A Mysterious Rash in a Patient with Interstitial Lung Disease

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Bilateral hilar lymphadenopathy

• The chest radiograph (CXR) notes very large hilar shadows, most probably due to enlarged lymph nodes
• This is known as bilateral hilar lymphadenopathy, shorted commonly to BHL

Cardiomegaly

• The cardiac diameter is normal (less than half the width of the chest is a commonly used as a guide to normality)

Right para-tracheal prominence

• This is a more subtle sign, but if you look closely you will see slight swelling, with a convexity pointing to the patient's right side
• This hints at right para-tracheal lymphadenopathy and is common seen in association with bilateral hilar lymphadenopathy

Left pleural effusion

• The left cardiophrenic angle is preserved
• Pleural effusions are very rare in sarcoidosis and suggest, in most patients, alternative pathology

Diffuse pulmonary infiltrates

• The lung parenchyma is not homogenously black and often looks a little streaky (due to normal blood vessels and airways coursing through it)
• Distinguishing normal vs abnormal can be challenging in milder cases
• Fortunately for our patient the lung fields look clear with no interstitial change (which when speaking with patients it is helpful to call "cloudy white shadowing")