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Case Reports
. 2025 Jun 6;17(6):e85460.
doi: 10.7759/cureus.85460. eCollection 2025 Jun.

Necrotizing Sarcoid Granulomatosis: Another Great Imitator

Georgios Koukounides  1 , Martin Ringel  1 , Michael Osthoff  1 , Manuel Schuster  2
Affiliations
Case Reports

Necrotizing Sarcoid Granulomatosis: Another Great Imitator

Georgios Koukounides et al. Cureus. .

Abstract

Sarcoidosis with a necrotizing sarcoid granulomatosis (NSG) pattern is a rare disease that shares similar findings with sarcoidosis and is considered a distinct variant. However, the histological presence of necrosis may lead to misdiagnosis and a delay in treatment. We report the case of a 56-year-old Caucasian woman with cough, fatigue, dyspnea with lymphadenopathy, and consolidations on a CT scan. Histological examinations and a wide spectrum of diagnostic investigations, which excluded other infectious and non-infectious causes as well as malignancy, confirmed the diagnosis of sarcoidosis with an NSG pattern. Treatment with corticosteroids initially led to the regression of symptoms. However, the treatment had to be discontinued after a manifestation of corticosteroid-induced psychosis. The reintroduction of corticosteroids at a reduced dose was well tolerated and resulted in a good clinical and imaging response. Sarcoidosis with an NSG pattern must be distinguished from other systemic and infectious diseases. As emphasized in this report, a rigorous diagnostic workup is mandatory to establish the diagnosis. Although corticosteroids are considered the treatment of choice, possible side effects and dosage adjustments should be evaluated regularly.

Keywords: atypical presentation of sarcoidosis; multiple pulmonary nodules; necrotizing sarcoid granulomatosis; pulmonary sarcoidosis; sarcoidosis treatment.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Chest X-ray showing a widened mediastinum (arrows).
A. Posteroanterior view. B. Lateral view.
Figure 2
Figure 2. Initial CT of the thorax (axial view).
A. Increased, enlarged, and confluent hilomediastinal lymph nodes (arrows). B. Bronchial thickening and interlobular septal thickening accentuated in both basal lobes, with peribronchovascular consolidations (arrows).
Figure 3
Figure 3. Cryobiopsy of the subcarinal lymph node (level 7).
A. Epithelioid cellular granuloma without necrosis. B. Epithelioid cellular granuloma with central necrosis (★). Hematoxylin and eosin, original scale ×200.
Figure 4
Figure 4. F18-fluorodeoxyglucose positron emission tomography/computed tomography scan (coronal view).
The image shows intense metabolically active hilar, mediastinal, cervical/supraclavicular, upper abdominal, and retroperitoneal lymphadenopathy. Mild-to-severe pulmonary changes can be noted without evidence of cardiac involvement.
Figure 5
Figure 5. Thoracic CT at the ninth-month follow-up after the start of therapy (axial view).
A. Compared to the previous CT scan, mediastinal and hilar lymph nodes (arrows) are smaller on both sides. B. Reduction in bronchial thickening, interlobular septal thickening, and subpleural consolidation (arrows).
See this image and copyright information in PMC

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