Pneumo Stagiu Sarcoidoza

7/30/2019 Pneumo Stagiu Sarcoidoza

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SARCOIDOZADEFINIIE:

- Granulomatoz multisistemic

- Cauz necunoscut

- Aduli tineri- Limfadenopatie hilar, infiltrat pulmonar i leziuni

cutanate i oculare

- Histologic - granulomul epitelioid necazeificat


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EPIDEMIOLOGIE

Prevalena 1 - 40 / 100.000 locuitoriAfecteaz n special vrsta 20-40 aniHeterogenitate epidemiologic prevalen i severitateMai frecventa n nordul Europei i la negrii americani

(1,15 % la suedezi i 2,4% la negrii americani)Afecteaz aproximatic egal ambele sexe


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ETIOLOGIE

Susceptibilitate genetic a gazdei(genotipul sarcoidozei)

Expunere la diferiiageni din mediu

SarcoidozFenotip clinic


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Etiologiefactori de mediu

Ageni infecioiVirui (herpes, Epstein-Barr, retrovirus,coxsackie B, cytomegalovirus)Borrelia burgdorferiPropionibacterium acnesM. tuberculosisMycoplasmaRickettsia

Substane anorganiceAluminiu

ZirconiuTalc

Substane organicePolen de pinRini


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Etiologiefactori genetici

Risc geneticpoligenicpredispoziie, clinic, evoluie,prognostic

Evoluie favorabil sindrom Lofgren

CW7DR3HLA-B8

Evoluie cronicHLAB13

Risc familial


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Celule T, Macrofage

Factori de cretereFactori chemoatractani

Proliferare celularGranulom

Fibroz

FIZIOPATOLOGIE


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MORFOPATOLOGIE

Alveolita - infiltraia peretelui alveolar predominant macrofage i limfocite T

Secundar neutrofile, eozinofile, bazofile, mastocite etc.

Granulom epitelioid necazeificat

Aglomerare de celule epitelioide pe fondul unei reele dereticulin care la periferie prezint o coroan de limfocite.

Prezena de celule gigante care conin incluziuni citoplasmatice(corpi Schauman):

Corpi asteroiziCorpi conchoizi

Corpi birefringenti

Granulomul nespecifictuberculoz, lepr, sifilis,bruceloz

Fibroza


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Sarcoid Granuloma


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Sarcoidosis Lung Gross


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LANGHANS' GIANT CELL

Langhans' giant cell in center of granuloma is

surrounded by epithelioid cells .


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ADVANCED COLLAGENOUS FIBROSIS

Elongated fibroblasts (FB) with extensive

collagenous tissue (C). Giant cells (arrows)


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CYTOPLASMIC INCLUSION BODY

Schaumann body (arrow) is common in

sarcoidosis but is nonspecific.

CASEOUS NECROSIS


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CASEOUS NECROSIS

Cellular destruction in TB granuloma appears

as clumped debris (arrows). This necrosis

does not occur in sarcoidosis.

M t b l i BACILLI


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M. tuberculos isBACILLI

Caseous necrosis is most common in TB, but

Gram negative, acid fast bacilli must be

identified to make the diagnosis.


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SUBPLEURAL GRANULOMA IN LUNG


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MECANISM IMUNOLOGIC

Deprimarea imunitii de tip celular

IDR la PPD

Exacerbarea imunitii de tip umoral Hipergammaglobulinemie, complexe imune circulante

Limfopenie absolut


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MANIFESTRI CLINICE

Simptomatologie de debut

50% asimptomatic

Simptomatologie general nespecific Simptomatologie dependent de organ

(polimorfism simptomatic)

30% debut acut

- Sindrom Lofgren

- Sindrom Heerfordt

- Sindrom Miculicz-Sjogren


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FORME CLINICE PARTICULARE

Sindrom Lofgren:

- adenopatie hilara bilaterala

- febra

- poliartralgii

- eritem nodos

Sindrom Heerfordt:

- febr- uveita (iridociclita)

- parotidit

- paralizie nerv facial

- Sindrom Miculicz-Sjogren:

- keratoconjunctivita uscat

- hiposecreie salivar, gastric, pancreatic- poliartrit cronic- eczeme.


