Pulmonary sarcoidosis

Lack of pulmonary involvement leads to a 3 years delay of diagnosis in a childhood sarcoidosis case with arthritis, ocular symptoms, and bilateral parotid swelling

Key Clinical Message

This paper presents a rare sarcoidosis case in a child of 12 years of age presented with arthritis, bilateral parotid enlargement and ocular, but unfortunately the diagnosis has been missed due to lack of pulmonary involvement.

Abstract

Diagnosis of sarcoidosis is by exclusion, and sometimes, it can be challenging. This paper presents a rare sarcoidosis case in a child of 12 years of age presented with bilateral parotid enlargement. The signs of musculoskeletal and ocular involvement were present before the parotid enlargement, and the parotid swelling persisted for 3 years; but unfortunately the definite diagnosis has been missed by the previous healthcare professionals most probably due to the rarity of the situation, especially lack of pulmonary involvement. Therefore, cooperation between different healthcare specialties is important for an effective diagnosis and management. Despite its rarity, sarcoidosis should always be present in the list of differential diagnosis when encountering multisystem entities like arthritis, ocular symptoms and parotid swelling.

A Retrospective Analysis of 2-Year Follow-Up of Patients with Incidental Findings of Sarcoidosis

INTRODUCTION

Sarcoidosis is a multi-system granulomatous disease most commonly involving the lungs. It may be incidentally diagnosed during imaging studies for other conditions or non-specific symptoms. The appropriate follow-up of incidentally diagnosed asymptomatic stage 1 disease has not been well defined.

OBJECTIVE

To define the clinical course of incidentally diagnosed asymptomatic stage 1 sarcoidosis and propose an algorithm for the follow-up of these patients.

METHODOLOGY

A retrospective case note analysis was performed of all EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration)-confirmed cases of stage 1 sarcoidosis presenting incidentally to Bristol and Liverpool Interstitial Lung Disease services. Clinical history, serology results, imaging scans, and lung function parameters were examined at baseline, 12, and 24 months. A cost analysis was performed comparing the cost of the current 2-year follow-up guidance to a 1 year follow-up period.

RESULTS

Sixty-seven patients were identified as the final cohort. There was no significant change in the pulmonary function tests over the two-year follow-up period. Radiological disease stability was observed in the majority of patients (58%, n = 29), and disease regression was evidenced in 40% (n = 20) at 1 year. Where imaging was performed at 2 years, the majority (69.8%, n = 37) had radiological evidence of disease regression, and 30.2% (n = 16) showed radiological evidence of stability. All patients remained asymptomatic and did not require therapeutic intervention over the study period.

CONCLUSIONS

Our results show that asymptomatic patients with incidental findings of thoracic lymph nodal non-caseating granulomas do not progress over a 2-year period. Our results suggest that the prolonged secondary-care follow-up of such patients may not be necessary. We propose that these patients are followed up for 1 year with a further year of patient-initiated follow-up (PIFU) prior to discharge.

The Relationship Between Serum Angiotensin Converting Enzyme Level and the Decision to Escalate Treatment of Sarcoidosis

PURPOSE

We performed a retrospective analysis of a sarcoidosis cohort who had sACE obtained at their initial clinic visit, but the treating physician was blinded to the results. We examined the relationship between sACE and the treating physician's decision to escalate sarcoidosis treatment.

METHODS

Treatment was considered escalated if the prednisone dose was increased or if the prednisone dose was not changed but an additional anti-sarcoidosis drug was added or the dose was increased.

RESULTS

561 sarcoidosis patients were analyzed. The most common target organ was the lung (84%). Using a cut-off of > 82 units/L for an elevated sACE, 31/82 (38%) with an elevated sACE had treatment escalation whereas 91/497 (18%) had treatment escalation with a normal sACE (p < 0.0001). For the need of treatment escalation, a sACE (cut-off of > 82) had sensitivity 0.25, specificity 0.89, positive predictive value 0.38, negative predictive value 0.81. These results were not appreciably different using other sACE cut-off values such as 70, 80, 90, or 100. A multivariable logistic regression model that included demographics, the target organ, spirometry results estimated that sACE level and lower FVC were significantly associated with the likelihood of treatment escalation. These findings held when sACE > 82 replaced sACE level in the multivariable logistic regression model.

CONCLUSIONS

Although there was a strong correlation between sACE at the initial sarcoidosis clinic visit and subsequent treatment escalation of sarcoidosis, the predictive power was such that sACE is not adequately reliable to be used in isolation to make this determination.

Sarcoidosis in Johannesburg, South Africa: A retrospective study

Background

Sarcoidosis is a multisystem granulomatous condition of uncertain aetiology that most frequently affects the lungs. Because of clinical and radiological similarities with tuberculosis (TB), particularly in high-prevalence regions, sarcoidosis is frequently misdiagnosed as TB.

Objectives

To review the clinical features of sarcoidosis patients in a South African (SA) population, adding clinical information to the relatively few studies that have been conducted in SA patients with sarcoidosis.

Methods

This was a retrospective study of 102 sarcoidosis patients conducted between 2002 and 2006 at the Charlotte Maxeke Johannesburg Academic Hospital.

