A 45-year-old woman with no smoking history presents with bilateral hilar lymphadenopathy on chest X-ray. CT confirms bilateral symmetrical hilar and right paratracheal lymphadenopathy (the classic 1-2-3 or pawn-broker sign) with multiple small pulmonary nodules along bronchovascular bundles and subpleural regions. Serum ACE is elevated. What is the most likely diagnosis?
- A Lymphoma
- B Primary tuberculosis
- C Sarcoidosis ✓
- D Silicosis
Explanation
Sarcoidosis classically presents with bilateral symmetric hilar lymphadenopathy often combined with right paratracheal enlargement forming the 1-2-3 or pawn-broker sign on chest X-ray. CT characteristically shows lymphangitic nodule distribution along bronchovascular bundles, interlobular septa, and subpleural regions with perilymphatic predominance. Elevated ACE supports the diagnosis. Lymphoma tends to cause asymmetric anterior mediastinal and hilar adenopathy. Primary TB in adults usually causes unilateral hilar adenopathy with ipsilateral parenchymal consolidation. Silicosis produces egg-shell calcified nodes predominantly in the hilar and paratracheal stations.
Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.
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