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Simptomatologie


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Afectare organic

Organ %

Adenopatii mediastinale 95-98%

Plmni >90%

Ficat 50-80%Splin 40-80%

Ochi 20-80%

Adenopatii periferice 30%Cutanate 25%

Sistem nervos 10%

Cardiovascular 5%


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Simptomatologie

Pulmonar

90%

dispnea, tuse seac, dureri toracice difuze

Renal Nefrit interstiial,insuficien renal,

nefrocalcinozMetabolism

fosfocalcic

Hipercalcemie, hipercalciurie


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Neurologic

10%

Paralizii de nervi cranieni, convulsii, meningitgranulomatoas, leziuni hipotalamus sau hipofiz,hidrocefalie, polineuropatie periferic i afectare

psihiatricOcular

20%

Uveit, chorioretinit, keratoconjunctivit,glaucom, cataract, orbire


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Cardiac

5%

Palpitaii, sincop, durere toracic, aritmii, moartesubit cardiac

Endocrine Hipo/hipertiroidism, insuficien adrenalExocrin Tumefacia glandelor parotide, keratoconjunctivita

sicca

Hepatic Hepatalgii, hepatomegalie

Limfatic Limfadenopatii, splenomegalie


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Cutanate

25%

Eritem nodos, eritem polimorf sau vasculitic,

lupus pernio, noduli subcutanai,erupiemaculopapular, alopecie, hiper/hipopigmentare


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EN Lupus Pernio


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LUPUS PERNIO

Facial lesions are most common, but the

extremities and buttocks can be involved.


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LUPUS PERNIO

Indurated and violaceous range from a few

small lesions to large lesions

SMALL NODULES


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SMALL NODULES

Papules and nodular lesions, can be found

anywhere on the body. Papules are often

multiple while nodules are often solitary.

RAISED PLAQUES


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RAISED PLAQUES

These raised plaques are the result of

coalescence of nodules.

PSORIASIS LIKE LESIONS


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PSORIASIS LIKE LESIONS

These small white lesions closely

resemble psoriasis.

EARLY COLLAGEN FORMATION


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EARLY COLLAGEN FORMATION

Extracellular collagen (C) is being produced

by fibroblasts


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Adenopatii

Localizri adenopatii centrale:

Mediastinal 100 %

Hilar bilateral 75 %Adenopatii periferice: laterocervical i supraclavicular,epitrohleari, axilari, inghinali

Ganglionii sunt mobili, nedureroi, cu diametru variabil,

nu ulcereaz, nu fistulizeazSplenomegaliarar, poate cauza hiperslenism

E l d bil t l hil i ht t h l


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Enlarged bilateral hilar, right paratracheal

(arrow), and aortopulmonary window

(arrowhead) nodes.


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PARACARDIAC LYMPH NODE

ABDOMINAL LYMPHADENOPATHY


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ABDOMINAL LYMPHADENOPATHY

Multiple enlarged paraaortic, paracaval, and

porta hepatis lymph nodes (arrows).

GASTRIC SARCOID


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GASTRIC SARCOID

Granuloma involves the gastric antrum leading

to irregular nonspecific narrowing.

COLONIC SARCOID


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Irregular narrowing of the rectosigmoid has the

appearance of inflammatory disease or

malignancy.

PUNCHED OUT LYTIC LESIONS


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PUNCHED OUT LYTIC LESIONS

Focal osteolytic lesions in the fingers are most

common abnormality.

LACY TRABECULAR PATTERN


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LACY TRABECULAR PATTERN

Osteolysis has left a lacy trabecular pattern in

this phalanx (arrow)

DEFORMING LESIONS


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Advanced sarcoidosis with osteolytic lesions

of the distal forearm, wrist, and bones of the

hand


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SCLEROTIC LESION

Rare and often in the axial skeleton.

SCLEROTIC LESIONS,


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NONSPECIFIC

Focal sclerosis (arrows) of distal phalanges is

unusual

NASAL BONE LESION


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NASAL BONE LESION

Nasal sarcoidosis can lead to osteolysis of the

nasal bone (arrows).

T2-W MR IMAGE


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T2-W MR IMAGE

High signal intensity edema surrounding

biopsy proven sarcoid lesion.