Results

Of 102 sarcoidosis patients, there were 69 (67.6%) females and 33 (32.4%) males. The majority (85.3%) were non-smokers. The mean age of the group was 44.6 years. One-third of patients had chronic comorbid diseases. Almost 17% had been treated initially for TB, prior to being diagnosed as having sarcoidosis. Two patients developed active TB while receiving corticosteroid treatment for sarcoidosis. The salient clinical manifestations were dry cough (the most common presenting symptom in 82.4%), dyspnoea in 53.9%, cutaneous lesions other than erythema nodosum in 33.3%, and on lung examination crackles were noted in 37.3% of patients. Raised angiotensin-converting enzyme (ACE) levels were found in 56.8% of patients. The majority (48%) of patients had stage II chest radiographic changes. Cutaneous (28.4%), mediastinal lymph node (25.5%) and transbronchial lung (25.5%) biopsies were the most frequent sites confirming granulomatous inflammation. Overall, 21.2% of patients had obstructive airway disease. Systemic corticosteroids were indicated in 87.3% of patients and the relapse rate was 60.7%.

Conclusion

Sarcoidosis is often initially misdiagnosed as TB in SA. The most common biopsy sites for histological confirmation were the skin and mediastinal lymph nodes, and transbronchial lung biopsies were also frequently taken. Stage II chest radiographic changes were most common. Overall, systemic corticosteroids were administered in 87.3% of cases and the relapse rate was 60.7%.

[Sarcoidosis coming from the galaxy]

Manifestations of sarcoidosis are variable and non-specific. We are reporting on the case of a 23-year-old man who presented multiple bilateral pulmonary nodules spiculated with peripherical micronodules (galaxy sign). He had no clinical symptom. Investigations led to the diagnosis of sarcoidosis. The galaxy sign is a rare manifestation of sarcoidosis which can be useful for diagnosis.

Clinical Features, Histopathology and Differential Diagnosis of Sarcoidosis

Sarcoidosis is a chameleon disease of unknown etiology, characterized by the growth of non-necrotizing and non-caseating granulomas and manifesting with clinical pictures that vary on the basis of the organs that are mainly affected. Lungs and intrathoracic lymph nodes are the sites that are most often involved, but virtually no organ is spared from this disease. Histopathology is distinctive but not pathognomonic, since the findings can be found also in other granulomatous disorders. The knowledge of these findings is important because it could be helpful to differentiate sarcoidosis from the other granulomatous-related diseases. This review aims at illustrating the main clinical and histopathological findings that could help clinicians in their routine clinical practice.

Mechanobiology of Pulmonary Diseases: A Review of Engineering Tools to Understand Lung Mechanotransduction

Cells within the lung micro-environment are continuously subjected to dynamic mechanical stimuli which are converted into biochemical signaling events in a process known as mechanotransduction. In pulmonary diseases, the abrogated mechanical conditions modify the homeostatic signaling which influences cellular phenotype and disease progression. The use of in vitro models has significantly expanded our understanding of lung mechanotransduction mechanisms. However, our ability to match complex facets of the lung including three-dimensionality, multicellular interactions, and multiple simultaneous forces is limited and it has proven difficult to replicate and control these factors in vitro. The goal of this review is to (a) outline the anatomy of the pulmonary system and the mechanical stimuli that reside therein, (b) describe how disease impacts the mechanical micro-environment of the lung, and (c) summarize how existing in vitro models have contributed to our current understanding of pulmonary mechanotransduction. We also highlight critical needs in the pulmonary mechanotransduction field with an emphasis on next-generation devices that can simulate the complex mechanical and cellular environment of the lung. This review provides a comprehensive basis for understanding the current state of knowledge in pulmonary mechanotransduction and identifying the areas for future research.

Pulmonary Sarcoidosis: Diagnosis and Differential Diagnosis

Sarcoidosis is a multisystem disorder of unknown origin and poorly understood pathogenesis that predominantly affects lungs and intrathoracic lymph nodes and is characterized by the presence of noncaseating granulomatous inflammation in involved organs. The disease is highly heterogeneous and can mimic a plethora of other disorders, making diagnosis a challenge even for experienced physicians. The evolution and severity of sarcoidosis are highly variable: many patients are asymptomatic and their disease course is generally benign with spontaneous resolution. However, up to one-third of patients develop chronic or progressive disease mainly due to pulmonary or cardiovascular complications that require long-term therapy. The diagnosis of sarcoidosis requires histopathological evidence of noncaseating granulomatous inflammation in one or more organs coupled with compatible clinical and radiological features and the exclusion of other causes of granulomatous inflammation; however, in the presence of typical disease manifestations such as Löfgren’s syndrome, Heerfordt’s syndrome, lupus pernio and asymptomatic bilateral and symmetrical hilar lymphadenopathy, the diagnosis can be established with high level of certainty on clinical grounds alone. This review critically examines the diagnostic approach to sarcoidosis and emphasizes the importance of a careful exclusion of alternative diagnoses.

