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IMAGES AND VIDEOS
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 212-214

Endoscopic ultrasound elastography to diagnose sarcoidosis


1 Department of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, USA
2 Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA

Date of Submission04-Feb-2015
Date of Acceptance30-Dec-2015
Date of Web Publication13-Jun-2016

Correspondence Address:
Erik Rahimi
University of Texas Health Science Center at Houston, Houston, Texas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.183972

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How to cite this article:
Rahimi E, Younes M, Zhang S, Thosani N. Endoscopic ultrasound elastography to diagnose sarcoidosis. Endosc Ultrasound 2016;5:212-4

How to cite this URL:
Rahimi E, Younes M, Zhang S, Thosani N. Endoscopic ultrasound elastography to diagnose sarcoidosis. Endosc Ultrasound [serial online] 2016 [cited 2020 Jul 15];5:212-4. Available from: http://www.eusjournal.com/text.asp?2016/5/3/212/183972

A 54-year-old man presented with a 3-month history of sharp intermittent lower abdominal pain along with decreased oral intake, nausea, and a 13.6 kg weight loss. Laboratory results were significant for normocytic anemia (hemoglobin-12.7 g/dL) and hypercalcemia (serum calcium-12.2 mg/dL). Abdominal ultrasound showed a well-defined heterogeneous complex solid mass at the level of the pancreatic head measuring 4.6 cm × 3 cm × 4 cm in size. Subsequently, a computed tomography (CT) abdomen/pelvis was obtained showing lymphadenopathy in the portacaval lymph node chain (5.7 cm × 4.2 cm × 6.4 cm), peripancreatic lymph node chain anterior to the pancreatic head (5.2 cm × 3.8 cm × 5.6 cm), and within the porta hepatis lymph node chain (2.1 cm × 1.4 cm × 2.2 cm) [Figure 1]. Further, blood workup showed an angiotensin-converting enzyme (ACE) level of 144 unit/L (range 8-52 unit/L), and serum protein electrophoresis showed prominent polyclonal hypergammaglobulinemia.
Figure 1: CT abdomen: Intra-abdominal lymphadenopathy (arrows)

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Endoscopic ultrasound (EUS) [PENTAX EG-3870UTK Ultrasound Video Gastroscope, HITACHI Hi VISION 900 (HV900) Ultrasound Scanner system] was performed to evaluate the intra-abdominal lymphadenopathy and adjacent structures. EUS showed a large sized (35 mm × 39 mm), well-circumscribed homogeneous appearing, round, peripancreatic lymph node [Figure 2]. Using EUS elastography, features of the enlarged lymph node showed a mixed, predominantly green pattern, with an elastography score of 3 [range 1 (soft)-5 (hard/solid)] [Figure 3]. Fine-needle aspiration (FNA) was performed using a 22-gauge ProCore needle (Cook Endoscopy, Winston-Salem, NC, USA). There was another large, 36 mm × 44 mm, retroperitoneal lymph node near the body of the pancreas. Other enlarged lymph nodes were seen in the porta hepatis region, the celiac area, the paraesophageal area, and the aortopulmonary window. Elastography of these additional lymph nodes showed similar mixed, predominantly green pattern. FNA results showed a naked granuloma with a cluster of epithelioid histiocytes on Diff-Quik stain [Figure 4], one multinucleated giant cell on Papanicolaou (Pap) stain [Figure 5], and a hyalinizing naked granuloma with two multinucleated giant cells (one with an asteroid body) on cellblock hematoxylin and eosin (H&E) stain [Figure 6]. Special stains for acid-fast bacilli and fungi were negative, along with normal flow cytometry. Overall findings were consistent with sarcoidosis.
Figure 2: EUS: Round homogeneous peripancreatic lymph node

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Figure 3: Lymph node elastography: A mixed, predominantly green pattern

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Figure 4: Diff-Quik stain: Epithelioid histiocytes

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Figure 5: Pap stain: A multinucleated giant cell

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Figure 6: H and E stain: Giant cells (arrows) and asteroid body (circled)

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Sarcoidosis is a granulomatous disorder of unknown etiology affecting multiple organs. Diagnostic criteria includes clinicoradiological findings and noncaseating granulomas with no alternative diagnosis.[1] In patients with mediastinal lymphadenopathy, diagnosis of sarcoidosis using EUS with FNA has a sensitivity and specificity of 89% and 96%, respectively.[2] We used EUS elastography to further characterize the targeted lymph node. EUS elastography shows differences in tissue hardness based on tissue elasticity. Blue colors are considered “harder” possibly malignant tissue versus mixed green–yellow–red hues being “softer” possibly benign tissue.[3] A previous case using EUS elastography further characterized a hepatic lesion from sarcoidosis with a predominant blue pattern.[4] Another case of a cervical lymph node had features highly suspicious for malignancy with a predominant blue pattern on EUS elastography; however, the pathology was consistent with sarcoidosis.[5] In contrast, our case showed a mixed, predominantly green pattern, which is more consistent with benign tissue being sarcoidosis. An elastographic score of 3 is consistent with a mixed pattern of hard and soft tissues “honeycombed pattern,” which may make the interpretation difficult. An elastography score can range 1-5, which is consistent with soft to hard/solid tissue, respectively.[6] In summary, EUS elastography can be used as an adjunct to characterize enlarged lymph nodes associated with sarcoidosis or other disease processes. Differing elastographic patterns have been seen in evaluation of sarcoidosis, and further studies are needed to define a set characteristic pattern for sarcoidosis using elastography.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999;160:736-55.  Back to cited text no. 1
    
2.
Wildi SM, Judson MA, Fraig M, et al. Is endosonography guided fine needle aspiration (EUS-FNA) for sarcoidosis as good as we think? Thorax 2004;59:794-9.  Back to cited text no. 2
    
3.
Săftoiu A, Vilmann P, Ciurea T, et al. Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes. Gastrointest Endosc 2007;66:291-300.  Back to cited text no. 3
    
4.
Rustemovic N, Hrstic I, Opacic M, et al. EUS elastography in the diagnosis of focal liver lesions. Gastrointest Endosc 2007;66:823-4.  Back to cited text no. 4
    
5.
Sandu I, Lenghel M, Băciuţ G, et al. Misleading appearance in cervical lymph node US diagnosis - a report on sarcoidosis, Warthin tumor and squamous cell carcinoma metastases. Med Ultrason 2014;16:182-5.  Back to cited text no. 5
    
6.
Giovannini M, Thomas B, Erwan B, et al. Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses: A multicenter study. World J Gastroenterol 2009;15:1587-93.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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