Endobronchial Sarcoidosis

A 40-year-old man was being treated as an outpatient with inhaled corticosteroids and bronchodilators for a presumed diagnosis of bronchial asthma. Worsening episodes of shortness of breath during the past few months sent him to the emergency department for a second opinion.

There was no history of fever, chills, rigors, hemoptysis or chest pain, and weight loss. The patient had smoked cigarettes for 15 years, consumed alcohol daily, and denied having any allergies.

Physical examination revealed a well-developed man with a pulse rate of 88 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 120/80 mm Hg. No clubbing, cyanosis, or hypertrophic osteoarthropathy was noted. Auscultation revealed wheezing, which was more prominent on the left side. The heart and abdomen evaluations were normal; neurologic findings were unremarkable.

Laboratory study results indicated borderline hypercalcemia, with a total serum calcium level of 10.8 mg/dL. Drs Arunabh and Anwar Awan of North Shore University Hospital of Forest Hills, NY, suspected sarcoidosis and ordered a bronchoscopy with transbronchial biopsy. The left upper lobe and lower lobe bronchus showed areas of stenosis caused by endobronchial lesions. A lung biopsy established the diagnosis of sarcoidosis.

The bronchial obstruction was the result of sarcoid involvement of the tracheobronchial tree.

There are various mechanisms of airway obstruction in sarcoidosis; bronchial fibrosis and granuloma that may intrude on the airway (endobronchial sarcoidosis) are the most common causes. Therefore, patients with bronchial obstruction in sarcoidosis clinically present with symptoms that mimic those of bronchial asthma (ie, cough, wheeze, and dyspnea).