DOI: 10.1148/rg.241035076
Radiologic Manifestations of Sarcoidosis in Various Organs1
Takashi Koyama, MD,
Hiroyuki Ueda, MD,
Kaori Togashi, MD,
Shigeaki Umeoka, MD,
Masako Kataoka, MD and
Sonoko Nagai, MD
1 From the Department of Radiology, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan (T.K., H.U.); and the Departments of Diagnostic and Interventional Imageology (K.T.), Nuclear Medicine and Diagnostic Imaging (S.U., M.K.), and Respiratory Medicine (S.N.), Graduate School of Medicine, Kyoto University of Medicine, Kyoto, Japan. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received March 21, 2003; revision requested April 23 and received August 28; accepted August 28. All authors have no financial relationships to disclose. Address correspondence to T.K. (e-mail: montpeti@kuhp.kyoto-u.ac.jp).
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Figure 1a. Hilar adenopathy in a 27-year-old man with Heerfordt syndrome. (a) Chest radiograph demonstrates typical bilateral hilar adenopathy. Adenopathy in the right paratracheal and left aortic-pulmonary window nodes (arrowheads) is also identified. (b) Contrast material-enhanced computed tomographic (CT) scan clearly depicts the bilateral hilar adenopathy (arrowheads).
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Figure 1b. Hilar adenopathy in a 27-year-old man with Heerfordt syndrome. (a) Chest radiograph demonstrates typical bilateral hilar adenopathy. Adenopathy in the right paratracheal and left aortic-pulmonary window nodes (arrowheads) is also identified. (b) Contrast material-enhanced computed tomographic (CT) scan clearly depicts the bilateral hilar adenopathy (arrowheads).
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Figure 2. Mediastinal adenopathy in a 26-year-old man who presented with severe back pain. Chest radiograph demonstrates markedly enlarged right paratracheal nodes. Left aortic-pulmonary window nodes with associated minimal hilar involvement are also seen.
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Figure 3. Mediastinal adenopathy in a 60-year-old man. Unenhanced chest CT scan demonstrates calcification in the affected hilar nodes, a finding that suggests a long clinical course. Note the simultaneous presence of huge subcarinal lymph nodes (arrowheads), an unusual finding in other granulomatous diseases such as tuberculosis.
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Figure 4. Pulmonary sarcoidosis in a 37-year-old man. High-resolution chest CT scan demonstrates small nodules with a perivascular distribution and irregular thickening of bronchovascular bundles (white arrowheads) and interlobular septa (black arrowheads). These findings reflect the pathologic distribution of sarcoid granulomas along the lymphatic vessels within interstitial tissue.
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Figure 5. Pulmonary sarcoidosis in a 24-year-old man. High-resolution chest CT scan demonstrates multiple miliary nodules and diffuse thickening of the bronchial wall (arrowheads). Note the simultaneous presence of small nodules with a perivascular distribution (large arrows) and along the interlobular pleura (small arrows).
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Figure 6a. Pulmonary sarcoidosis in a 31-year-old woman. (a) Chest radiograph shows hazy ground-glass opacity with a lower lung predominance, both of which are unusual findings. (b) High-resolution chest CT scan shows widespread areas of ground-glass attenuation with reticulonodular hyperattenuating areas. Mild bronchiectasis is present peripherally (arrowheads).
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Figure 6b. Pulmonary sarcoidosis in a 31-year-old woman. (a) Chest radiograph shows hazy ground-glass opacity with a lower lung predominance, both of which are unusual findings. (b) High-resolution chest CT scan shows widespread areas of ground-glass attenuation with reticulonodular hyperattenuating areas. Mild bronchiectasis is present peripherally (arrowheads).
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Figure 7a. Pulmonary sarcoidosis in a 26-year-old woman. (a) Chest radiograph demonstrates multiple lung nodules bilaterally and minimal hilar adenopathy, findings that may simulate metastatic disease. (b) CT scan obtained at the lower lung level demonstrates a nodular consolidation with ill-defined borders. Note the presence of an air bronchogram (arrowheads) within the nodules, a finding that is unusual for metastatic tumors.
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Figure 7b. Pulmonary sarcoidosis in a 26-year-old woman. (a) Chest radiograph demonstrates multiple lung nodules bilaterally and minimal hilar adenopathy, findings that may simulate metastatic disease. (b) CT scan obtained at the lower lung level demonstrates a nodular consolidation with ill-defined borders. Note the presence of an air bronchogram (arrowheads) within the nodules, a finding that is unusual for metastatic tumors.
