SHORTNESS OF BREATH: A``NEGATIVE'' LOWER EXTREMITY DOPPLER STUDY. C.W. Simpkins 1 , C. Passaretti 1 , A. Zaas 1 , J. Cofrancesco 1 ; 1 Johns Hopkins University, Baltimore, MD (Tracking ID #76910) LEARNING OBJECTIVES: 1. Assess subacute progressive dyspnea in a young woman. 2. Recognize the presentation of pulmonary sarcoidosis. 3. Recognize the pathology and pathophysiology of early pulmonary sarcoid. CASE INFORMATION: A 48 year old African American female with hypertension, gastroesophageal reflux disease, bipolar disorder, a remote history of lithium therapy and history of total abdominal hysterectomy and bilateral salpingoophorectomy on hormone replacement therapy (HRT), presents with slowly progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea for one year. Lower extremity duplex ultrasounds were negative for blood clot but did show inguinal adenopathy. Review of systems included loud snoring, possible apneic episodes during sleep, nonrestful sleep, intermittent lower extremity swelling, nonproductive cough for 1 week, but no daytime somnolence, fevers, chills, or sweats. She had an 18 pound intentional weight loss over the past year. No history of alcohol, tobacco, or illicit drug use. Physical exam: temperature 100.5 degrees F, blood pressure 146/57 mmHg, pulse 67 bpm, respiratory rate 20, pulse oximetry 95% on 2 liters supplemental oxygen. Patient was a mildly obese woman in no acute distress, with no palpable adenopathy, slightly elevated jugular venous pulse, normal air movement except for rare bibasilar crackles, a prominent P2 heart sound, and no peripheral edema, cyanosis, or clubbing. Arterial blood gas on room air: pH 7.44/PaCO2 35/PaO2 55/bicarb 23. Ventilation/perfusion (V/Q) scan was low probability for pulmonary embolism. Pulmonary function tests showed moderate combined obstructive and restrictive physiology with severe gas transfer defect. Computed tomography (CT) of the chest showed enlarged right atrium, bulky mediastinal adenopathy, and diffuse patchy ground glass infiltrates without effusion or consolidation. Echocardiogram showed normal left ventricular (LV) size and function, moderate dilatation of the right ventricle (RV) and right atrium (RA) with flattened septum. A diagnostic procedure was performed. IMPLICATIONS/DISCUSSION: Initial differential diagnosis included pulmonary embolus (young woman on hormones), sleep apnea (given the pulmonary hypertension), and hypertensive cardiomyopathy with heart failure. However, the negative V/Q and CT, and the bulky lymphadenopathy and patchy ground-glass infiltrates were suspicious for pulmonary sarcoid. Bronchoscopy with lavage and biopsy confirmed this diagnosis with negative cultures, peri-mucosal granuloma and reactive histiocytes. The patient was diuresed, started on high dose steroids with slow taper, and is doing well. The diagnosis, pathophysiology and treatment of pulmonary sarcoid will be discussed. LEARNING OBJECTIVES: 1) Review the differential diagnosis of normocytic anemia. 2) Recognize the cause of normocytic anemia by mixed processes of microcytic and macrocytic anemia.