EpistemisAsymmetrical basal Velcro-type crackles
Specialty: Respiratory.
Why it occurs
- Advanced-stage sarcoidosis with asymmetric lobar or segmental distribution of parenchymal fibrosis
- Chronic hypersensitivity pneumonitis where antigenic exposure or lobar ventilation has been heterogeneous
- Pulmonary fibrosis secondary to localized targeted radiotherapy (chronic actinic pneumonitis in the radiation field for breast, esophageal or lung cancer)
- Sequelae of extensive unilateral pulmonary tuberculosis with parenchymal destruction and localized traction bronchiectasis
- Nonspecific desquamative interstitial pneumonia with asymmetrical patchy involvement.
Initial workup
High-resolution chest computed tomography (CT) (HRCT) with contrast if an associated neoplastic or fungal complication is suspected; Forced spirometry and diffusing capacity for carbon monoxide (DLCO); Gallium-67 scan or PET-CT if looking for sarcoidosis inflammatory activity; Bronchoscopy with transbronchial biopsy or cryobiopsy.
red flags
Accelerated progression of habitual dyspnea on exertion, marked oxygen desaturation with minimal physical effort, suspicion of fungal or bacterial superinfection of the basal fibrotic cavities, or new-onset chest pain located over the area with the highest density of crackles.
Standard management
- Treatment depends strictly on the documented etiological cause
- Prednisone — 20-40 mg orally per day with a decreasing schedule in active inflammatory sarcoidosis
- Methotrexate — 7.5-15 mg orally once a week as a corticosteroid-sparing agent in refractory sarcoidosis
- Nintedanib (150 mg every 12 hours in case of documented fibrosing progression).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 5
- Treatment options
- 4