Dr/ Hytham Nafady

Bernie Mac
Definition
• Multisystem chronic inflammation
characterized by non caseating granulomas.

Caseating granulomas
TB

Non cas...
Sarcoidosis
• Can involve any organ.
• 90% thoracic (lung & LN).
• Thoracic involvement accounts for most
of the morbidity...
Epidemiology
• Age: 3rd decade.
• Sex: F > M.
• Race: black Americans.
Erythema nodosum
Laboratory findings
• Kviem test +ve.
• Elevated angiotensin converting enzyme
(ACE)
Lofgren syndrome
• Acute sarcoidosis characterized by triad
Heerfordt’s syndrome
• Acute sarcoidosis characterized by uveoparotitis
Heerfordt’s syndrome
Pulmonary sarcoidosis
Pulmonary sarcoidosis
Paradoxical response
• One of the distinguishing features of
sarcoidosis.
• As the lung disease worsens,
• the nodal enlar...
Calcified hilar & mediastinal LN
Calcified hilar & mediastinal LN
Calcified hilar LN
Calcified hilar & mediastinal LN
Calcified hilar & mediastinal LN
Hilar enlargement
Unilateral hilar enlargement

Bilateral hilar enlargement
•Sarcoiosis
•Silicosis

Infection

•TB

•TB

N...
LN enlargement # pulmonary
vascular enlargement

Smooth

Lobulated
DD of calcified hilar or mediastinal LN
•
•
•
•

Silicosis
Sarcoidosis.
TB.
Treated lymphoma.
Parenchymal sarcoidosis
Typical parenchymal sarcoidosis
Interstitial micronodules
• Coalescent groups of microscopic granulomas.
• Well defined, w...
Upper lobe predominance
Bilateral perihiar predominance
Nodular thickening of the
peri-broncho-vascular interstitium
Nodular thickening of interlobular septa
nodular fissures
Nodular thickening of
interlobular septa:
Irregular or nodular.
...
Sub-pleural nodules
(pseudo-plaques)
Fissure nodules
DD of nodular interstitial
thickening
• Sarcoidosis.
• Lymphangitis carcinomatosis.
Typical parenchymal sarcoidosis
Fibrosis

• Reticular opacities.
• Traction bronchiectasis.
• Architectural distortion.
Atypical parenchymal sarcoidosis
Pulmonary nodules or masses
15-25 %
Sarcoid Galaxy sign
Atypical sarcoidosis
Pulmonary consolidation
10-20%
Atypical parenchymal sarcoidosis
Patchy ground glass opacities
40%
Atypical parenchymal sarcoidosis
Linear reticular opacities
15-20%
Atypical parenchymal sarcoidosis
Miliary opacities
Rare 1%
Pleural disease
Rare < 1%
• Pleural effusion.
• Hemothorax.
• Chylothorax (due to involvement of the
mediastinal LN or tho...
Air way involvement
• May occur at any level
• Bronchial wall
thickening
• Luminal abnormalities
• Obstruction of lobular
...
Atlas of sarcoidosis
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Neurosarcoidosis
Neurosarcoidosis

Parenchymal

Pachymeningeal

Leptomeningeal
Periventricular white matter non
enhancing lesions
Multiple enhancing nodules
Nodules may have low T2
signal due to high cellularity
Pachymeningeal sarcoidosis
• Dural mass.
• Diffuse dural thickening.
Pachymeningeal sarcoidosis
dural masses
Pachymeningeal sarcoidosis
diffuse dural thickening
Breast cancer metastasis

Intracranial hypotension
VPS

SDH
Leptomeningeal sarcoidosis
•
•
•
•

Basal cisterns.
Cerebral sulci.
Cerebellar fissures.
Virchow Robin perivascular spaces...
Leptomeningeal sarcoidosis
basal cisterns
Leptomeningeal sarcoidosis
Perivascular spaces

Corticosteroids
Leptomeningeal sarcoidosis
cerebellar fissures
Leptomeningeal or pachymeningeal?
Lymphoma

