whereas older children are more likely to report symptoms related to lung involvement or enlarged lymph nodes The presence of cough and dyspnea usually indicates pulmonary involvement However, extensive pulmonary disease can be present without significant clinical manifestations Hoarseness, dyspnea, and dysphagia can result from laryngeal involvement Arrhythmia or congestive heart failure can be the initial findings of cardiac disease Other symptoms vary depending on affected systems and may include bone and joint pain, visual acuity impairment, ocular swelling or pain, parotid gland enlargement, headache, and unexplained fever On physical examination, lymph node enlargement is the most frequently detected abnormality Intrathoracic nodes including hilar, paratracheal, or mediastinal chains are enlarged in 75% to 90% of patients When present, hilar adenopathy is usually bilateral and symmetric (see Fig 99.8 ) Peripheral adenopathy is also common, particularly in cervical, axillary, and inguinal regions Affected lymph nodes are firm, nontender, mobile, and nonulcerative Some patients have a skin rash that is similar in appearance to erythema nodosum Plaques, subcutaneous nodules, and maculopapular eruptions can also be seen Uveitis is present in up to 25% of patients Small yellow nodules are frequently found on the conjunctiva in these patients Hepatosplenomegaly and joint effusions can be present Management Laboratory test abnormalities in patients with sarcoidosis tend to be nonspecific Hyperproteinemia, elevated erythrocyte sedimentation rate (ESR), hypercalciuria, eosinophilia, and rarely hypercalcemia can be seen Although not pathognomonic, an elevated serum angiotensin-converting enzyme level is strongly supportive of the diagnosis of sarcoidosis On CXR, between 40% and 60% of symptomatic children will have hilar adenopathy alone or in combination with parenchymal infiltrates Pulmonary function testing usually reveals restrictive lung disease