The joint disease of sarcoidosis

The clinical characteristics of sarcoid arthropathy based on a prospective cohort study

BACKGROUND

Sarcoidosis is known as a Th1-mediated disease, which can mimic many primary rheumatologic diseases or sometimes co-exist with them. Clinical characteristics of sarcoid arthropathy are not well described and the studies reported in the literature so far are mostly based on data from referrals. The aim of this study was to evaluate the incidence and clinical characteristics of sarcoid arthropathy.

METHODS

All our patients were prospectively evaluated in our rheumatology outpatient center from 2011 to 2015. A total of 114 (32 male) patients with sarcoidosis who were admitted to our clinic were included in the study. Clinical, demographical, laboratory, radiological and histological data of these patients obtained during 4-year follow-up and treatment period were compiled and analyzed.

RESULTS

The mean patient age was 48.1 years (range, 20-82 years), and the mean disease duration was 40.5 months (range, 1-300 months). Sarcoid arthritis was observed in 71 (62.3%), and arthralgia in 106 (92.9%) patients. Out of the 71 patients with arthritis, 61 (85.9%) had involvement of ankle, 7 (9.8%) knee, 2 (2.8%) wrist, MCP and PIP joints, and 1 (1.4%) had shoulder periarthritis. Oligoarthritis (two to four joints) was the most common pattern followed by monoarthritis and polyarthritis. Arthritis and erytjhema nodosum and arthritis and female sex was found to be correlated (p = 0.03 and p = 0.001). Again, in patients with arthritis, even higher levels of CRP/ESR as well as ANA and RF positivity were observed (p = 0.03, p = 0.01, p = 0.01, and p = 0.02, respectively). A total of 11 patients had another rheumatic pathology concurrent with sarcoidosis.

CONCLUSIONS

Inflammatory arthritis occurs in a majority of patients with sarcoidosis. Acute arthritis with bilateral ankle involvement is the most common pattern of sarcoid arthropathy. Sarcoidosis can mimic many primary rheumatic diseases or may coexist with them. Sarcoidosis should be considered not only as a mimicker but also as a Th1-mediated primary rheumatologic pathology.

The prevalence of antinuclear antibodies in patients with sarcoidosis

Introduction. Sarcoidosis, which is a chronic inflammatory granulomatous disease, can mimic different rheumatologic diseases including connective tissue diseases. Antinuclear antibodies are the markers used for connective tissue diseases. Aim. To determine antinuclear antibody frequency and any possible correlation with clinical and laboratory data in sarcoidosis patients. Material and Method. Forty-two sarcoidosis patients, 45 rheumatoid arthritis patients, and 45 healthy volunteers who were followed up in rheumatology outpatient clinic were included in this study. Demographic, clinical, serological, and radiological data of all patients were recorded. Antinuclear antibodies were determined with indirect immunofluorescent method and 1/100 titration was accepted as positive. The cases that were ANA positive were evaluated with immunoblot method. Results. Average age of the 42 patients (10 males) with sarcoidosis was 45.2 (20–70 years), and average disease duration was 3.5 years. ANA positivity was detected in 12 (28.5%) patients with sarcoidosis (1/100 in 10 patients, 1/320 in two patients), in 19 of RA patients (42.2%), and in two of healthy volunteers in low titer (P < 0.001). In the subgroup analysis made by immunblot test, one patient had anticentromere antibody, one had anti-Ro antibody, one had anti-Scl-70 antibody, one had anti-dsDNA antibody, and eight patients were negative. The two patients who had anticentromere and anti-Scl-70 antibodies had also Sjögren's syndrome and scleroderma diagnosis, respectively. Discussion. The prevalence of ANA in patients with sarcoidosis was found to be significantly higher than healthy control group and lower than RA patients. This result shows that ANA may have an important role in the pathogenesis of sarcoidosis and also could be important in revealing the overlap syndromes of sarcoidosis-connective tissue diseases. Further studies with larger series are necessary in this subject.

