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Jornal de Pneumologia

versión impresa ISSN 0102-3586versión On-line ISSN 1678-4642

J. Pneumologia v.29 n.4 São Paulo jul./ago. 2003 



Question: what is the diagnosis?



Jorge KavakamaI; Nestor MüllerII

IRadiologist, Image Diagnosis, Instituto do Coração-InCor, HCFMUSP, São Paulo, SP
IISt. Paul’s Hospital, Vancouver, BC, Canadá



The aim of this section is to stimulate a practical approach to the diagnosis based on the clinical information and the radiologic findings. We invite all our readers to participate. You may send your opinion by filling out a form that can be found at the site, or by e-mail ( Do not forget to identify yourself; we will publish the names of the individuals who make the correct diagnosis. The images shown above are the key ones for the diagnosis. Further details can be found at THE DIAGNOSIS OF THIS CASE WILL BE PUBLISHED IN THE NEXT ISSUE OF THE JOURNAL.


Diagnosis of previous case

J Pneumol 2003;29(3):169



Poorly defined nodular opacities, predominantly in the middle lung zones.

Perivascular and peribronchial nodules with confluent some areas of confluence, most severe in the right upper lobe.

Also noted are a few centrilobular nodules and branching lines resulting in a tree-in-bud pattern. This reflects the presence of peribronchiolar nodules.


Sarcoidosis is a granulomatous disease of unknown etiology, characterized by the presence of noncaseating granulomas.

It affects mainly young adults, aged between 20 to 40 years.

The most common presentation is of symmetric, enlarged bilateral hilar and paratracheal lymph nodes (“potato nodes”).

The granulomas are located in a perilymphatic distribution, ie, along bronchi, vessels, pleura and, to lesser extent, interlobular septa. The characteristic HRCT findings consist of nodular thickening along bronchi, arteries, and veins and of subpleural nodules, mainly in middle and upper lung zones.

Other abnormalities include: conglomerate nodules; ground glass opacities, consolidation, and septal thickening. Fibrosis results in architectural distortion, traction bronchiectasis, irregular lines (reticular pattern) cavity formation, and, occasionally, honeycombing.

The differential diagnosis on HRCT includes berylliosis, silicosis, lymphangitic carcinomatosis, paraccocidioidomycosis, and tuberculosis.

The asymmetric distribution and the presence of a tree-in-bud pattern in this case raised concern for tuberculosis. A tree-in-bud pattern is often seen in tuberculosis, reflecting the presence of  endobronchial spread. 

The diagnosis of sarcoidosis was confirmed by trans-bronchial biopsy.


Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of diseases of the chest. 2nd ed. St. Louis: Mosby, 1995.

Fraser RS, Müller NL, Colman N, Pare PD. Diagnosis of diseases of the chest. 4th ed. Philadelphia, Pennsylvania: WB Saunders, 1999.

Webb RW, Müller NL, Naidich DP. High resolution CT of the lung. 3rd ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2001.


The seven participants cited below gave the correct diagnosis

Danielle Cristina S. Clímaco – Hospital Geral Otávio de Freitas, Recife, PE; Fernando S. Costa – Escola Paulista de Medicina/Unifesp, São Paulo, SP; Marlon  B.M. Molina – HAGF, Ponte Nova, MG; Jaquelina Sonoe Ota – Escola Paulista de Medicina/Unifesp, São Paulo, SP; Luiz Pereira – Universidade Federal de Minas Gerais, Belo Horizonte, MG; Marcio Adriano Leite Bastos – Hospital de Clínicas Sul, São José dos Campos, SP; Marcelo Alcântara – Universidade Federal do Ceará, Fortaleza, CE. 

Editor’s note: Most of the 46 participants answered correctly the list of differential diagnosis.

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