Rapidly recurring massive pleural effusion as the initial presentation of sarcoidosis: A case report

Abstract

Rationale: Sarcoidosis is a multisystem granulomatous disease with unknown etiology. It affects mainly the lungs, but it can affect almost any other organ. Nevertheless, pleural involvement with the development of pleural effusion is relatively rare. It is usually mild and responsive to treatment with systemic steroids. Here we present a case of rapidly recurring massive unilateral pleural effusion caused by sarcoidosis that was resistant to systemic steroids.

Patient concerns: A 55-year-old lady presented with shortness of breath of 2-months duration. No other respiratory symptoms were reported. On physical examination, there were signs of left-sided pleural effusion, splenomegaly, and inguinal lymph nodes. These findings were confirmed by chest x-ray showing massive pleural effusion. Work up of the effusion revealed an exudative effusion with lymphocyte predominance. Pan-computed tomography scan revealed multiple thoracic, abdominal and inguinal lymphadenopathy; additionally, a left-sided pleural effusion and an enlarged spleen; that contained variable hypodense nodular lesions. Positron emission tomography-computed tomography showed intense uptake in the spleen and the lymph nodes. Inguinal lymph node biopsy showed non-necrotizing granulomatous inflammation. Due to suspicion of malignancy, left medical thoracoscopy was done, and biopsy of the parietal pleura showed nonspecific inflammation without evidence of malignancy or tuberculosis.

Diagnosis: Sarcoidosis was diagnosed based on the finding of the non-necrotizing granulomatous inflammation with no evidence of malignancy or infection on several microbiological and pathological samples.

Interventions: The patient was treated with repeated pleural fluid drainage. Steroids failed to prevent pleural effusion recurrence. Surgical left side pleurodesis was eventually performed.

Outcomes: At more than 1 year follow up, the patient showed no recurrence of pleural effusion or development of any other symptoms.

Lessons: Sarcoidosis may rarely present with massive pleural effusion, as this presentation is rare; it is imperative to rule out other causes of massive pleural effusion. Massive pleural effusion in sarcoidosis may be steroid-resistant. Pleurodesis may have a role in such a scenario.

Figure 1

Chest X ray at presentation showed complete opacification of the left hemithorax consistent with massive pleural effusion. The mediastinum appears shifted to the right side.

Figure 2

Chest and abdomen CT scan (coronal view) showed massive left sided pleural effusion, mediastinal shifting, multiple splenic hypo-attenuated nodular lesions along with multiple abdominal paraaortic lymph nodes. CT = computed tomography.

Figure 3

PET-CT scan showed increased pathological FDG uptake involving lymph nodes above and below the diaphragm in addition to the spleen. PET-CT = Positron emission tomography-computed tomography.