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Figure 8a. Stage IV pulmonary sarcoidosis in a 48-year-old man. (a) Chest CT scan (lung window) demonstrates traction bronchiectasis (arrowheads) and fibrotic lesions with extensive calcification, findings that indicate stage IV disease. (b) Chest CT scan (mediastinal window) demonstrates calcification in the fibrotic lesions, mediastinal adenopathy, and irregularly thickened pleura (arrowheads).
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Figure 8b. Stage IV pulmonary sarcoidosis in a 48-year-old man. (a) Chest CT scan (lung window) demonstrates traction bronchiectasis (arrowheads) and fibrotic lesions with extensive calcification, findings that indicate stage IV disease. (b) Chest CT scan (mediastinal window) demonstrates calcification in the fibrotic lesions, mediastinal adenopathy, and irregularly thickened pleura (arrowheads).
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Figure 9. Stage IV pulmonary sarcoidosis in a 60-year-old man. Chest CT scan demonstrates extensive fibrotic change and cavitary lesions with a central distribution (arrows) that distort the lung parenchyma. Irregular thickening of the pleura (arrowheads) and overinflation of the peripheral lung parenchyma are also seen.
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Figure 10. Cardiac sarcoidosis in a 59-year-old woman with abnormal electrocardiographic findings. Contrast-enhanced turbo fast low-angle shot inversion-recovery image (short-axis view) shows enhancement in the interventricular septum (arrows). The long-axis view was deleted.
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Figure 11. Cardiac sarcoidosis in a 60-year-old man who presented with complete atrioventricular blockage. Image obtained with Ga-67 citrate single photon emission computed tomography (short-axis view) shows diffuse abnormal radiotracer accumulation in the myocardium. Areas of strong uptake represent foci of increased disease activity.
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Figure 12a. Neurosarcoidosis in a 24-year-old man who presented with diabetes insipidus. (a) Axial T2-weighted MR image demonstrates an isointense periventricular lesion (arrow) surrounded by minimal high-signal-intensity edema. (b) On a contrast-enhanced T1-weighted MR image, the lesion demonstrates enhancement (arrow).
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Figure 12b. Neurosarcoidosis in a 24-year-old man who presented with diabetes insipidus. (a) Axial T2-weighted MR image demonstrates an isointense periventricular lesion (arrow) surrounded by minimal high-signal-intensity edema. (b) On a contrast-enhanced T1-weighted MR image, the lesion demonstrates enhancement (arrow).
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Figure 13. Neurosarcoidosis in a 60-year-old man who presented with decreased visual acuity and lower cranial nerve paresis. Axial fluid-attenuation inversion-recovery (FLAIR) MR image shows a left-sided thalamic mass with a ringlike appearance (arrow).
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Figure 14. Neurosarcoidosis. On a FLAIR MR image obtained in the same patient as in Figure 13, the optic chiasm demonstrates increased signal intensity (arrows).
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Figure 15. Neurosarcoidosis. Midsagittal T1-weighted MR image obtained in the same patient as in Figure 12 reveals an enlarged hypothalamus (arrowheads) and loss of the high signal intensity normally seen in the posterior pituitary lobe (arrow).
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Figure 16a. Leptomeningeal involvement in a 23-year-old woman. Sagittal (a) and axial (b) contrast-enhanced T1-weighted MR images show diffusely enhancing leptomeningeal lesions (arrows) surrounding the upper cervical spinal cord.
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Figure 16b. Leptomeningeal involvement in a 23-year-old woman. Sagittal (a) and axial (b) contrast-enhanced T1-weighted MR images show diffusely enhancing leptomeningeal lesions (arrows) surrounding the upper cervical spinal cord.
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Figure 17. Leptomeningeal involvement in a 34-year-old man who presented with bilateral facial palsy. Coronal contrast-enhanced T1-weighted MR image shows enhancing miliary nodules covering the undersurface of the thalamus bilaterally, the hypothalamus, and the left temporal lobe (arrowheads).
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Figure 18a. Spinal cord involvement in a 23-year-old man who presented with mild paresis of the hands. (a) T1-weighted MR image shows swelling of the cervical spinal cord. (b) Contrast-enhanced T1-weighted MR image depicts an enhancing intramedullary lesion (arrow), a finding that represents sarcoid granuloma. (c) T2-weighted MR image shows associated edema with markedly increased signal intensity.