A Primer on the Clinical Aspects of Sarcoidosis for the Basic and Translational Scientist

The immunopathogenesis of sarcoidosis remains unclear. This failure in understanding has been clinically impactful, as it has impeded the accurate diagnosis, treatment, and prevention of this disease. Unraveling the mechanisms of sarcoidosis will require input from basic and translational scientists. In order to reach this goal, scientists must have a firm grasp of the clinical aspects of the disease, including its diagnostic criteria, the immunologic defects, clinical presentations, response to therapy, risk factors, and clinical course. This manuscript will provide an overview of the clinical aspects of sarcoidosis that are particularly relevant for the basic and translational scientist. The variable phenotypic expression of the disease will be described, which may be integral in identifying immunologic disease mechanisms that may be relevant to subgroups of sarcoidosis patients. Data concerning treatment and risk factors may yield important insights concerning germane immunologic pathways involved in the development of disease. It is hoped that this manuscript will stimulate communication between scientists and clinicians that will eventually lead to improved care of sarcoidosis patients.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Pulmonary Sarcoidosis: A Clinical Update

Sarcoidosis remains difficult to diagnose, assess and treat. The last decade has brought significant diagnostic and therapeutic advances in the field of sarcoidosis including endobronchial ultrasound, 18F-fluorodeoxyglucose positron emission tomography and biologics. In this article we use clinical vignettes to discuss commonly encountered cases to illustrate and explain the application of these, and other advances.

Screening Sarcoidosis Patients for Occult Disease

As sarcoidosis may involve any organ, sarcoidosis patients should be evaluated for occult disease. Screening for some organ involvement may not be warranted if it is unlikely to cause symptoms, organ dysfunction, or affect clinical outcome. Even organ involvement that affects clinical outcome does not necessarily require screening if early detection fails to change the patient's quality of life or prognosis. On the other hand, early detection of some forms of sarcoidosis may improve outcomes and survival. This manuscript describes the approach to screening sarcoidosis patients for previously undetected disease. Screening for sarcoidosis should commence with a meticulous medical history and physical examination. Many sarcoidosis patients present with physical signs or symptoms of sarcoidosis that have not been recognized as manifestations of the disease. Detection of sarcoidosis in these instances depends on the clinician's familiarity with the varied clinical presentations of sarcoidosis. In addition, sarcoidosis patients may present with symptoms or signs that are not related to specific organ involvement that have been described as parasarcoidosis syndromes. It is conjectured that parasarcoidosis syndromes result from systemic release of inflammatory mediators from the sarcoidosis granuloma. Certain forms of sarcoidosis may cause permanent and serious problems that can be prevented if they are detected early in the course of their disease. These include (1) ocular involvement that may lead to permanent vision impairment; (2) vitamin D dysregulation that may lead to hypercalcemia, nephrolithiasis, and permanent kidney injury; and (3) cardiac sarcoidosis that may lead to a cardiomyopathy, ventricular arrhythmias, heart block, and sudden death. Screening for these forms of organ involvement requires detailed screening approaches.

Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display

Sarcoidosis is a multisystemic granulomatous disorder that can affect virtually any organ. However, pulmonary and thoracic lymph node involvement predominates; abnormalities on chest radiographs are present in 80 to 90% of patients with sarcoidosis. High-resolution computed tomographic (HRCT) scans are superior to chest X-rays in assessing extent of disease, and some CT features may discriminate an active inflammatory component (which may be amenable to therapy) from fibrosis (for which therapy is not indicated). Typical findings on HRCT include micronodules, perilymphatic and bronchocentric distribution, perihilar opacities, and varying degrees of fibrosis. Less common findings on CT include mass-like or alveolar opacities, miliary opacities, mosaic attenuation, honeycomb cysts, and cavitation. With progressive disease, fibrosis, architectural distortion, upper lobe volume loss with hilar retraction, coarse linear bands, cysts, and bullae may be observed. We discuss the salient CT findings in patients with sarcoidosis (with a major focus on pulmonary features) and present classical radiographic and histopathological images of a few extrapulmonary sites.

Lung mass with bilateral mediastinal hypermetabolic lymphadenopathy in a chronic smoker indicative of lung cancer?

We present the case of an asymptomatic woman, a chronic heavy smoker, who presented with an incidental lung mass and mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsy and endobronchial ultrasound-guided transbronchial needle aspiration did not show malignancy. A positron emission tomography/computed tomography scan showed increased uptake with a standardized uptake value of 26.4 in the mediastinal lymph node and an additional hypermetabolic right supraclavicular lymph node. Surgical biopsy of the supraclavicular node revealed non-necrotizing granuloma. Discussion of the clinical dilemma is provided.

Systemic phenotype of sarcoidosis associated with radiological stages. Analysis of 1230 patients

BACKGROUND

To analyze the association between Scadding radiological stages of sarcoidosis at diagnosis and the disease phenotype (epidemiology, clinical presentation and extrathoracic involvement) in one of the largest cohorts of patients with sarcoidosis reported from southern Europe.

