[Subcutaneous nodules, mediastinal and hilar lymphadenopathy]

A 52-year old man was admitted to our hospital because of dyspnea on exertion for 2 months and subcutaneous nodules for 1 month. Chest enhanced CT showed bilateral hilar and mediastinal lymphadenopathy. Bronchial alveolar lavage fluid revealed a CD₄⁺/CD₈⁺ T cell subsets ratio of 4.3 and culture for acid-fast bacillus (AFB) was negative. The pathology of skin nodules and transbronchial needle aspiration biopsy guided by endoscopic ultrasound (EBUS-TBNA) revealed non-caseating necrotizing epithelioid granulomas with negative acid-fast bacilli staining and periodic acid-Schiff staining, which was compatible with sarcoidosis. The patient was diagnosed as sarcoidosis and glucocorticoid was administrated. The subcutaneous nodules were improved. However, the lymph nodes were enlarged instead of shrinking after 6-month therapy. The failure to respond to glucocorticoids raised the possibility of sarcoidosis complicated with tuberculosis infection. The patient received anti-tuberculosis therapy. Lymphadenopathy responded within 4 months, and there was complete regression after 18-month treatment. The patient was followed up for 5 years and repeated chest CT scan showed that the sizes of bilateral hilar and mediastinal lymph nodes were normal.