International Journal of Research and Review Vol.7; Issue: 11; November 2020 Website: www.ijrrjournal.com Case Report E-ISSN: 2349-9788; P-ISSN: 2454-2237

A Deviant Manifestation of Sarcoidosis: Bilateral Inguinal

Uthaya Sankar M K1, Swapna U S2, Sivaram A3, Mythreini B S4

1Professor, 2,3,4Post graduate residents, Department of General , Sri Manakula Vinayagar Medical College and Hospital, Puducherry 605107.

Corresponding Author: Swapna U S

ABSTRACT of sarcoidosis varies from asymptomatic to complicated sarcoidosis. Respiratory Background: Sarcoidosis is a systemic involvement (> 90 %) is most common1, but granulomatous disorder, characterized by it is non specific in nature with non specific involvement of multisystem, frequently involves constitutional symptoms. Typical pulmonary system. Sarcoidosis can have varied pulmonary manifestations are easily presentations. The clinical presentation of sarcoidosis ranges from asymptomatic to organ identified. failure. It is unclear how often sarcoidosis is The typical manifestations of this asymptomatic. Lymph node involvement is disease include bilateral hilar found rarely in isolation. lymphadenopathy and pulmonary reticular Case Report: A 63-year-old asymptomatic male opacities2. The clinical presentation of presented with bilateral pelvic and inguinal sarcoidosis depends as age, sex, and race, lymphadenopathy. An ultrasonogram scan of the the duration of the disease and the sites of abdomen, and pelvis revealed bilateral deep involvement. Frequency of common organ pelvic and inguinal bulky lymphadenopathy. involvement is lung (90%), skin (24%), eye Excision biopsy revealed sarcoidosis. He (12%), extra thoracic lymphnode (15%), responded to six months of oral steroid liver (12%), Spleen (7%), neurological treatment. Conclusion: This case illustrates the different (5%), cardiac (2%) with Constitutional symptoms like fatigue, fever, night sweats presentation of sarcoidosis and the difficulty in 1 diagnosing sarcoidosis in its initial stages. A and weight loss . Diagnosis of high suspicion and excision biopsy is the key in asymptomatic presentations in sarcoidosis diagnosing this condition. remains a challenge as it can influence prognosis. Keywords: Sarcoidosis, Lymph nodes, Biopsy CASE REPORT INTRODUCTION A 63 year old male presented with Sarcoidosis is a global disease of swelling over the bilateral inguinal region unknown etiology. It is an inflammatory since 3 months, multiple in number and was disease characterized by the presence of non non tender, non discharging .History of caseating granuloma with varied yellowish discolouration of urine for 7 days, presentations thus leading to confusion 2 months back. For which patient took whether asymptomatic individuals with native treatment. History of generalized suspected diagnosis of sarcoidosis should be fatiguability and weight loss present. investigated further. This disease is often Besides he was a smoker and quitted multisystem and requires the presence of smoking 3 years back. involvement in two or more organs for the The vital signs were stable. In specific diagnosis1. The clinical presentation physical examination three non tender

International Journal of Research and Review (ijrrjournal.com) 605 Vol.7; Issue: 11; November 2020 Uthaya Sankar M K et.al. A deviant manifestation of sarcoidosis: bilateral inguinal lymphadenopathy. lymphnodes were present over the right inguinal region, largest measuring 3*3 and two non tender lymphnodes were present over the left inguinal region, largest measuring 2.5*2. Hepatomegaly was present.

