A 34-year-old black woman presents to your office with symptoms of cough, dyspnea, and fatigue. Physical examination shows cervical adenopathy and hepatomegaly. Spleen tip is palpable. Her chest radiograph is shown below. Which of the following is the best approach in establishing a diagnosis?
a. Open lung biopsy
Sarcoidosis is a systemic illness of unknown etiology. There is a higher prevalence in female patients and in the African American population. Most patients have respiratory symptoms, including cough and dyspnea. Hilar and peripheral lymphadenopathy is common, and 20% to 30% of patients have hepatosplenomegaly. The chest x-ray shows symmetrical hilar lymphadenopathy. The diagnostic method of choice is fiberoptic bronchoscopy with transbronchial biopsy, which will show a mononuclear cell granulomatous inflammatory process. While liver and mediastinal lymph node biopsies are often positive, bronchoscopy is a safer and less invasive procedure. ACE levels are elevated in two-thirds of patients; since an elevated ACE value is common in other granulomatous diseases, it is not specific enough to exclude alternative diagnoses. Open-lung biopsy is more invasive and would only be considered if fiberoptic bronchoscopy failed to yield a diagnosis.