Chest pain

Recognising chest pain
Author: Diana Campelo Delgado | 14 January 2021

A case study diagnosing pulmonary sarcoidosis in a patient who presented with chest pain and difficulty breathing highlights the importance of including sarcoidosis in the differential diagnosis of chest pain.

The study, “Sarcoidosis Presenting as Acute Respiratory Distress Syndrome”, was published in Clinical Practice and Cases in Emergency Medicine.

Sarcoidosis is an inflammatory disease of unknown cause that can affect several organs, especially the lungs. When the lungs are affected, it is called pulmonary sarcoidosis. People with pulmonary sarcoidosis may experience a persistent dry cough, shortness of breath, fatigue or chest pain.

Chest pain is one of the most common complaints seen by emergency-care providers. Emergency clinicians must be able to distinguish between different causes of chest pain in order to minimise both acute and long-term illness and mortality.

Researchers at Kingman Regional Medical Center in Arizona reported the case of a patient with chest pain who was diagnosed with pulmonary sarcoidosis. The 36-year-old man was admitted after experiencing left-sided chest pain and difficulty breathing for four months.

He reported a chronic dry cough that had continued for several years and was not related to illness or exercise. He had never smoked and reported no family history of autoimmune or genetic disease. On admission, his physical examination and laboratory results were within normal limits, including vital signs, lung sounds, cardiac rhythm (electrocardiogram) and blood tests.

Chest radiography and computed tomography showed nodules in both lungs, apparently more pronounced on the left. After consultation with pulmonology, the medical team considered lymphoma, tuberculosis, fungal infection and pulmonary sarcoidosis as possible diagnoses.

Bronchoalveolar lavage, a procedure in which fluid is introduced into a small part of the lung and then aspirated for analysis, was negative for fungal and bacterial infection as well as malignant cells. Lung biopsies, in which a small piece of lung tissue is removed for examination, showed collections of activated immune cells known as granulomas.

The man was diagnosed with stage III pulmonary sarcoidosis, characterised in this case by granulomas in the lungs. He began daily prednisone treatment together with sulfamethoxazole/trimethoprim three times a week for eight weeks. His symptoms resolved after treatment.

The researchers wrote that, although emergency clinicians are trained to diagnose and treat life-threatening causes of chest pain, they must also look further when assessing a patient with a relatively low-risk condition. The team added that pulmonary sarcoidosis should be considered as a possible acute cause of chest pain in appropriate patients and treated promptly to help prevent long-term complications.

This article is for education and does not replace urgent medical assessment. New, severe or worsening chest pain or breathing difficulty requires immediate medical attention.