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Yamamoto K, Ishii T, Takasaki T, Doi E, Kashima J, Shiota S, Miyazaki E. An Unusual Case of Sarcoidosis with a Prolonged Fever and Progressive Arthropathy. Intern Med 2024; 63:601-605. [PMID: 37380457 PMCID: PMC10937121 DOI: 10.2169/internalmedicine.1890-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/23/2023] [Indexed: 06/30/2023] Open
Abstract
A 70-year-old man had developed a high fever and arthralgia in his right elbow 6 months prior. Loxoprofen improved the symptoms temporarily, but arthropathy developed in other joints. Long-term recurrent arthropathy and the fever caused activity reduction and progressive debilitation. We performed fluorine-18 fluorodeoxyglucose-positron emission tomography and detected a positive accumulation in multiple joints and lymph nodes. A lymph node biopsy revealed epithelioid cell granulomas, which, along with elevated angiotensin-converting enzyme levels, led to the diagnosis of sarcoid arthropathy. After prednisolone administration, the fever and arthralgia resolved, and his activities of daily living improved. Clinicians should be aware of this type of sarcoid arthropathy.
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Affiliation(s)
- Kyoko Yamamoto
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Medical Education, Oita University Faculty of Medicine, Japan
| | - Toshihiro Ishii
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Tomomi Takasaki
- Department of General Medicine, Oita University Faculty of Medicine, Japan
| | - Eri Doi
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Jin Kashima
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Seiji Shiota
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Eishi Miyazaki
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
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2
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Leštan Ramovš Z, Sodin-Šemrl S, Lakota K, Čučnik S, Manevski D, Zbačnik R, Zupančič M, Verbič M, Terčelj M. Correlation of the High-Resolution Computed Tomography Patterns of Intrathoracic Sarcoidosis with Serum Levels of SAA, CA 15.3, SP-D, and Other Biomarkers of Interstitial Lung Disease. Int J Mol Sci 2023; 24:10794. [PMID: 37445972 DOI: 10.3390/ijms241310794] [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: 05/24/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Studies on the serum biomarkers of granulomatous inflammation and pulmonary interstitial disease in intrathoracic sarcoidosis have shown conflicting results. We postulated that differences in the concentrations of serum biomarkers can be explained by the heterogenous patterns of sarcoidosis seen on thoracic HRCT. Serum biomarker levels in 79 consecutive patients, newly diagnosed with intrathoracic sarcoidosis, were compared to our control group of 56 healthy blood donors. An analysis was performed with respect to HRCT characteristics (the presence of lymph node enlargement, perilymphatic or peribronchovascular infiltrates, ground-glass lesions, or fibrosis), CXR, and disease extent. Serum levels of CXCL9, CXCL10, CTO, and CCL18 were statistically significantly increased in all patients compared to controls. Serum levels of CA15.3 were statistically significantly increased in all patients with parenchymal involvement. SAA was increased in patients with ground-glass lesions while SP-D levels were statistically significantly increased in patients with lung fibrosis. Only SP-D and CA15.3 showed a significant correlation to interstitial disease extent. In conclusion, we found that sarcoidosis patients with different HRCT patterns of intrathoracic sarcoidosis have underlying biochemical differences in their serum biomarkers transcending Scadding stages. The stratification of patients based on both radiologic and biochemical characteristics could enable more homogenous patient selection for further prognostic studies.
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Affiliation(s)
- Zala Leštan Ramovš
- Department of Pulmonary Diseases, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia
| | - Snežna Sodin-Šemrl
- Faculty of Mathematics, Natural Sciences and Information Technologies (FAMNIT), University of Primorska, 6000 Koper, Slovenia
| | - Katja Lakota
- Faculty of Mathematics, Natural Sciences and Information Technologies (FAMNIT), University of Primorska, 6000 Koper, Slovenia
- Department of Rheumatology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Saša Čučnik
- Department of Rheumatology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Damjan Manevski
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Rok Zbačnik
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia
| | - Mirjana Zupančič
- Laboratory Department, Children's Hospital, University Medical Center Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia
| | - Martin Verbič
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Marjeta Terčelj
- Department of Pulmonary Diseases, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia
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3
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Judson MA. The management of sarcoidosis in the 2020's by the primary care physician. Am J Med 2023; 136:534-544. [PMID: 36889493 DOI: 10.1016/j.amjmed.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/20/2023] [Accepted: 02/20/2023] [Indexed: 03/08/2023]
Abstract
Sarcoidosis is an idiopathic granulomatous disease that occurs worldwide and may affect any organ. Because the presenting symptoms of sarcoidosis are not specific for the disease, the primary care physician is usually the first provider to assess these patients. In addition, patients who have previously been diagnosed with sarcoidosis are usually followed longitudinally by primary care physicians. Therefore, these physicians are often the first to address sarcoidosis patient symptoms related to exacerbations of the disease, as well as first observe complications of sarcoidosis medications. This article outlines the approach to the evaluation, treatment and monitoring of sarcoidosis patients by the primary care physician.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Albany Medical College, 16 New Scotland Avenue, Albany, New York 12208 USA.
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Muacevic A, Adler JR. Löfgren Syndrome: Clinical Presentation, Clinical Course, and Literature Review. Cureus 2023; 15:e33651. [PMID: 36788849 PMCID: PMC9912994 DOI: 10.7759/cureus.33651] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
Löfgren syndrome is an acute presentation of sarcoidosis that comprises fever, bilateral and symmetric hilar lymphadenopathies, polyarthritis, and erythema. We present the case of a 34-year-old male patient who presented with ankle monoarthritis without a history of a traumatic event. Contralateral ankle arthritis associated with erythema nodosum and fever developed one week later. Laboratory tests showed anemia, thrombocytosis, and elevated inflammatory parameters. A chest CT revealed symmetrical mediastinal and hilar adenopathies. A transbronchial biopsy was compatible with granulomatous lymphadenitis, and the diagnosis of Löfgren syndrome was confirmed. Our case report and literature review emphasize the wide web of mimicry of acute sarcoidosis. Secondary forms of acute sarcoidosis are likely to benefit from additional and more complex immunomodulatory therapies. Close monitoring and follow-up should be conducted because it is possible that these patients experience higher rates of recurrence or relapse.
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Brito-Zerón P, Pérez-Álvarez R, Ramos-Casals M. Sarcoidosis. Med Clin (Barc) 2022; 159:195-204. [PMID: 35680449 DOI: 10.1016/j.medcli.2022.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022]
Abstract
Sarcoidosis is a systemic autoimmune disease that is associated with the development of non-caseating granulomas. The disease especially affects the lymph nodes, lungs, skin and eyes. It is an infrequent but not rare disease, especially in northern Europe, the United States and India. Sarcoidosis affects more women and is diagnosed between the ages of 30 and 50. Etiopathogenically, it is closely linked to environmental factors, especially occupational exposures. Clinically, it stands out for a wide variety of presentation phenotypes (casual diagnosis, involvement of a single organ or systemic presentation). The diagnosis of sarcoidosis is complex and requires the integration of clinical, analytical, radiological, and histolopathogical data carried out by multidisciplinary clinical units. The evolution of the disease is variable, as is the indication for systemic treatment, based on the use of corticosteroids as first-line option, the use of immunosuppressants as second-line therapy, and anti-TNF agents in severe and/or refractory cases.
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Affiliation(s)
- Pilar Brito-Zerón
- Research and Innovation Group in Autoimmune Diseases, Sanitas Digital Hospital, Hospital-CIMA-Centre Mèdic Millenium Balmes Sanitas, Barcelona, España; Línea de Investigación en Sarcoidosis del GEAS, Sociedad Española de Medicina Interna (SEMI), Madrid, España
| | - Roberto Pérez-Álvarez
- Línea de Investigación en Sarcoidosis del GEAS, Sociedad Española de Medicina Interna (SEMI), Madrid, España; Servicio de Medicina Interna, Hospital San Rafael, La Coruña, España
| | - Manuel Ramos-Casals
- Línea de Investigación en Sarcoidosis del GEAS, Sociedad Española de Medicina Interna (SEMI), Madrid, España; Servicio de Enfermedades Autoinmunes, ICMiD, Hospital Clínic, Barcelona, España; Departament de Medicina, Universtat de Barcelona, Barcelona, España.
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Perspective of sarcoidosis in terms of rheumatology: a single-center rheumatology clinic experience. Rheumatol Int 2022; 42:2191-2197. [PMID: 36006458 DOI: 10.1007/s00296-022-05193-2] [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: 07/19/2022] [Accepted: 08/16/2022] [Indexed: 10/15/2022]
Abstract
Sarcoidosis may present with many rheumatological symptoms as well as mimic and/or may occur concomitantly with many other rheumatic diseases. We examined the demographic, clinical and laboratory characteristics of patients diagnosed with sarcoidosis in the rheumatology department. This study planned as retrospective cross-sectional study. Medical records of patients who applied to our rheumatology outpatient clinic due to complain of musculoskeletal problems and then diagnosed sarcoidosis were retrospectively investigated. Joint findings, extrapulmonary involvements, and coexisting rheumatic disease were evaluated. Fifty-six patients (41.21 ± 7.83 years, 75% female) were included. The duration of the disease was 49.61 ± 29.11 months, and the follow-up period was 26.66 ± 13.26 months. All patients had pulmonary system involvement. Arthralgia was present in 91.10% of 56 patients and arthritis in 89.29% of patients. Examining the subtypes of the arthritis findings, mono-arthritis was found in 31/50 (62%) patients, oligo-arthritis in 15/50 (30%) patients, and polyarthritis in 4/50 (8%) patients. A total of 11 (19.60%) patients were diagnosed with uveitis. Excision of the mediastinal LAP was performed in a total of 37 patients (66.1%) and became the most commonly employed method. Considering the treatment distribution of the patients under followed-up, it is seen that non-steroidal anti-inflammatory treatments were used in 15 (26.8%) patients, corticosteroids in a total of 40 (71.4%) patients, methotrexate in a total of 15 patients (26.8%), azathioprine in six (10.7%) patients, hydroxychloroquine in 14 (25%) patients, and infliximab in one (1.8%) patient. As sarcoidosis is a mimicking disease, a good differential diagnosis should be made to avoid misdiagnosis and in order not to be late in diagnosis and treatment. Physicians, especially rheumatologists, should remember sarcoidosis more frequently as the disease may overlap with other rheumatological diseases and may occur with many rheumatological manifestations.
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Afacan Yıldırım E, Aladağ Öztürk P, Adışen E, Köktürk N. The relationship between erythema nodosum and prognosis in systemic sarcoidosis: a retrospective cohort study. An Bras Dermatol 2022; 97:606-611. [PMID: 35811196 PMCID: PMC9453497 DOI: 10.1016/j.abd.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/22/2021] [Accepted: 09/02/2021] [Indexed: 11/24/2022] Open
Abstract
Background Erythema Nodosum (EN) is the most common skin manifestation in sarcoidosis and has often been associated with a good prognosis. Objectives To compare the clinical characteristics and treatment-related features in patients with sarcoidosis according to whether or not EN was seen as a presenting symptom at the time of diagnosis. Methods A 20-year single-center retrospective study was performed. The following two groups were identified: one group with EN as one of the presenting symptoms at the time of diagnosis of sarcoidosis (EN group) and a second group without EN as a presenting symptom at diagnosis (non-EN group). The clinical characteristics and treatment modalities were collected from the medical records. Results A total of 122 patients (31 in the EN group, 91 in the non-EN group) were included. Radiological stages of pulmonary disease were significantly lower in the EN group. Articular involvement was more common in the EN group (p = 0.001), whereas other systemic organ involvements (p = 0.025), especially neurological involvement (p = 0.036), were significantly more common in the non-EN group. In the EN group, a higher percentage of patients were managed without systemic therapy (71.0% vs. 54.9%) and spontaneous remission was more frequent (25.0% vs. 14.1%), however, this wasn’t statistically significant. Study limitations Retrospective design. Conclusions The lower radiological stage of pulmonary sarcoidosis and lower frequency of systemic organ involvement in patients with EN augment the prognostic value of EN highlighted in the literature. However, this study couldn’t confirm that the patients with EN would need less systemic therapy in the course of their disease.
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Affiliation(s)
- Elif Afacan Yıldırım
- Department of Dermatology, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | | | - Esra Adışen
- Department of Dermatology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Nurdan Köktürk
- Department of Pulmonary Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
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Hasbani GE, Uthman I, Jawad AS. Musculoskeletal Manifestations of Sarcoidosis. CLINICAL MEDICINE INSIGHTS. ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441211072475. [PMID: 35185345 PMCID: PMC8854226 DOI: 10.1177/11795441211072475] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/09/2021] [Indexed: 01/12/2023]
Abstract
Since its initial description in the late 19th century, sarcoidosis has been extensively studied. Although the general mechanism of immune activation is known, many details especially in the context of disease associations are still missing. One of such associations is the musculoskeletal complications that are widely variable in terms of presentation and response to treatment. Sarcoidosis can involve the joints leading to acute and, less commonly chronic, arthritis. While acute arthritis is mostly self-resolving in nature, chronic arthritis may lead to deformity and destruction of the joint. Sarcoidosis can also involve the muscles, leading to different pathologies primarily categorized according to the clinical presentation, despite the efforts to find a new classification based on imaging, histological, and clinical findings. The bones can be directly and indirectly affected. Different types of bone lesions have been described, although around half of these patients remain asymptomatic. Osteoporosis, increased risk of fractures, hypercalcemia, and hypercalciuria are examples of the indirect effect of sarcoidosis on the bones, possibly contributed to elevated levels of calcitriol. Nevertheless, sarcoidosis can be associated with small-vessel, medium-vessel, and large vessel vasculitis, although it is frequently difficult to differentiate between the co-existence of a pure vasculitis and sarcoidosis and sarcoid vasculitis.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Sm Jawad
- Department of Rheumatology, The Royal London Hospital, London, UK
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Matsuo T, Honda H, Tanaka T, Uraguchi K, Kawahara M, Hagiya H. COVID-19 mRNA Vaccine-Associated Uveitis Leading to Diagnosis of Sarcoidosis: Case Report and Review of Literature. J Investig Med High Impact Case Rep 2022; 10:23247096221086450. [PMID: 35313760 PMCID: PMC8943455 DOI: 10.1177/23247096221086450] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 12/02/2022] Open
Abstract
A 34-year-old Japanese person with male gender identity who had been taking intramuscular injection of methyltestosterone depot for 11 years after bilateral mastectomy noticed blurred vision 5 days after the second vaccination for COVID-19 (Tozinameran; Pfizer-BioNTech) in the interval of 3 weeks following the first vaccination. The patient was diagnosed as granulomatous iritis with mutton-fat keratic precipitates and small iris nodules at the pupillary margin in the right eye and began to have 0.1% betamethasone eye drops with good response. The patient, however, continued to have fever and malaise and showed a high level of serum soluble interleukin-2 receptor (sIL-2R) even 4 weeks after the second vaccination. Computed tomographic scan disclosed mediastinal and bilateral hilar small lymphadenopathy together with limited granular lesion in the right lung. Gallium-67 scintigraphy demonstrated high uptake not only in mediastinal and hilar lymph nodes but also in bilateral parotid glands. Right parotid gland biopsy revealed noncaseating granulomas and proved pathological diagnosis of sarcoidosis. The systemic symptoms were relieved by oral prednisolone 20 mg daily. Even though the causal relationship remains undetermined, this case is unique at the point that vaccine-associated uveitis led to the detection of pulmonary lesions and lymphadenopathy, resulting in clinical and pathological diagnosis of sarcoidosis. In literature review, 3 patients showed sarcoidosis-like diseases after COVID-19 vaccination: 2 patients were diagnosed clinically as Lofgren syndrome with acute onset of erythema nodosum and ankle swelling, with or without mediastinal and hilar lymphadenopathy, whereas 1 patient with mediastinal lymphadenopathy but no uveitis was diagnosed pathologically by biopsy as sarcoidosis.
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Affiliation(s)
- Toshihiko Matsuo
- Graduate School of Interdisciplinary
Science and Engineering in Health Systems, Okayama University, Japan
- Department of Ophthalmology, Okayama
University Hospital, Japan
| | - Hiroyuki Honda
- Department of General Medicine, Okayama
University Hospital, Japan
| | - Takehiro Tanaka
- Department of Pathology, Graduate
School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University,
Japan
| | - Kensuke Uraguchi
- Department of Otolaryngology, Head
& Neck Surgery, Okayama University Hospital, Japan
| | | | - Hideharu Hagiya
- Department of General Medicine, Okayama
University Hospital, Japan
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Tana C, Donatiello I, Caputo A, Tana M, Naccarelli T, Mantini C, Ricci F, Ticinesi A, Meschi T, Cipollone F, Giamberardino MA. Clinical Features, Histopathology and Differential Diagnosis of Sarcoidosis. Cells 2021; 11:59. [PMID: 35011621 PMCID: PMC8750978 DOI: 10.3390/cells11010059] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/17/2021] [Accepted: 12/23/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcoidosis is a chameleon disease of unknown etiology, characterized by the growth of non-necrotizing and non-caseating granulomas and manifesting with clinical pictures that vary on the basis of the organs that are mainly affected. Lungs and intrathoracic lymph nodes are the sites that are most often involved, but virtually no organ is spared from this disease. Histopathology is distinctive but not pathognomonic, since the findings can be found also in other granulomatous disorders. The knowledge of these findings is important because it could be helpful to differentiate sarcoidosis from the other granulomatous-related diseases. This review aims at illustrating the main clinical and histopathological findings that could help clinicians in their routine clinical practice.
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Affiliation(s)
- Claudio Tana
- Geriatrics Clinic, SS. Medical Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - Iginio Donatiello
- Internal Medicine Unit, Medical Department, University Hospital of Salerno, 84121 Salerno, Italy;
| | - Alessandro Caputo
- Anatomical Pathology Unit, Department of Anatomical Pathology, University Hospital of Salerno, 84121 Salerno, Italy;
| | - Marco Tana
- 2nd Internal Medicine Unit, SS. Medical Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy;
| | - Teresa Naccarelli
- Oncoematology Unit, Oncoematology Department, Tor Vergata Hospital of Rome, 00133 Rome, Italy;
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Radiology, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy; (C.M.); (F.R.)
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Radiology, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy; (C.M.); (F.R.)
| | - Andrea Ticinesi
- Internal Medicine Unit, Geriatric-Rehabilitation Department and Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.T.); (T.M.)
| | - Tiziana Meschi
- Internal Medicine Unit, Geriatric-Rehabilitation Department and Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.T.); (T.M.)
| | - Francesco Cipollone
- Department of Medicine and Science of Aging, Medical Clinic, SS Annunziata Hospital of Chieti, G. D’Annunzio University of Chieti, 66100 Chieti, Italy;
| | - Maria Adele Giamberardino
- Department of Medicine and Science of Aging and CAST, Geriatrics Clinic, SS. Annunziata Hospital of Chieti, G. D’Annunzio University of Chieti, 66100 Chieti, Italy;
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Chopra A, Foulke L, Judson MA. Sarcoidosis associated pleural effusion: Clinical aspects. Respir Med 2021; 191:106723. [PMID: 34954636 DOI: 10.1016/j.rmed.2021.106723] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
A sarcoidosis associated pleural effusion (SAPE) is a pleural effusion caused by active granulomatous inflammation from sarcoidosis. We describe the epidemiology, clinical features, diagnostic approach, treatment strategies and outcome of this condition. SAPE occurs in approximately 1% of sarcoidosis patients. The condition most commonly occurs at the initial presentation of sarcoidosis or within the first year. Dyspnea is the most common presenting symptom. Although a definitive diagnosis of SAPE requires a pleural biopsy, the diagnosis may be established on the basis of clinical features alone provided that alternative conditions can be reliably excluded. Pleural fluid analysis is essential in establishing the clinical diagnosis of SAPE. Corticosteroids are the drugs of choice for SAPE, and they are usually rapidly effective with courses of therapy often lasting less than two months. SAPE tends to have a low rate of recurrence that appears be to lower than for many other forms of sarcoidosis.
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Affiliation(s)
- Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA.
| | - Llewellyn Foulke
- Department of Pathology, Albany Medical College, Albany, NY, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
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12
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Mihalov P, Krajčovičová E, Káčerová H, Sabaka P. Lofgren syndrome in close temporal association with mild COVID-19 - Case report. IDCases 2021; 26:e01291. [PMID: 34580630 PMCID: PMC8458104 DOI: 10.1016/j.idcr.2021.e01291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 01/02/2023] Open
Abstract
Coronavirus infection disease 2019 (COVID-19) has been linked to the development of various autoimmune disorders. Lofgren syndrome, consisting of bilateral pulmonary hilar lymphadenopathy, erythema nodosum and polyarthritis, is a rare autoimmune disease that represents an acute form of sarcoidosis. We present the case of Lofgren syndrome developing in close temporal association with COVID-19. Clinical presentation consisted of fever, bilateral lung lymphadenopathy, arthralgias and erythema nodosum. Hilar lymph node biopsy revealed pathology consistent with sarcoidosis. Three weeks prior to presentation, the patient experienced respiratory symptoms. Serological examination at the time of presentation revealed positive IgM and IgG antibodies against SARS-CoV-2 nucleocapsid protein. Most symptoms resolved following a course of oral prednisone. This case report suggests a possible link between COVID-19 and the development of sarcoidosis, however, further studies are needed to conclude this association.
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Affiliation(s)
- Peter Mihalov
- Department of Infectology and Geographical Medicine, University Hospital in Bratislava, Faculty of Medicine, Comenius University in Bratislava, Limbová 5, 83105 Bratislava, Slovakia
| | - Eliška Krajčovičová
- Department of Infectology and Geographical Medicine, University Hospital in Bratislava, Faculty of Medicine, Comenius University in Bratislava, Limbová 5, 83105 Bratislava, Slovakia
| | - Helena Káčerová
- Department of Infectology and Geographical Medicine, University Hospital in Bratislava, Faculty of Medicine, Comenius University in Bratislava, Limbová 5, 83105 Bratislava, Slovakia
| | - Peter Sabaka
- Department of Infectology and Geographical Medicine, University Hospital in Bratislava, Faculty of Medicine, Comenius University in Bratislava, Limbová 5, 83105 Bratislava, Slovakia
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13
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Bernardinello N, Petrarulo S, Balestro E, Cocconcelli E, Veltkamp M, Spagnolo P. Pulmonary Sarcoidosis: Diagnosis and Differential Diagnosis. Diagnostics (Basel) 2021; 11:diagnostics11091558. [PMID: 34573900 PMCID: PMC8472810 DOI: 10.3390/diagnostics11091558] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/11/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcoidosis is a multisystem disorder of unknown origin and poorly understood pathogenesis that predominantly affects lungs and intrathoracic lymph nodes and is characterized by the presence of noncaseating granulomatous inflammation in involved organs. The disease is highly heterogeneous and can mimic a plethora of other disorders, making diagnosis a challenge even for experienced physicians. The evolution and severity of sarcoidosis are highly variable: many patients are asymptomatic and their disease course is generally benign with spontaneous resolution. However, up to one-third of patients develop chronic or progressive disease mainly due to pulmonary or cardiovascular complications that require long-term therapy. The diagnosis of sarcoidosis requires histopathological evidence of noncaseating granulomatous inflammation in one or more organs coupled with compatible clinical and radiological features and the exclusion of other causes of granulomatous inflammation; however, in the presence of typical disease manifestations such as Löfgren’s syndrome, Heerfordt’s syndrome, lupus pernio and asymptomatic bilateral and symmetrical hilar lymphadenopathy, the diagnosis can be established with high level of certainty on clinical grounds alone. This review critically examines the diagnostic approach to sarcoidosis and emphasizes the importance of a careful exclusion of alternative diagnoses.
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Affiliation(s)
- Nicol Bernardinello
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (N.B.); (S.P.); (E.B.); (E.C.)
| | - Simone Petrarulo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (N.B.); (S.P.); (E.B.); (E.C.)
| | - Elisabetta Balestro
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (N.B.); (S.P.); (E.B.); (E.C.)
| | - Elisabetta Cocconcelli
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (N.B.); (S.P.); (E.B.); (E.C.)
| | - Marcel Veltkamp
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, 3430 EM Nieuwegein, The Netherlands;
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (N.B.); (S.P.); (E.B.); (E.C.)
- Correspondence: ; Tel.: +39-049-8211272; Fax: +39-049-8213110
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Acute Sarcoidosis Clusters in Cold Season and Is Associated with Ambient Air Pollution: A Retrospective Clinical-Meteorological Study. Ann Am Thorac Soc 2021; 18:1415-1417. [PMID: 33567226 DOI: 10.1513/annalsats.202008-1083rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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A Primer on the Clinical Aspects of Sarcoidosis for the Basic and Translational Scientist. J Clin Med 2021; 10:jcm10132857. [PMID: 34203188 PMCID: PMC8268437 DOI: 10.3390/jcm10132857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 12/19/2022] Open
Abstract
The immunopathogenesis of sarcoidosis remains unclear. This failure in understanding has been clinically impactful, as it has impeded the accurate diagnosis, treatment, and prevention of this disease. Unraveling the mechanisms of sarcoidosis will require input from basic and translational scientists. In order to reach this goal, scientists must have a firm grasp of the clinical aspects of the disease, including its diagnostic criteria, the immunologic defects, clinical presentations, response to therapy, risk factors, and clinical course. This manuscript will provide an overview of the clinical aspects of sarcoidosis that are particularly relevant for the basic and translational scientist. The variable phenotypic expression of the disease will be described, which may be integral in identifying immunologic disease mechanisms that may be relevant to subgroups of sarcoidosis patients. Data concerning treatment and risk factors may yield important insights concerning germane immunologic pathways involved in the development of disease. It is hoped that this manuscript will stimulate communication between scientists and clinicians that will eventually lead to improved care of sarcoidosis patients.
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16
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Chauhan A, Jandial A, Mishra K, Sandal R. Acute arthritis, skin rash and Lofgren's syndrome. BMJ Case Rep 2021; 14:14/6/e239239. [PMID: 34099443 PMCID: PMC8186550 DOI: 10.1136/bcr-2020-239239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Sarcoidosis is an autoimmune multisystem granulomatous disorder of unknown aetiology, which mainly affects the adults in the age group of 20–39 years. The disease can affect any organ in the body but mainly presents as bilateral hilar lymphadenopathy, pulmonary infiltrates, cutaneous lesions, ocular manifestations and arthropathy. Lofgren’s syndrome is an uncommon initial presentation of sarcoidosis which is recognised by the classical triad of acute arthritis, erythema nodosum and bilateral hilar lymphadenopathy. We describe a newly diagnosed case of sarcoidosis who presented as Lofgren’s syndrome. Acute sarcoid arthritis should be kept as one of the differential diagnoses for patients presenting with acute arthritis and skin lesions; and chest X-ray should be considered to rule out bilateral hilar lymphadenopathy in these patients. Early suspicion and identification of classical clinical features are essential to establish early diagnosis.
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Affiliation(s)
- Ajay Chauhan
- Internal Medicine, Dr Rajinder Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Aditya Jandial
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kundan Mishra
- Internal Medicine, Army Hospital Research and Referral, New Delhi, Delhi, India
| | - Rajeev Sandal
- Department of Radiotherapy and Oncology, IGMC, Shimla, Himachal Pradesh, India
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17
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Abstract
Sarcoidosis is a chronic multi-system disorder with an unknown etiology that can affect the cardiac tissue, resulting in Cardiac Sarcoidosis (CS). The majority of these CS cases are clinically silent, and when there are symptoms, the symptoms are vague and can have a lot in common with other common cardiac diseases. These symptoms can range from arrhythmias to heart failure. If CS goes undetected, it can lead to detrimental outcomes for patients. Diagnosis depends on timely utilization of imaging modalities and non-invasive testing, while in some cases, it does necessitate biopsy. Early diagnosis and treatment with immunosuppressive agents are crucial, and it is essential that follow-up testing be performed to ensure resolution and remission. This manuscript provides an in-depth review of CS and the current literature regarding CS diagnosis and treatment.
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18
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Komishke B, Foulds JL, McMillan T, Avdimiretz N. Bilateral leg swelling as the presenting symptom of Löfgren syndrome in a paediatric patient: a rare presentation of a rare paediatric disease. BMJ Case Rep 2021; 14:14/3/e239434. [PMID: 33664030 PMCID: PMC7934771 DOI: 10.1136/bcr-2020-239434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 17-year-old previously healthy man presented with a 4-week history of progressive bilateral leg swelling with discomfort and erythema, but no signs of arthritis or erythema nodosum. An incidental finding of a query pulmonary nodule on chest X-ray prompted chest CT for further evaluation, revealing bilateral hilar and mediastinal lymphadenopathy. The patient then underwent endobronchial ultrasound and transbronchial needle aspiration biopsies of mediastinal lymph nodes. Biopsies and bronchoalveolar lavage samples were negative for microbiology, including mycobacterial culture. Pathology demonstrated non-caseating granulomas consistent with a diagnosis of sarcoidosis. Weeks later, he developed arthralgias of the left metacarpophalangeal joints and erythema nodosum and was diagnosed with Löfgren syndrome, a phenomenon rarely described in the paediatric population. This case highlights an approach to lower extremity swelling as well as hilar lymphadenopathy in the paediatric population. In addition, it emphasises the importance of multidisciplinary teamwork for accurate and timely diagnoses.
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Affiliation(s)
- Bailey Komishke
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jessica L Foulds
- Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Tamara McMillan
- Pediatric Rheumatology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Nicholas Avdimiretz
- Pediatric Respirology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Patil S, Hilliard CA, Arakane M, Koppisetti Jenigiri S, Field EH, Singh N. Musculoskeletal sarcoidosis: A single center experience over 15 years. Int J Rheum Dis 2021; 24:533-541. [PMID: 33559378 DOI: 10.1111/1756-185x.14068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Musculoskeletal (MSK) sarcoidosis presents with a variety of clinical phenotypes. Four subtypes of MSK sarcoidosis have been identified to date: Lofgren syndrome, chronic sarcoid arthritis, osseous sarcoidosis, sarcoid myopathy. Each subtype has been reported with varying incidence mainly due to lack of universal classification criteria. METHODS We performed a retrospective chart review of patients with MSK sarcoidosis at a single academic center between January 2000 and December 2014. Descriptive statistics were used to describe the proportion of patients with sarcoidosis who had the 4 MSK syndromes of interest, demographic characteristics and therapeutic agents used. RESULTS A cohort of 58 patients with MSK manifestations were identified among 1016 patients with sarcoidosis. Frequency of subtypes include: Lofgren syndrome 46.6%, osseous sarcoidosis 25.9%, chronic sarcoid arthritis 24.1% and sarcoid myopathy 6.9%. The cohort was predominantly female (43/58 patients, 74%) and Caucasian (48/58 patients, 82.8%). Mean age was 47.2 years. One patient had overlap of osseous sarcoidosis and chronic sarcoid arthritis, another patient initially had Lofgren syndrome and later developed chronic sarcoid arthritis. Sarcoid myopathy patients presented with myalgia more often than muscle weakness. CONCLUSION We identified a large cohort of MSK sarcoidosis and determined the prevalence of all 4 subtypes. In patients who do develop MSK manifestations of sarcoidosis, they are commonly a part of the initial presentation of sarcoidosis. There is an unmet need to establish standardized classification criteria for the 4 MSK sarcoidosis syndromes.
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Affiliation(s)
- Sanjeev Patil
- Rheumatology, The University of Vermont Medical Center, Burlington, VT, USA
| | - Carolyn A Hilliard
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Sreedevi Koppisetti Jenigiri
- Division of Nephrology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Elizabeth H Field
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, USA
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20
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Challenges in Cardiac and Pulmonary Sarcoidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:1878-1901. [PMID: 33059834 DOI: 10.1016/j.jacc.2020.08.042] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
Sarcoidosis is a complex disease with heterogeneous clinical presentations that can affect virtually any organ. Although the lung is typically the most common organ involved, combined pulmonary and cardiac sarcoidosis (CS) account for most of the morbidity and mortality associated with this disease. Pulmonary sarcoidosis can be asymptomatic or result in impairment in quality of life and end-stage, severe, and/or life-threatening disease. The latter outcome is seen almost exclusively in those with fibrotic pulmonary sarcoidosis, which accounts for 10% to 20% of pulmonary sarcoidosis patients. CS is problematic to diagnose and may cause significant morbidity and death from heart failure or ventricular arrhythmias. The diagnosis of CS usually requires surrogate cardiac imaging biomarkers, as endomyocardial biopsy has relatively low yield, even with directed electrophysiological mapping. Treatment of CS is often multifactorial, involving a combination of antigranulomatous therapy and pharmacotherapy for cardiac arrhythmias and/or heart failure in addition to device placement and cardiac transplantation.
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21
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Abstract
Sarcoidosis is a systemic disease with a number of extrapulmonary manifestations, rarely limited to a single system. The objective of this review is to provide a overview of the systemic features of sarcoidosis and their surveillance. Sarcoidosis is disease that can affect any organ system, resulting in a number of complications that can cause significant morbidity and mortality, including ophthalmological and cardiac complications. A number of investigations play a role in identifying manifestations of sarcoidosis. Respiratory physicians have an important role to play in identifying complications and monitoring patients with sarcoidosis, as they may be the first to encounter them. Sarcoidosis can involve any organ system, with several complications, particularly ophthalmological and cardiac disease, that are important to recognise in clinical practice and monitor, no matter one's area of expertisehttps://bit.ly/36oLXxm
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Affiliation(s)
- Katrin Mannes
- Dept of Respiratory Medicine, Prince of Wales' Hospital, Sydney, Australia.,Prince of Wales' Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Paul S Thomas
- Dept of Respiratory Medicine, Prince of Wales' Hospital, Sydney, Australia.,Prince of Wales' Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Mechanisms of Disease and Translational Research, Faculty of Medicine, University of New South Wales, Sydney, Australia
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22
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Abstract
As sarcoidosis may involve any organ, sarcoidosis patients should be evaluated for occult disease. Screening for some organ involvement may not be warranted if it is unlikely to cause symptoms, organ dysfunction, or affect clinical outcome. Even organ involvement that affects clinical outcome does not necessarily require screening if early detection fails to change the patient's quality of life or prognosis. On the other hand, early detection of some forms of sarcoidosis may improve outcomes and survival. This manuscript describes the approach to screening sarcoidosis patients for previously undetected disease. Screening for sarcoidosis should commence with a meticulous medical history and physical examination. Many sarcoidosis patients present with physical signs or symptoms of sarcoidosis that have not been recognized as manifestations of the disease. Detection of sarcoidosis in these instances depends on the clinician's familiarity with the varied clinical presentations of sarcoidosis. In addition, sarcoidosis patients may present with symptoms or signs that are not related to specific organ involvement that have been described as parasarcoidosis syndromes. It is conjectured that parasarcoidosis syndromes result from systemic release of inflammatory mediators from the sarcoidosis granuloma. Certain forms of sarcoidosis may cause permanent and serious problems that can be prevented if they are detected early in the course of their disease. These include (1) ocular involvement that may lead to permanent vision impairment; (2) vitamin D dysregulation that may lead to hypercalcemia, nephrolithiasis, and permanent kidney injury; and (3) cardiac sarcoidosis that may lead to a cardiomyopathy, ventricular arrhythmias, heart block, and sudden death. Screening for these forms of organ involvement requires detailed screening approaches.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
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23
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Castro MDC, Pereira CADC. Nonlife-Threatening Sarcoidosis. Semin Respir Crit Care Med 2020; 41:733-740. [PMID: 32777854 DOI: 10.1055/s-0040-1710371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown etiology. The outcome is quite variable and is mainly related to persistent inflammatory processes and the development of fibrosis. Many prognostic factors have been described, but the disease evolution is not yet entirely known. The nonthreatening course is characterized by spontaneous involution or stability after treatment withdrawal. Löfgren's syndrome is a subset within the spectrum of sarcoidosis phenotypes, composed of acute onset of fever, bilateral hilar lymphadenopathy, erythema nodosum and/or bilateral ankle periarticular inflammation/arthritis, specifically characterized by a self-limiting disease course. In contrast, advanced fibrotic sarcoidosis with pulmonary hypertension phenotype is correlated with a poor prognosis. Further studies are necessary to detail phenotypes to better understand the mechanisms of the disease and plan future clinical therapeutic studies.
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Affiliation(s)
- Marina Dornfeld Cunha Castro
- Department of Medicine, Division of Respiratory Diseases, Interstitial Lung Diseases Center, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Carlos Alberto de Castro Pereira
- Department of Medicine, Division of Respiratory Diseases, Interstitial Lung Diseases Center, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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24
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Saha BK, Chong W, Bonnier A, Wallace S. Löfgren Syndrome in Histoplasma Endemic Rural America. Am J Med Sci 2020; 360:419-422. [PMID: 32736828 DOI: 10.1016/j.amjms.2020.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/19/2020] [Accepted: 06/25/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri.
| | - Woon Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Alyssa Bonnier
- Division of Critical Care Nursing, Albany Medical Center, Albany, New York
| | - Samantha Wallace
- Division of Medicine, Ozarks Medical Center, West Plains, Missouri
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25
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Abstract
Introduction: The treatment of pulmonary sarcoidosis is not standardized. Treatment involves a multi-step decision process beginning with whether treatment is warranted, determining initial therapy, then assessing when therapy requires modifications or can be discontinued.Areas covered: This manuscript will address the following issues concerning the treatment of pulmonary sarcoidosis: Treatment indications, initial anti-granulomatous therapy, therapy for chronic and fibrotic disease, glucocorticoid therapy, alternative therapy to glucocorticoids, non-granulomatous therapies, and managing complications of disease. Information was obtained through a literature search of PubMed and Web of Science databases.Expert opinion: Although glucocorticoids are highly effective for pulmonary sarcoidosis, their potential to cause significant side effects often mandates consideration of alternative agents. As the most common indication for the treatment of pulmonary sarcoidosis is quality of life impairment, traditional objective tests of lung function and radiographic imagining often have a minor role in therapeutic decision-making. The development of pulmonary fibrosis from sarcoidosis often causes major morbidity and mortality and should be a major focus of concern.
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Affiliation(s)
- W Ennis James
- Division of Pulmonary and Critical Care Medicine; Program Director, Susan Pearlstine Sarcoidosis Center of Excellence, Medical University of South Carolina, Charleston, SC, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College MC-91, Albany, NY, USA
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26
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Razdan PS, Buteau D, Pollock NW. A case of Löfgren's syndrome confused with decompression sickness. Diving Hyperb Med 2019; 49:306-310. [PMID: 31828751 DOI: 10.28920/dhm49.4.306-310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/14/2019] [Indexed: 11/05/2022]
Abstract
A broad differential diagnosis is important to provide appropriate care. This may be challenging for conditions like decompression sickness (DCS) which can be easily confused with other conditions. In suspected DCS, treatment may be an important part of the diagnosis. An improvement in symptoms after hyperbaric oxygen treatment (HBOT) is consistent with a DCS event. However, HBOT may also impact symptoms in other conditions, including Löfgren's syndrome (LS). LS, a poorly understood, clinically distinct phenotype of sarcoidosis, is a complex, multi-system granulomatous inflammatory condition. Like DCS, LS symptoms are heterogeneous and idiosyncratic. We report on a patient initially diagnosed with DCS who presented new symptoms suggestive of LS after HBOT.
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Affiliation(s)
- Payal S Razdan
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,CISSS Chaudière-Appalaches (CHAU-Hôtel-Dieu de Lévis), Hyperbaric Medicine Unit, Lévis, Québec, Canada.,Corresponding author: Rm 4807, Hôtel-Dieu de Lévis, 143 rue Wolfe, Lévis, QC, Canada, G6V 3Z1,
| | - Dominique Buteau
- Family Medicine and Emergency Medicine Department, Faculty of Medicine, Université Laval, Québec, Canada.,CISSS Chaudière-Appalaches (CHAU-Hôtel-Dieu de Lévis), Hyperbaric Medicine Unit, Emergency Department, Lévis, Quebec, Canada
| | - Neal W Pollock
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,CISSS Chaudière-Appalaches (CHAU-Hôtel-Dieu de Lévis), Hyperbaric Medicine Unit, Lévis, Québec, Canada
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Sarcoidosis presenting with and without Löfgren's syndrome: Clinical, radiological and behavioral differences observed in a group of 691patients. Joint Bone Spine 2019; 87:141-147. [PMID: 31606494 DOI: 10.1016/j.jbspin.2019.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/01/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Just a few series of Löfgren's syndrome have been reported. Our aim was to describe the epidemiology and clinical profile of sarcoidosis patients presenting with Löfgren's syndrome vs. non-Löfgren's syndrome. METHODS Retrospective cohort study of 691consecutive patients with sarcoidosis diagnosed at the Bellvitge University Hospital in Barcelona, Spain, between 1976 and 2018. RESULTS Three hundred and nine patients (44.7%) were diagnosed with Löfgren's syndrome and 382with non-Löfgren's syndrome (55.3%). The mean age at diagnosis was 39.8years-old (SD 11.7) vs. 46.6 (SD 14.5) (P<0.001). 249 patients (80.6%) vs. 218 (57.1%) were female (P<0.001), and mostly Caucasians (304, 98.4% vs. 351, 91.9%, P=0.002). Out of the total 309, Löfgren's syndrome patients developed more frequently fever and articular involvement, and 45 (14.6%) presented with isolated periarticular ankle inflammation. When compared, radiological stages at diagnosis were more advanced in non-Löfgren's syndrome patients: stage 0 (2.9% vs. 14.7%), stage I (82.5% vs. 41.4%), stage II (14.6% vs. 29.3%), and stage III/IV (0 vs. 14.7%) (P<0.001). Chronic trend>2years was more prevalent in non-Löfgren's syndrome (66, 22.6% vs. 233, 67.4%; P<0.001), as well as the proportion of patients in whom treatment was needed (58, 18.8% vs. 224, 58.6%; P<0.001). Risk factors related to chronic trend>2 years were older age, stage II at diagnosis and the need of treatment. CONCLUSIONS Löfgren's syndrome is a well-differentiated form of sarcoidosis with persuasive different epidemiological, clinical, radiological and prognostic features.
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28
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Bennett D, Bargagli E, Refini RM, Rottoli P. New concepts in the pathogenesis of sarcoidosis. Expert Rev Respir Med 2019; 13:981-991. [DOI: 10.1080/17476348.2019.1655401] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- David Bennett
- Respiratory Diseases and Lung Transplantation Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplantation Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
- Department of Medical and Surgical Sciences & Neurosciences, University of Siena, Siena, Italy
| | - Rosa Metella Refini
- Respiratory Diseases and Lung Transplantation Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
- Department of Medical and Surgical Sciences & Neurosciences, University of Siena, Siena, Italy
| | - Paola Rottoli
- Department of Medical and Surgical Sciences & Neurosciences, University of Siena, Siena, Italy
- Regional Coordinator for Rare Respiratory Diseases for Tuscany, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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29
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Ungprasert P, Ryu JH, Matteson EL. Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clin Proc Innov Qual Outcomes 2019; 3:358-375. [PMID: 31485575 PMCID: PMC6713839 DOI: 10.1016/j.mayocpiqo.2019.04.006] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
The focus of this review is current knowledge about the epidemiology, clinical manifestations, diagnosis, and treatment of both pulmonary sarcoidosis and extrapulmonary sarcoidosis. Although intrathoracic involvement is the hallmark of the disease, present in over 90% of patients, sarcoidosis can affect virtually any organ. Clinical presentations of sarcoidosis are diverse, ranging from asymptomatic, incidental findings to organ failure. Diagnosis requires the presence of noncaseating granuloma and compatible presentations after exclusion of other identifiable causes. Spontaneous remission is frequent, so treatment is not always indicated unless the disease is symptomatic or causes progressive organ damage/dysfunction. Glucocorticoids are the cornerstone of treatment of sarcoidosis even though evidence from randomized controlled studies is lacking. Glucocorticoid-sparing agents and biologic agents are often used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects.
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Key Words
- ATS, American Thoracic Society
- AV, atrioventricular
- CMRI, cardiovascular magnetic resonance imaging
- DLCO, diffusing capacity of the lung for carbon monoxide
- DMARD, disease-modifying antirheumatic drugs
- ECG, electrocardiographic
- ERS, European Respiratory Society
- FDG-PET, 18F-fluorodeoxyglucose–positron emission tomography
- FVC, forced vital capacity
- GI, gastrointestinal tract
- LVEF, left ventricular ejection fraction
- NSAID, nonsteroidal anti-inflammatory drug
- PFT, pulmonary function test
- TBB, transbronchial lung biopsy
- TNF-α, tumor necrosis factor α
- WASOG, World Association of Sarcoidosis and other Granulomatous Disorders
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Affiliation(s)
- Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Address to Patompong Ungprasert, MD, MS, Clinical Epidemiology Unit, 3rd Floor, SIMR Bldg, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Jay H. Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eric L. Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research (E.L.M.), Mayo Clinic, Rochester, MN
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30
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Elderly sarcoidosis: A comparative study from a 42-year single-centre experience. Respir Med 2019; 152:1-6. [PMID: 31128602 DOI: 10.1016/j.rmed.2019.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To describe the clinical features and outcomes in elderly patients with sarcoidosis and to compare them with younger patients. MATERIAL AND METHODS Retrospective study of a large cohort of 668 consecutive patients with sarcoidosis prospectively collected during 42 years at the Bellvitge University Hospital, a tertiary care single-centre in Barcelona, Spain. Elderly sarcoidosis was defined as sarcoidosis diagnosed in patients ≥65 years-old. RESULTS Elderly sarcoidosis was diagnosed in 47 (7%) patients. In younger patients, Löfgren's syndrome was the predominant mode of onset (8.5% vs. 42.2%, p < 0.001). At diagnosis, elderly patients more frequently demonstrated radiographic stage III and IV sarcoidosis (21.3% vs. 7.6%, p = 0.001), isolated extrapulmonary involvement (21.3% vs. 8.2%, p = 0.003), subcutaneous nodules (17% vs. 3.4%, p < 0.001) and intraabdominal/retroperitoneal lymph nodes (23.4% vs. 9.5%, p = 0.003). Furthermore, patients with elderly sarcoidosis achieved remission (spontaneous and under treatment) less frequently during the follow-up period (14 patients, 35% vs. 305 patients, 53%, p = 0.027) and had a higher incidence of pulmonary fibrosis (15% vs. 6.1%, p = 0.029). Death related to sarcoidosis was more prevalent in elderly patients (6.4% vs. 1.3%, p = 0.036). CONCLUSIONS Sarcoidosis in elderly patients requires a high index of suspicion. Aged pulmonary sarcoidosis patients presented with more severe disease at presentation and worse outcomes compared to younger patients. Isolated extrapulmonary involvement at diagnosis and certain particular extrapulmonary organ involvement were more frequent in elderly sarcoidosis. Remission was less frequent in elderly sarcoidosis.
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Brandão Guimarães J, Nico MA, Omond AG, Silva FD, Aivazoglou LU, Carneiro BC, Fernandes ARC. Radiologic Manifestations of Musculoskeletal Sarcoidosis. Curr Rheumatol Rep 2019; 21:7. [PMID: 30762131 DOI: 10.1007/s11926-019-0806-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review article is to present the spectrum of abnormalities and multi-modality imaging evaluations in patients with musculoskeletal sarcoidosis. RECENT FINDINGS The articular manifestations of sarcoidosis are difficult to distinguish from those of the other inflammatory and degenerative arthropathies, and the muscular lesions in sarcoidosis are generally clinically silent and therefore often missed. Magnetic resonance imaging has shown these manifestations to be very common in active sarcoidosis, and should thus be included in the screening if musculoskeletal sarcoidosis is suspected. The clinician should consider magnetic resonance imaging for the evaluation of patients with sarcoidosis who have unexplained osteoarticular complaints if standard radiographs are negative. Furthermore, radiologists should include sarcoidosis in the differential diagnosis of musculoskeletal disease detected at magnetic resonance imaging in the appropriate clinical setting.
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Affiliation(s)
- Júlio Brandão Guimarães
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil. .,Department of Radiology, Escola Paulista de Medicina, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil. .,Department of Radiology and Biomedical Imaging, University of California, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA.
| | - Marcelo A Nico
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Alípio G Omond
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Flávio D Silva
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil.,Department of Radiology, Escola Paulista de Medicina, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Laís Uyeda Aivazoglou
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil.,Department of Radiology, Escola Paulista de Medicina, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Bruno C Carneiro
- Department of Radiology, Grupo Osteomuscular, Fleury Medicina e Saúde, São Paulo, Brazil
| | - Artur R C Fernandes
- Department of Radiology, Escola Paulista de Medicina, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
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Ramos-Casals M, Retamozo S, Sisó-Almirall A, Pérez-Alvarez R, Pallarés L, Brito-Zerón P. Clinically-useful serum biomarkers for diagnosis and prognosis of sarcoidosis. Expert Rev Clin Immunol 2019; 15:391-405. [DOI: 10.1080/1744666x.2019.1568240] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Rheumatology Unit, Instituto Modelo de Cardiología Privado S.R.L, Córdoba, Argentina
- Rheumatology Unit, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Antoni Sisó-Almirall
- Centre d’Assistència Primària ABS Les Corts, CAPSBE, Barcelona, Spain
- Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain
| | - Roberto Pérez-Alvarez
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Department of Internal Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Lucio Pallarés
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Systemic Autoimmune Diseases Uni, Department of Internal Medicine, Hospital de Son Espases, Palma de Mallorca, Spain
| | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA, Sanitas, Spain
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Agarwal V, Agrawal V, Aggarwal A, Aggarwal P, Chowdhury AC, Ghosh P, Jain A, Lawrence A, Misra DP, Misra R, Mohapatra MM, Nath A, Negi VS, Pandya S, Reddy VV, Prasad S, Sharma A, Shobha V, Singh YP, Tripathy SR, Wakhlu A. Arthritis in sarcoidosis: A multicentric study from India. Int J Rheum Dis 2018; 21:1728-1733. [PMID: 30187668 DOI: 10.1111/1756-185x.13349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Vishnu V. Reddy
- Vizag Rheumatology and Immunology Centre; Vishakhapatnam India
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Santhosh L, Koth L, Baudendistel TE, Sharpe B, Monash B. Tissue Isn't the Issue. J Hosp Med 2018; 13:500-504. [PMID: 29694457 DOI: 10.12788/jhm.2963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Lekshmi Santhosh
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Laura Koth
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - Bradley Sharpe
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Bradley Monash
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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Bechman K, Christidis D, Walsh S, Birring SS, Galloway J. A review of the musculoskeletal manifestations of sarcoidosis. Rheumatology (Oxford) 2018; 57:777-783. [PMID: 28968840 DOI: 10.1093/rheumatology/kex317] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Indexed: 01/09/2023] Open
Abstract
Sarcoidosis is a systemic disease of unknown aetiology that is characterized by granulomatous inflammation that can develop in almost any organ system. Musculoskeletal manifestations are seen in up to one-third of patients, ranging from arthralgia through to widespread destructive bone lesions. Inflammatory tendon lesions and periarticular swelling are more common than true joint synovitis. Despite advances in our understanding of the pathophysiology of the disease, diagnosis remains challenging. Definitive diagnosis, irrespective of organ site involvement, hinges on histological confirmation of non-caseating granuloma combined with an appropriate clinical syndrome. Musculoskeletal involvement usually develops early in the disease course. Imaging modalities, particularly fluorodeoxyglucose PET, are helpful in delineating the extent of involvement and measuring disease activity. Bone involvement may only become apparent following isotope imaging. Corticosteroids remain the cornerstone of treatment. MTX is the steroid-sparing agent of choice unless there is renal involvement. Biologic therapies are sometimes used in severe disease, although the evidence base for efficacy is inconsistent.