CT thorax -Sub pleural interlobular septal thickening over bilateral lung peripheries. [figure 3]

Lymph node biopsy – high power view of epithelioid granuloma with hemorrhagic background s/o granulomatous lymphadenitis [figure 1]

Test results were as follows: Hemoglobin: 11.4g/dL, Erythrocyte sedimentation rate: 40 mm/h, Alanine aminotransferase: 51 U/L, Aspartate aminotransferase: 78 U/L, Alkaline phosphatase: 391, GGT: 798 U/L, Total bilirubin: 1.2mg/dL, bilirubin (direct): 0.26mg/dL. Angiotensin-converting enzyme CT thorax -Multiple fissural nodules of size about 1 mm [figure 4] (ACE) level : 163 U/L, and coagulation tests were within the normal limit In the initial stage suspected and tuberculous etiology. Patient underwent Lymph node biopsy which shows: Granuloma with hemorrhagic background suggestive of granulomatous lymphadenitis indicating sarcoidosis (figure 1). Biopsy CBNAAT was negative.

CT thorax -Peri tracheal lymphnode[figure5]

Chest X-ray was normal (figure 2). Abdominal and pelvic ultrasound shows pelvic lymphnodes. For additional investigations CT thorax was taken showed multiple fissural nodules of size about 1mm,

Chest x-ray of patient [figure 2]

International Journal of Research and Review (ijrrjournal.com) 606 Vol.7; Issue: 11; November 2020 Uthaya Sankar M K et.al. A deviant manifestation of sarcoidosis: bilateral inguinal lymphadenopathy. para tracheal and perivascular lymphnodes. pathologic findings such as of non-caseating (figure3,4,5). epithelioid-cell granulomas.. Early diagnosis is the key to prevent the potentially damaging effects of sarcoidosis. Many people with sarcoidosis may not require any treatment, and self-resolution of sarcoidosis might occur after several years without causing serious complications. The appropriate for sarcoidosis is based on symptoms and presence of organ failure. <10% patient requires no systemic therapy, in the other cases, treatment with corticosteroids is needed.

CONCLUSION For asymptomatic inguinal lymphadenopathy one should consider the CT thorax -Perivascular lymph nodes [figure6] differential diagnosis of sarcoidosis

DISCUSSION REFERENCES The patient presented with bilateral 1. Kasper DL, Hauser SL, Jameson JL, Fauci inguinal swelling with weight loss. Findings AS, Longo DL, Loscalzo J, Harrison’s from patients’ examination revealed principle of .20th ed. New elevated levels of liver enzymes. After York. The McGraw Hill Companies; 2015. histological examination of lymphnode p2600-2601 biopsy showed extra pulmonary sarcoidosis 2. Criado E, Sanchez M , Ramirez J ,Arguis P (showed epithelioid granuloma with ,de Caralt TM ,Perea RJ,et al. Pulmonary hemorrhagic background suggestive of sarcoidosis: typical and atypical granulomatous lymphadenopathy) which is manifestations at high resolution CT with uncommon in the absence of pulmonary pathologic correlation. Radiographics 2010; involvement. Retrospective investigation 30(6):1567-1586 3. Keici B, Toros AB, Bayraktar L, Dervisoglu like CT thorax showed lymphadenopathy. A. Sarcoidosis Incidentally diagnosed: a ACE level increased suggestive of case report. Case rep Pulmonol 2014; sarcoidosis. ACE normally increased by 20- 2014:702868 3,4 30% in sarcoidosis patients . 4. Belhomme N, Jouneau S, Bouzille G, Isolated peripheral lymphadenopathy Decaux O, Lederlin M, Guillot S, et al. Role is the uncommon presentation, particularly of serum immunoglobulins for predicting involving the cervical, axillary, epitrochlear, sarcoidosis outcome: A cohort study. PLos and inguinal nodes. Important differential One 2018; 13(4):e0193122 diagnosis include Crohn’s disease, , and vascuitis, retroviral How to cite this article: Uthaya Sankar MK, infection should be excluded. In our case, Swapna US, Sivaram A et.al. A deviant manifestation of sarcoidosis: bilateral inguinal inguinal lymph node biopsy.There is no lymphadenopathy. International Journal of laboratory test that will diagnose sarcoidosis Research and Review. 2020; 7(11): 605-607. for certain. Diagnosis of sarcoidosis requires both compatible clinical and

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International Journal of Research and Review (ijrrjournal.com) 607 Vol.7; Issue: 11; November 2020