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I Adenopatie hilar bilateral iparatraheal

55-90%

remisie

II Adenopatie mediastinal culeziuni ale parenchimului

pulmonar

40-70%

III Modificri parenchimul pulmonarfr adenopatii

10-20%

IV Fibroz pulmonar 0-5%

ASPECTE RADIOLOGICE


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Stadiile 14

Limfadenopatii +Infiltrate

infiltrate Fibroz

Stages


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Stages


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Stadiu I Stadiu II


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Tip 1


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Tip 1


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Tip 2


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Tip 2


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Stadiu III Stadiu IV


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Tip 3


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Atipice: - nodular-infiltrative

- pseudotumorale

- atelectazii

- caverne

ASPECTE RADIOLOGICE

STAGE IV


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STAGE IV

Broad bands of fibrosis in the upper lobes.

MILIARY SARCOIDOSIS


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CT shows well defined lung nodules less than

5mm in diameter. This pattern is rare.

ALVEOLAR SARCOIDOSIS


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Multiple lung masses are an unusual form of

sarcoidosis, resembles lung metastases.

ALVEOLAR SARCOIDOSIS


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Computed tomography shows a mass which

has air containing bronchi (arrows) within it.

CAVITARY SARCOIDOSIS


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Rare pattern of multiple cavitary sarcoid lung

lesions. Note lymphadenopathy.

RETICULONODULAR PATTERN


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Common appearance of sarcoidosis involving

the lung parenchyma.

RETICULONODULAR PATTERN CLOSEUP


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Well defined linear and nodular densities

characteristic of lung interstitial disease.


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NODULAR PATTERN

Small 5mm nodules are subpleural along fissures and


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Small 5mm nodules are subpleural, along fissures and

bronchovascular bundles. Give the vessels (arrow) and

fissures a beaded appearance.

SUBPLEURAL NODULES


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Cluster of small nodules looks like a tumor on

a radiograph.

MOST COMMON PATTERN


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Bilateral symmetric hilar and right paratracheal

mediastinal adenopathy.

LYMPHADENOPATHY ON CTPara-aortic and retrocaval lymphadenopathy


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Para-aortic and retrocaval lymphadenopathy.

CT shows enlarged lymph nodes not visible on

radiographs.

POSTERIOR MEDIASTINAL LYMPH NODE


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next to the aorta (A). Bilateral hilar adenopathy

was also shown.

STAGE IV


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STAGE IV

Permanent lung fibrosis. (20%)

ADENOPATHY AT TIME OF DIAGNOSIS


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Marked enlarged hilar and mediastinal lymph

nodes.

ADENOPATHY DECREASED 2 YRS LATER

L h d ll d th i


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Lymph nodes are smaller and there is

parenchymal lung disease.


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Aspecte funcionale

Corelaie imperfect cu aspectul clinico-radiologic Anomalii predominant de tip restrictiv

Tulburri ale transferului gazos Sindromul obstructiv distal 30-40 % din stadiile I si II Anomalii diverse la 74 % din pacieni n stadiul I

MODIFICARI BRONHOSCOPICE


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MODIFICARI BRONHOSCOPICE

ASPECTE

PATOLOGICE:

capilaritate crescut

proliferri de mucoas

stenoze bronice

granulaii sidefii-glbui

compresii extrinseci

TEHNICISUPLIMENTARE

Prelevri bioptice demucoasPuncia-biopsie

transbronicLavajul bronho-alveolar

ASPECT NORMAL LA 50 % DIN CAZURI !!

(Discordan ntre modificrile bronhoscopice i aspectul radiologic)

L j b h l l


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Lavaj bronhoalveolar

Alveolit limfocitarlimfocitoz 80-90% din cazuri,nespecific pentru sarcoidoz

Severitatea limfocitozei

> 28% - debut acut - evoluie favorabil< 28% debut insidiosevoluie cronic

PMN>3% i eozinofile >1% markeri ai progresieiraport LTh/ LTS (CD4/CD8) > 3,5

Alveolita neutrofilicsingurul element care indicnecesitatea tratamentului


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Transbronchial Needle Aspiration (TBNA) Cytology in


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Transbronchial Needle Aspiration (TBNA) Cytology in

Sarcoidosis

Smojver-Jezek S, et al. Cytopathology 2007; 18: 3

Multinucleated giant cell

of Langhans type

Scattered epithelioid cells

and lymphocytes

Linear Real-time Endobronchial Ultrasound-guidedTransbronchial Needle Aspiration Scope


