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Meena N, Hulett C, Patolia S, Bartter T. Exploration under the dome: Esophageal ultrasound with the ultrasound bronchoscope is indispensible. Endosc Ultrasound 2016; 5:254-7. [PMID: 27503158 PMCID: PMC4989407 DOI: 10.4103/2303-9027.187886] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Effective use of the convex curvilinear ultrasound bronchoscope in the esophagus (EUS-B) for fine needle aspiration biopsy of mediastinal structures is now well described. In contrast, there is little to no reporting, depending on the site of EUS-B for access to sub-diaphragmatic structures. Our practice has been accessing sub-diaphragmatic sites for years. This review documents our experience with EUS-B to biopsy liver, left adrenal glands, and coeliac lymph nodes. Methods: After Institutional Review Board's approval, all endosonographic procedures performed by interventional pulmonary between July 2013 and June 2015 were reviewed. Those including biopsy of sub-diaphragmatic sites were then selected for analysis. Results: Over the study interval, 45 sub-diaphragmatic biopsy procedures (25 left adrenal glands, 7 liver, and 13 celiac node) were performed with EUS-B. In all cases, cellular adequacy was present, and samples were large enough for immunohistochemistry and any relevant ancillary studies. Metastatic malignancy was documented in 58% of cases, 16% of cases contained benign diagnostic findings, and in 27% of cases, normal organ tissue was documented. There were no complications. Conclusions: Operators comfortable with the endobronchial ultrasound scope in both the airway and the esophagus can actively seek and successfully perform biopsy of sub-diaphragmatic abnormalities when present and can thereby add to the diagnostic value of the procedure.
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Affiliation(s)
- Nikhil Meena
- Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA
| | - Cidney Hulett
- Department of Internal Medicine, CHI St. Vincent Infirmary, Little Rock, AR, USA
| | - Setu Patolia
- Department of Internal Medicine, St. Louis University, St. Louis, MO, USA
| | - Thaddeus Bartter
- Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA
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Khangura T, Uddin G, Davies A, Keating J. A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge. Euroasian J Hepatogastroenterol 2016; 5:118-121. [PMID: 29201707 PMCID: PMC5578541 DOI: 10.5005/jp-journals-10018-1149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/04/2015] [Indexed: 11/23/2022] Open
Abstract
Pancreatic sarcoidosis is one of the variant of systemic sarcoidosis which is extremely rare in literature and opined as an enigma. Hence, its diagnosis is very challenging as its presentation mimics pancreatic carcinoma. In view of a better understanding, we are presenting a case of pancreatic sarcoidosis to emphasize the above. To clearly distinguish sarcoidosis from malignancy, repeated computed tomography scans, Positron emission tomography scans, fine needle aspiration cytology, endoscopic retrograde cholangio-pancreatography supplemented with histology and relevant blood tests proved it to be a pancreatic sarcoidosis then a malignancy. Over the course, concrete evidence was divulged from lymph node biopsy and histology in clinching the diagnosis which later transformed into a malignancy. Therefore, we concluded it is a rare variant of pancreatic sarcoidosis and careful serial investigations include repeated imaging, histology and blood tests are essential to establish and most importantly differentiate the diagnosis. How to cite this article Khangura T, Uddin G, Davies A, Keating J. A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge. Euroasian J Hepato-Gastroenterol 2015;5(2):118-121.
