Sarcoidosis – Diagnosis by Endoscopic Ultrasonography

A 67-year-old woman presented with intermittent solid food dysphagia, which had 3 months of evolution. There weren't any other symptoms. Was evaluated with an upper endoscopy that revealed a sub-epithelial lesion in the esophageal wall, at 27cm from the incisor teeth. Endoscopic ultrasonography disclosed, between 23 and 30cm from the incisor teeth, a heterogeneous lesion mostly hypoechoic, with calcifications and areas suggestive of necrosis. The lesion presented mostly extrinsic to the esophageal wall but with small areas where it wasn't possible to define a cleavage plane with both adventitia and muscularis propria; the lesion had an irregular border and a maximum transversal diameter of 37mm. There were periesophageal and peritracheal lymph nodes, the largest with 10mm of diameter. It was performed a fine needle aspiration cytology under endoscopic ultrasonography guidance of this lesion. The histological examination identified epithelioid granulomas with some multinucleated giant cells, without caseation necrosis, suggestive of sarcoidosis. The axial computed tomography showed the lesion and the enlarged mediastinal lymph nodes noted in the endoscopic ultrasonography and revealed few pericentimetric nodes in the right lung periphery. The patient reported a progressive improve of the dysphagia, being at the present free of any symptom. She wasn't submitted to any treatment. We concluded that the patient has sarcoidosis, with predominance of lymph node involvement, in spontaneous remission and in clinical surveillance at the moment. We emphasize the rare form of clinical presentation of sarcoidosis and the role of fine needle aspiration guided by endoscopic ultrasonography in the diagnosis of this particular case. We also emphasize the importance of endoscopic ultrasonography in the study of lesions that present with protrusion of the digestive tract wall.