METHODS

The SARCOGEAS-Study Group includes a multicenter database of consecutive patients diagnosed with sarcoidosis according to the WASOG 1999 criteria. Extrathoracic disease at diagnosis was defined according to the 2014 instrument and the clusters proposed by Schupp et al. RESULTS: We analyzed 1230 patients (712 female, mean age 47 yrs.) who showed the following Scadding radiologic stages at diagnosis: stage 0 (n = 98), stage I (n = 395), stage II (n = 500), stage III (n = 195) and stage IV (n = 42). Women were overrepresented in patients presenting with extrathoracic/extrapulmonary disease, while the diagnosis was made at younger ages in patients presenting with BHL, and at older ages in those presenting with pulmonary fibrosis (q values <0.05). Multivariable adjusted analysis showed that patients presenting with pulmonary involvement (especially those with stages II and III) had a lower frequency of concomitant systemic involvement in some specific extrathoracic clusters (cutaneous-adenopathic/musculoskeletal, ENT and neuro-ocular/OCCC) but a higher frequency for others (hepatosplenic), in comparison with patients with extrapulmonary involvement (stages 0 and I). The presence of either BHL or fibrotic lesions did not influence the systemic phenotype of patients with pulmonary involvement.

CONCLUSIONS

The key determinant associated with a differentiated systemic phenotype of sarcoidosis at diagnosis was interstitial pulmonary involvement rather than the individual Scadding radiological stage.

Sarcoidosis: A Diagnosis of Exclusion

OBJECTIVE. This article will review the typical and atypical imaging features of sarcoidosis, identify entities that may be mistaken for sarcoidosis, and discuss patterns and clinical scenarios that suggest an alternative diagnosis. CONCLUSION. Radiologists must be familiar with the characteristic findings in sarcoidosis and be attentive to situations that suggest alternative diagnoses. The radiologist plays a major role in prompt diagnosis and one that may help reduce patient morbidity and mortality.

New advances in the management of pulmonary sarcoidosis

Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.

The diagnosis of sarcoidosis

PURPOSE OF REVIEW

To review the diagnostic approach to sarcoidosis. There is no gold standard diagnostic test, procedure or algorithm for sarcoidosis. The diagnosis is based on a compatible clinical presentation, histologic findings of granulomatous inflammation, exclusion of alternative diseases, and evidence of systemic involvement. Occasionally, there may be exceptions to several of these requirements.

RECENT FINDINGS

The diagnostic specificity of several specific clinical features are discussed. Typical histologic findings of sarcoidosis are described. Several diseases that may mimic sarcoidosis are reviewed.

SUMMARY

The diagnosis of sarcoidosis usually involves weighing the clinical evidence for and against the diagnosis, coupled in most cases with histologic evidence of granulomatous inflammation. This approach requires knowledge of the varied presentations of the disease and other alternative conditions as well as histologic examination of an affected tissue in most instances.

Sarcoidosis: muchas caras, una enfermedad. Revisión narrativa de la literatura

La sarcoidosis es una enfermedad granulomatosa sistémica de etiología desconocida. Esta puede afectar a pacientes de todas las latitudes y edades, siendo más frecuente entre la tercera y cuarta década de la vida con un segundo pico alrededor de los 50 años en las poblaciones escandinava y japonesa. Es más frecuente en mujeres y grave en la población afrodescendiente.Los antígenos que inician esta respuesta granulomatosa son desconocidos, pero se presume que son aerotransportados por la alta frecuencia de compromiso pulmonar en esta enfermedad. Su presentación clínica abarca una amplia gama de manifestaciones, desde formas agudas y limitadas hasta el compromiso crónico con daño orgánico progresivo y muerte. Su diagnóstico se basa en la existencia de los granulomas no caseificantes en los tejidos, con la exclusión de otras enfermedades, entre ellas infección por micobacterias. 

Optimized angiotensin-converting enzyme activity assay for the accurate diagnosis of sarcoidosis

BACKGROUND

Serum angiotensin-converting enzyme (ACE) activity determination can aid the early diagnosis of sarcoidosis. We aimed to optimize a fluorescent kinetic assay for ACE activity by screening the confounding effects of endogenous ACE inhibitors and interfering factors. Genotype-dependent and genotype-independent reference values of ACE activity were established, and their diagnostic accuracies were validated in a clinical study.

METHODS

Internally quenched fluorescent substrate, Abz-FRK(Dnp)P-OH was used for ACE-activity measurements. A total of 201 healthy individuals and 59 presumably sarcoidotic patients were enrolled into this study. ACE activity and insertion/deletion (I/D) genotype of the ACE gene were determined.

RESULTS

Here we report that serum samples should be diluted at least 35-fold to eliminate the endogenous inhibitor effect of albumin. No significant interferences were detected: up to a triglyceride concentration of 16 mM, a hemoglobin concentration of 0.71 g/L and a bilirubin concentration of 150 μM. Genotype-dependent reference intervals were considered as 3.76-11.25 U/L, 5.22-11.59 U/L, 7.19-14.84 U/L for II, ID and DD genotypes, respectively. I/D genotype-independent reference interval was established as 4.85-13.79 U/L. An ACE activity value was considered positive for sarcoidosis when it exceeded the upper limit of the reference interval. The optimized assay with genotype-dependent reference ranges resulted in 42.5% sensitivity, 100% specificity, 100% positive predictive value and 32.4% negative predictive value in the clinical study, whereas the genotype-independent reference range proved to have inferior diagnostic efficiency.

