Necrotizing sarcoid granulomatosis with hemoptysis: a case report and literature review

Abstract

We present a case of 39-year-old male with the symptoms of fever, cough, chest pain and bloody phlegm, whose chest CT showed multiple subpleural nodules and inflammatory infiltration. Video-Assisted Thoracic Surgery ( VATS ) for right subplural nodule was performed and confirmed the diagnosis of necrotizing sarcoid granulomatosis. Prednisolone was administered and the symptoms were under control untill the occurrence of intermittent hemoptysis after 10 months. Chest CT and bronchoscope revealed the right lower lobe nodule with intraluminal necrotic tissue in the right lower lobe posterior basal segment respectively. Fatal hemoptysis happened during endobronchial biopsy by flexible bronchoscope forcep. Based on this case, we reviewed the relevant literature and discussed the clinical features, pathological changes and prognosis of the disease.

Virtual slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1955868163936338.

Figure 1

CT findings upon admission.

Figure 2

Different degrees of small pulmonary vasculitis were showed under HE staining. A, Vessel wall was infiltrated by lymphocytes, but the lumen is still maitain without obstruction(100×); B, Epithelioid granuloma invaded small vessel wall, broke into the lumen, more than 60% of the lumen was obstructed (100×); C, Last stage of epithelioid granulomatous vasculitis with thickening vessel wall as well as severe narrow lumen. Epithelioid granuloma invaded the vessel wall with messed vascular structures, lumen atresia (200×).

Figure 3

Structures of epithelioid granuloma with varies of coagulation necrosis in the lung under HE staining. A, Lung epithelioid granuloma with coagulation necrosis in the center, composed of a lot of lymphocytes and scattered multinucleated giant cells. Bronchial ciliated columnar epithelium structure was shown in the top left direction of figure, alveolar epithelium was shown in the lower left direction of figure (100×); B, Necrosis in the center of epithelioid granuloma, surrounded by lymphocytes and several multinucleated giant cells(100×);C, Fusion of epithelioid granuloma, amounts of coagulation necrosis located in the junction(100×).

Figure 4

CD8+ T lymphocytes were positive with brown stained in EnVision immunohistochemistry staining (40×).

Figure 5

Periodic Aacid Schiff (PAS) staining was negative in a pulmonary epithelioid granuloma with coagulation necrosis (100×).

Figure 6

CT findings upon follow up.

Figure 7

Bronchoscopy findings for biopsy.