The prevalence of sacroiliitis and spondyloarthritis in patients with sarcoidosis

Introduction. Sarcoidosis is a chronic granulomatous disease, which can involve different organs and systems. Coexistence of sarcoidosis and spondyloarthritis has been reported in numerous case reports. Purpose. To determine the prevalence of sacroiliitis and spondyloarthritis in patients previously diagnosed with sarcoidosis and to investigate any possible relation with clinical findings. Materials and Methods. Forty-two patients with sarcoidosis were enrolled in the study. Any signs and symptoms in regard to spondyloarthritis (i.e., existence of inflammatory back pain, gluteal pain, uveitis, enthesitis, dactylitis, inflammatory bowel disease, and psoriasis) were questioned in detail and biochemical tests were evaluated. Sacroiliac joint imaging and lateral heel imaging were performed in all patients. Results. Sacroiliitis was found in 6 of the 42 (14.3%) sarcoidosis patients and all of these patients were female. Common features of the disease in these six patients were inflammatory back pain as the major clinical complaint, stage 2 sacroiliitis as revealed by radiological staging, and the negativity of HLA B-27 test. These six patients with sacroiliitis were diagnosed with spondyloarthritis according to the criteria of ASAS and of ESSG. Conclusion. We found spondyloarthritis in patients with sarcoidosis at a higher percentage rate than in the general population (1-1.9%). Controlled trials involving large series of patients are required for the confirmation of the data.

Sarcoidois: is it only a mimicker of primary rheumatic disease? A single center experience

BACKGROUND

Sarcoidosis is known as a T helper 1 lymphocyte (Th1-Ly) mediated disease which can imitate or sometimes accompany many primary rheumatic diseases. The purpose of this study is to share the clinical, demographic and laboratory data of patients presenting with rheumatologic manifestations and diagnosed with sarcoidosis.

METHODS

A total of 42 patients (10 men) were included in the study. The patients were admitted to the rheumatology outpatient clinic for the first time with different rheumatic complaints between November 2011 and May 2013 and were diagnosed with sarcoidosis after relevant tests. Clinical, demographic, laboratory, radiological and histological data of these patients were collected during the 18-month follow-up period and then analyzed.

RESULTS

Mean patient age was 45.2 years (20-70 years) and mean duration of disease was 3.5 years (1 month-25 years). Evaluation of system and organ involvement revealed that 20 (47.6%) patients had erythema nodosum, 3 (7.1%) had uveitis, 1 (2.3%) had myositis, 1 (2.3%) had neurosarcoidosis, 32 (76.2%) had arthritis and 40 (95.2%) had arthralgia. Of the 32 patients with arthritis, 28 (87.5%) had involvement of the ankle, 3 (9.4%) had involvement of the knee and 1 (3.2%) had involvement of the wrist. No patient had cardiac involvement. Thoracic computed tomography scan showed stage 1, 2, 3 and 4 sarcoidosis in 12 (28.5%), 22 (52.4%), 4 (9.5%) and 4 (9.5%) patients, respectively. Histopathology of sarcoidosis was verified by endobronchial ultrasound, mediastinoscopy and skin and axillary biopsy of lymphadenopathies, which revealed noncaseating granulomas. Laboratory tests showed elevated serum angiotensin-converting enzyme in 15 (35.7%) patients, elevated serum calcium level in 6 (14.2%) patients and elevated serum 1,25-dihydroxyvitamin D concentrations in 2 (4.7%) patients. Serological tests showed antinuclear antibody positivity in 12 (28.5%) patients, rheumatoid factor positivity in 7 (16.6%) patients and anticyclic citrullinated antibody positivity in 2 (4.8%) patients.

CONCLUSION

Sarcoidosis can imitate or accompany many primary rheumatic diseases. Sarcoidosis should be considered not simply as an imitator but as a primary rheumatic pathology mediated by Th1-Ly. New studies are warranted on this subject.

