Imaging Case of the Week 106

The following chest x-rays are from a 35 year old man who has presented with chest pain and exertional dyspnoea. What radiological sign is noticeable in these x-rays?


PA chest x-ray

Lateral chest x-ray


[peekaboo_link name=”Answer”]Answer[/peekaboo_link] [peekaboo_content name=”Answer”]

The PA chest x-ray shows enlargement of the right paratracheal, right and left hilar lymph nodes. This pattern of lymph node enlargement is suggestive of sarcoidosis. The radiological sign visible is the 1-2-3 sign or the Garland’s triad.

1-2-3 Sign

This patient had a CT chest scan and a lymph node biopsy and was subsequently diagnosed with stage II sarcoidosis.

Staging of Sarcoidosis:

Stage 1 – Bilateral hilar lymphadenopathy

Stage 2 – Bilateral hilar adenopathy and infiltrates

Stage 3 – Infiltrates alone

Stage 4 – Fibrosis

Sarcoidosis is a chronic granulomatous disease of unknown aetiology. Though it most commonly affects the lungs, it can technically manifest in any organ within the body.

Organs affected are:

  •  Lungs (90%) – hilar adenopathy, lung infiltrates, pulmonary fibrosis, pulmonary hypertension.
  • Liver (60-90%) – abnormal LFTs.
  • Spleen (40%) – splenomegaly, anaemia.
  • Eyes (30%) – uveitis, keratoconjunctivitis.
  • Skin (30%) – lupus pernio, erythema nodosum.
  • Joint (25%) – acute or chronic arthritis.
  • Endocrine (10%) – hypercalcaemia.
  • CNS (5%) – cranial nerve palsies (commonly facial nerve), aseptic meningitis.
  • CVS (5%) – conduction defects, heart block, cor pulmonale.