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Affiliation(s)
- Taran Khangura
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - Gias Uddin
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - Albert Davies
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
| | - John Keating
- Department of Gastroenterology and Hepatology, Furness General Hospital, University Hospitals of Morecambe Bay NHS Foundation Trust, Barrow in Furness, Cumbria, LA14 4LF, United Kingdom
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3
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Lima TB, Domingues MAC, Caramori CA, Silva GF, Oliveira CVD, Yamashiro FDS, Franzoni LDC, Sassaki LY, Romeiro FG. Pancreatic paracoccidioidomycosis simulating malignant neoplasia: Case report. World J Gastroenterol 2013; 19:5750-5753. [PMID: 24039371 PMCID: PMC3769915 DOI: 10.3748/wjg.v19.i34.5750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 02/20/2013] [Accepted: 03/27/2013] [Indexed: 02/06/2023] Open
Abstract
Paracoccidioidomycosis is a systemic granulomatous disease caused by fungus, and must be considered in the differential diagnosis of intra-abdominal tumors in endemic areas. We report a rare case of paracoccidioidomycosis in the pancreas. A 45-year-old man was referred to our institution with a 2-mo history of epigastric abdominal pain that was not diet-related, with night sweating, inappetence, weight loss, jaundice, pruritus, choluria, and acholic feces, without signs of sepsis or palpable tumors. Abdominal ultrasonography (US) showed a solid mass of approximately 7 cm × 5.5 cm on the pancreas head. Abdominal computerized tomography showed dilation of the biliary tract, an enlarged pancreas (up to 4.5 in the head region), with dilation of the major pancreatic duct. The patient underwent exploratory laparotomy, and the surgical description consisted of a tumor, measuring 7 to 8 cm with a poorly-defined margin, adhering to posterior planes and mesenteric vessels, showing an enlarged bile duct. External drainage of the biliary tract, Roux-en-Y gastroenteroanastomosis, lymph node excision, and biopsies were performed, but malignant neoplasia was not found. Microscopic analysis showed chronic pancreatitis and a granulomatous chronic inflammatory process in the choledochal lymph node. Acid-alcohol resistant bacillus and fungus screening were negative. Fine-needle aspiration of the pancreas was performed under US guidance. The smear was compatible with infection by Paracoccidioides brasiliensis. We report a rare case of paracoccidioidomycosis simulating a malignant neoplasia in the pancreas head.
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4
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Weinreb RN, Lipson BK, Ryder MI, Freeman W. Diagnostic Testing in Ophthalmic Sarcoidosis. Semin Ophthalmol 2009. [DOI: 10.3109/08820538709068808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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5
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Samuraki M, Nakahashi T, Aoyama S, Hinoue Y, Takahashi H, Saito K, Hayashi S. Liver sarcoidosis that presented with dysphagia. Intern Med 2008; 47:1259-61. [PMID: 18591852 DOI: 10.2169/internalmedicine.47.1050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of liver sarcoidosis with dysphagia. Although akinesia of the soft palate, disappearance of the palatal reflex, and pyramidal signs indicated brainstem lesions, brain magnetic resonance imaging showed no lesion and the focus was obscure. Iritis, parotiditis, and hilar lymphadenopathy supported the diagnosis of sarcoidosis. However, lung biopsy was normal. Finally, sarcoidosis was diagnosed by liver biopsy. We speculated that microgranulomas in the brainstem that did not exhibit imaging abnormalities causing the neurological symptoms and that liver biopsy can be an effective diagnostic tool even for cases that presented with neurological signs, but no gastrointestinal symptom.
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Affiliation(s)
- Miharu Samuraki
- Department of Internal Medicine, Toyama City Hospital, Toyama, Japan.
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6
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Harder H, Büchler MW, Fröhlich B, Ströbel P, Bergmann F, Neff W, Singer MV. Extrapulmonary sarcoidosis of liver and pancreas: A case report and review of literature. World J Gastroenterol 2007; 13:2504-9. [PMID: 17552036 PMCID: PMC4146771 DOI: 10.3748/wjg.v13.i17.2504] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sarcoidosis is a chronic multisystemic granulomatous disease of unknown origin, which can involve nearly all organs. In the case of an infrequent gastrointestinal tract involvement in systemic sarcoidosis, granulomas of the liver are most commonly described while isolated pancreatic sarcoid lesions are rarely seen. We report a case of systemic sarcoidosis with exclusive extrapulmonal involvement of the liver and the pancreas in a 71-year-old white man. The diagnosis of liver involvement was confirmed by biopsy. Pancreatic surgery was needed because preoperative evaluation could not exclude pancreatic cancer and for biliary decompression. An extensive literature review of systemic sarcoidosis, focusing on reported cases with unusual presentation of sarcoidosis in the liver and the pancreas, its diagnosis, treatment, and prognosis was made.