CONCLUSIONS

An optimized fluorescent kinetic assay of serum ACE activity combined with ACE I/D genotype determination is an alternative to invasive biopsy for confirming the diagnosis of sarcoidosis in a significant percentage of patients.

Reprint of: The pathology of pulmonary sarcoidosis: update

Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.

YKL-40, Soluble IL-2 Receptor, Angiotensin Converting Enzyme and C-Reactive Protein: Comparison of Markers of Sarcoidosis Activity

The aims of this study were to describe the clinical, radiological and immunological features of a population of sarcoidosis patients and to analyse chitinase-3-like protein 1 (YKL-40), soluble interleukin-2 receptor (sIL-2R), neopterin concentrations and adenosine deaminase (ADA) activity in serum of these patients in order to understand their potential as disease markers. Fifty-nine patients affected by chronic sarcoidosis, in active (20 patients) and inactive (39 patients) phase according to the clinical, radiological and laboratory criteria were studied. Serum YKL-40, sIL-2R, high-sensitive C-reactive protein (hs-CRP), neopterin levels and ADA activities were evaluated and compared with those of 25 healthy controls. Individuals with chronic sarcoidosis were significantly higher serum YKL-40, sIL-2R, neopterin, hs-CRP concentrations, angiotensin converting enzyme (ACE) and ADA activity than those of control subjects. Sarcoidosis patients in the active phase of the disease were significantly higher YKL-40, sIL-2R, hs-CRP levels and ACE activity than those in the inactive phase, while ADA activities and neopterin levels did not display any significant difference between the active and inactive disease groups. In comparison to the other parameters, as panel measurement of the serum YKL-40, sIL-2R, ACE and hs-CRP indicate a greater discrimination between active and inactive disease. The results indicate that serum YKL-40, sIL-2R, ACE and hs-CRP concentrations may be useful marker for monitoring sarcoidosis disease activity.

Case Report: Pulmonary and Liver Sarcoidosis Suspected of Metastasis

Introduction: Sarcoidosis is a granulomatous disease with unknown cause that can vary from an asymptomatic condition. Almost half of the patients with sarcoidosis have no symptoms. In this article, we describe a sarcoidosis patient with lung and liver engagement; it may be confused with metastasis.

Case report: A 39-year-old man, with known as hypothyroidism who had come to the emergency ward with dyspnea and coughing after exposure to detergents in a closed environment. The patient smoked for 10 years (3 pack/year). No other findings were found in clinical examinations except for wheezing in the right lung. The patient's chest radiography was shown a mass. For further investigation, spiral CT scan was performed. Large lymph nodes on the right side of the trachea, measuring about 23 mm and a mass of 70 × 77 mm in the vicinity of the right lung hilum and a hypodense nodule in the posterior part of the liver with malignancy suspicious were reported. After several biopsy results was shown chronic granulomatous inflammation, the most important differential diagnosis is tuberculosis (TB) and sarcoidosis. Sputum smear, culture, and PCR were performed for tuberculosis. Also, the level of angiotensin-converting enzyme (ACE) was measured for sarcoidosis. the results ruled out TB and shown a higher level of ACE (ACE = 88 IU/L).After diagnosis treatment started with prednisolone. Now, the patient is in the follow- up.

Conclusion: In hilar lymphadenopathy of lung sarcoidosis is the importance differential diagnosis that should be considered.

Pulmonary sarcoidosis with and without extrapulmonary involvement: a cross-sectional and observational study in China

OBJECTIVES

Sarcoidosis is a multisystem disease characterised by the formation of granulomas within various organs, mainly the lungs. Several studies from different countries have been undertaken to investigate sarcoidosis with extrapulmonary involvement except from China. The objective of this study is to investigate a comparative clinical analysis in patients with pulmonary sarcoidosis with and without extrapulmonary involvement from China.

METHODS

Data from inpatients diagnosed with sarcoidosis at Shanghai Pulmonary Hospital (Shanghai, China) between January 2009 and December 2014 were retrospectively collected and analysed. Six hundred and thirty-six patients with biopsy-proven sarcoidosis were included in the study, including 378 isolated pulmonary sarcoidosis and 258 pulmonary sarcoidosis plus extrapulmonary involvement.

RESULTS

Two hundred and fifty-eight (40.6%) patients with pulmonary sarcoidosis had extrapulmonary involvement. Extrapulmonary localisations were detected mostly in extrathoracic lymph nodes (n=147) and skin (n=86). Statistically significant differences were demonstrated between patients with pulmonary sarcoidosis plus extrapulmonary involvement and patients with isolated pulmonary sarcoidosis for fatigue (16.6%vs8.3%, P<0.05), serum ACE (SACE) levels (79.0±46.9 IU/L vs 69.7±38.7 IU/L, P<0.05), and high-resolution CT (HRCT) findings (53.8%vs46.2%, P<0.05).