Typical Jaccoud's arthropathy in a patient with sarcoidosis

Jaccoud's arthropathy (JA) is a deforming, non-erosive form of arthritis initially described in rheumatic fever but recently observed more frequently in patients with systemic lupus erythematosus. However, cases of JA have been described in association with other diffuse connective tissue diseases, neoplasias, and infection. We describe a rare case of sarcoidosis in a female subject who developed JA in her hands later in the course of the disease.

Chronic sarcoid arthritis presenting as an intra-articular knee mass

Patients may present with a primary complaint of intra-articular knee masses causing mechanical symptoms of snapping or locking. If the history, physical examination, laboratory tests, and imaging studies point to a benign process, acceptable treatment consists of arthroscopic excision and postoperative pathology analysis. As reported in several case series, the final diagnosis can be pigmented villonodular synovitis, localized nodular synovitis, hemangioma, lipoma, or rheumatoid nodules. In this case presentation, a 39-year-old man with no previous medical conditions and a negative preoperative chest radiograph underwent arthroscopic surgery for a single intra-articular knee mass. The unexpected diagnosis, after pathology review and further medical work-up, was arthritis secondary to chronic sarcoidosis.

Osseous destruction and rupture of the extensor tendon caused by sarcoidosis of the finger

We describe a woman with osseous destruction and rupture of the extensor tendon as a result of sarcoidosis in the left third finger with no evidence of systemic involvement. The tendon was repaired and she was successfully treated with prednisone.

Sarcoid arthritis: clinical characteristics, diagnostic aspects, and risk factors

OBJECTIVES

(a) To describe the clinical characteristics of acute sarcoid arthritis and the diagnostic value of its presenting clinical features; (b) to evaluate whether disease onset is seasonal; and (c) to evaluate whether smoking behaviour or the presence of HLA class II alleles is a risk factor for the disease.

METHODS

579 consecutive patients with recent onset arthritis who had been newly referred to a rheumatology outpatient clinic were included in a prospective cohort study. The presenting clinical features, the smoking behaviour, and the results of HLA-DQ and HLA-DR DNA typing of 55 patients with sarcoid arthritis, 524 patients with other arthritides of recent onset, and samples of the normal population were compared.

RESULTS

In all cases the disease showed a self limiting arthritis and overall good prognosis. The diagnostic ability of a combination of four clinical features--symmetrical ankle arthritis, symptoms of less than two months, age below 40 years, and erythema nodosum--was exceptionally high. When test positivity is defined as the presence of at least three of four criteria the set rendered a sensitivity of 93%, a specificity of 99%, a positive predictive value of 75%, and a negative predictive value of 99.7%. The disease clustered in the months March-July. The disease was negatively associated with smoking (odds ratio (OR) 0.09; 95% confidence interval (95% CI) 0.02 to 0.37) and positively associated with the presence of the DQ2 (DQB1*0201)-DR3 (DRB1*0301) haplotype (OR 12.33; 95% CI 5.97 to 25.48).

CONCLUSION

The disease entity acute sarcoid arthritis has highly diagnostic clinical features. The seasonal clustering, the protective effect of smoking, and the association with specific HLA class II antigens support the hypothesis that it results from exposure of susceptible hosts to environmental agents through the lungs.

Management of a patient with sarcoid calcaneitis and dactylitis

Dactylitis and calcaneitis developed in a patient with untreated sarcoidosis of the skin and lungs. Radiographs showed a defect in the second phalanx of the left middle finger. Radiographs of the feet were normal, but magnetic resonance imaging demonstrated a defect in the left calcaneus. Methylprednisolone therapy (1 g per day for 3 consecutive days) induced a dramatic improvement within 48 hours. Low-dose oral glucocorticoid therapy was given subsequently. One year later, a recurrent episode of dactylitis responded promptly to the same regimen. Maintenance therapy was given, and no further recurrences were noted during the four-year follow-up. Sarcoid bone lesions are uncommon and arise selectively in the small bones of the hands and feet. Involvement of the calcaneus is exceedingly rare, and its treatment is not standardized. In our patient, glucocorticoid therapy combined with methotrexate and hydroxychloroquine were effective in controlling the disease.