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Figure 18b. Spinal cord involvement in a 23-year-old man who presented with mild paresis of the hands. (a) T1-weighted MR image shows swelling of the cervical spinal cord. (b) Contrast-enhanced T1-weighted MR image depicts an enhancing intramedullary lesion (arrow), a finding that represents sarcoid granuloma. (c) T2-weighted MR image shows associated edema with markedly increased signal intensity.
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Figure 18c. Spinal cord involvement in a 23-year-old man who presented with mild paresis of the hands. (a) T1-weighted MR image shows swelling of the cervical spinal cord. (b) Contrast-enhanced T1-weighted MR image depicts an enhancing intramedullary lesion (arrow), a finding that represents sarcoid granuloma. (c) T2-weighted MR image shows associated edema with markedly increased signal intensity.
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Figure 19a. Ocular involvement in the same patient as in Figure 1. (a, b) Coronal T2-weighted MR images show symmetrically enlarged lacrimal glands (arrows in a) and parotid glands (arrowheads in b) with increased signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows diffuse, prominent enhancement of the lacrimal glands (arrows). (d) Coronal contrast-enhanced fat-suppressed T1-weighted MR image also shows diffuse enhancement of the parotid glands (arrowheads). (e) Ga-67 scintigram demonstrates increased radiotracer accumulation in the lacrimal and parotid glands and normal accumulation in the nasopharynx, creating the mottled appearance of a giant panda ("panda sign").
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Figure 19b. Ocular involvement in the same patient as in Figure 1. (a, b) Coronal T2-weighted MR images show symmetrically enlarged lacrimal glands (arrows in a) and parotid glands (arrowheads in b) with increased signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows diffuse, prominent enhancement of the lacrimal glands (arrows). (d) Coronal contrast-enhanced fat-suppressed T1-weighted MR image also shows diffuse enhancement of the parotid glands (arrowheads). (e) Ga-67 scintigram demonstrates increased radiotracer accumulation in the lacrimal and parotid glands and normal accumulation in the nasopharynx, creating the mottled appearance of a giant panda ("panda sign").
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Figure 19c. Ocular involvement in the same patient as in Figure 1. (a, b) Coronal T2-weighted MR images show symmetrically enlarged lacrimal glands (arrows in a) and parotid glands (arrowheads in b) with increased signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows diffuse, prominent enhancement of the lacrimal glands (arrows). (d) Coronal contrast-enhanced fat-suppressed T1-weighted MR image also shows diffuse enhancement of the parotid glands (arrowheads). (e) Ga-67 scintigram demonstrates increased radiotracer accumulation in the lacrimal and parotid glands and normal accumulation in the nasopharynx, creating the mottled appearance of a giant panda ("panda sign").
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Figure 19d. Ocular involvement in the same patient as in Figure 1. (a, b) Coronal T2-weighted MR images show symmetrically enlarged lacrimal glands (arrows in a) and parotid glands (arrowheads in b) with increased signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows diffuse, prominent enhancement of the lacrimal glands (arrows). (d) Coronal contrast-enhanced fat-suppressed T1-weighted MR image also shows diffuse enhancement of the parotid glands (arrowheads). (e) Ga-67 scintigram demonstrates increased radiotracer accumulation in the lacrimal and parotid glands and normal accumulation in the nasopharynx, creating the mottled appearance of a giant panda ("panda sign").
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Figure 19e. Ocular involvement in the same patient as in Figure 1. (a, b) Coronal T2-weighted MR images show symmetrically enlarged lacrimal glands (arrows in a) and parotid glands (arrowheads in b) with increased signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows diffuse, prominent enhancement of the lacrimal glands (arrows). (d) Coronal contrast-enhanced fat-suppressed T1-weighted MR image also shows diffuse enhancement of the parotid glands (arrowheads). (e) Ga-67 scintigram demonstrates increased radiotracer accumulation in the lacrimal and parotid glands and normal accumulation in the nasopharynx, creating the mottled appearance of a giant panda ("panda sign").
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Figure 20a. Hepatic involvement in a 49-year-old woman with pulmonary sarcoidosis. (a) Contrast-enhanced abdominal CT scan shows multiple, irregularly shaped nodules of variable size in the liver. (b) T2-weighted MR image obtained after the administration of ferumoxides (Feridex; Advanced Magnetics, Cambridge, Mass) demonstrates multiple small, high-signal-intensity nodules throughout the liver.