CONCLUSIONS

Extrapulmonary involvement is common in patients with pulmonary sarcoidosis, with the most common sites being extrathoracic lymph nodes and skin. Patients with sarcoidosis with extrapulmonary involvement are more symptomatic (fatigue), have higher SACE levels and more deteriorating HRCT findings, to which clinicians should pay attention.

Necrotizing sarcoid granulomatosis: A distinctive form of pulmonary granulomatous disease

OBJECTIVES

To define the characteristics of necrotizing sarcoid granulomatosis (NGS) a very rare pulmonary disease hardly recognised by pulmonologists and pathologists.

DATA SOURCE

PubMed was searched for the term necrotising or necrotizing sarcoid granulomatosis.

STUDY SELECTION

All cases reported in the English literature were included.

RESULTS

NGS is presented at all ages (range 8-68 years) with a median age of 42 years old. It shows female (62%) and Caucasian (80%) predominance. The most frequent symptoms are cough, fever, dyspnoea and chest pain. Extra-pulmonary involvement is found in one third of the cases, with ocular being the most common (12.5%). At imaging, multiple nodules (64.75%) or a solitary mass (20.49%) are found accompanied by mediastinal lymphadenopathy at one third of the cases. It can be clinically mistaken for malignancy as it is tumour-like, increases rapidly in size and it is hyperfixating in PET-SCAN. Histologically, NGS is defined by large areas of necrosis, well-formed granulomas and vascularitis.

CONCLUSION

NGS is a disease often confounded clinically with malignancy or with sarcoidosis even histologically when all criteria are not strictly applied. This review provides NGS' characteristics and discusses its differential diagnosis form sarcoidosis, Wegener granulomatosis and tuberculosis.

Analysis of sarcoidosis in the Oporto region (Portugal)

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Epidemiological studies of different populations are essential because clinical presentation, organ involvement, disease severity, and prognosis vary significantly according to region and population. The aim of this study was to assess epidemiological and clinical characteristics, staging factors, and clinical course in patients with sarcoidosis from a tertiary hospital in Oporto, Portugal.

METHODS

A retrospective analysis of patients with sarcoidosis and at least 2 years of follow-up evaluated at the Centro Hospitalar de São João between 2000 and 2014.

RESULTS

We identified 409 patients with sarcoidosis (females, 58.9%; mean age at diagnosis, 38.9±13.4 years; smokers, 14.4%]. All the patients were diagnosed according to the ERS/ATS/WASOG consensus statement and 64.1% had evidence of noncaseating epithelioid cell granulomas in biopsy specimens. Bronchoalveolar lavage was performed as part of the diagnostic work-up in 289 patients and 90.2% had lymphocytosis (CD4/CD8 ratio ≥3.5 in 60.9% of cases). Exertion dyspnea, cough, and constitutional symptoms were the most common presenting symptoms; 10.1% of patients were asymptomatic, 22.8% had Löfgren syndrome, and 50.5% had extrathoracic involvement. Radiographic stages of disease according to the Scadding criteria were as follows: stage 0 (5.2%), stage I (33.7%), stage II (47.0%), stage III (8.4%), and stage IV (5.7%). Impaired respiratory function was observed in 45.6% patients and was mostly mild. Systemic treatment was administered in 58.6% of cases. Overall, 45.3% of patients experienced disease resolution.

CONCLUSION

The epidemiological and clinical characteristics of this cohort of patients with sarcoidosis from the Oporto region in northern Portugal revealed epidemiological and clinical characteristics that were generally similar to those described in other Western Europe populations and in the US ACCESS study. However, we found a higher proportion of patients who progressed to chronic forms.

Ventilatory disturbances in patients with intrathoracic sarcoidosis - a study from a functional and histological perspective

Background: Although sarcoidosis is commonly considered a restrictive disorder, more recent studies demonstrated opposite results. Objectives: To determine the prevalent functional pattern in patients with intrathoracic sarcoidosis and to assess the role of granulomatous inflammation in determining ventilatory disturbances. Methods: We included 144 consecutive newly diagnosed patients with sarcoidosis, who were evaluated by chest radiography, chest high resolution computer tomography, pulmonary function tests and dyspnea score. Additionally, endobronchial and transbronchial biopsies were performed to a subset of 78 patients. Results: We obtained a wide range of ventilatory abnormalities that characterize airways impairment: FEV1/FVC<70% - in 14 (9.7%) cases, low MMEF25-75 - in 69 (47.9%) patients, increased RV/TLC - in 65 (45.1%) subjects, while the subjects with restrictive defects was observed in a minority of cases - 7 (4.9%). Decreased DLCO was found in 100 (69.4%) individuals, in the majority of cases with mild changes. Patients in whom endobronchial biopsy showed granuloma had worse ventilatory results versus those in whom they have not been detected, with significant differences in FEV1 and MMEF25-75. We found significant correlations between radiological stage and pulmonary function tests. Dyspnea score (mMRC scale) in our cohort reflected lung volumes and DLCO modifications. Conclusion: The dominant functional abnormality in patients with intrathoracic sarcoidosis is obstruction, which affects the entire length of the bronchial tree causing a wide range of airways impairment and altered gas diffusion. These functional disturbances are prevalent from early stages of the disease and have a tendency to coexist with restriction as the disease advances. Granulomatous inflammation seems to have an important role in determining obstructive defect, even from "infra-radiological" stages. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 58-67).