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Transbronchial Needle Aspiration Scope

Herth FJF. Eur Respir J

(BF-UC160F-OL8; Olympus Medical Systems, Tokyo,

Japan)

Endobronchial Ultrasound


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in Sarcoidosis

Wong M et al. Eur Respir J 2007; 29: 1182

Right paratracheal

LN

Vena cava

superior

Endobronchial Ultrasound


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in Sarcoidosis

Wong M et al. Eur Respir J 2007; 29: 1182

Needle

BIOCHIMIE


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BIOCHIMIE

Cresc

.-VSH, PCR, globuline- Calcemia

- Calciuria

- Proteinemia

- Lizozim

- Angiotensin convertaza

seric

Scad

- Limfocite. CD4

COMPUTER TOMOGRAFIE


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COMPUTER TOMOGRAFIE

Tomografia computerizat evaluare extindere leziuni iprognostic:

- Micronoduli bronhovasculari i subpleuralireversibilitate crescut

- Imagini n fagure de miere sau reticularefibroz-ireversibil

- Sticl matcu evoluie variabil

Confirm prezen adenopatii

Nu este necesar de rutin, doar n cazuri atipiceradiologic sau clinic.


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Scintigrafia cu galiu


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Scintigrafia cu galiu

Extinderea i distribuia leziunilor inflamatorii

Captare n celulele mononucleare

Dou aspecte distincte:

- captare n lambdagg limfatici intratoracici

- captare n pandagl parotide i lacrimale

Examenul histologic


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Examenul histologic

Test Kveimcel mai specific test pentru sarcoidoz

Biopsii

Ganglionar prin mediastinoscopie

Pulmonar

Bronic

Ganglionii periferici

Leziuni cutanate

Leziuni hepatice Sediul leziunii

Investigaii specifice afectrii de organ


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Investigaii specifice afectrii de organ

RMNafectare cerebral, muscular, osoasAngiografia cu fluorescen - vascular retinian

Scintigrafia cu Thaliu, monitorizare Holter,

angiografie coronarian afectare cardiac

Biopsie miocardic


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Biopsie miocardic

Diagnostic


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Diagnostic

Diagnostic de excludereadenopatie hilarbilateral

IDR negativ

ACS crescut

Observaie ndelungat Ansamblu concordant de semne

Scopuri: - confirmare histologic, evaluare

extindere i severitate, progresie i necesitatetratamentPrezena granulomului epitelioid necazeificat


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ETAPE DIAGNOSTIC

Anamnez i examen clinicRadiografie toracicCT

Biopsie Diagnostic de certitudinebiopsie pulmonar transbronicExplorri funcionale respiratorii, gaze

arterialeAlte teste specifice: ecg, examenoftalmologic, etc


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Kveim Test


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Kveim test, or Kveim-Siltzbach test is a skin test usedto detect sarcoidosis:

Part of spleen of person with known sarcoidosis is

injected in the skin of the patient being tested

If granulomas are found, usually 4-6 weeks latertest is positive

It is named for the Norwegian pathologist Morten Ansgar

Kveim, who first reported the test in 1941 using lymphnode tissue from sarcoidosis patients

Diagnostic diferenial


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Pulmonare Adenopatii

Tuberculoz Tuberculoz

Pneumonii atipice Micobacterii atipice

Criptococcoz Bruceloz

Aspergiloz Toxoplasmoz

Histoplasmoz

Coccidioidomicoz tumorale

Blastomiocoz

Pneumocistic carini

Micoplasma

Pneumonii de hipersensibilitate

Pneumoconioz: Limfom Non-Hodgkin

berillium, titaniu, aluminiu

Aspiraie de corp strin

Granulomatoz Wegener

Pneumonie interstiiale

PROGNOSTIC


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PROGNOSTIC

Remisie 60% din cazuriDificil de prezis

Boal cronic progresiv10-20%

Mortalitate 1-5%

Prognostic bun:

Stadiu I 80% remisie spontan

sindrom Lofgren

Asimptomatic

Europeni

Prognostic nefavorabil:

Multisistemic (>3)Ras neagr

Infiltrate pulmonare

Neurologic, cardiac, uveitcronic

Vrst > 40 ani

Lupus pernio

Hipercalcemie

AG OS C SA CO O


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DIAGNOSTIC: SARCOIDOZ

TRATM PACIENTUL?