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Affiliation(s)
- Katie Bechman
- Academic Department of Rheumatology, King's College London, London, UK
| | - Dimitrios Christidis
- Rheumatology Department, Epsom and St Helier's Hospital NHS Foundation Trust, Carshalton, UK
| | - Sarah Walsh
- Dermatology Department, King's College Hospital NHS Foundation Trust, London, UK
| | | | - James Galloway
- Academic Department of Rheumatology, King's College London, London, UK
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Spagnolo P, Rossi G, Trisolini R, Sverzellati N, Baughman RP, Wells AU. Pulmonary sarcoidosis. THE LANCET RESPIRATORY MEDICINE 2018; 6:389-402. [DOI: 10.1016/s2213-2600(18)30064-x] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/14/2022]
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Abstract
Musculoskeletal manifestations in the context of sarcoidosis are frequently observed. The rheumatologist regularly encounters this disease in clinical practice. In the present review, we aim to give a current overview of the manifestations and treatments relevant to the practicing rheumatologist. The most frequently encountered manifestation is Lofgren's syndrome, which is characterized by bilateral ankle periarthritis, bilateral hilar lymphadenopathy, and erythema nodosum and has an excellent prognosis. Chronic arthropathy most commonly manifests as oligoarthritis, which sometimes hampers its differentiation from spondylarthropathies, especially when sacroiliitis, enthesitis or dactylitis are simultaneously present. Isolated vertebral granulomas are rare and require infectious and malignant disorders to be excluded, since there are no specific imaging findings that are exclusively found in vertebral sarcoidosis. The presence of granulomas in skeletal muscle is common in muscle biopsies, whereas clinically overt myopathy is present in only around 1-2% of patients. Therapeutic responses vary among the different clinical phenotypes. Non-steroidal anti-inflammatory drugs and low to medium dose glucocorticoids are the first-line therapy for musculoskeletal manifestations and often lead to adequate disease control in acute sarcoidosis. When these are ineffective or not tolerated, steroid-sparing agents are increasingly used in chronic sarcoidosis. Evidence for all medications used in sarcoid-related arthritis is comparatively scant. When supplementing vitamin D, the possible development of hypercalcemia, even at standard doses, needs to be considered; the optimal therapeutic levels for the prevention of medication-induced osteoporosis in sarcoidosis have not been firmly established.
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Affiliation(s)
- P Korsten
- Klinik für Nephrologie und Rheumatologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - G Chehab
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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Th17-lineage cells in pulmonary sarcoidosis and Löfgren's syndrome: Friend or foe? J Autoimmun 2018; 87:82-96. [DOI: 10.1016/j.jaut.2017.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 01/17/2023]
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Iriarte A, Rubio-Rivas M, Corbella X, Mañá J. Recurrence of Lofgren's syndrome 32 years later. A case report and review of the literature. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2018; 35:289-291. [PMID: 32476915 DOI: 10.36141/svdld.v35i3.7630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/02/2022]
Affiliation(s)
- Adriana Iriarte
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Manuel Rubio-Rivas
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Juan Mañá
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
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Ungprasert P, Crowson CS, Matteson EL. Clinical Characteristics of Sarcoid Arthropathy: A Population-Based Study. Arthritis Care Res (Hoboken) 2017; 68:695-9. [PMID: 26415117 DOI: 10.1002/acr.22737] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/18/2015] [Accepted: 09/15/2015] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The epidemiology and clinical characteristics of sarcoid arthropathy are not well described, as only referral-based studies have been reported. This study aimed to use the data from a geographically well-defined population to characterize the clinical characteristics of sarcoid arthropathy. METHODS An inception cohort of patients with incident sarcoidosis in the years 1976-2013 in a geographically well-defined population was identified based on comprehensive individual medical records review. Inclusion required physician diagnosis supported by histopathology and radiologic features of intrathoracic sarcoidosis, compatible clinical presentation, and exclusion of other granulomatous diseases. Patients with joint pain were then identified from this cohort. RESULTS In 1976-2013, all 345 incident cases of sarcoidosis were identified. Symptoms of joint pain occurred in 42 patients (mean age 41.2 years, 57.1% female, and 95% white), and 35 patients had swollen joint(s) on physical examination. Most patients had arthralgia prior to the diagnosis of sarcoidosis, with an average time to diagnosis of 21 days. Of the 35 cases, oligoarthritis (2 to 4 joints) was the most common pattern (88% of cases), followed by monoarthritis (6%) and polyarthritis (6%). Ankles were involved in 91% of cases. In the majority of patients (88%), the arthritis resolved within 6 weeks. Classic Lofgren's syndrome was observed in 11 patients (26%). CONCLUSION Inflammatory arthritis occurs in a minority of patients with sarcoidosis. Acute oligoarthritis with bilateral ankle involvement was the most common pattern of sarcoid arthropathy. It should be noted that the generalizability of the results may be limited, as the cohort was predominantly white.
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Judson MA, Chopra A, Conuel E, Koutroumpakis E, Schafer C, Austin A, Zhang R, Cao K, Berry R, Khan MMHS, Modi A, Modi R, Jou S, Ilyas F, Yucel RM. The Assessment of Cough in a Sarcoidosis Clinic Using a Validated instrument and a Visual Analog Scale. Lung 2017; 195:587-594. [PMID: 28707109 DOI: 10.1007/s00408-017-0040-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/08/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Cough is a common symptom of pulmonary sarcoidosis. We analyzed the severity of cough and factors associated with cough in a university sarcoidosis clinic cohort. METHODS Consecutive patients completed the Leicester Cough Questionnaire (LCQ) and a cough visual analog scale (VAS). Clinical and demographic data were collected. Means of the LCQ were analyzed in patients who had multiple visits in terms of constant variables (e.g., race, sex). RESULTS 355 patients completed the LCQ and VAS at 874 visits. Cough was significantly worse in blacks than whites as determined by the LCQ-mean (16.5 ± 2.6 vs. 17.8 ± 3.0, p < 0.001) and VAS-mean (3.8 ± 3.0 vs. 2.0 ± 2.6, p < 0.0001). Cough was worse in women than men as measured by the VAS-mean (2.7 ± 2.9 vs. 2.2 ± 2.7, p = 0.002), one of the LCQ-mean domains (LCQ-Social-mean 5.4 ± 0.9 vs. 5.2 ± 1.0, p = 0.03), but not the total LCQ-mean score. Cough was not significantly different by either measure in terms of smoking status, age, or spirometric parameter (FVC % predicted, FEV1 % predicted, FEV1/FVC). In a multivariable linear regression analysis, cough was significantly worse in blacks than whites and in pulmonary sarcoidosis than non-pulmonary sarcoidosis with both cough measures, in women than men for the VAS only, and not for spirometric parameters, Scadding stage, or age. The LCQ and VAS were strongly correlated. CONCLUSIONS In a large university outpatient sarcoidosis cohort, cough was worse in blacks than whites. Cough was not statistically significantly different in terms of age, spirometric measures, Scadding stage, or smoking status. The LCQ correlated strongly with a visual analog scale for cough.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, 12208, USA.
