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Moore CE, Marshall L. Diagnosing Extrapulmonary Sarcoidosis and the Implications of Diagnosis on Military Service. Cureus 2023; 15:e47115. [PMID: 38021643 PMCID: PMC10647944 DOI: 10.7759/cureus.47115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Sarcoidosis is a systemic inflammatory disease that can cause granulomatous infiltration of almost all organs and tissues which allows for a wide variety of presentations that may overlap with other disease processes. Renal sarcoidosis is a much rarer site of extrapulmonary involvement and may present as hypercalcemia, tubular or glomerular dysfunction, and/or granulomatous interstitial nephritis. Prompt diagnosis of sarcoidosis is crucial for initiating appropriate treatment and avoiding organ dysfunction. Herein, we describe a case of an armed forces service member who developed extrapulmonary sarcoidosis and renal sarcoidosis with acute complications refractory to glucocorticoids requiring adalimumab. The case highlights and emphasizes a rare manifestation of extrapulmonary sarcoidosis, the importance of avoiding premature closure of the differential diagnosis to avoid diagnostic delay and treatment imitation, and the unique clinical reasoning that occurs in active-duty personnel where diagnoses and subsequent treatments can have career implications and affect the ability of the service member to maintain the ability to deploy worldwide.
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Affiliation(s)
- Caroline E Moore
- Internal Medicine, Naval Medical Center San Diego, San Diego, USA
| | - Landry Marshall
- Internal Medicine, Naval Medical Center Camp Lejeune, Camp Lejeune, USA
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2
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Toriola SL, Satnarine T, Zohara Z, Adelekun A, Seffah KD, Salib K, Dardari L, Taha M, Dahat P, Penumetcha SS. Recent Clinical Studies on the Effects of Tumor Necrosis Factor-Alpha (TNF-α) and Janus Kinase/Signal Transducers and Activators of Transcription (JAK/STAT) Antibody Therapies in Refractory Cutaneous Sarcoidosis: A Systematic Review. Cureus 2023; 15:e44901. [PMID: 37818515 PMCID: PMC10561529 DOI: 10.7759/cureus.44901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023] Open
Abstract
The widely accepted standard of care for chronic cutaneous sarcoidosis is corticosteroids. However, when this treatment is shown to be refractory, other interventions must be considered. In this review, we report the current progress of clinical studies on various monoclonal antibody therapies and their future potential as primary interventions for refractory cutaneous sarcoidosis. In this systematic review, clinical studies on the management of refractory cutaneous sarcoidosis were retrieved from PubMed and ScienceDirect databases. Studies were screened based on article type, publication within the last 10 years, and access to free full text. The articles selected consisted of case studies, clinical trials, and observational studies. The studies needed to focus on cases of diagnosed cutaneous sarcoidosis at the time of the study and involve adult patients resistant to corticosteroid regimens, with or without additional immunomodulators. Only interventions that included tumor necrosis factor-alpha (TNF-α) (e.g., infliximab and adalimumab) or Janus kinase/signal transducers and activators of transcription (JAK/STAT) (e.g., ruxolitinib and tofacitinib) antibody therapy were considered. Two authors independently conducted quality assessments using the Joanna Briggs Institute Critical Appraisal and NIH Study Quality Assessment tools. A total of 16 clinical studies were included in this systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Of the 16 cases included, 15 studies demonstrated partial to complete resolution of cutaneous lesions within a range of two weeks to 18 months from initiation of antibody therapy. Studies on anti-TNF-α intervention demonstrated the most adverse events, including two deaths and one case associated with cutaneous exacerbation. Studies on anti-JAK-STAT interventions demonstrate no adverse events after treatment; however, patient study size was limiting. Recent studies have shown promising potential for anti-TNF-α and anti-JAK-STAT inhibitors to become the mainstay interventions in refractory cutaneous sarcoidosis. Due to limited population studies, the current data on the efficacy and safety of antibody therapies have not yielded a standardized FDA-approved steroid-sparing treatment. Therefore, a need for more population studies on the effectiveness of third-line intervention in refractory cutaneous sarcoidosis is necessary.
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Affiliation(s)
- Stacy L Toriola
- Pathology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Medicine, St. George's University School of Medicine, New York, USA
| | - Travis Satnarine
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Zareen Zohara
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ademiniyi Adelekun
- Family Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kofi D Seffah
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Korlos Salib
- General Practice, El-Demerdash Hospital, Cairo, EGY
| | - Lana Dardari
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Maher Taha
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Purva Dahat
- Medical Student, St. Martinus University, Willemstad, CUW
| | - Sai Sri Penumetcha
- General Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- General Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Telangana, IND
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3
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Samia AM, Fabara Pino S, Sun L. Sarcoidosis With Skeletal Involvement Masquerading as Metastatic Malignancy. Cureus 2023; 15:e44457. [PMID: 37791207 PMCID: PMC10544283 DOI: 10.7759/cureus.44457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 10/05/2023] Open
Abstract
Sarcoidosis is a systemic disorder characterized by noncaseating granuloma formation, which can affect any organ in the body; however, skeletal involvement is relatively uncommon. This case report presents a rare case of sarcoidosis primarily affecting the skeletal system in a 39-year-old man with a history of neurosarcoidosis. The patient presented with symptoms of nausea, vomiting, fatigue, weight loss, and lower back and pelvic pain, which were initially suspicious for malignancy. Computed tomography scans revealed lytic bone lesions and lymphadenopathy. However, a biopsy of a left inguinal lymph node confirmed necrotizing granulomatous lymphadenitis, which was consistent with necrotizing sarcoid granulomatosis - a rare variant of sarcoidosis. The patient was treated with systemic corticosteroids, which led to clinical improvement. The prognosis of sarcoidosis is generally good, with spontaneous remission occurring in up to two-thirds of patients; however, some patients may develop chronic and/or progressive disease. In particular, patients with a history of neurosarcoidosis may be at an increased risk for chronic or recurrent disease. This case highlights the importance of considering sarcoidosis in the differential diagnosis of patients presenting with nonspecific symptoms and lymphadenopathy, even in the absence of pulmonary involvement.
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Affiliation(s)
| | - Stephanie Fabara Pino
- Internal Medicine, University of Central Florida, School of Medicine/North Florida Hospital, Gainesville, USA
| | - Liang Sun
- Internal Medicine, University of Central Florida, School of Medicine/North Florida Hospital, Gainesville, USA
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4
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Ji B, Khatun N, Mostafidi E, Gupta R, McFarlane SI. Sarcoidosis Versus Lymphoma: A Clinical Diagnostic Dilemma in a Patient With Extensive Lymphadenopathy. Cureus 2023; 15:e43281. [PMID: 37692669 PMCID: PMC10492610 DOI: 10.7759/cureus.43281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Sarcoidosis is a granulomatous disease involving multiple organ systems. In its classic form, sarcoidosis is associated with non-caseating granuloma. Several differential diagnostic entities exist for sarcoidosis, including tuberculosis (TB), as well as lymphomas. In this report, we present a case of sarcoidosis in a 55-year-old male with diffuse lymphadenopathy and hepatosplenic involvement, highlighting the differential diagnostic point for this disease.
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Affiliation(s)
- Beisi Ji
- Internal Medicine, Downstate-Health Sciences University of New York, Downstate Medical Center, Brooklyn, USA
| | - Nazima Khatun
- Internal Medicine, Downstate-Health Sciences University of New York, Downstate Medical Center, Brooklyn, USA
| | - Elmira Mostafidi
- Pathology, Downstate-Health Sciences University of New York, Downstate Medical Center, Brooklyn, USA
| | - Raavi Gupta
- Pathology, Downstate-Health Sciences University of New York, Downstate Medical Center, Brooklyn, USA
| | - Samy I McFarlane
- Internal Medicine, Downstate-Health Sciences University of New York, Brooklyn, USA
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5
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Kc P, Ayele FK, Karki S, Waleed MS. Whipple's Disease Mimicking Sarcoidosis. Cureus 2023; 15:e41839. [PMID: 37575808 PMCID: PMC10423070 DOI: 10.7759/cureus.41839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Whipple's disease is a rare systemic disease caused by a Tropheryma whipplei infection. Although older literature reports a low rate of incidence, case reports continue to rise due to increased awareness of the disease. Classic Whipple's disease presents as weight loss, diarrhea, and arthralgia and may involve the heart, central nervous system (CNS), or any other organ system. Some patients with Whipple's disease do not have the classic signs and symptoms of the disease. We present a case of Whipple's disease in a patient with poor appetite, weight loss, and granulomatous inflammation of various organs, including the kidneys and spleen, mimicking sarcoidosis. She had presented three years earlier with acute kidney injury (AKI) and hypercalcemia. The renal biopsy revealed diffuse granulomatous interstitial nephritis. Both AKI and hypercalcemia resolved with prednisone; however, her weight loss and decreased appetite continued. The initial positron emission tomography (PET) scan showed increased fluorodeoxyglucose (FDG) avidity in the spleen and large intestine, and the splenic biopsy revealed non-caseating granulomas. A diagnosis of sarcoidosis was made, and she was started on methotrexate with prednisone. Nevertheless, the weight loss and poor appetite were relentless. A repeat PET scan showed increased FDG avidity in loops of the small and large intestines. A small intestinal biopsy revealed positive periodic acid-Schiff (PAS) and negative acid-fast bacilli (AFB) revealing the diagnosis of Whipple's disease. Whipple's disease should be considered in the differential diagnosis of sarcoidosis, especially in those patients worsening on standard immunosuppression.
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Affiliation(s)
- Pawan Kc
- Rheumatology, Emory University School of Medicine, Atlanta, USA
| | | | - Sabin Karki
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
| | - Madeeha S Waleed
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
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6
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Adhikari B, Ji B, Waqar SHB, Khatri S. A Hypercalcemic Enigma: A Rare Case of Bone Marrow Sarcoidosis. Cureus 2023; 15:e40534. [PMID: 37461767 PMCID: PMC10350330 DOI: 10.7759/cureus.40534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Sarcoidosis is a multisystem inflammatory disease involving granuloma formation. The exact etiology of the disease remains unknown. While the lungs are the most commonly involved organs in sarcoidosis, bone marrow-only involvement is quite rare. As bone marrow-only involvement can have a presentation that closely resembles multiple myeloma, a significant diagnostic dilemma can occur as the treatment for sarcoidosis is different compared to multiple myeloma. We present a case of a 62-year-old female who presented with worsening lower extremity weakness and fatigue. She was found to have new-onset hypercalcemia, normocytic anemia, and lytic bony lesions. Extensive laboratory workup for multiple myeloma was negative with bone marrow biopsy showing non-caseating granulomas, thus diagnosing the patient with sarcoidosis involving the bone marrow.