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Figure 20b. Hepatic involvement in a 49-year-old woman with pulmonary sarcoidosis. (a) Contrast-enhanced abdominal CT scan shows multiple, irregularly shaped nodules of variable size in the liver. (b) T2-weighted MR image obtained after the administration of ferumoxides (Feridex; Advanced Magnetics, Cambridge, Mass) demonstrates multiple small, high-signal-intensity nodules throughout the liver.
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Figure 21. Splenic involvement in the same patient as in Figure 5. Contrast-enhanced abdominal CT scan demonstrates multiple small, hypoattenuating nodules scattered diffusely throughout the spleen.
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Figure 22a. Splenic involvement in the same patient as in Figure 6. (a) Unenhanced gradient-echo T1-weighted MR image of the upper abdomen demonstrates irregularly shaped, low-signal-intensity nodules peripherally in the liver (arrows) and widening of the periportal tract (arrowheads). (b) On a T2-weighted MR image of the upper abdomen, the peripheral liver nodules demonstrate increased signal intensity. Multiple hypointense nodules in the spleen create a heterogeneous appearance. The area of focal hyperintensity (arrowheads) represents gastric mucosal involvement. (c) Ferumoxides-enhanced gradient-echo T2*-weighted MR image shows multiple hyperintense nodules scattered throughout the periphery of the liver (arrows) and a hyperintense, widened periportal tract.
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Figure 22b. Splenic involvement in the same patient as in Figure 6. (a) Unenhanced gradient-echo T1-weighted MR image of the upper abdomen demonstrates irregularly shaped, low-signal-intensity nodules peripherally in the liver (arrows) and widening of the periportal tract (arrowheads). (b) On a T2-weighted MR image of the upper abdomen, the peripheral liver nodules demonstrate increased signal intensity. Multiple hypointense nodules in the spleen create a heterogeneous appearance. The area of focal hyperintensity (arrowheads) represents gastric mucosal involvement. (c) Ferumoxides-enhanced gradient-echo T2*-weighted MR image shows multiple hyperintense nodules scattered throughout the periphery of the liver (arrows) and a hyperintense, widened periportal tract.
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Figure 22c. Splenic involvement in the same patient as in Figure 6. (a) Unenhanced gradient-echo T1-weighted MR image of the upper abdomen demonstrates irregularly shaped, low-signal-intensity nodules peripherally in the liver (arrows) and widening of the periportal tract (arrowheads). (b) On a T2-weighted MR image of the upper abdomen, the peripheral liver nodules demonstrate increased signal intensity. Multiple hypointense nodules in the spleen create a heterogeneous appearance. The area of focal hyperintensity (arrowheads) represents gastric mucosal involvement. (c) Ferumoxides-enhanced gradient-echo T2*-weighted MR image shows multiple hyperintense nodules scattered throughout the periphery of the liver (arrows) and a hyperintense, widened periportal tract.
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Figure 23. Lymphadenopathy in the paraaortic region in the same patient as in Figure 9. Contrast-enhanced abdominal CT scan shows multiple paraaortic areas of adenopathy (arrowheads) that mimic lymphoma or metastases.
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Figure 24. Renal involvement in the same patient as in Figures 1 and 19. Contrast-enhanced CT scan shows striated nephrograms in both kidneys. Renal function was within the normal range.
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Figure 25. Renal sarcoidosis in a 71-year-old man who presented with swelling of the distal right thigh. Contrast-enhanced CT scan demonstrates multiple hypoattenuating nodules in both kidneys (arrows). The right kidney also contains a large renal cyst.
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Figure 26a. Intrascrotal sarcoidosis in a 16-year-old boy who presented with epididymal pain and swelling. (a) US image of the scrotum (longitudinal view) demonstrates a markedly enlarged left epididymis (arrows) and multiple hypoechoic nodules in the left testis (arrowheads). (b, c) T2-weighted (b) and contrast-enhanced (c) MR images show an enlarged left epididymis (arrows) and multiple nodules in both testes (arrowheads). The nodules are hypointense on the T2-weighted image and demonstrate enhancement on the contrast-enhanced image.
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Figure 26b. Intrascrotal sarcoidosis in a 16-year-old boy who presented with epididymal pain and swelling. (a) US image of the scrotum (longitudinal view) demonstrates a markedly enlarged left epididymis (arrows) and multiple hypoechoic nodules in the left testis (arrowheads). (b, c) T2-weighted (b) and contrast-enhanced (c) MR images show an enlarged left epididymis (arrows) and multiple nodules in both testes (arrowheads). The nodules are hypointense on the T2-weighted image and demonstrate enhancement on the contrast-enhanced image.