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, 12208, USA
| | - Edward Conuel
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | | | | | - Adam Austin
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Robert Zhang
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Kerry Cao
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Rani Berry
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Malik M H S Khan
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, 12208, USA
| | - Aakash Modi
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, 12208, USA
| | - Ritu Modi
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Stephanie Jou
- Department of Medicine, Albany Medical Center, Albany, NY, USA
| | - Furqan Ilyas
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, 12208, USA
| | - Recai M Yucel
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, Rensselaer, NY, 12144, USA
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Mañá J, Rubio-Rivas M, Villalba N, Marcoval J, Iriarte A, Molina-Molina M, Llatjos R, García O, Martínez-Yélamos S, Vicens-Zygmunt V, Gámez C, Pujol R, Corbella X. Multidisciplinary approach and long-term follow-up in a series of 640 consecutive patients with sarcoidosis: Cohort study of a 40-year clinical experience at a tertiary referral center in Barcelona, Spain. Medicine (Baltimore) 2017; 96:e7595. [PMID: 28723801 PMCID: PMC5521941 DOI: 10.1097/md.0000000000007595] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 06/09/2017] [Accepted: 07/02/2017] [Indexed: 01/12/2023] Open
Abstract
Cohort studies of large series of patients with sarcoidosis over a long period of time are scarce. The aim of this study is to report a 40-year clinical experience of a large series of patients at Bellvitge University Hospital, a tertiary university hospital in Barcelona, Spain. Diagnosis of sarcoidosis required histological confirmation except in certain specific situations. All patients underwent a prospective study protocol. Clinical assessment and follow-up of patients were performed by a multidisciplinary team.From 1976 to 2015, 640 patients were diagnosed with sarcoidosis, 438 of them (68.4%) were female (sex ratio F/M 2:1). The mean age at diagnosis was 43.3 ± 13.8 years (range, 14-86 years), and 613 patients (95.8%) were Caucasian. At diagnosis, 584 patients (91.2%) showed intrathoracic involvement at chest radiograph, and most of the patients had normal pulmonary function. Erythema nodosum (39.8%) and specific cutaneous lesions (20.8%) were the most frequent extrapulmonary manifestations, but there was a wide range of organ involvement. A total of 492 patients (76.8%) had positive histology. Follow-up was carried out in 587 patients (91.7%), over a mean of 112.4 ± 98.3 months (range, 6.4-475 months). Corticosteroid treatment was administered in 255 patients (43.4%), and steroid-sparing agents in 49 patients (7.7%). Outcomes were as follows: 111 patients (18.9%) showed active disease at the time of closing this study, 250 (42.6%) presented spontaneous remission, 61 (10.4%) had remission under treatment, and 165 (28.1%) evolved to chronic sarcoidosis; among them, 115 (19.6%) with mild disease and 50 (8.5%) with moderate to severe organ damage. A multivariate analysis showed that at diagnosis, age more than 40 years, the presence of pulmonary involvement on chest radiograph, splenic involvement, and the need of treatment, was associated with chronic sarcoidosis, whereas Löfgren syndrome and mediastinal lymphadenopathy on chest radiograph were indicators of good outcome.Sarcoidosis is a multisystem disease with protean clinical-radiographic manifestations. Although almost half of patients follow a spontaneous resolution or under treatment, a significant number of them may have several degrees of organ damage. This study emphasizes the value of a multidisciplinary approach and long-term follow-up by specialized teams in sarcoidosis.
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Affiliation(s)
- Juan Mañá
- Department of Internal Medicine
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Rubio-Rivas
- Department of Internal Medicine
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Nadia Villalba
- Department of Internal Medicine
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquim Marcoval
- Department of Dermatology
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Adriana Iriarte
- Department of Internal Medicine
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - María Molina-Molina
- Department of Pulmonary
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Roger Llatjos
- Department of Pathology
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Olga García
- Department of Ophthalmology
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Sergio Martínez-Yélamos
- Department of Neurology
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Vanessa Vicens-Zygmunt
- Department of Pulmonary
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Cristina Gámez
- Department of PET Unit-Institut de Diagnòstic per la Imatge
- Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ramón Pujol
- Department of Internal Medicine
- University of Barcelona
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Corbella
- Department of Internal Medicine
- Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya
- Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Goussault C, Albert JD, Coiffier G, Lamer F, Guillin R, Le Goff B, Bouvard B, Dernis E, Ferreyra M, Cormier G, Guggenbuhl P, Perdriger A. Ultrasound characterization of ankle involvement in Löfgren syndrome. Joint Bone Spine 2017; 85:65-69. [PMID: 28343011 DOI: 10.1016/j.jbspin.2017.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bilateral ankle arthritis is a classic diagnostic criterion for Löfgren syndrome. The objective of this study was to use ultrasonography to characterize the articular and periarticular involvement of the ankles in patients with Löfgren syndrome. METHODS Multicenter descriptive cohort study of patients with Löfgren syndrome who underwent ultrasonography of the ankles. We collected clinical data, imaging study findings, blood test results, and joint fluid properties in patients who underwent joint aspiration. RESULTS Findings from ultrasonography of the ankles in 40 patients were analyzed. The most common B-mode abnormality was subcutaneous edema (26/40), followed by tenosynovitis (22/40), with no differences in frequency across compartments. Joint involvement manifested as synovitis in 7 patients and effusion in 10 patients. Synovitis with increased vascularity by power Doppler was found in 3 patients. No statistically significant associations were found linking synovitis or tenosynovitis to clinical features (age and gender), laboratory tests, or imaging study findings. CONCLUSION Contrary to the classical view, our results indicate that ankle involvement in Löfgren syndrome is more often abarticular than articular. The inclusion of bilateral ankle arthritis among the diagnostic criteria for Löfgren syndrome deserves reappraisal.
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Affiliation(s)
- Claire Goussault
- Service de rhumatologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France.
| | - Jean-David Albert
- Service de rhumatologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - Guillaume Coiffier
- Service de rhumatologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - François Lamer
- Cabinet de rhumatologie, 21, boulevard Franklin-Roosevelt, 35000 Rennes, France
| | - Raphaël Guillin
- Service de radiologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - Benoit Le Goff
- Service de rhumatologie, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - Béatrice Bouvard
- Service de rhumatologie, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - Emmanuelle Dernis
- Service de rhumatologie, centre hospitalier du Mans, 194, avenue Rubillard, 72000 Le Mans, France
| | - Marine Ferreyra
- Service de rhumatologie, CH de Vannes, 20, boulevard Général-Maurice-Guillaudot, 56000 Vannes, France
| | - Grégoire Cormier
- Service de rhumatologie, CHD Vendée, boulevard Stéphane-Moreau, 85925 La-Roche-sur-Yon cedex 9, France
| | - Pascal Guggenbuhl
- Service de rhumatologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - Aleth Perdriger
- Service de rhumatologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
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Lung Lesions During Fever of Unknown Origin. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1022:35-43. [DOI: 10.1007/5584_2017_37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sait S, Mubashir M, Anwar R, Khan N. Poncet's disease (tubercular rheumatism) with primary involvement of the foot - A case report. Foot Ankle Surg 2016; 22:e17-e20. [PMID: 27502237 DOI: 10.1016/j.fas.2016.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/24/2015] [Accepted: 01/15/2016] [Indexed: 02/04/2023]
Abstract
We present a rare case with primary tubercular involvement of the foot, accomapanied by a reactionary (aseptic) effusion in the knee. The diagnosis was delayed due to unusual presentation and also because of failure to elicit a detailed history. Incision and drainage of the foot abscess and antitubercular drug therapy resulted in satisfactory control of tubercular infection. Polyarticular presentation may not always signify active tubercular focus in every joint; it may reflect reactive synovitis known as Poncet's disease, which resolves with multidrug antitubercular therapy.A multidispilinary approach should be adopted and chest physicians, rheumatologists and orthopaedic surgeons should work in close association to correctly diagnose and treatthis condition.
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Affiliation(s)
- Saif Sait
- Trauma & Orthopaedics, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohd Mubashir
- Department of General Surgery, Mayo Institute of Medical Sciences, Safedabad, Lucknow, India
| | - Rahij Anwar
- Department of Orthopaedic Surgeon, Pilgrim Hospital, Boston, Lincolnshire, United Kingdom.
| | - Nissa Khan
- Emergency Department, Holbaek Hospital Denmark
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A 49-Year-Old Man with Fever, Erythema Nodosum, and Ankle Swelling. Final Diagnosis: Extrapulmonary tuberculosis with hepatic and bone marrow involvement. Ann Am Thorac Soc 2016; 12:1575-7. [PMID: 26448353 DOI: 10.1513/annalsats.201503-155cc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Jeny F, Bouvry D, Freynet O, Soussan M, Brauner M, Planes C, Nunes H, Valeyre D. Management of sarcoidosis in clinical practice. Eur Respir Rev 2016; 25:141-50. [DOI: 10.1183/16000617.0013-2016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/07/2016] [Indexed: 11/05/2022] Open
Abstract
Sarcoidosis is a systemic disease of unknown cause with very diverse presentation, outcome, severity and need for treatments. While some presentations may be very typical, for many patients, the presentation is nonspecific, with shared associations with other diseases at times being by far more frequent or misleading, which can be a cause of significant delay and often several consultations before a diagnosis of sarcoidosis can be confirmed. This is particularly the case when pulmonary manifestations are in the forefront. The diagnosis relies on three well-known criteria. In clinical practice, these criteria are not easily implemented, particularly by physicians without expertise in sarcoidosis, which can lead to a risk of either under- or over-diagnosis. Qualifying the presentation according to sarcoidosis diagnosis is essential. However, it is often not easy to classify the presentation as typical versus compatible or compatible versus inconsistent. Further investigations are needed before any other hypothesis is to be considered. It is important to detect events and to determine whether or not they are indicative of a flare of sarcoidosis. Eventually, treatment needs to be related to the correct indications. The evaluation of the efficacy and safety of treatments is crucial. To address such issues, we present five emblematic cases that illustrate this.
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Abstract
Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.
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Yee AM. Sarcoidosis: Rheumatology perspective. Best Pract Res Clin Rheumatol 2016; 30:334-356. [DOI: 10.1016/j.berh.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/12/2016] [Indexed: 02/07/2023]
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