50-year-old male presents with history of Stage 4 sarcoidosis with acute chest pain and dyspnea.
The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion

A chest tube was placed and a chest CT shows confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension.

A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced.

The patient presents 2 years later, again with progressive dyspnea and chest pain

CT without Contrast shows extensive lymph node calcification not previously present

CT PA shows large non-occlusive, subacute pulmonary embolism of the LPA, encasement of the airways, right middle lobe pulmonary artery and encasement by the left lower pulmonary vein by the fibrotic broncho-vascular masses . There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated.

He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy.

 

The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm.

CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery.