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Vij O, Dey M, Morrison K, Kouranloo K. Incidence, management and prognosis of new-onset sarcoidosis post COVID-19 infection. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2024; 41:e2024004. [PMID: 38567560 PMCID: PMC11008326 DOI: 10.36141/svdld.v41i1.15027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/25/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIM SARS-CoV-2 infection has been linked to hyperinflammation in multiple organs with a potential mechanistic link with resulting autoimmunity. There have been reports of many inflammatory complications following COVID-19, including sarcoidosis. A literature review on new-onset sarcoidosis following COVID-19 is lacking. We evaluated potential associations between COVID-19 and development of new-onset sarcoidosis. METHODS Articles discussing biopsy-proven sarcoidosis after confirmed COVID-19 infection, published 1956 until April 2023, were included. All article types were deemed eligible except opinion and review articles. RESULTS A pooled total of 15 patients with new-onset diagnosis of sarcoidosis after COVID-19 infection were included, 45.5% female, mean age 46.1 years (standard deviation 14.7) at onset of sarcoidosis. Patients were from: Europe (n=11); North America (n=2); South America (n=1); Asia (n=1). The mean time between COVID-19 infection and diagnosis of sarcoidosis was 56.3 days, although this ranged from 10 to 140 days. Organ systems predominantly affected by sarcoidosis were: pulmonary (n=11); cutaneous (n=3); cardiac (n=2); ocular (n=1); systemic (n=1) (with overlapping features in certain patients). Sarcoidosis was treated as follows: glucocorticoids (n=8); azathioprine (n=1); cardiac re-synchronisation therapy (n=1); heart transplant (n=1). All patients were reported to have survived, with one requiring intensive care admission. CONCLUSIONS Our result suggests there is a potential link between COVID-19 and new-onset sarcoidosis. The potential mechanism for this is through cytokine mediated immune modulation in COVID-19 infection. Obtaining a tissue sample remains key in confirming the diagnosis of sarcoidosis and this may be delayed during active COVID-19 infection.
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Affiliation(s)
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Centre for Rheumatic Diseases, King’s College London, London, UK
| | | | - Koushan Kouranloo
- School of Medicine, University of Liverpool, Merseyside, UK
- Department of Rheumatology, East Surrey Hospital, Redhill, UK
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Rubinstein A, Kudryavtsev I, Malkova A, Mammedova J, Isakov D, Isakova-Sivak I, Kudlay D, Starshinova A. Sarcoidosis-related autoimmune inflammation in COVID-19 convalescent patients. Front Med (Lausanne) 2023; 10:1271198. [PMID: 38179278 PMCID: PMC10765615 DOI: 10.3389/fmed.2023.1271198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Currently, there are a large number of reports about the development of autoimmune conditions after COVID-19. Also, there have been cases of sarcoid-like granulomas in convalescents as a part of the post-COVID-19 syndrome. Since one of the etiological theories of sarcoidosis considers it to be an autoimmune disease, we decided to study changes in the adaptive humoral immune response in sarcoidosis and SARS-CoV-2 infection and to find out whether COVID-19 can provoke the development of sarcoidosis. This review discusses histological changes in lymphoid organs in sarcoidosis and COVID-19, changes in B cell subpopulations, T-follicular helper cells (Tfh), and T-follicular regulatory cells (Tfr), and analyzes various autoantibodies detected in these pathologies. Based on the data studied, we concluded that SARS-CoV-2 infection may cause the development of autoimmune pathologies, in particular contributing to the onset of sarcoidosis in convalescents.
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Affiliation(s)
- Artem Rubinstein
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
| | - Igor Kudryavtsev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
- Far Eastern Federal University, Vladivostok, Russia
| | - Annа Malkova
- Ariel University Faculty of Natural Sciences, Ariel, Israel
| | | | - Dmitry Isakov
- First Saint Petersburg State I. Pavlov Medical University, Saint Petersburg, Russia
| | | | - Dmitry Kudlay
- Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- NRC Institute of Immunology, Moscow, Russia
- Department of Pharmacognosy and Industrial Pharmacy, Faculty of Fundamental Medicine, Moscow, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, Saint Petersburg, Russia
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Watanabe K, Koji O, Matsumura M, Kaneko T. Post-COVID-19 Granulomatous Inflammation in the Lung, Distinct From Sarcoidosis: A Report of Two Cases. Cureus 2023; 15:e50821. [PMID: 38249269 PMCID: PMC10797456 DOI: 10.7759/cureus.50821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/23/2024] Open
Abstract
This report describes two cases of granulomatous lung inflammation following coronavirus disease 2019 (COVID-19), presenting as a sarcoidosis-like reaction with granuloma formation in airspaces and interstitium. Clinical and pathological findings in both cases were similar to but still distinct from sarcoidosis. In the first case, the chest CT of a 55-year-old male with a history of polymerase chain reaction (PCR)-confirmed COVID-19 showed well-defined multiple nodules in the bilateral lung fields. He underwent video-assisted thoracic surgery for diagnostic purposes. The pathological specimen showed loose non-caseous granulomas with mild lymphoplasmacytic infiltration and early fibroblastic proliferation in alveolar spaces. In the second case, a 68-year-old male, who presented with consolidation in the anterior segment of the right upper lobe, underwent bronchoscopy and transbronchial lung biopsy showed non-caseous granulomas with mild lymphoplasmacytic infiltration in the peribronchiolar interstitium. The opacities improved spontaneously in both cases. Further studies are needed to determine whether COVID-19 could cause granulomatous lung inflammation distinct from sarcoidosis.