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Affiliation(s)
- Biplov Adhikari
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Beisi Ji
- Internal Medicine, State University of New York Downstate Health Sciences University, New York City, USA
| | - Syed Hamza Bin Waqar
- Internal Medicine, State University of New York Downstate Health Sciences University, New York City, USA
| | - Sagun Khatri
- Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, NPL
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7
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Dow CT, Lin NW, Chan ED. Sarcoidosis, Mycobacterium paratuberculosis and Noncaseating Granulomas: Who Moved My Cheese. Microorganisms 2023; 11:microorganisms11040829. [PMID: 37110254 PMCID: PMC10143120 DOI: 10.3390/microorganisms11040829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
Clinical and histological similarities between sarcoidosis and tuberculosis have driven repeated investigations looking for a mycobacterial cause of sarcoidosis. Over 50 years ago, "anonymous mycobacteria" were suggested to have a role in the etiology of sarcoidosis. Both tuberculosis and sarcoidosis have a predilection for lung involvement, though each can be found in any area of the body. A key histopathologic feature of both sarcoidosis and tuberculosis is the granuloma-while the tuberculous caseating granuloma has an area of caseous necrosis with a cheesy consistency; the non-caseating granuloma of sarcoidosis does not have this feature. This article reviews and reiterates the complicity of the infectious agent, Mycobacterium avium subsp. paratuberculosis (MAP) as a cause of sarcoidosis. MAP is involved in a parallel story as the putative cause of Crohn's disease, another disease featuring noncaseating granulomas. MAP is a zoonotic agent infecting ruminant animals and is found in dairy products and in environmental contamination of water and air. Despite increasing evidence tying MAP to several human diseases, there is a continued resistance to embracing its pleiotropic roles. "Who Moved My Cheese" is a simple yet powerful book that explores the ways in which individuals react to change. Extending the metaphor, the "non-cheesy" granuloma of sarcoidosis actually contains the difficult-to-detect "cheese", MAP; MAP did not move, it was there all along.
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Affiliation(s)
- Coad Thomas Dow
- McPherson Eye Research Institute, University of Wisconsin, Madison, WI 53705, USA
| | - Nancy W Lin
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO 80206, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Edward D Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Academic Affairs, National Jewish Health, Denver, CO 80206, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Department of Medicine, Aurora, CO 80045, USA
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8
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Muacevic A, Adler JR, Reid GE, Arif A, Adams E. Systemic Bacillus Calmette-Guerin Infection One Year After Intravesical Immunotherapy Mimicking Sarcoidosis. Cureus 2022; 14:e31697. [PMID: 36561593 PMCID: PMC9767275 DOI: 10.7759/cureus.31697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 11/21/2022] Open
Abstract
A patient presented with pancytopenia and hypercalcemia after intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) for bladder cancer. Bone marrow biopsy performed six months later revealed noncaseating granulomas with negative stains for AFB. He was diagnosed with sarcoidosis and treated with prednisone. Hypercalcemia resolved, but mild pancytopenia persisted. One year later, he developed sepsis. Blood cultures six weeks later grew Mycobacterium tuberculosis complex, ultimately identified as Mycobacterium bovis. Despite triple antibiotic therapy, the patient progressively declined and expired.
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9
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Dongre A, Dongre T, Deshmukh M, Agrawal S, Kanchankar N. Pulmonary sarcoidosis masquerading as metastatic breast cancer: a case report. Pan Afr Med J 2021; 38:245. [PMID: 34104293 PMCID: PMC8164421 DOI: 10.11604/pamj.2021.38.245.28421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022] Open
Abstract
Pulmonary lesions on imaging are presumed to be metastatic lesions in patients with breast cancer. Here, we report an interesting case of a 63-year-old lady with breast carcinoma showing pulmonary lesions on imaging suggestive of pulmonary metastases. Detailed evaluation of pulmonary lesions confirmed the presence of co-existing pulmonary sarcoidosis. Modern diagnostic methods like 18-flurodeoxyglucose positron emission tomography (18-FDG PET) are unable to clearly differentiate metastatic disease from granulomatous diseases like sarcoidosis. Thus, histological confirmation is needed for accurate staging and determining response to treatment and rarely, in non-responders, detecting any co-existing disease. This case emphasizes the need for detailed histopathological examination of lymph nodes in patients with non-responsive disease or recurrent disease despite adequate chemotherapy.
