoscopic biopsy revealed non-necrotizing granulomas in the bronchial wall (H&E stain, ×100). (B) The mediastinoscopic biopsy of right paratracheal lymph node revealed that all normal structures were entirely replaced by non-caseating granulomas, each composed of aggregates of tightly clustered epithelioid cells (H&E stain, ×400).