Case Files: Breathing My Life Out (Answer)

The provisional diagnosis would be sarcoidosis.

Thus, the confirmatory investigation would be a.

Sarcoidosis is a systemic illness of unknown etiology. Many patients have respiratory symptoms,
including cough and dyspnea as well as general malaise such as lethargy. Hilar and peripheral lymphadenopathy is common, and 20 to 30% of patients have hepatomegaly.

In general, common symptoms are vague, such as fatigue unchanged by sleep, lack of energy, weight loss, aches and pains, arthralgia, dry eyes, blurry vision, shortness of breath, a dry hacking cough or skin lesions. The cutaneous symptoms vary, and range from rashes and noduli (small bumps) to erythema nodosum or lupus pernio. It is often asymptomatic.

The chest x-ray shows symmetrical hilar lymphadenopathy. The diagnostic method of choice
is transbronchial biopsy, which will show a mononuclear cell granulomatous inflammatory process. While liver and scalene node biopsies are often positive, noncaseating granulomas are so frequent in these sites that they are not considered acceptable for primary diagnosis. ACE levels are elevated in twothirds of patients, but false-positive values are common in other granulomatous disease processes.

Follow-up on a patient with sarcoidosis should always include an electrocardiogram, ocular examination by an ophthalmologist, liver function tests, serum calcium and 24-hour urine calcium. In female patients sarcoidosis is significantly associated with hypothyroidism, hyperthyroidism and other thyroid diseases, hence close surveillance of thyroid function is recommended.

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