60%: rezoluie spontan!

Tratament: motive s nu-l administrm!


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Tratament: motive s nu l administrm!

Cauza bolii necunoscutMoment optim de iniiere a terapiei greu destabilit

Vindecare spontan frecventCorticosteroizii prezint efecte secundare multiple

Recidivele dup vindecarea spontan sunt rare

Tratamentul nceput trebuie s fie de lung durat

TRATAMENT


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TRATAMENT

Corticosteroizi sistemicmanifestri cardiace, neurologice,afectare pulmonar progresiv sau n cazul hipercalcemieiPrednison = 20 - 40 mg/zi

Indicaii absolute:afectarea organelor vitale

tendina la fibrozDurata: aproximativ 1 an

Monitorizare la 3 luniCorticosteroizi topici-afectare cutanat sau oftalmic

TRATAMENT


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TRATAMENT

TRATAMENT


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TRATAMENT

TRATAMENT


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TRATAMENT

Monitorizare


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Monitorizare

ClinicRadiologic

Adesea rezorbie lezional

Uneori: imagine adenopatii inghetateFuncional

Cretere ACS = puseu evolutiv

Efecte adverse ale corticoterapiei

Alternative terapeutice la corticoterapie


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Medicament, dozaj Utilizare n sarcoidoz Efecte adverse

Metotrexat 10-25 mg/sptmn, maxim 1-2 g/an

Sarcoidoz sever, cronicMedicaie de linia II Greuri, neutropenie,

toxicitate hepatic

Azatioprin 50-200mg/zi

Fibroz pulmonarSarcoidoz sever, cronic

Medicaie de linia II

Greuri, neutropenie

Ciclofosfamid 50-150mg/zi sau 500-2000 mg

la 2 sptmni IV

Sarcoidoz refractar lacorticoterapie

Greuri, neutropenie

Hidroxiclorochin 200-400 mg/zi

Manifestricutanate,hipercalcemie,

fibroz pulmonar

Retinopatie, depozite

corneene.


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Bilateral hilar lymphadenopathy :


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A 30 - year - old man with

bilateral lymph node

enlargement and fine

reticulations in both lung fields

Judges wig appearance

Deepak D and Shah A. Indian J Radiol Imag

2001 ; 11 : 191 198

Bilateral asymmetrical hilar nodes


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A 50 - year - old man with

bilateral asymmetrical hilar

lymph nodes with lobulated

border on the right side .

Bilateral reticulonodular

opacities are also visible

Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 198

Asymmetrical mediastinal lymphadenopathy

in a 32 - year - old man with sarcoidosis


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Radiograph shows striking

asymmetric enlargement of

mediastinal lymph nodes

potato nodes

y

HRCT of the same patient shows

bilateral multiple mediastinal

lymphadenopathy


1 - 2 - 3 sign orGarlands / pawnbrokers sign


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p g

Radiograph of 34 - year - old

man shows bilateral hilar and

right paratracheal lymph nodesenlargement ( 1 - 2 - 3 sign ).

Also visible is bilateral

parenchymal involvement with

reduced lung volumes

Deepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198

Unilateral hilar adenopathy


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Postero - anterior chest

radiograph in a 42 - year - old

man with sarcoidosis shows

a left hilar lymph node and

consolidation in right upper

and mid zones mistaken for

tuberculosis

Deepak D and Shah A . Indian J Radiol Imag2001 ; 11 : 191 - 198

Regression of lymphadenopathy and

progression of pulmonary lesion


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p g p y

Deepak D and Shah A. Ind ian J Radiol Imag2001 ; 11 : 191 198

2 years later

Bilateral hilar lymph

nodes with prominent

reticulonodular shadows

regression of the hilar lymph

nodes with calcification ( arrow )

and honeycombing

Unilateral disease


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Radiograph of 49 - year - old

woman shows predominantly

unilateral disease involving left

side with cavities ( arrows )

and features of parenchymal

fibrosis in the left upper zone

as evidenced by the pulled - up

left hilum & tracheal deviation


Parenchymal nodules


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CECT of a 52 - year - old

woman through the level

of left upper lobe

bronchus shows bilateral

nodular opacities

Deepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198

Reticulations


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Chest radiograph in a

40 - year - old man shows

bilateral reticulations.