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Figure 26c. Intrascrotal sarcoidosis in a 16-year-old boy who presented with epididymal pain and swelling. (a) US image of the scrotum (longitudinal view) demonstrates a markedly enlarged left epididymis (arrows) and multiple hypoechoic nodules in the left testis (arrowheads). (b, c) T2-weighted (b) and contrast-enhanced (c) MR images show an enlarged left epididymis (arrows) and multiple nodules in both testes (arrowheads). The nodules are hypointense on the T2-weighted image and demonstrate enhancement on the contrast-enhanced image.
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Figure 27a. Nodular type muscle involvement in the same patient as in Figure 25. T2-weighted (a) and contrast-enhanced (b) MR images demonstrate a nodular type muscle lesion (arrows). The lesion has a central area of decreased signal intensity (as it did with all sequences). The periphery of the lesion demonstrates increased signal intensity on the T2-weighted image and prominent enhancement on the contrast-enhanced image.
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Figure 27b. Nodular type muscle involvement in the same patient as in Figure 25. T2-weighted (a) and contrast-enhanced (b) MR images demonstrate a nodular type muscle lesion (arrows). The lesion has a central area of decreased signal intensity (as it did with all sequences). The periphery of the lesion demonstrates increased signal intensity on the T2-weighted image and prominent enhancement on the contrast-enhanced image.
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Figure 28a. Bone sarcoidosis in a 28-year-old man who presented with left thumb pain. (a) Close-up view from a radiograph of the left hand shows a pathologic fracture caused by an extensive osteolytic lesion in the thumb (arrow). (b) Close-up view from a radiograph of the right hand reveals a radiolucent lesion in the middle phalanx of the third finger. The lesion has a lacelike appearance and is accompanied by a soft-tissue mass (arrowheads). This combination of findings is virtually diagnostic for bone sarcoidosis.
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Figure 28b. Bone sarcoidosis in a 28-year-old man who presented with left thumb pain. (a) Close-up view from a radiograph of the left hand shows a pathologic fracture caused by an extensive osteolytic lesion in the thumb (arrow). (b) Close-up view from a radiograph of the right hand reveals a radiolucent lesion in the middle phalanx of the third finger. The lesion has a lacelike appearance and is accompanied by a soft-tissue mass (arrowheads). This combination of findings is virtually diagnostic for bone sarcoidosis.
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Figure 29a. Bone sarcoidosis in the same patient as in Figure 2. (a) Contrast-enhanced CT scan demonstrates an osteolytic lesion in the posterior portion of the sixth thoracic vertebra (arrows). Bilateral hilar lymphadenopathy is also present. (b) Sagittal unenhanced T1-weighted MR image demonstrates multiple lesions in the posterior portion of the thoracic vertebrae. The lesions extend into the epidural spaces (arrowheads) and adjacent soft tissue (arrows). (c) On a contrast-enhanced fat-suppressed T1-weighted MR image, the lesions display diffuse enhancement. The presence of enhancement in the vertebral bodies (arrows) suggests disease involvement.
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Figure 29b. Bone sarcoidosis in the same patient as in Figure 2. (a) Contrast-enhanced CT scan demonstrates an osteolytic lesion in the posterior portion of the sixth thoracic vertebra (arrows). Bilateral hilar lymphadenopathy is also present. (b) Sagittal unenhanced T1-weighted MR image demonstrates multiple lesions in the posterior portion of the thoracic vertebrae. The lesions extend into the epidural spaces (arrowheads) and adjacent soft tissue (arrows). (c) On a contrast-enhanced fat-suppressed T1-weighted MR image, the lesions display diffuse enhancement. The presence of enhancement in the vertebral bodies (arrows) suggests disease involvement.
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Figure 29c. Bone sarcoidosis in the same patient as in Figure 2. (a) Contrast-enhanced CT scan demonstrates an osteolytic lesion in the posterior portion of the sixth thoracic vertebra (arrows). Bilateral hilar lymphadenopathy is also present. (b) Sagittal unenhanced T1-weighted MR image demonstrates multiple lesions in the posterior portion of the thoracic vertebrae. The lesions extend into the epidural spaces (arrowheads) and adjacent soft tissue (arrows). (c) On a contrast-enhanced fat-suppressed T1-weighted MR image, the lesions display diffuse enhancement. The presence of enhancement in the vertebral bodies (arrows) suggests disease involvement.
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Copyright © 2004 by the Radiological Society of North America.
