A Rare Case of Pediatric Pulmonary Sarcoidosis Without Lymph Node Involvement Presenting With Centrilobular Ground-Glass Opacities

A 17-year-old previously healthy male presented with acute hypoxic respiratory failure after one month of progressively worsening dyspnea on exertion, non-productive cough, fevers, and weight loss. He was initially discharged on oral steroids with a working diagnosis of cryptogenic organizing pneumonia, but was readmitted after one month for acute hypoxic respiratory failure. Extensive laboratory workup, including serum angiotensin converting enzyme level, hypersensitivity pneumonitis panel, and bronchoalveolar lavage fluid cultures, was normal. Computed tomography scan of the chest revealed diffuse centrilobular ground-glass opacities and a 4-mm solid right lower lobe pulmonary nodule, and he underwent a video-assisted thoracoscopic surgery (VATS) procedure with segmental resection of the lingula. Pathology ultimately showed non-necrotizing granulomatous inflammation in the interstitium of the lung parenchyma, airways, and blood vessels, consistent with sarcoidosis. Diagnosis of interstitial lung disease is difficult when histologic diagnosis requires an invasive, costly VATS biopsy, but prompt recognition of sarcoidosis is critical to prevent potentially fatal pulmonary fibrosis or cardiac sarcoidosis. To our knowledge, this is the first case report of pediatric pulmonary sarcoidosis with ground-glass opacities lacking any lymphadenopathy, skin, or neurologic manifestations.