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Affiliation(s)
- Keisuke Watanabe
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, JPN
| | - Okudela Koji
- Department of Pathology, Yokohama City University Graduate School of Medicine, Yokohama, JPN
| | - Mai Matsumura
- Department of Pathology, Yokohama City University Graduate School of Medicine, Yokohama, JPN
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, JPN
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Smith DJF, Meghji J, Moonim M, Ross C, Viola P, Wickremasinghe M, Gleeson LE. Sarcoidosis following COVID infection: A case series. Respirol Case Rep 2023; 11:e01231. [PMID: 37840600 PMCID: PMC10570663 DOI: 10.1002/rcr2.1231] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023] Open
Abstract
Here we describe three cases of sarcoidosis which were diagnosed following COVID infection. Treating clinicians should consider post-COVID-19 sarcoidosis in their differential, as it represents a potentially treatable cause of persistent symptomatology.
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Affiliation(s)
- David J. F. Smith
- Department of Inflammation Repair & Development, National Heart & Lung InstituteImperial College LondonLondonUK
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Jamilah Meghji
- Department of Respiratory MedicineCambridge University Hospitals NHS TrustCambridgeUK
| | - Mufaddal Moonim
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- North West London PathologyLondonUK
| | - Clare Ross
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Patrizia Viola
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- North West London PathologyLondonUK
| | - Melissa Wickremasinghe
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Laura E. Gleeson
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- Department of Respiratory MedicineTrinity College DublinDublinRepublic of Ireland
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Kidambi TD, Manesh R, Mannan R. Gastric Sarcoidosis Flare After Years of Remission Following COVID Infection. Dig Dis Sci 2023; 68:3473-3475. [PMID: 37474718 DOI: 10.1007/s10620-023-07994-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Trilokesh D Kidambi
- Division of Gastroenterology, Department of Medicine, City of Hope Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Reza Manesh
- Division of Hospital Medicine, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA, USA
| | - Rifat Mannan
- Department of Pathology, City of Hope Medical Center, Duarte, CA, USA
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Koc AS, Fener N, Kobak S. SARS-CoV-2 Infection-Induced Necrotising Sarcoid Granulomatosis. Mediterr J Rheumatol 2023; 34:386-390. [PMID: 37941860 PMCID: PMC10628879 DOI: 10.31138/mjr.20230731.si] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/25/2022] [Accepted: 01/06/2023] [Indexed: 11/10/2023] Open
Abstract
SARS-CoV-2 infection is a pandemic that affects predominantly upper airways and lungs. It may lead to reactivation of known inflammatory rheumatic diseases and/or initiation of various granulomatous disorders. Necrotising sarcoid granulomatosis (NSG) is a rare condition that can be confused with malignancy, granulomatosis with polyangiitis, and sarcoidosis. Herein we reported the development of NSG following a SARS-CoV-2 infection which mimicked granulomatosis with polyangiitis.