Sarcoid and erythema nodosum arthropathies

Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized in affected organs by an accumulation of activated T lymphocytes and macrophages. Musculoskeletal manifestations of sarcoidosis include acute and chronic arthritis and muscular and osseous sarcoidosis. In certain populations, acute sarcoidosis often presents with constitutional symptoms, polyarthritis and erythema nodosum (Löfgren's syndrome). Erythema nodosum, often with joint symptoms, also occurs in association with several other conditions including infections, medications and other underlying diseases. The diagnosis of sarcoidosis should be based on a tissue biopsy, but a patient with typical Löfgren's syndrome may not require biopsy proof. Among the long list of biochemical markers that have been suggested as aids for diagnosis and monitoring of sarcoidosis, calcium in serum and urine and angiotensin-converting enzyme in serum are well-established clinical tools. Serum angiotensin-converting enzyme can be used for monitoring disease activity in the individual patient, but because of lack of sensitivity and specificity its diagnostic value is rather low. Non-steroidal anti-inflammatory agents usually effectively alleviate acute sarcoid arthritis and joint symptoms associated with erythema nodosum. In severe acute arthritis and in chronic arthritis, corticosteroids may be required to control the symptoms. In patients requiring persistent corticosteroid therapy, antimalarial agents and methotrexate constitute therapeutic alternatives.

The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital

Sarcoidosis is an enigmatic disease with extremely variable manifestations in pattern, severity and course. Since Longcope and Freiman's descriptive monograph in 1952 (50) summarizing the clinical findings of the first half of this century, new dimensions of assessing the disease and treatment have been added. The impact of corticosteroids is central. The present review extends the studies to the second half of this century. Earlier diagnosis is facilitated and treatment often reverses many of the disease manifestations and improves the quality and extent of life for the patient. The management issues and guidelines outlined in this paper for both intrathoracic and extrathoracic disease are based on several longitudinal studies of the sarcoidosis patients summarized here, and 50 years of clinical experience by the senior author (CJJ) at Johns Hopkins Hospital, a tertiary referral center with an active Sarcoid Clinic. Case reports are presented in the appendix. It is clear that corticosteroids are the most effective therapeutic agent for sarcoidosis, usually with impressive and prompt response. This represents the dramatic difference in this disease after 1950. No more specific or effective immunosuppressive or antiinflammatory agents have been identified. Undesirable side effects are minimal if excessive doses are avoided. The effectiveness of "steroid-sparing agents" such as methotrexate is uncertain. Although irreversible tissue damage from the disease may limit the effectiveness of treatment, benefits of corticosteroids greatly exceed the negative side effects. Since spontaneous remissions without treatment do occur, a period of observation of 2 years are more is warranted if the patient is relatively asymptomatic. Gradual radiographic progression for 2 or more years, even without major symptoms or reduction in pulmonary function, indicates the need for a trial of corticosteroid treatment, especially in white patients where symptoms may lag behind the radiographic changes. Relapses as treatment is withdrawn are frequent, especially in African-American patients, who tend to have more severe and more prolonged disease than white patients. A minimum of 1 year of treatment is recommended unless no improvement is noted after 3 months. Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease. Periodic attempts at tapering are justified. Repeated relapses may indicate the need for life-long treatment. When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents. Many agents related to sarcoidosis require further research. The most important question facing sarcoid researchers today is etiology. It is difficult to design specific therapy when the fundamental causes and disease mechanisms are not established. Rather than being a single disease with a single cause, it is possible that a number of genetic factors and environmental or infectious agents may result in an immune response that is manifested as sarcoidosis. Understanding basic causal mechanisms may help explain the varied disease manifestations and aid in designing curative treatments. Such etiologic questions should be explored from both a basic science and an epidemiologic approach. Therapeutic trials of new drugs such as pentoxyfylline and possibly thalidomide are needed to address their potential as well as limitations of steroid therapy. Finally, for patients who have progressed to organ failure, the problems of sarcoid recurrence in transplanted tissue, increased allograft rejection, and long-term prognosis of solid organ transplants have yet to be resolved. (ABSTRACT TRUNCATED)