Serum ACE Level in Sarcoidosis Patients with Typical and Atypical HRCT Manifestation

BACKGROUND

Sarcoidosis is an inflammatory disease that affects multiple organs. Before widespread use of computed tomography (CT), the severity of sarcoidosis was assessed based on chest X-ray abnormalities. HRCT can distinguish between active inflammatory changes and irreversible fibrosis. In this study, we analyzed different ACE levels in 148 patients diagnosed with sarcoidosis.

MATERIAL/METHODS

We categorized these patients based on their HRCT results into four groups: 1) patients diagnosed with chronic disease; 2) patients diagnosed with non-chronic disease; 3) patients who exhibited typical HRCT changes; and 4) patients who exhibited atypical HRCT changes. Afterward the mean ACE level of each group was calculated and compared.

RESULT

The HRCT scans of chronic sarcoidosis patients tended to show more atypical sarcoidosis patterns. Moreover, there was a reverse correlation between chronicity and ACE level (P-value <0.05).

CONCLUSIONS

HRCT is another modality which would be useful when the diagnosis of sarcoidosis is not definite.

Pulmonary Sarcoidosis

Sarcoidosis is a systemic disease, with lung involvement in almost all cases. Abnormal chest radiography is usually a key step for considering diagnosis. Lung impact is investigated through imaging; pulmonary function; and, when required, 6-minute walk test, cardiopulmonary exercise testing, or right heart catheterization. There is usually a reduction of lung volumes, and forced vital capacity is the most accurate parameter to reflect the impact of pulmonary sarcoidosis with or without pulmonary infiltration at imaging. Various evolution patterns have been described. Increased risk of death is associated with advanced pulmonary fibrosis or cor pulmonale, particularly in African American patients.

Biomarkers in sarcoidosis

INTRODUCTION

Numerous biomarkers have been evaluated for the diagnosis, assessment of disease activity, prognosis, and response to treatment in sarcoidosis. In this report, we discuss the clinical and research utility of several biomarkers used to evaluate sarcoidosis. Areas covered: The sarcoidosis biomarkers discussed include serologic tests, imaging studies, identification of inflammatory cells and genetic analyses. Literature was obtained from medical databases including PubMed and Web of Science. Expert commentary: Most of the biomarkers examined in sarcoidosis are not adequately specific or sensitive to be used in isolation to make clinical decisions. However, several sarcoidosis biomarkers have an important role in the clinical management of sarcoidosis when they are coupled with clinical data including the results of other biomarkers.

The Clinical Features of Sarcoidosis: A Comprehensive Review

Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.

Histopathology of Explanted Lungs From Patients With a Diagnosis of Pulmonary Sarcoidosis

BACKGROUND

Pathologic features of end-stage pulmonary sarcoidosis (ESPS) are not well defined; anecdotal reports have suggested that ESPS may mimic usual interstitial pneumonia (UIP). We hypothesized that ESPS has distinct histologic features.

METHODS

Twelve patients who received a diagnosis of pulmonary sarcoidosis and underwent lung transplantation were included. Control subjects were 10 age- and sex-matched lung transplant patients with UIP. Hematoxylin and eosin-stained tissue sections were examined for the following features: extent/pattern of fibrosis; presence and quantity (per 10 high-power fields) of fibroblast foci and granulomas; distribution and morphology of granulomas; and presence and extent of honeycomb change. Extent of fibrosis and honeycomb change in lung parenchyma was scored as follows: 1 = 1% to 25%; 2 = 26% to 50%; 3 = 51% to 75%; 4 = 76% to 100% of lung parenchyma.

RESULTS

Eight of 12 cases demonstrated histologic findings typical of ESPS. All showed well-formed granulomas with associated fibrosis distributed in a distinct lymphangitic fashion. Granulomas were present in hilar or mediastinal lymph nodes from six of six patients with ESPS and none of eight control subjects. The extent of fibrosis, honeycomb change, and fibroblast foci was significantly lower in ESPS cases compared with control cases. Two patients with remote histories of sarcoidosis showed histologic features of diseases other than ESPS (UIP and emphysema) without granulomas. Two patients with atypical clinical findings demonstrated nonnecrotizing granulomas combined with either severe chronic venous hypertension or UIP.

CONCLUSIONS

ESPS and UIP have distinct histopathologic features in the lungs. Patients with a pretransplant diagnosis of sarcoidosis may develop other lung diseases that account for their end-stage fibrosis.

Worsening of pulmonary sarcoidosis

PURPOSE OF REVIEW

Despite the frequent occurrence of worsening pulmonary symptoms in pulmonary sarcoidosis patients, there is little available information concerning this topic.

RECENT FINDINGS

In this review, we outline the various causes for these symptoms. We propose to partition the various causes for these symptoms into specific categories.