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Affiliation(s)
- Amol Dongre
- Department of Medical Oncology, Alexis Multispecialty Hospital, Nagpur, Maharashtra, India
| | - Trupti Dongre
- Department of Pathology, Narendra Kumar Prasadrao (NKP) Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
| | - Mahesh Deshmukh
- Department of Pathology, Alexis Multispecialty Hospital, Nagpur, Maharashtra, India
| | - Suraj Agrawal
- Department of Surgical Oncology, Alexis Multispecialty Hospital, Nagpur, Maharashtra, India
| | - Niraj Kanchankar
- Department of Radiology, Alexis Multispecialty Hospital, Nagpur, Maharashtra, India
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Tripipitsiriwat A, Komoltri C, Ruangchira-Urai R, Ungprasert P. Clinical Characteristics of Sarcoidosis in Asian Population: A 14-year Single Center Retrospective Cohort Study from Thailand. Sarcoidosis Vasc Diffuse Lung Dis 2020; 37:e2020011. [PMID: 33597798 PMCID: PMC7883518 DOI: 10.36141/svdld.v37i4.10136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
Background: Little is known about epidemiology and clinical characteristics of sarcoidosis in Asian population. Objectives: This study aimed to examine the epidemiology and clinical characteristics of Thai patients with sarcoidosis, using databases of a tertiary care medical center. Methods: Potential cases of sarcoidosis were identified from two sources, the medical record-linkage system and the pathology database of Siriraj Hospital, Mahidol University in Bangkok, Thailand. Patients with ICD-10-CM codes for sarcoidosis were identified and retrieved from the medical record-linkage system from 2005 to 2018. Patients with histopathology positive for non-caseating granuloma were identified and retrieved from the pathology database from the same time period. All potential cases underwent individual medical record review to confirm the diagnosis of sarcoidosis which required compatible clinical pictures supported by presence of non-caseating granuloma, radiographic evidence of intrathoracic sarcoidosis and exclusion of other granulomatous diseases. Results: From 2005 to 2018, 89 confirmed cases of sarcoidosis were identified. 80.9% of them were female and mean age at diagnosis was 46.8 years (standard deviation (SD) 13.9 years). The majority of patients had intrathoracic disease (81 cases; 91.0%) but less than half had respiratory symptoms (34 cases; 41.9%). Extrathoracic disease was common in this cohort that pulmonary sarcoidosis was accompanied by extrathoracic involvement in 53 patients (65.4%). Sarcoid uveitis was the most common extrathoracic disease (35 cases; 39.3%), followed by cutaneous sarcoidosis (24 cases; 26.9%), extrathoracic lymphadenopathy (18 cases; 22.5%) and sarcoid arthropathy (4 cases; 4.5%). Conclusion: The current study examined clinical characteristics of sarcoidosis in an Asian population and found high prevalence of uveitis and marked female predominance. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020011)
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Affiliation(s)
- Athiwat Tripipitsiriwat
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulaluk Komoltri
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ruchira Ruangchira-Urai
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Arif S, Arif S, Liaqat J, Slehria AUR, Palwa AR. Central Nervous System Vasculitis Secondary to Sarcoidosis: A Rare Case of Lupus Pernio With Complete Occlusion of Right Internal Carotid Artery. Cureus 2020; 12:e10274. [PMID: 33042710 PMCID: PMC7538030 DOI: 10.7759/cureus.10274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Sarcoidosis is a systemic inflammatory disorder resulting from an inappropriate immune response to ubiquitous environmental stimuli. It has a predilection for African Americans and people of Northern European countries. The classic histology is that of a non-caseating granuloma. Central nervous system involvement is a rare occurrence in sarcoidosis and even in this manifestation, the presence of vasculitis is comparatively uncommon. We present a case of a 35-year-old female, who presented with complaints of persistent headache of moderate intensity and had a violaceous plaque on nose, being treated by a dermatologist. The patient on further workup had mildly raised proteins on cerebrospinal fluid analysis. MRI brain showed multiple foci in bilateral frontoparietal regions and centrum semiovale, while digital subtraction angiography brain depicted vasculitis of small vessels of brain and complete occlusion of right internal carotid artery at its origin. Biopsy of lesion on nose was performed that showed chronic granulomatous inflammation. A diagnosis of brain vasculitis secondary to sarcoidosis was made. The patient was treated with plasmapheresis and pulse steroid therapy initially, and later on with cyclophosphamide and azathioprine. This resulted in resolution of headache and nose lesion.
