IT’S NOT ALWAYS TUBERCULOSIS! TREE-IN-BUD OPACITIES LEADING TO A DIAGNOSIS OF PULMONARY SARCOID J. Hong BA, J. Spraglin MD, H. Shi MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: The “tree-in-bud” sign can be commonly caused by respiratory infections including that of mycobacterial, bacterial, and viral causes. The pattern of the tree correlates to an intralobular inflammatory bronchiole and the bud correlates to inflammatory filling in alveolar ducts. Pulmonary sarcoid can show nodules in a perilymphatic distribution, but not in this particular appearance. Thus, a high degree of suspicion is required to proceed to invasive testing such as bronchoscopy, especially in a mycobacterial tuberculosis rule-out. CASE: A 27-year-old homeless man with Brugada syndrome and implanted cardioverter defibrillator initially presented for acute onset of chest pain and cough for three days. EKG showed normal sinus rhythm with no signs of ischemia. His ICD was interrogated with no events evident. Labs showed troponin <0.015 (normal 0.015- 0.045), WBC 7.2 (4.5- 11.0), lactate 1.1 (0.9- 1.7 mmol/L), NT-Pro-B Natriuretic Peptide BNP 7 (0 - 450 pg/mL). He was about to be discharged when the results of his chest X-ray showed multifocal patchy airspace opacities. The patient endorsed a history of alcohol abuse, intranasal cocaine use, and vaping. He previously had been incarcerated and was a machinist at a shipyard. CT chest scan showed centrilobular tree-in-bud opacities and mediastinal lymphadenopathy. With concern for MTB, a bronchoscopy was performed with bronchoalveolar lavage (BAL) and endobronchial biopsy was performed. AFB, fungal, bacterial cultures were negative. T-spot, Mycobacterium tuberculosis (MTB) PCR from sputum and BAL were negative. Finally, pathology from the biopsy showed fibrosing non-necrotizing granulomatous pneumonitis consistent with sarcoid. Angiotensin converting enzyme (ACE) level was elevated at 127 (14- 82 U/L). DISCUSSION: Pulmonary sarcoidosis is often very difficult to diagnose, especially when a patient presents with nonspecific respiratory symptoms. In this patient, there was a broad differential on admission given his cardiac history of Brugada and nonspecific symptoms of cough. Ultimately, he fulfilled sarcoid criteria with tissue biopsy and exclusion of MTB. He will need to undergo further testing to rule out extrapulmonary sarcoid manifestations, such as cardiac sarcoid, as he is high risk given his genetic Brugada.
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