Sarcoidosis
Mixed leptomeningeal & pachymeningeal
thickening
Lymphoma

Sarcoidosis
Cranial nerve involvement
• Optic nerve.
• Facial nerve.
Optic N sarcoidosis
DD of bilateral optic neuritis
• MS.
• Devic’s disease
• Sarcoidosis.
Hypothalamic sarcoidosis
Pituitary stalk sarcoidosis
Calvarial sarcoidosis
Calvarial sarcoidosis
Pacchionian granulation
Parietal foramina
Leptomeningeal cyst
Calvarial hemangioma
Eosinophilic granuloma
Calvarial metastasis
Musculoskeletal sarcoidosis
Musclar nodular sarcoidosis
• Low signal intensity centre due to fibrosis.
Sarcoid dacytilits
• Tenosynovitis + lace like lytic lesion
DD of dactylitis
•
•
•
•
•

TB (spina ventosa).
Syphilis (TB like but bilateral & symmetrical).
Sarcoid dactylitis (lace l...
Orbital sarcoidosis
• Bilateral enlargement & enhancement of
the lacrimal glands.
• Bilateral uveitis.
DD of bilateral lacrimal gland
enlargement
•
•
•
•
•
•

Sjogren syndrome.
Miculik’s disease.
Sarcoidosis.
TB.
Orbital pseu...
Bilateral parotitis
Panda sign
• Bilateral lacirmal gland, parotid gland &
normal nasopharyngelal uptake, on Ga-67
scintigraphy.
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
Sarcoidosis
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Sarcoidosis