Myositis and eosinophilia in a patient with sarcoidosis

We present a patient with muscle manifestations of sarcoidosis associated with raised creatine kinase levels, eosinophilia and interstitial lung disease. She had significant improvement on prednisolone 30 mg per day.

Skeletal Involvement in Sarcoidosis: A Case Report

A patient is described in whom sarcoidosis caused a pathological fracture of the middle phalanx of the little finger. A bone scan showed increased uptake. She was treated by resection of the diseased area and bone grafting, which led to bone healing. The bony manifestations of sarcoidosis are reviewed.

Synovitis with non-specific histological changes in synovium in chronic sarcoidosis

Polyarthritic episodes in seven patients during the course of chronic sarcoidosis involved the knees and less frequently other joints. Synovial effusions were non-inflammatory or mildly inflammatory. Needle synovial biopsies 10 days to seven weeks after the onset of joint symptoms have revealed varying patterns, including mild lining cell proliferation, occasional vascular congestion, diffuse infiltrates with lymphocytes and histiocytes, but no granulomas. These studies show distinctly less inflammation than in rheumatoid arthritis. Granulomas need not be identifiable in synovium in all chronic sarcoidosis with arthritis.

Sarcoid dactylitis

Dactylitis is a rare rheumatological complication of sarcoidosis. It may be accompanied by underlying bone changes, and management is often difficult. We report these 4 cases of dactylitis in which there have been significant bone changes and associated management problems. One case is further complicated by biopsy-proved sarcoid synovitis, uncommon in a British resident, and 2 cases show destructive bone changes, which have rarely been reported in sarcoidosis.

Sarcoidosis presenting with severe thrombocytopenia and arthritis

In this case report a patient with biopsy-proven sarcoidosis is described, presenting with joint symptoms and severe thrombocytopenia, due to immune-mediated platelet destruction.

Comparison of the manifestations of acute sarcoid arthritis with and without erythema nodosum. Immunopathogenic significance

This retrospective study deals with the clinical, radiological and biological data of 16 patients suffering from sarcoid arthritis with (n = 11) and without (n = 5) erythema nodosum (EN). The average age and sex distribution were the same and we failed to demonstrate any significant difference between the two groups. However, it is worth noting that the average number of the joints affected was less in a patient with (3.0) than in a patient without EN (4.8) and that persistence of polyalgias was associated with EN. Nevertheless, one may assume that the current series corroborates the common immunological pathophysiology of these two pictures of sarcoid arthritis.

Chronic sarcoid synovitis in the Caucasian: an arthroscopic and histological study

Chronic synovitis is a rare complication of sarcoidosis, virtually confined to the black population. Synovial histology may be nonspecific or show typical sarcoid granulomata. We report 2 cases of chronic sarcoid synovitis in Caucasians. Histology showed typical granulomata in one patient, whose distinctive arthroscopic appearance is discussed.

Extensive phalangeal cystic lesions: sarcoidosis limited to the hands and feet?

A young black man is presented with a 33-month course of insidious but eventually striking hand deformity and limitation of motion in the absence of any other symptoms. Radiologic and histologic findings of the digits support the diagnosis of sarcoidosis, though physical, laboratory, and chest x-ray examination show no evidence of this multisystem disease.