Pleural thickening ( arrow )

is also seen in the left

upper zone


Pulmonary sarcoidosis : alveolar pattern


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areas of consolidation with

irregular borders preferentially

involving central areas


HRCT showing bilateral

consolidation with air

bronchogram ( arrow )

Alveolar pattern : 11 years post treatmentDeepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198


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bilateral bullous areas

pleural thickening

clearing of consolidation

HRCT :

bronchiectasis and bullae

Alveolar sarcoidosis with subpleural nodules


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HRCT of a 30 year old man

through the level of left lower

lobe bronchus showing

alveolar pattern of

involvement on the left side.

Also visible are bilateral

sub - pleural nodules (arrows)

Deepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198

Stage IV sarcoidosis : 50 - year - old womanDeepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198


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- beaded appearance of

bronchovascular bundles with

- perihilar concentration of

fibrosis and lobular distortion

Left side : cystic spaces & fibrosis

Pulmonary sarcoidosis :simultaneous ground glass & honeycombing


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HRCT through right lower lobe

bronchus shows :

- air bronchogram ( arrow )

- ground glass opacities

Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 - 198

HRCT through apical region :

- honeycombing on right side

Pleura : a 35 - year - old man with

a non - resolving pleural effusion


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a non resolving pleural effusion

Panjabi C et al. Indian J Tuberc2004 ; 51 ; 37 - 41

B / l mediastinal lymphadenopathy & thickening of both fissures

Merci lessly received second l ine ant i tuberculou s therapy


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Well circumscribed noncaseating granuloma consisting of

epitheloid cells and multinucleated giant cells ( H & E 100 )Panjabi C et al. Indian J Tuberc2004 ; 51 : 37 - 41

Spontaneous pneumothorax

R 2 4 %


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Chest radiograph in a

45 - year - old woman with

sarcoidosis shows

pneumothorax ( arrows )

along with b / l hilar

prominence, reticular

opacities in lower zones


Rare : 2 - 4 %

Mihailovic - Vucinic V and Jovanovic D . Clin Chest Med2008 ; 29 : 459 - 473

Sarcoidosis : miliary pattern in

a 40 - year - old man


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Deepak D and Shah A . Indian J Radiol Imag2001; 11 : 191 - 198

a 40 year old man

A 65 - year - old lady with cavitation9 months pr ior to referral


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Bilateral diffuse

non - homogeneous opacities

Bilateral hilar enlargement

Acinar pattern seen in the

right mid and lower zones

A well - defined cavitary lesion

in the anterior segment of the

right upper lobe

Panjabi C et al. Brazi l ian J Pulmonol2009 ( in press )

Aspergilloma formation in a sarcoid cavity

1 - year after commencement o f therapy for sarcoidos is


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C T in prone position

showing positional change

of the fungal ball

C T in supine position

showing fungal ball

within the cavity

Panjabi C et al. Brazi lian J Pulmono l2009 ( in press )

Mediastinal lymphadenopathy in a

35 - year - old lady


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A 35 - year - old lady

presented with a history

of dry cough , fever and

weight loss for one month

Chest X - ray showed

bilateral symmetrical

hilar lymphadenopathy

FOB done elsewhere :

inconclusive

35 year old lady

On presentation :investigated for pulmonary sarcoidosis

Spirometry : mixed obstruction with restriction


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Spirometry : mixed obstruction with restriction ,

diffusion per unit volume normal

Serum ACE : 25.7 IU / ml ( 8 52 IU / ml )

Mantoux test : 20 mm x 22 mm ( 1 TU )

Bilateral extensive

mediastinal lymphadenopathy

Bilateral ground glass haze with

right upper lobe consolidation and

peri - bronchial cuffing

Six weeks later


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Patient went out of town and

reported later with persistent

fever and productive cough

Chest X - ray revealed a cavity

in the right middle zone

All three consecutive samples for

AFB were positive

Sputum culture : positive

Bronchial aspirate culture by

BACTEC : positive

cavity

After six months of ATT


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She complained of dyspnoeaChest X- ray :

shrunken lung fields

Bilateral multiple mediastinal

lymphadenopathy

Ground glass haze

Pneumo Stagiu Sarcoidoza

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