Sarcoidosis Presenting as Unilateral Dacryocystitis and Nasolacrimal Duct Obstruction

Objectives To report a case of an unusual presentation of sarcoidosis in the setting of unilateral dacryocystitis and nasolacrimal duct obstruction. To discuss clinical, radiographic, and pathologic findings of sinonasal sarcoidosis and to review the treatment options and prognosis.

Methods A case of sarcoidosis initially presenting with unilateral dacryocystitis and nasolacrimal duct obstruction at an urban tertiary medical center is reported. Clinical, radiographic, and pathologic data were collected and reviewed. A literature search of sinonasal sarcoidosis was performed.

Case Report A 48-year-old Caucasian woman was referred to the otolaryngology clinic for evaluation of a 6-month history of right-sided nasal obstruction and epiphora. Her symptoms began after an episode of acute sinusitis treated with a course of oral antibiotics and intranasal corticosteroids. Despite her treatment, her congestion and epiphora had persisted. Her physical exam including nasal endoscopy was unremarkable. A CT scan of the sinuses revealed left deviation of mid-portion of the nasal septum, diffuse mild mucosal thickening, and otherwise normal anatomic variations.

A diagnosis of right dacryocystitis with nasolacrimal duct obstruction was made. Since she had previously failed conservative therapy including lacrimal duct irrigation, an endoscopic dacryocystorhinostomy was performed. Intraoperatively, there was purulence in the lacrimal sac, but grossly normal anatomy of the nasal cavity except mildly inflamed mucosa. There were no mucosal or submucosal lesions. The nasal mucosa and lacrimal bone that were removed were sent for histologic examination and cultures were performed. Pathology demonstrated noncaseating granulomas suggestive of sarcoidosis.

The patient reported nonspecific history of arthralgias and arthritis affecting multiple joints, as well as fatigue for several years. She had no renal or pulmonary symptoms. Because of the histologic findings, work-up for sarcoidosis was initiated and included referral to rheumatology and pulmonology, CT scan of the chest, and autoimmune laboratory tests. Blood work revealed a mildly elevated C-reactive protein level. CT scan of the chest showed bilateral bulky partially calcified hilar and mediastinal lymph nodes. Given the combination of clinical, radiographic, and pathologic findings, a diagnosis of sarcoidosis was made and the patient was started on therapeutic prednisone.

Conclusion Sarcoidosis is a systemic inflammatory disease of unknown cause, which may rarely present with primarily sinonasal symptoms. Dacryocystitis with nasolacrimal duct obstruction is an unusual initial presentation of this condition, with very few reported cases in the literature. Histologic examination is key to making the diagnosis. A high index of suspicion must be maintained in cases with atypical presenting symptoms, as demonstrated in this case. Proper communication with the pathologist, pulmonologist, and rheumatologist are necessary to ensure a favorable outcome.