A 50-year-old man of African descent presents with bilateral hilar lymphadenopathy on chest X-ray found incidentally. He is asymptomatic. Serum ACE is elevated. Biopsy of an enlarged supraclavicular lymph node shows non-caseating granulomas. Staining and culture for mycobacteria and fungi are negative. What is the MOST appropriate management?
- A Start oral prednisolone immediately
- B Initiate antitubercular therapy
- C Start hydroxychloroquine for ocular prophylaxis
- D Observe without treatment; reassess in 6–12 months ✓
Explanation
This presentation is classic for stage I sarcoidosis (bilateral hilar lymphadenopathy without parenchymal infiltrates). Stage I disease is asymptomatic in the majority and has a high rate of spontaneous remission (> 60–80%) over 1–2 years. Guidelines recommend watchful waiting with serial clinical assessment and pulmonary function tests for 6–12 months before considering corticosteroids. Systemic corticosteroids are indicated when there is symptomatic pulmonary disease (stage II/III with declining lung function), hypercalcemia, cardiac sarcoidosis, neurosarcoidosis, or significant ocular involvement. Antitubercular therapy is inappropriate because the granulomas are non-caseating and mycobacterial cultures are negative. Hydroxychloroquine alone is used adjunctively for cutaneous and mild systemic sarcoidosis, not as prophylaxis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.