WBR0776

Author	[[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Pulmonology
Prompt	[[Prompt::A 52-year-old African American diabetic woman presents to the chronic care clinic for indurated nodules on her lower extremities. The patient reports that she noticed them just 2 days ago. The nodules were small at first but have been enlarging since. They seem to be warmer and slightly redder than the rest of the skin, and very tender to touch. Upon further questioning, the patient reports a dry cough for the past 2 months and a 9 kg (20 lbs) unintentional weight loss in the same time frame. Concerned with the latter findings, you decide to order a chest CT scan especially given the family history of lung cancer. A cut at the level of the great cardiac vessels is shown below. What would you expect to find on pathology of the observed lesions? ]]
Answer A	AnswerA::Giant cells, granuloma formation with caseating necrosis
Answer A Explanation	AnswerAExp::Caseating necrosis within intrathoracic granulomas is usually indicative of a tuberculosis infection.
Answer B	AnswerB::Giant cells, non-caseating granuloma formation
Answer B Explanation	AnswerBExp::Patients with sarcoidosis have multiple noncaseating epithelioid-cell (giant cell) granulomas.
Answer C	AnswerC::Inflammatory reaction with molds branching at acute angles
Answer C Explanation	AnswerCExp::Molds branching at acute angles are seen in aspergillomas usually growing in immunocompromised patients with previous cavitary disease colonized by Aspergillus spp.
Answer D	AnswerD::Multiplying type II pneumocytes
Answer D Explanation	AnswerDExp::Type II pneumocytes are seen in the alveolar spaces and multiply during lung injury to restore parenchymal integrity.
Answer E	AnswerE::Nests or cords of uniform cells with central nuclei
Answer E Explanation	AnswerEExp::Carcinoid tumors are usually characterized by nests or cords of uniform cells with central nuclei.
Right Answer	RightAnswer::B
Explanation	[[Explanation::Sarcoidosis is a systemic disease characterized by the development and accumulation of multiple systemic granulomas. Sarcoidosis may involve virtually any organ but is classically most common in the lungs, liver, eyes, and skin. Symptoms of fatigue, night sweats, and weight loss are common at presentation. Löfgren's syndrome, a possible presentation of sarcoidosis consists of arthritis, erythema nodosum, and bilateral hilar adenopathy, and can be seen in up to 35% of patients. Although all racial and ethnic groups can have sarcoidosis, African Americans are 3 times more likely than Caucasians to develop the disease. Diagnosis is usually with a combination of clinical and radiologic findings supported by histopathological evidence of noncaseating epithelioid-cell granulomas with absence of any causative organisms or particles. Granulomas classicaly produce angiotensin-converting enzyme (ACE) with 60% of patients having elevated serum levels (not-diagnostic). Treatment is usually with corticosteroids although therapy is not indicated for everyone. Two thirds of patients recover completely within 10 years of diagnosis. Educational Objective: Sarcoidosis is characterized by the development of multiple noncaseating epithelioid-cell granulomas. References: Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357(21):2153-65.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Sarcoidosis, WBRKeyword::Granuloma, WBRKeyword::Lung nodule, WBRKeyword::Lymph nodes, WBRKeyword::Perihilar, WBRKeyword::Autoimmune, WBRKeyword::Sarcoid
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