Case report—A 55-year-old woman with breast carcinoma was admitted for a left mastectomy. A routine preoperative chest radiograph identified multiple bilateral pulmonary nodules (Figure 1). A high-resolution computed tomography (CT) scan confirmed the nodules were predominantly in the upper zones, with borderline mediastinal lymphadenopathy (Figure 2). The features were suggestive of miliary pulmonary metastases so surgery was postponed until a diagnosis was confirmed. She had no respiratory symptoms but kept parrots.

(Click here to view Figure 1 and Figure 2)

Bronchioalveolar lavage, infectious serology, serum calcium, and angiotensin-converting enzyme levels were all normal. A transbronchial biopsy showed multiple non-caseating epithelioid granulomas, containing multinucleated giant cells (Figure 3). There were no acid fast bacilli, fungi, or metastatic carcinoma cells. The granulomatous inflammation was consistent with sarcoid.

Discussion—Sarcoidosis is a chronic multisystem disorder of unknown cause that most frequently affects the lungs. Most patients are symptomatic, experiencing dyspnea or a dry cough. Haemoptysis or sputum production is rare. Pulmonary sarcoidosis has three distinct radiological patterns: type I-bilateral hilar adenopathy with no parenchymal abnormalities; type II-bilateral hilar adenopathy with diffuse parenchymal changes; and type III-diffuse parenchymal changes without hilar adenopathy. Large metastatic-like nodules are unusual but can occur.

Author information: Simon Janes, House Surgeon, Department of General Surgery; Birgit Dijkstra, Consultant Surgeon, Department of General Surgery; Carina Miles, Consultant Pathologist, Department of Anatomical Pathology; Ian Cowan, Consultant Radiologist, Department of Radiology, Christchurch Public Hospital, Christchurch

Correspondence: Simon Janes, Surgical Senior House Officer, Department of Surgery, New Cross Hospital, Wolverhampton WV10 0QP, England. Fax: +44 1753 634825; email: simonjanes@doctors.org.uk