SUMMARY

We believe that these categories will provide the clinician a framework to evaluate pulmonary sarcoidosis patients with such symptoms in a rigorous way that may be useful in optimizing their care.

Bronchiectasis: Mechanisms and Imaging Clues of Associated Common and Uncommon Diseases

Bronchiectasis is permanent irreversible dilatation of the airways and occurs in a variety of pathologic processes. Recurrent infection and inflammation and the resulting chemical and cellular cascade lead to permanent architectural changes in the airways. Bronchiectasis can confer substantial potential morbidity, usually secondary to recurrent infection. In severe cases of bronchiectasis, massive hemoptysis can lead to death. Thin-section computed tomography is the most sensitive imaging modality for the detection of bronchiectasis; findings include bronchial diameter exceeding that of the adjacent pulmonary artery and lack of normal tapering of terminal bronchioles as they course toward the lung periphery. The authors will review various causes of bronchiectasis, including common causes, such as recurrent infection or aspiration, and uncommon causes, such as congenital immunodeficiencies and disorders of cartilage development. The authors will also present an approach emphasizing the distribution (apical versus basal and central versus peripheral) and concomitant findings, such as nodules, cavities, and/or lymphadenopathy, that can assist in narrowing the differential diagnosis. Although an adequate understanding of these underlying causes in conjunction with their specific imaging appearances will allow radiologists to more confidently determine the process causing this common radiologic finding, clinical history and patient demographic characteristics play an integral role in determining a pertinent and concise differential diagnosis.

Splenic and lymph nodal involvement in sarcoidosis mimicking lymphoma on fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography

Sarcoidosis is a multisystemic disease presenting with well-defined, bilateral, symmetric hilar and right paratracheal lymph node enlargement. Recently, fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) has been used to stage and detect occult site of active inflammation in sarcoidosis. F-18 FDG PET/CT has become a cornerstone imaging modality in the modern lymphoma management, which can present with generalized lymphadenopathy including mediastinal. We present a case series, which shows how sarcoidosis can be a “great mimic of lymphoma” on F-18 FDG PET/CT and how histopathology is essential in diagnosing sarcoidosis and ruling out lymphoma.

Colonic sarcoidosis: Unusual onset of a systemic disease

Sarcoidosis is a multisystem chronic inflammatory condition of unknown etiology that has the potential to involve every tissue in the body. Sarcoidosis in the gastrointestinal system, and particularly the colon, is very rare. Here, we report the case of a 57-year-old man with no previous diagnosis of sarcoidosis who presented with new onset of abdominal pain and constipation. A colonoscopy revealed that the abdominal pain was caused by an obstructing lesion in the cecum-ascending colon and lacked a clear histologic diagnosis. Radiologic investigation revealed concentric wall thickening of the cecum-ascending colon with multiple satellite lymphadenopathies, highly suggestive of a malignancy. The patient underwent a laparotomy and a right hemicolectomy was performed. A diagnosis of colonic sarcoidosis was made after the resected specimen was examined. Additionally, a chest computed tomography scan revealed lung involvement with atypical radiologic features in the absence of respiratory symptoms. Only histologic examination of the surgical specimen can yield a diagnosis of gastrointestinal sarcoidosis due to the non-specificity of endoscopic and radiologic findings.

Determining factors in diagnosing pulmonary sarcoidosis by endobronchial ultrasound-guided transbronchial needle aspiration

BACKGROUND

Although the role of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) in pulmonary sarcoidosis has previously been investigated, the determining factors in diagnosing sarcoidosis by EBUS-TBNA without rapid on-site evaluation (ROSE) are unclear.

METHODS

Patients with clinically and radiographically suspected sarcoidosis underwent EBUS-TBNA without ROSE in a prospective study. Presence of non-caseating epithelioid cell granulomas was pathologic evidence of sarcoidosis.

RESULTS

The EBUS-TBNA was performed in 120 patients, 111 of whom had confirmed sarcoidosis. For the patients with sarcoidosis (62 stage I, 49 stage II) EBUS-TBNA provided sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 93.69%, 100%, 100%, 56.25%, and 94.17%, respectively, in the diagnosis of sarcoidosis. Diagnostic yield of EBUS-TBNA for sarcoidosis was associated with disease stage, but not associated with serum angiotensin converting enzyme level, number of lymph node stations sampled per patient, or total number of passes performed per patient. At EBUS-TBNA, 284 mediastinal and hilar lymph nodes were aspirated in 111 patients. Multivariate logistic regression revealed that short-axis diameter and more than 1 needle pass per lymph node were independent risk factors associated with positive pathology. No major procedure-related complications were observed.

CONCLUSIONS

Endobronchial ultrasound-guided transbronchial needle aspiration is a safe procedure with high sensitivity for diagnosing sarcoidosis, having a higher diagnostic yield in stage I than stage II. To obtain a higher diagnostic yield of EBUS-TBNA in pulmonary sarcoidosis without ROSE, operators should select the largest mediastinal or hilar lymph node accessible and puncture with 3 to 5 passes.