  1. 1. Dr/ Hytham Nafady Bernie Mac
  2. 2. Definition • Multisystem chronic inflammation characterized by non caseating granulomas. Caseating granulomas TB Non caseating granulomas Sarcoidosis
  3. 3. Sarcoidosis • Can involve any organ. • 90% thoracic (lung & LN). • Thoracic involvement accounts for most of the morbidity & mortality associated with the disease.
  4. 4. Epidemiology • Age: 3rd decade. • Sex: F > M. • Race: black Americans.
  5. 5. Erythema nodosum
  6. 6. Laboratory findings • Kviem test +ve. • Elevated angiotensin converting enzyme (ACE)
  7. 7. Lofgren syndrome • Acute sarcoidosis characterized by triad
  8. 8. Heerfordt’s syndrome • Acute sarcoidosis characterized by uveoparotitis
  9. 9. Heerfordt’s syndrome
  10. 10. Pulmonary sarcoidosis
  11. 11. Pulmonary sarcoidosis
  12. 12. Paradoxical response • One of the distinguishing features of sarcoidosis. • As the lung disease worsens, • the nodal enlargement usually regresses.
  13. 13. Calcified hilar & mediastinal LN
  14. 14. Calcified hilar & mediastinal LN Calcified hilar LN
  15. 15. Calcified hilar & mediastinal LN
  16. 16. Calcified hilar & mediastinal LN
  17. 17. Hilar enlargement Unilateral hilar enlargement Bilateral hilar enlargement •Sarcoiosis •Silicosis Infection •TB •TB Neoplasm •Bronchogenic carcinoma. •Metastasis (lung, head & neck, thyroid or testis). •Lymphoma •Metastases Vascular •Post-stenotic dilatation (left side). •Pulmonary artery aneurysm. •Pulmonary hypertension. •Pulmonary artery aneurysm.
  18. 18. LN enlargement # pulmonary vascular enlargement Smooth Lobulated
  19. 19. DD of calcified hilar or mediastinal LN • • • • Silicosis Sarcoidosis. TB. Treated lymphoma.
  20. 20. Parenchymal sarcoidosis
  21. 21. Typical parenchymal sarcoidosis Interstitial micronodules • Coalescent groups of microscopic granulomas. • Well defined, with irregular margins. • 2-4 mm. Location: • Bilateral upper lobe predominance. • Bilateral perihilar. Distribution:(Perilymphatic distribution) • Peribronchovascular interstitium, • Interlobular septa & • Subpleural (subpleural plaques & fissure nodules).
  22. 22. Upper lobe predominance
  23. 23. Bilateral perihiar predominance
  24. 24. Nodular thickening of the peri-broncho-vascular interstitium
  25. 25. Nodular thickening of interlobular septa nodular fissures Nodular thickening of interlobular septa: Irregular or nodular. Nodular fissures: Dot-dash pattern (.-.-.-.-.-.-).
  26. 26. Sub-pleural nodules (pseudo-plaques)
  27. 27. Fissure nodules
  28. 28. DD of nodular interstitial thickening • Sarcoidosis. • Lymphangitis carcinomatosis.
  29. 29. Typical parenchymal sarcoidosis Fibrosis • Reticular opacities. • Traction bronchiectasis. • Architectural distortion.
  30. 30. Atypical parenchymal sarcoidosis Pulmonary nodules or masses 15-25 %
  31. 31. Sarcoid Galaxy sign
  32. 32. Atypical sarcoidosis Pulmonary consolidation 10-20%
  33. 33. Atypical parenchymal sarcoidosis Patchy ground glass opacities 40%
  34. 34. Atypical parenchymal sarcoidosis Linear reticular opacities 15-20%
  35. 35. Atypical parenchymal sarcoidosis Miliary opacities Rare 1%
  36. 36. Pleural disease Rare < 1% • Pleural effusion. • Hemothorax. • Chylothorax (due to involvement of the mediastinal LN or thoracic duct).
  37. 37. Air way involvement • May occur at any level • Bronchial wall thickening • Luminal abnormalities • Obstruction of lobular or segmental bronchi • Mosaic perfusion • Air-trapping on expiration
  38. 38. Atlas of sarcoidosis
  39. 39. Case 1
  40. 40. Case 2
  41. 41. Case 3
  42. 42. Case 4
  43. 43. Case 5
  44. 44. Case 6
  45. 45. Case 7
  46. 46. Case 8
  47. 47. Neurosarcoidosis
  48. 48. Neurosarcoidosis Parenchymal Pachymeningeal Leptomeningeal
  49. 49. Periventricular white matter non enhancing lesions
  50. 50. Multiple enhancing nodules
  51. 51. Nodules may have low T2 signal due to high cellularity
  52. 52. Pachymeningeal sarcoidosis • Dural mass. • Diffuse dural thickening.
  53. 53. Pachymeningeal sarcoidosis dural masses
  54. 54. Pachymeningeal sarcoidosis diffuse dural thickening
  55. 55. Breast cancer metastasis Intracranial hypotension VPS SDH
  56. 56. Leptomeningeal sarcoidosis • • • • Basal cisterns. Cerebral sulci. Cerebellar fissures. Virchow Robin perivascular spaces.
  57. 57. Leptomeningeal sarcoidosis basal cisterns
  58. 58. Leptomeningeal sarcoidosis Perivascular spaces Corticosteroids
  59. 59. Leptomeningeal sarcoidosis cerebellar fissures
  60. 60. Leptomeningeal or pachymeningeal? Lymphoma Sarcoidosis
  61. 61. Mixed leptomeningeal & pachymeningeal thickening Lymphoma Sarcoidosis
  62. 62. Cranial nerve involvement • Optic nerve. • Facial nerve.
  63. 63. Optic N sarcoidosis
  64. 64. DD of bilateral optic neuritis • MS. • Devic’s disease • Sarcoidosis.
  65. 65. Hypothalamic sarcoidosis
  66. 66. Pituitary stalk sarcoidosis
  67. 67. Calvarial sarcoidosis
  68. 68. Calvarial sarcoidosis
  69. 69. Pacchionian granulation
  70. 70. Parietal foramina
  71. 71. Leptomeningeal cyst
  72. 72. Calvarial hemangioma
  73. 73. Eosinophilic granuloma
  74. 74. Calvarial metastasis
  75. 75. Musculoskeletal sarcoidosis
  76. 76. Musclar nodular sarcoidosis • Low signal intensity centre due to fibrosis.
  77. 77. Sarcoid dacytilits • Tenosynovitis + lace like lytic lesion
  78. 78. DD of dactylitis • • • • • TB (spina ventosa). Syphilis (TB like but bilateral & symmetrical). Sarcoid dactylitis (lace like lytic pattern). Psoriasis (sausage digit). Sickle cell dactylitis (hand & foot syndrome).
  79. 79. Orbital sarcoidosis • Bilateral enlargement & enhancement of the lacrimal glands. • Bilateral uveitis.
  80. 80. DD of bilateral lacrimal gland enlargement • • • • • • Sjogren syndrome. Miculik’s disease. Sarcoidosis. TB. Orbital pseudotumor Lymphoma.
  81. 81. Bilateral parotitis
  82. 82. Panda sign • Bilateral lacirmal gland, parotid gland & normal nasopharyngelal uptake, on Ga-67 scintigraphy.
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