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Harper LJ, Farver CF, Yadav R, Culver DA. A framework for exclusion of alternative diagnoses in sarcoidosis. J Autoimmun 2024:103288. [PMID: 39084998 DOI: 10.1016/j.jaut.2024.103288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.
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Affiliation(s)
- Logan J Harper
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
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2
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Oliveira DS, Branco M, Silva R, Meireles E, Ruano L. Sarcoidosis presenting as encephalitis: case report and review of the literature. Neurol Sci 2023; 44:4557-4561. [PMID: 37548756 DOI: 10.1007/s10072-023-06980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Daniela Santos Oliveira
- Neurology Department, Centro Hospitalar de Entre Douro E Vouga, Rua Dr. Cândido Pinho, No. 5, 4520‑220, Santa Maria da Feira, Portugal.
| | - Mariana Branco
- Neurology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Renata Silva
- Neurology Department, Unidade Local de Saúde Do Alto Minho, Estrada de Santa Luzia, 4904-858, Viana Do Castelo, Portugal
| | - Elsa Meireles
- Intensive Care Unit, Centro Hospitalar de Entre Douro E Vouga, Rua Dr. Cândido Pinho, No. 5, 4520‑220, Santa Maria da Feira, Portugal
| | - Luís Ruano
- Neurology Department, Centro Hospitalar de Entre Douro E Vouga, Rua Dr. Cândido Pinho, No. 5, 4520‑220, Santa Maria da Feira, Portugal
- Instituto de Saúde Pública, Universidade Do Porto, Rua das Taipas, No. 135, 4050‑600, Porto, Portugal
- Laboratório Para a Investigação Integrativa E Translacional Em Saúde Populacional (ITR), Rua das Taipas, No. 135, 4050‑600, Porto, Portugal
- Faculdade de Medicina da Universidade Do Porto, Alameda Prof. Hernâni Monteiro, 4200‑319, Porto, Portugal
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Sedeta E, Ilerhunmwuwa NP, Hindu Pahlani R, Aiwuyo H, Wasifuddin M, Uche I, Hakobyan N, Perry J, Terebelo S. A Diagnostic Dilemma: A Case of Neurosarcoidosis Without Systemic Sarcoidosis. Cureus 2023; 15:e42844. [PMID: 37664296 PMCID: PMC10472481 DOI: 10.7759/cureus.42844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Sarcoidosis is a multisystem granulomatous disorder of unknown etiology characterized by non-caseating granulomas in involved organs. Approximately 10% of patients with sarcoidosis exhibit central nervous system involvement. However, the occurrence of isolated neurosarcoidosis without concurrent systemic signs is very rare, affecting less than 1% of patients. We report a case of isolated neurosarcoidosis in a previously healthy patient who initially presented with a single episode of seizure and loss of consciousness. Brain MRI showed T2/fluid-attenuated inversion recovery (FLAIR) hyperintense extra-axial soft tissue mass over the left cerebral convexity measuring approximately 14 mm in maximum depth. Excisional biopsy of the brain mass showed chronic non-caseating granulomatous inflammation with epitheloid cells that was consistent with sarcoidosis. Treatment with high dose-steroids led to significant clinical improvement. At a two-year follow-up, there were no signs of systemic disease or recurrence of the meningeal mass. This case emphasizes the rarity of such presentation, diagnostic difficulties, and the importance of high suspicion and timely management to prevent debilitating neurologic complications.
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Affiliation(s)
- Ephrem Sedeta
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | | | | | - Henry Aiwuyo
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | | | - Ifeanyi Uche
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Narek Hakobyan
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Jamal Perry
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Sima Terebelo
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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Shen J, Lackey E, Shah S. Neurosarcoidosis: Diagnostic Challenges and Mimics A Review. Curr Allergy Asthma Rep 2023; 23:399-410. [PMID: 37256482 PMCID: PMC10230477 DOI: 10.1007/s11882-023-01092-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis. RECENT FINDINGS Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.
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Affiliation(s)
- Jeffrey Shen
- Duke Department of Medicine, Division of Rheumatology and Immunology, Duke University, 40 Duke Medicine Cir Clinic 1J, Durham, NC, 27710, USA.
| | - Elijah Lackey
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
| | - Suma Shah
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
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Tuna T, Ozkaya S, Dirican A, Erkan L. An intracerebral mass: tuberculosis or sarcoidosis? BMJ Case Rep 2013; 2013:bcr-2013-009570. [PMID: 23645654 DOI: 10.1136/bcr-2013-009570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sarcoidosis is an idiopathic, chronic granulomatous disease and it can affect almost any organ. In autopsy series, it has been reported that the central nervous system involvement has occurred in 5-16% of the patients with sarcoidosis, while the neurological symptoms have occurred only in 3-9% of them. A 40-year-old female patient was admitted to the hospital with complaints of aphasia, balance disorder and drowsiness. An intracerebral mass was detected on cranial CT scans and neurosarcoidosis was diagnosed with clinical, radiological and histopathological findings.
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Affiliation(s)
- Tibel Tuna
- Department of Pulmonary Medicine, Samsun Chest Diseases and Thoracic Surgery Hospital, Samsun, Turkey
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Abstract
Sarcoidosis is a multisystem granulomatous disorder that most commonly presents with pulmonary involvement. The diagnosis is suggested on the basis of clinical and radiologic manifestations and is supported by the histological demonstration of noncaseating granulomas in affected tissues. Different imaging modalities, including chest radiography, X-rays, computed tomography, magnetic resonance imaging, and (67) Ga scintigraphy are currently employed to help diagnose and help plan treatment strategy in sarcoidosis patients. Here, we discuss the potential role of positron emission tomography in the diagnosis, assessment of disease activity, and management of patients with sarcoidosis. We also point out some of the limitations of this technique.
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Affiliation(s)
- Vivek Jain
- GW Medical Faculty Associates, Division of Pulmonary, Critical Care, and Sleep Medicine, George Washington University Hospital, Washington, DC, USA.
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The challenge of profound hypoglycorrhachia: two cases of sarcoidosis and review of the literature. Clin Rheumatol 2011; 30:1631-9. [PMID: 21870035 DOI: 10.1007/s10067-011-1834-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 08/15/2011] [Indexed: 10/17/2022]
Abstract
We report two cases of sarcoidosis which were initially misdiagnosed due to profound hypoglycorrhachia. Sarcoidosis is a systemic inflammatory disorder which can mimick other entities and has a vast array of presentations including altered mentation and signs of increased intracranial pressure. Though hypoglycorrhachia has been described previously, these two cases are unique in not only the level of hypoglycorrhachia but also the diagnostic challenge presented. We propose that sarcoidosis should be in the differential of all cases of CNS diseases with any level of hypoglycorrhachia.
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Oldroyd A, Dawson T, Nixon J. A case of neurosarcoidosis that presented with symptoms of Guillain-Barré syndrome. BMJ Case Rep 2011; 2011:bcr0220113800. [PMID: 22700608 PMCID: PMC3079465 DOI: 10.1136/bcr.02.2011.3800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case report is of a patient who presented with clinical features suggestive of Guillain-Barré syndrome, who on investigation was found to have neurosarcoidosis. The patient was treated with high-dose corticosteroids and physiotherapy and he improved in condition substantially over 1 month. Neurosarcoidosis and its various presentations are discussed in the literature review.
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Affiliation(s)
- A Oldroyd
- Department of Medicine, Lancaster University, Lancaster, UK.
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Mariani M, Shammi P. Neurosarcoidosis and Associated Neuropsychological Sequelae: A Rare Case Of Isolated Intracranial Involvement. Clin Neuropsychol 2010; 24:286-304. [DOI: 10.1080/13854040903347942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Although neurosarcoidosis seems to occur in only 5% to 10% of patients who have sarcoidosis, it may lead to significant complications. The diagnosis of neurosarcoidosis usually relies on indirect information from imaging and spinal fluid examination. Although MR imaging remains the most sensitive technique for detecting neurologic disease, other tests, including positron emission tomography scanning and cerebral spinal fluid examination, can provide important information. The role of immunosuppressive agents such as methotrexate, cyclophosphamide, and azathioprine has been expanded, and these agents should be considered for the treatment of some manifestations of neurosarcoidosis. Reports of the antitumor necrosis factor agent infliximab suggest that this drug can be helpful for patients who have neurosarcoidosis.
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Affiliation(s)
- Elyse E Lower
- Interstitial Lung Disease and Sarcoidosis Center, University of Cincinnati Medical Center, 3235 Eden Avenue, Cincinnati, OH 45267, USA.
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13
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Abstract
The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.
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Dakdouki GK, Kanafani ZA, Ishak G, Hourani M, Kanj SS. Intracerebral Bleeding in a Patient With Neurosarcoidosis While on Corticosteroid Therapy. South Med J 2005; 98:492-4. [PMID: 15898534 DOI: 10.1097/01.smj.0000146621.42198.31] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neurosarcoidosis can have variable clinical manifestations. Intracerebral bleeding is very rare in the setting of neurosarcoidosis and has been reported only twice. In this report, we describe a patient with neurosarcoidosis who had intracerebral bleeding while on corticosteroid therapy, despite apparent clinical improvement.
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Affiliation(s)
- Ghenwa K Dakdouki
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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Abstract
Sarcoidosis is an inflammatory multisystem disorder of unknown cause. Practically no organ is immune to sarcoidosis; most commonly, in up to 90% of patients, it affects the lungs. The nervous system is involved in 5-15% of patients. Neurosarcoidosis is a serious and commonly devastating complication of sarcoidosis. Clinical diagnosis of neurosarcoidosis depends on the finding of neurological disease in multisystem sarcoidosis. As the disease can present in many different ways without biopsy evidence, solitary nervous-system sarcoidosis is difficult to diagnose. Corticosteroids are the drug of first choice. In addition, several cytotoxic drugs, including methotrexate, have been used to treat sarcoidosis. The value of new drugs such as anti-tumour necrosis factor alpha will be assessed. In this review we describe the clinical manifestations of neurosarcoidosis, diagnostic dilemmas and considerations, and therapy.
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Affiliation(s)
- Elske Hoitsma
- Department of Neurology, Sarcoidosis Management Center, University Hospital Maastricht, Netherlands.
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Abstract
MRI has become of great importance in the study of several aspects of sarcoidosis. The main development has taken place in the assessment of neurosarcoidosis, but MRI may be also useful in the evaluation of sarcoidosis of the bone, muscle, heart, and intrathoracic. Nuclear imaging in sarcoidosis acquired a great expansion with the introduction of (67)gallium scanning as a marker of activity. Although its current use has decreased, it is still very helpful in particular situations of the disease. Other more recently introduced nuclear imaging techniques may have a role in the evaluation of cardiac sarcoidosis and in the assessment of the extension of the disease.
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Affiliation(s)
- Juan Mañá
- University of Barcelona, Department of Internal Medicine, Bellvitge Hospital, Barcelona, Spain.
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Abstract
Sarcoidosis is a multisystemic disorder characterised by the presence of multiple noncaseating granulomas. Clinically recognisable nervous system involvement occurs in 5-16% of patients with sarcoidosis. However, the incidence of subclinical neurosarcoidosis may be higher. The following article presents a review of the disease, including its pathophysiology, clinical and radiological characteristics and treatment. Neurosarcoidosis should be included in the differential diagnosis of infectious and noninfectious neurological syndromes.
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Affiliation(s)
- F C Vinas
- Department of Neurosurgery, Halifax Medical Center, 311 N Clyde Morris Blvd., Suite 310, Daytona Beach, FL, USA.
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Affiliation(s)
- A O Dare
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, Buffalo 14209-1194, USA
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Abstract
Sarcoidosis in childhood is seldom reported. Most cases are observed in older children and preadolescents as bilateral pulmonary disease and eye lesions. Arthritic features are more likely to be observed in infants and children younger than 4 years of age who do not develop pulmonary disease. Neurosarcoidosis is exceptional in this age group and seldom suspected when the neurologic symptoms are present. The authors report a pediatric patient with systemic sarcoidosis who developed a severe but silent neurologic involvement. Numerous masslike lesions were discovered on systematic cranial magnetic resonance imaging. The authors recommend a complete screening of extrapulmonary manifestations in children with sarcoidosis. The proper management of patients with incidentally discovered neurosarcoidosis has yet to be established.
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Affiliation(s)
- I Koné-Paut
- Department of Pediatrics, Hôpital Nord, Marseilles, France
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Krejchi D, Caldemeyer KS, Vakili ST, Pritz MB. Neurosarcoidosis resembling meningioma: MRI characteristics and pathologic correlation. J Neuroimaging 1998; 8:177-9. [PMID: 9664858 DOI: 10.1111/jon199883177] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 37-year-old woman had visual changes. Magnetic resonance imaging showed an extraaxial mass in the anterior clinoid region that was presumed to be meningioma. There was no evidence of systemic or leptomeningeal disease. Pathologic findings were consistent with sarcoidosis. Isolated mass-like neurosarcoidosis, without systemic or leptomeningeal disease is difficult to diagnose preoperatively.
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Affiliation(s)
- D Krejchi
- Department of Radiology, Indiana University School of Medicine, Indianapolis, USA
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Abstract
In many neurologic diseases, activated leukocytes enter the nervous system and initiate a chronic inflammatory process. Understanding how the cellular and humoral responses are associated with pathogenesis is essential for the formulation of a unifying model of central and peripheral nervous system inflammation. Based on such a model, immunotherapeutic strategies and protocols can be designed.
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