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Affiliation(s)
- Saeed Arif
- Neurology, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | - Shaheer Arif
- Neurology, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | | | | | - Abdur Rahim Palwa
- Radiology, Armed Forces Institute of Radiology and Imaging, Rawalpindi, PAK
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12
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Abstract
We report a 54-year-old man, who presented with an acute onset of diplopia and ptosis on the left side. On admission, neurological examination showed left oculomotor and abducens nerve palsy. Brain MRI showed thickening of the left parieto-temporal dura mater with gadolinium enhancement. Whole-body CT revealed a mass lesion in the right submandibular gland, diffuse goiter, and bilateral hilar lymph node enlargement. Initially, IgG4-related disease was considered because of an elevated serum IgG4 level (240 mg/dl); however, biopsy of the submandibular gland showed non-caseating epithelioid cell granulomas that suggested sarcoidosis, which could be associated with the intracranial lesions causing his neurological manifestation. In cases of hypertrophic pachymeningitis, especially with increased serum IgG4 including our case, a careful assessment with pathological examination is critical for identifying various underlying conditions.
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Affiliation(s)
- Yuzo Fujino
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kozo Saito
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Keiko Maezono
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takashi Kasai
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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13
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Abstract
Background: In the absence of confirmatory biopsy, the criteria for diagnosis of neuro-ophthalmic sarcoidosis are not well established. Diagnostic criteria for both intraocular sarcoidosis and neurosarcoidosis have been proposed, but the diagnosis of neuro-ophthalmic sarcoidosis remains challenging. It is our intention to augment what is currently known about the diagnosis of neuro-ophthalmic sarcoidosis by providing a series of biopsy-proven cases that contribute to the continued development of diagnostic criteria for this enigmatic condition. Methods: Case series of four Caucasian women with biopsy-proven neuro-ophthalmic sarcoidosis. Results: The first patient was initially diagnosed with traumatic optic neuropathy following a fall. Years later, the presence of pathologic submandibular lymphadenopathy was identified and biopsied, revealing non-caseating granulomas. The second and third cases involved sarcoidosis of the extraocular muscles without clear or common systemic features of sarcoidosis. In the fourth and final case, the patient presented with a Horner syndrome attributed to sarcoid infiltration of the ipsilateral sympathetic chain. Bronchoscopy with biopsy showed non-caseating granulomas consistent with sarcoidosis. Conclusions: We describe four cases of neuro-ophthalmic sarcoidosis and propose possible neuro-orbital and neuro-ophthalmic criteria both with and without diagnostic biopsy.
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Affiliation(s)
| | - Claudia M Prospero Ponce
- Department of Pathology and Genomic Medicine, Ocular Pathology, Houston Methodist Hospital, Houston, Texas, USA
| | - Aroucha Vickers
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Bennett Yau-Bun Hong
- Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Francesco Pellegrini
- Neuro-Ophthalmology Service, Department of Ophthalmology, De Gironcoli Hospital, Conegliano, Italy
| | - Daniele Cirone
- Uveitis Service, Department of Ophthalmology, Clinica Villa Anna, San Benedetto del Tronto, Italy
| | - Francesco Romano
- Neuro-Ophthalmology Service, Department of Ophthalmology, De Gironcoli Hospital, Conegliano, Italy
| | | | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA.,Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch, Galveston, Texas, USA.,Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York City, New York, USA.,Department of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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Hokama A, Kinjo F, Tomiyama R, Makishi T, Kobashigawa K, Sunagawa T, Yonamine Y, Kugai Y, Matayoshi R, Saito A. Bamboo trees in the stomach. Gut 2004; 53:1589, 1631. [PMID: 15479677 PMCID: PMC1774280 DOI: 10.1136/gut.2003.038323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- A Hokama
- First Department of Internal Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan.
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