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Affiliation(s)
- Aysu Sinem Koc
- Department of Pulmonology, Istinye University Faculty of Medicine, LIV Hospital, Istanbul, Turkey
| | - Neslihan Fener
- Department of Pathology, University of Health Sciences, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Senol Kobak
- Department of Internal Medicine and Rheumatology Istinye University Faculty of Medicine, LIV Hospital, WASOG Sarcoidosis Clinic, Istanbul, Turkey
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Pokhriyal SC, Nabeel Pasha M, Khan A, Uwiringiyimana R, Idris H. Sarcoidosis Presenting as a Lung Mass in a Patient With COVID-19 Infection: A Case Report. Cureus 2023; 15:e39136. [PMID: 37332432 PMCID: PMC10275395 DOI: 10.7759/cureus.39136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is known to be associated with immune dysregulation and can cause multiorgan dysfunction. Sarcoidosis is another disease associated with increased inflammatory responses due to immune dysregulation which can also affect multiple organs. Although sarcoidosis, like COVID-19 infection, can affect virtually any organ, the lungs are the most commonly affected organs. Sarcoidosis most commonly presents as lung nodules and bilateral hilar lymphadenopathy. Rarely, multiple granulomatous lesions can coalesce and manifest as lung masses, and these often mimic lung cancer. We present a case of a 64-year-old male who presented with shortness of breath and pneumonia-like symptoms for one week and a nasopharyngeal swab for SARS-CoV-2 was positive. Workup revealed a large 6.3×4.7 cm lung mass in the right upper lobe along with enlarged bilateral lymph nodes. A CT-guided lung biopsy was done which revealed non-caseating granulomas containing epithelioid cells. Other causes of granuloma like tuberculosis and fungal infections were ruled out. The patient was managed with low-dose steroids and a follow-up CT scan done after eight months revealed complete resolution of lung mass with minimal mediastinal lymphadenopathy. This is, as far as we are aware, the first case of COVID-19 infection manifesting as a lung mass that was ultimately diagnosed as sarcoidosis.
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Affiliation(s)
| | | | - Ahmad Khan
- Pulmonology, Interfaith Medical Center, New York City, USA
| | | | - Hadeeqa Idris
- Internal Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
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Tchernev G, Kordeva S, Kirilova H, Broshtilova V. First reported case of erythrodermic sarcoidosis with systemic involvement during vaccination for Covid-19. Dermatol Reports 2023. [DOI: 10.4081/dr.2023.9636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Post-vaccinal and parainfectious activation of the immunity with subsequent development of a certain immunological/skin-immunological disease isn’t rare in the clinical practice. This concept is mentioned in relation to molecular/antigenic mimicry. To this day, the pathogenesis of sarcoidosis and sarcoid-type reactions remains a mystery. Moreover, they can be a warning sign of changes in tissue homeostasis, whether it is infectious, non-infectious-immunological, tumor-related, etc. We present a rare form of erythrodermic sarcoidosis with massive systemic involvement (pericarditis, supraventricular tachycardia, hepatitis, iritis/iridocyclitis, pulmonary fibrosis/bihilar lymphadenopathy, and arthritis) developed after receiving the ChadOx1-S vaccine for Covid-19. Systemic immunosuppressive therapy with Methylprednisolone was introduced according to a scheme (in a reduction mode with an initial dose of 40 mg/day intravenously) in combination with: topical Pimecrolimus 1% cream twice a day. Rapid improvement of the symptoms was observed within the first two days of treatment. According to the references in the scientific literature, the presented patient turns out to be the first case of erythrodermic sarcoidosis (with systemic involvement), described as a side effect after vaccination and/or administration of a certain medicinal form.
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Racil H, Znegui T, Maazoui S, Touil A, Habibech S, Henda N, Chaouch N. Can Coronavirus Disease 2019 Induce Sarcoidosis: A Case Report. THORACIC RESEARCH AND PRACTICE 2023; 24:45-58. [PMID: 37503599 PMCID: PMC10765196 DOI: 10.5152/thoracrespract.2023.22076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/19/2022] [Indexed: 07/29/2023]
Abstract
Since the emergence of coronavirus disease 2019, a large spectrum of clinical manifestations following this acute viral infection has been reported especially autoimmune manifestations and inflammatory disorders. However, a causal link has not yet been established. Herein, we reported a case of pulmonary mediastinal sarcoidosis following coronavirus disease 2019 infection. A 41-year-old woman with no clinical or radiographic symptoms or signs of sarcoidosis prior to coronavirus disease 2019 infection developed dyspnea, cough, and fatigue, a few months after discharge. A chest thoracic scan performed 3 months after hospital discharge showed regression of groundglass opacities with the appearance of pulmonary micronodules. Clinical examination and spirometry were normal. The evolution was marked by progressive worsening of dyspnea and significant weight loss. A chest thoracic scan performed 6 months after discharge showed bilateral and symmetrical hilar and mediastinal and paratracheal lymphadenopathy. Bronchoalveolar lavage with cell count showed a lymphocytosis of 19.5% and a CD4/CD8 T cell ratio of 2.2. Endobronchial lung biopsy revealed noncaseating epithelioid granulomas. Sputum culture excluded tuberculosis. The diagnosis of pulmonary-mediastinal sarcoidosis was made. She was treated with an oral corticosteroid. The patient showed significant improvement during the 3-month follow-up period. Post-coronavirus disease sarcoidosis is very rare. Complementary studies are needed to discern the link between these diseases.
