Search

A 44-year-old man who had worked as a plumber and was currently working as a bricklayer was referred to our hospital because of a 2-year history of progressive dyspnea. Physical examination revealed cyanosis, clubbing of the fingers, and edema of the inferior extremities. Chest auscultation revealed bilateral inspiratory crackles predominantly at the lung bases. Remarkably, there were several painful, firm papules and nodular lesions over the fingertips of the hands, some with whitish crusts (Fig. 1). These lesions had appeared 2 years before and gradually increased in number and size. A full blood count was normal apart from moderate erythrocytosis and lymphopenia. The biochemical profile (including serum levels of calcium and phosphorus and daily urinary calcium excretion) was normal. Serum angiotensin converting enzyme activity was increased at 60 U/mL (normal range, 6.1–21.1 U/mL). An antinuclear antibody test was negative. Serum complement levels were normal. Chest X-ray film showed cardiomegaly, bilateral hilar lymphadenopathy, and interstitial infiltrates (reticulo-nodular pattern) with a predilection for the mid and lower lung zones. A computed tomography scan of the chest confirmed mediastinal adenopathy and revealed bilateral and diffuse parenchymal abnormalities consisting of nodular opacities along the bronchovascular bundles and interlobular septa, irregular linear opacities oriented along the bronchovascular bundles, and distortion of the lobules. A gallium-67 scan showed a “lambda” pattern created by uniform uptake in bilateral intrathoracic and right paratracheal lymphadenopathy, which is highly specific for the diagnosis of sarcoidosis.1 The recovery of bronchoalveolar lavage [TAB1][TAB]showed 61% macrophages (normal range, 80%–90%) and 35% lymphocytes (normal value