D2.128 - Sarcoid-like reaction induced by aspirin therapy after aspirin desensitization in a patient with aspirin-exacerbated respiratory disease
Case report
Background: Aspirin-exacerbated respiratory disease (AERD) is a chronic condition characterized by asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and hypersensitivity to aspirin or other cyclooxygenase-1 inhibitors. Aspirin therapy after aspirin desensitization (ATAD) effectively manages AERD symptoms. However, long-term, higher dose aspirin use may result in rare adverse reactions. This case presents a drug-induced sarcoid-like reaction in a patient with AERD undergoing aspirin therapy, a phenomenon not previously documented.
Case Presentation: A 27-year-old woman with AERD presented with pruritic, papular skin lesions on her arms, nodular changes with bruising on her legs, and changes resembling erythema nodosum on her left shin. She had been on high-dose aspirin therapy (600 mg per day, twice daily) after aspirin desensitization for fifty-four months. A chest X-ray revealed right hilar enlargement. Further imaging (CT with HRCT) identified asymmetrical enlargement of lymph nodes in the right hilar, subcarinal, and paratracheal region on the right side. Laboratory tests showed elevated blood eosinophils (440/mm³), positive ANA screening test (1:320), and negative ANCA test. Bronchoscopy with endobronchial ultrasound (EBUS) biopsies group 7 and 11R lymph nodes revealed non-necrotizing granulomas in lymph nodes, while bronchial mucosal biopsy showed mild chronic inflammation with increased eosinophils. Bronchoalveolar lavage (BAL) fluid analysis showed mildly elevated lymphocyte (20%, compared to over 40% in typical sarcoidosis) and eosinophils (2%, compared to normal values below 1%) levels. Skin biopsy revealed nonspecific inflammatory changes. Aspirin was discontinued. One month later, skin lesions resolved, and a follow-up chest X-ray after six months showed no abnormalities.
Discussion and Conclusion: This case suggests a rare drug-induced sarcoid-like reaction to long-term aspirin therapy in AERD, likely caused by immune dysregulation. This is a rare but recognized phenomenon. It mimics sarcoidosis but is triggered by medications and other external factors, rather than being classified as a primary granulomatous disease. Clinicians should be aware of this possibility in patients with AERD on chronic aspirin therapy.