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Affiliation(s)
- Hermann Harder
- Department of Medicine II (Gastroenterology, Hepatology and Infectious Diseases), University Hospital of Heidelberg at Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
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7
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Lachman RS. S. TAYBI AND LACHMAN'S RADIOLOGY OF SYNDROMES, METABOLIC DISORDERS AND SKELETAL DYSPLASIAS 2007. [PMCID: PMC7315357 DOI: 10.1016/b978-0-323-01931-6.50027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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8
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Romboli E, Campana D, Piscitelli L, Brocchi E, Barbara G, D'Errico A, Fusaroli P, Corinaldesi R, Pezzilli R. Pancreatic involvement in systemic sarcoidosis. A case report. Dig Liver Dis 2004; 36:222-7. [PMID: 15046194 DOI: 10.1016/j.dld.2003.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report a case of serum pancreatic hyperenzymemia as a primary manifestation of sarcoidosis; pancreatic involvement was confirmed by endoscopic ultrasonography which revealed a notable glandular fibrosis of the pancreas. It is important that patients with systemic sarcoidosis who have increased serum levels of amylase and lipase be checked in order to detect the presence of possible pancreatic involvement. Endoscopic ultrasonography represents the technique of choice used to confirm the clinical suspicion of pancreatic inflammation.
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Affiliation(s)
- E Romboli
- Department of Internal Medicine and Gastroenterology, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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9
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Zinck SE, Schwartz E, Berry GJ, Leung AN. CT of noninfectious granulomatous lung disease. Radiol Clin North Am 2001; 39:1189-209, vi. [PMID: 11699668 DOI: 10.1016/s0033-8389(05)70338-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Noninfectious granulomatous diseases of the lung consist of a diverse group of disorders that logically can be subdivided into those with and without associated vasculitis. This article reviews the epidemiologic, clinical, pathologic, and radiologic features of sarcoidosis, hypersensitivity pneumonitis, berylliosis, and the five entities traditionally classified as pulmonary angiitis and granulomatosis.
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Affiliation(s)
- S E Zinck
- Department of Radiology, Stanford University Medical Center, California 94305-5105, USA.
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10
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Renston JP, Goldman ES, Hsu RM, Tomashefski JF. Peripheral blood eosinophilia in association with sarcoidosis. Mayo Clin Proc 2000; 75:586-90. [PMID: 10852419 DOI: 10.4065/75.6.586] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To review retrospectively our experience with peripheral blood eosinophilia (PBE) in sarcoidosis and to analyze histologically lung biopsy specimens for the presence of lung tissue eosinophils. PATIENTS AND METHODS We reviewed 140 cases of sarcoidosis diagnosed between May 1975 and January 1998. Ninety-five patients (66.3% women; 70.5% African American; mean age, 35.9 years) met the inclusion criteria. Transbronchial biopsy specimens from 82 patients were divided into 4 morphologic compartments: parenchyma, bronchial wall, parenchymal granulomas, and bronchial wall granulomas. Within compartments, up to 10 high-power fields were scored semiquantitatively for eosinophils, from 0 (none) to 4+ (numerous). RESULTS Thirty-nine patients (41%) had PBE. Four had PBE greater than 10%. The highest eosinophil count (21%) occurred in 1 patient. Sixty-five (79%) of 82 patients had no or few (1+) eosinophils in lung tissue; 17 patients had eosinophils scored as 2+ or higher. There was no correlation between peripheral blood eosinophil count and presence of eosinophils in transbronchial biopsy specimens. Eosinophils were least conspicuous in parenchyma but evenly distributed in bronchial wall and parenchymal and bronchial wall granulomas. CONCLUSIONS Peripheral blood eosinophilia occurs frequently in sarcoidosis. However, there appears to be no association between peripheral blood eosinophil count and presence of lung tissue eosinophils. Whether eosinophils participate in the pathogenesis of sarcoidosis requires further study.
