This 54-years old lady presented with breathlessness.

A well done CT scan showed enlarged non-necrotic subcarinal and bilateral hilar nodes. The subcarinal node showed the “black pearl” sign described by Rochita V from Chennai, a sign that is highly suggestive of sarcoidosis. The lung images also show fissural nodules.
The diagnosis still had to be confirmed and I did a subcarinal node biopsy with saline hydro-dissection of the pleura from the vertebral body using an extra-pleural approach with a 20G coaxial biopsy gun. The diagnosis was noncaseating granulomatous inflammation of undetermined etiology consistent with sarcoidosis and AFB was negative on PCR and culture.