Intimal granulomatous angiitis in sarcoid pulmonary vasculitis: worth remembering

Neurosarcoidosis complicated by systemic vasculitis

A 62-year-old woman with medical history of hypertension, diabetes mellitus, coronaropathy, neurosarcoidosis, s/p craniotomy (brain mass resection) presented with worsening headaches, generalized weakness, vomiting, and hyporexia over two weeks. Brain MRI showed worsening of the known right cavernous sinus mass, vasculitis panel was negative. Patient received IV steroids; during hospitalization, she had a syncopal episode, CT Head was normal, EKG showed new T-wave inversion with troponin elevation. She experienced worsening mentation, left-sided hemiparesis; CT head showed acute hypodensity in the right MCA territory, CTA revealed bilateral distal M1 segment stenosis. Ineligible for thrombolysis/thrombectomy, she was started on aspirin. Echocardiograms were normal. Ischemic signs in her right toes prompted an aortogram showing arterial obstructions in the RLE, necessitating SFA stent placement, and clopidogrel. IV cyclophosphamide was added without additional vascular complications. This case illustrates neurosarcoidosis complicated by systemic vasculitis of medium-large vessels, responding to aggressive immunosuppression with glucocorticoids and cytotoxic agents.

PECULIARITIES OF THE COURSE OF PULMONARY SARCOIDOSIS AGAINST THE BACKDROP OF SYSTEMIC VASCULITIS AND THE INFLUENCE OF A SET OF TRIGGERS

The review focused on managing patients with pulmonary sarcoidosis against the backdrop of systemic vasculitis and the influence of a set of triggers which can be manifested by basal lymphadenopathy, infiltration of lung tissue, and damage to the eyes and skin, histologically characterized by the formation of non-caseous epithelioid-cell granulomas. A clinical case for managing patients with pulmonary sarcoidosis against systemic vasculitis was proposed. In this clinical case, it is crucial to consider the multifactorial nature of the pathology in the patient with the dominance of exogenous triggers (autoimmune pathology, sensitization, exposure to infectious factors, chemicals, stress), which can trigger the development of PS, complicate the course of accompanying pathology, and deteriorate the quality of life. Additionally, diagnosing PS in patients with other lung pathology, such as bronchial asthma, is often tricky and can affect the course of the underlying disease. Long-term immunosuppressive therapy may cause a secondary infection (viral, bacterial, fungal), which may require adequate etiotropic therapy.

Cystic lung in sarcoidosis: Clinico-radiologic characteristic and evolution

BACKGROUND AND OBJECTIVE

Sarcoidosis can manifest with atypical findings on chest computed tomography (CT). Cysts are a rare manifestation of lung sarcoidosis. The aim of the study was to describe a series of patients with cystic sarcoidosis and their clinical-radiological characteristics and progression.

METHODS

In this retrospective, bicentric study we recruited all patients affected by sarcoidosis with lung cystic lesions at chest CT. We collected clinical characteristics, pulmonary tests and tracked number, distribution and size of the cysts at diagnosis and at the last evaluation.

RESULTS

Twelve patients (6 males, median age 53 years) were identified (prevalence: 1.9%; 95% Confidence Interval: 0.8%-2.9%). All patients presented multiple cystic lesions (median number: 14 [range: 2-216]) with a bilateral distribution in 10/12, micronodules and nodules in 11/12 and fibrotic lesions in 4/12. Seven patients had normal lung function test, three had an obstructive syndrome, one had a restrictive syndrome and one had coexistence of both. During follow-up (median: 10 years [range 1-16 years]), an increase of the number of cysts was observed in four patients. At last evaluation, 3/12 patients experienced a decline of forced vital capacity >10% and 3/12 patients a decline of diffusing capacity for carbon monoxide (DLCO) >10%. A lower DLCO at diagnosis, and the presence of nodules or fibrotic lesions on CT were associated with an increase in the number of cysts.

CONCLUSION

Cystic lung lesions are rare in patients with sarcoidosis and do not influence long term prognosis.