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Affiliation(s)
- J P Renston
- Department of Medicine, Mt Sinai Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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11
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Abstract
A 67-year-old woman sought medical treatment of cardiomyopathy, which had been diagnosed 2 years earlier; the causative factor was sarcoidosis. A screening mammogram revealed multiple spiculated masses in both breasts. A review of previous films obtained elsewhere showed that these masses had been increasing in prominence during the past 3 years. The patient had no visible axillary nodal abnormalities. Sarcoidosis was considered a diagnostic possibility, and a large-core needle biopsy was done with stereotactic guidance. The histological diagnosis was non-necrotizing granulomatous inflammation, consistent with sarcoidosis.
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Affiliation(s)
- J J Gisvold
- Department of Diagnostic Radiology, Mayo Clinic Rochester, MN 55905, USA
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12
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Ku A, Lachmann E, Tunkel R, Nagler W. Neurosarcoidosis of the conus medullaris and cauda equina presenting as paraparesis: case report and literature review. PARAPLEGIA 1996; 34:116-20. [PMID: 8835038 DOI: 10.1038/sc.1996.21] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sarcoidosis is a multi-system, non-caseating granulomatous disease of unknown etiology. Although spinal cord involvement is rare, it may cause severe neurological complications. We report the case of a 52-year-old woman who developed low back pain and a progressive flaccid paraparesis whose investigations revealed pulmonary and spinal sarcoidosis. To our knowledge, this is the first reported case of sarcoidosis of the conus medullaris and cauda equina diagnosed by an unusual enhancement pattern observed on magnetic resonance imaging with gadolinium. Biopsy of the lumbar nerve roots and of the lung revealed a non-caseating granuloma. Treatment with steroids and intensive rehabilitation resulted in remarkable functional improvement. Although rare, sarcoidosis of the conus medullaris and cauda equina should be considered in the differential diagnosis of flaccid paraparesis, particularly in patients with non-diagnostic evaluations.
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Affiliation(s)
- A Ku
- New York Hospital, Cornell Medical Center, New York, USA
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13
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Soyer P, Gottlieb L, Bluemke DA, Fishman E. Sarcoidosis of the pancreas mimicking pancreatic cancer: CT features. Eur J Radiol 1994; 19:32-3. [PMID: 7859757 DOI: 10.1016/0720-048x(94)00561-p] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- P Soyer
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD 21205
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14
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Abstract
We report a case of pancreatic sarcoidosis in a patient with radiographic and clinical findings suggestive of pancreatic cancer. Clinically apparent involvement of the pancreas is uncommon in patients with known sarcoidosis and is distinctly unusual as the initial presentation of disease. Sarcoid involvement of the pancreas can mimic adenocarcinoma and should be considered in the differential diagnosis of a pancreatic mass in a patient with symptoms suggestive of sarcoidosis.
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Affiliation(s)
- M S Brady
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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15
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Tammela T, Kallioinen M, Kontturi M, Hellström P. Sarcoidosis of the bladder: a case report and literature review. J Urol 1989; 141:608-9. [PMID: 2645423 DOI: 10.1016/s0022-5347(17)40910-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A case of bladder sarcoidosis in a woman with known systemic involvement of this disease is reported. The lesion improved and ureteral obstruction was relieved after transurethral resection and systemic corticosteroid treatment. Sarcoidosis and malacoplakia are believed to represent distinct disease processes in the bladder.
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Affiliation(s)
- T Tammela
- Department of Pathology, University of Oulu, Finland
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 44-1988. A 25-year-old man with multiple bone lesions, hilar lymphadenopathy, and a pericardial effusion. N Engl J Med 1988; 319:1209-16. [PMID: 3173457 DOI: 10.1056/nejm198811033191807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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