A Case of Bronchial Sarcoidosis Complicated with Atelectasis of the Right Lower Lobe

Abstract

We experienced a thirty year-old male with a chief complaint of severe cough and sputum which started four months prior. On physical examination the supraclavicular, right cubital and inguinal lymphnodes which were movable and nontender were palpable. Slight macular degenerative change was observed, but the uveitis was not detectable. His plain chest film showed atelectasis of right lower lobe, but the cause was not indicated, even by tomography. Bronchography disclosed stenosis close to the orifice of the right lower lobe bronchus.
On admission in March 1978 because of pneumonia after bronchography the leucocyte count was 11200/mm³, the blood sedimentation rate was 35mm per hour and the C-reactive protein was positive. The serum Ca concentration was normal.
Bronchoscopy showed irregular tracheal bifurcation, unclear bronchial cartilagenous grooves and longitudinal mucosal corrugation of the right main bronchus and the intermediate portion, remarkably reddened and erosive mucosal membrane, suggestive of severe inflammation. The orifice of the right lower lobe bronchus was almost completely obstructed.
Biopsy near the orifice of the right lower lobe bronchus showed chronic bronchitis but a second biopsy near the same region revealed a small tubercle suggestive of sarcoid. The right supraclavicular lymphnode was removed. This microscopically showed tubercles composed of epithelioid cells, with an occasional Langhans giant cell and asteroid body but without any caseation. An inguinal lymphnode was removed. This also showed a non-caseating epithelioid cell granuloma. All stains for tubercle bacilli were negative. Mantoux's reaction was negative and sputum culture revealed no tubercle bacilli.
We thought that the atelectasis was primarily due to the endobronchial sarcoid granuloma and treated it as a case of bronchial sarcoidosis with atelectasis with predonisolone. After two weeks the superficial lymphnodes became nonpalpable, but there was no improvement of atelectasis. Even after four months the atelectasis remains completely unchanged. We think that some irreversible change other than sarcoid granuloma, perhaps inflammatory scar formation of the bronchus may be involved with the atelectasis.