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Affiliation(s)
- Hajer Racil
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Tasnim Znegui
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Sarra Maazoui
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Amany Touil
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Sonia Habibech
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Neji Henda
- Department of Radiology, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Nawel Chaouch
- Department of Pulmonology and Interventional Endoscopy, Abderrahman Mami Hospital, Ariana, Tunisia
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Sarcoidosis and COVID-19: At the Cross-Road between Immunopathology and Clinical Manifestation. Biomedicines 2022; 10:biomedicines10102525. [PMID: 36289785 PMCID: PMC9599235 DOI: 10.3390/biomedicines10102525] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 02/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been associated with dysregulation of the immune system featuring inappropriate immune responses, exacerbation of inflammatory responses, and multiple organ dysfunction syndrome in patients with severe disease. Sarcoidosis, also known as Besnier-Boeck-Schaumann disease, is an idiopathic granulomatous multisystem disease characterized by dense epithelioid non-necrotizing lesions with varying degrees of lymphocytic inflammation. These two diseases have similar clinical manifestations and may influence each other at multiple levels, eventually affecting their clinical courses and prognosis. Notably, sarcoidosis patients are at high risk of severe COVID-19 pneumonia because of the underlying lung disease and chronic immunosuppressive treatment. In this narrative review, we will discuss interactions between sarcoidosis and COVID-19 in terms of clinical manifestations, treatment, and pathogenesis, including the role of the dysregulated renin-angiotensin system, altered immune responses involving increased cytokine levels and immune system hyperactivation, and cellular death pathways.
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Song X, Shao F, Lan X. The Onset of Sarcoidosis After COVID-19 Vaccination Revealed by the 18 F-FDG PET. Clin Nucl Med 2022; 47:869-871. [PMID: 35867999 DOI: 10.1097/rlu.0000000000004352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
ABSTRACT Sarcoidosis is a heterogeneous multisystem disease characterized by noncaseating granulomas. We presented 18 F-FDG PET/CT findings of sarcoidosis in a previously healthy 43-year-old man who presented intermittent cough after the third dose of COVID-19 vaccination. 18 F-FDG PET/CT showed high uptake of one solitary nodule in the right middle lobe, mediastinal lymph nodes, bilateral hila, and multiple nodules under the right pleura, mimicking the malignancy. Nevertheless, the biopsy confirmed distinct noncaseating granulomas. This case emphasizes the onset of sarcoidosis revealed by 18 F-FDG PET/CT after COVID-19 vaccination.
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Affiliation(s)
- Xiangming Song
- From the Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Hubei Key Laboratory of Molecular Imaging; and Key Laboratory of Biological Targeted Therapy, the Ministry of Education, Wuhan, China
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Shukla AK, Peter A, Bhargava JK, Arya V, Gupta MK, Yadav N, Tiwari P. Sarcoidosis presenting as bilateral optic neuritis after ChAdOx1 nCoV-19 vaccination. Monaldi Arch Chest Dis 2022; 93. [PMID: 35678536 DOI: 10.4081/monaldi.2022.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 02/03/2023] Open
Abstract
Sarcoidosis is an idiopathic granulomatous disease and can virtually affect any organ system. Multiple factors, including tubercular antigens organic and environmental exposures, have been implicated in its pathogenesis. In addition to drugs, sarcoid-like reactions have been reported following varicella and influenza vaccination. Few reports of erythema nodosum and Lofgren syndrome have been reported after the COVID19 vaccination, though no histologic diagnosis was pursued in these cases. We herein report a case of sarcoidosis presenting with bilateral acute onset vision loss with a temporal association with COVID19 vaccination (ChadOx-1 n-COV, COVISHIELDTM). Symptoms started within two weeks of receiving the vaccine. Alternate causes for optic neuritis were excluded. Transbronchial lung biopsy showed the presence of non-caseating epithelioid cell granulomas. The patient received high-dose corticosteroids immediately after diagnosis, albeit with incomplete clinical improvement in vision on a three-month follow-up. In conclusion, we report a novel case of sarcoidosis-related optic neuritis following COVID19 vaccination.
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Affiliation(s)
- Amarendra Kumar Shukla
- Department of Pulmonary, Critical Care and Sleep Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Amrutha Peter
- Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Jitendra Kishore Bhargava
- Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Veerendra Arya
- Department of Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Manish Kumar Gupta
- Department of Pathology, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Nishtha Yadav
- Department of Neuroradiology, Superspeciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur.
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur.
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