Sarcoidosis-associated pulmonary hypertension due to pulmonary arteries stenosis - a case report

BACKGROUND

Sarcoidosis-associated pulmonary hypertension (SAPH) is listed in Group 5 of the clinical classification of pulmonary hypertension, due to its complex and multifactorial pathophysiology. The most common cause of SAPH development is advanced lung fibrosis with the associated destruction of the vascular bed, and/or alveolar hypoxia. However, a substantial proportion of SAPH patients (up to 30%) do not have significant fibrosis on chest imaging. In such cases, the development of pulmonary hypertension may be due to the lesions directly affecting the pulmonary vasculature, such as granulomatous angiitis, pulmonary veno-occlusive disease, chronic thromboembolism or external compression of vessels by enlarged lymph nodes. Based on the case of a 69-year-old female who developed SAPH due to pulmonary arteries stenosis, diagnostic difficulties and therapeutic management are discussed.

CASE PRESENTATION

The patient, non-smoking female, diagnosed with stage II sarcoidosis twelve years earlier, presented with progressive dyspnoea on exertion, dry cough, minor haemoptysis and increasing oedema of the lower limbs. Computed tomography pulmonary angiography (CTPA) showed complete occlusion of the right upper lobe artery and narrowing of the left lower lobe artery, with post-stenotic dilatation of the arteries of the basal segments. The vascular pathology was caused by adjacent, enlarged lymph nodes with calcifications and fibrotic tissue surrounding the vessels. Pulmonary artery thrombi were not found. The patient was treated with systemic corticosteroid therapy and subsequently with balloon pulmonary angioplasty. Partial improvement in clinical status and hemodynamic parameters has been achieved.

CONCLUSIONS

An appropriate screening strategy is required for early detection of pulmonary hypertension in sarcoidosis patients. Once SAPH diagnosis is confirmed, it is crucial to determine the appropriate phenotype of pulmonary hypertension and provide the most effective treatment plan. Although determining SAPH phenotype is challenging, one should remember about the possibility of pulmonary arteries occlusion.

Sarcoidosis-Associated Pulmonary Hypertension

Sarcoidosis-associated pulmonary hypertension (SAPH) is a very severe complication of the disease, largely impacting its morbidity and being one of its strongest predictors of mortality. With the recent modifications of the hemodynamic definition of pulmonary hypertension (mean arterial pulmonary pressure >20 instead of <25 mmHg,) its prevalence is presently not precisely known, but it affects from 3 to 20% of sarcoid patients; mostly, although not exclusively, those with an advanced, fibrotic pulmonary disease. Its gold-standard diagnostic tool remains right heart catheterization (RHC). The decision to perform it relies on an expert decision after a non-invasive work-up, in which echocardiography remains the screening tool of choice. The mechanisms underlying SAPH, very often entangled, are crucial to define, as appropriate and personalized therapeutic strategies will aim at targeting the most significant ones. There are no recommendations so far as to the indications and modalities of the medical treatment of SAPH, which is based upon the opinion of a multidisciplinary team of sarcoidosis, pulmonary hypertension and sometimes lung transplant experts.

Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension-A Challenging Mystery

Sarcoidosis has been a well-recognised risk factor for pulmonary hypertension (PH) for a long time, but still, the knowledge about this concatenation is incomplete. Sarcoidosis-associated PH (SAPH) is an uncommon but serious complication associated with increased morbidity and mortality among sarcoidosis patients. The real epidemiology of SAPH remains unknown, and its pathomechanisms are not fully explained. Sarcoidosis is a heterogeneous and dynamic condition, and SAPH pathogenesis is believed to be multifactorial. The main roles in SAPH development play: parenchymal lung disease with the destruction of pulmonary vessels, the extrinsic compression of pulmonary vessels by conglomerate masses, lymphadenopathy or fibrosing mediastinitis, pulmonary vasculopathy, LV dysfunction, and portal hypertension. Recently, it has been recommended to individually tailor SAPH management according to the predominant pathomechanism, i.e., SAPH phenotype. Unfortunately, SAPH phenotyping is not a straightforward process. First, there are gaps in our understanding of undergoing processes. Second, the assessment of such a pivotal element as pulmonary vasculature on a microscopic level is non-feasible in SAPH patients antemortem. Finally, SAPH is a dynamic condition, multiple phenotypes usually coexist, and patients can switch between phenotypes during the course of sarcoidosis. In this article, we summarise the basic knowledge of SAPH, describe SAPH phenotypes, and highlight some practical problems related to SAPH phenotyping.