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We describe a 50-year-old man who presented with constitutional symptoms and bilateral pulmonary masses initially suggestive of metastatic malignancy. Extensive infectious, malignant, and autoimmune workup was negative. Histopathology from lung biopsies and a video-assisted thoracoscopic surgery (VATS) resection revealed granulomatous inflammation with necrosis and no evidence of malignancy or infection. A trial of corticosteroids resulted in clinical, biochemical, and radiological improvement. This case highlights the diagnostic challenges of NSG and the importance of multidisciplinary evaluation to avoid misdiagnosis.  \n1 | Introduction  \nNecrotising sarcoid granulomatosis (NSG) is a rare variant of granulomatous lung disorder that is characterised by noncaseating granulomas, necrosis, and granulomatous vasculitis [1] . It was first reported in 1973 by the American pathologist Leibow [2], who distinguished it from other non-infectious pulmonary angiitis and granulomatous conditions such as Granulomatosis with Polyangiitis (GPA) or Eosinophilic Granulomatosis with Polyangiitis (EGPA) [2] . NSG poses a diagnostic challenge because its clinical and pathological profile overlaps with other infectious, malignant, and vasculitic lung conditions [1, 3] . The clinical course is usually benign, with many patients experiencing spontaneous regression or responding well to corticosteroid therapy [3, 4] . An accurate diagnosis is important prior to treatment initiation, and this requires a comprehensive evaluation, including clinical examination, laboratory tests, pulmonary function studies, imaging, and histopathology.  \n2 | Case Report  \nA 50-year-old New Zealand European male presented in early September 2023 with a few weeks of fever, fatigue, and constitutional symptoms. He was a former smoker with a 15-pack year history. He is employed as a manager in a building company, with no reported occupational exposure to noxious substances or asbestos. Chest X-ray revealed bilateral ‘cannonball’pulmonary lesions (Figure 1A) . There were no clinical features of extra-pulmonary sarcoidosis at initial presentation. The patient denied extra-pulmonary symptoms, including ocular involvement. Given the imaging findings, metastatic malignancy was initially suspected. An extensive evaluation was undertaken over the course of the following days to identify the source.  \nLaboratory investigations at presentation showed normal levels of haemoglobin (127 g/L), mildly raised white cell count  \nThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.  \n© 2026 The Author(s). Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology.  \nRespirology Case Reports, 2026; 14:e70449 1 of 4  \n[https://doi.org/10.1002/rcr2.70449](https://doi.org/10.1002/rcr2.70449)  \n(WBC 11.67 × 109/L, Neutrophilia 8.1 × 109/L, Eosinophils 0.32 × 109/L) and raised inflammatory markers (CRP 140 mg/L) . Biochemistry revealed normal electrolytes, hypoalbuminemia (mid 20s g/L) and stable liv","cbCaimHJacI1GLvG","https://ap.wps.com/l/cbCaimHJacI1GLvG","pdf",750823,"English","# Introduction\n## Diagnostic challenge of NSG\n# Case Report\n## Initial presentation and imaging\n## Laboratory and serological findings\n## Infectious workup and biopsy results\n## Treatment and clinical response","[{\"question\":\"What makes necrotising sarcoid granulomatosis (NSG) difficult to diagnose?\",\"answer\":\"NSG overlaps clinically and pathologically with infectious, malignant, and vasculitic lung conditions, so it can mimic other diseases. Accurate diagnosis requires comprehensive evaluation including histopathology and multidisciplinary assessment.\"},{\"question\":\"Why was metastatic malignancy initially suspected in this case?\",\"answer\":\"The patient had constitutional symptoms and bilateral pulmonary “cannonball” masses on imaging, which are suggestive of metastatic malignancy. This prompted an extensive search for a primary source.\"},{\"question\":\"What confirmed the diagnosis and what was the treatment response?\",\"answer\":\"Lung biopsies and VATS resection revealed granulomatous inflammation with necrosis and no evidence of malignancy or infection. A trial of corticosteroids led to clinical, biochemical, and radiological improvement.\"}]","A Rare Case of Necrotising Sarcoid Granulomatosis Presenting as Bilateral Pulmonary Masses Mimicking Malignancy | PDF",1790699090]