Medical image of the week: sarcoidosis

A 42 year old African-American man from Indianapolis presented with cough and skin lesions. ACE level was elevated at 86 μg/L. Spirometry was normal except for a diffusing capacity 52% of predicted. Imaging was suggestive of sarcoidosis versus granulomatous infection. Bronchoscopy with bronchoalveolar lavage cytospin revealed a lymphocytic alveolitis (27% lymphocytes) with a CD4:CD8 ratio of 6.2:1 by flow cytometry. Biopsy showed classic noncaseating granulomas and no organisms supporting the diagnosis of sarcoidosis. The patient’s symptoms and radiographic findings improved with 20 mg prednisone every other day for 3 months duration.