Manifestations ostéo-articulaires de la sarcoïdose

Spondyloarthritis and sarcoidosis: Related or fake friends? A systematic literature review

BACKGROUND

Sarcoidosis and spondyloarthritis (SpA) have been regularly associated. Bone iliac granulomas have also been described. We propose herein a systematic review of rheumatologic axial manifestations of sarcoidosis.

METHODS

PubMed and the Cochrane Library were used to conduct this systematic literature review. Case reports and cross-sectional studies were reviewed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 41 articles were eligible. Three cross-sectional studies on the association between SpA and sarcoidosis showed a prevalence of sacroiliitis and SpA ranging from 12.9 to 44.8% and 12.9 to 48.3% in inflammatory back pain (IBP) subgroups, respectively. However, the IBP definitions and sacroiliac joint (SIJ) imaging modalities (X-rays or magnetic resonance imaging) were heterogeneous, and X-ray was mainly used for sacroiliitis diagnosis (in 78% of cases). Thirty-one case-report articles of the sarcoidosis-sacroiliitis association were identified, representing 35 patients. ASAS criteria for SpA were met in half of cases (16/32) and 46% (12/26) had HLA B27 positivity. Sarcoidosis occurred after sacroiliac symptoms in 47% of cases. In the seven case-report articles with granulomatous sacroiliac bone involvement, unilateral involvement seemed higher than in the sarcoidosis-sacroiliitis group.

CONCLUSION

Literature analysis found a good evidence of the association between SpA and sarcoidosis, and special attention should be given to patients reporting IBP. Unilateral sacroiliitis may raise suspicion of granulomatous bone involvement, distinct from sacroiliitis. Imaging modalities used to study the SIJ in patients with sarcoidosis have been heterogeneous and further investigation is needed.

Sarcoidosis: An unusual presentation

A 35-year-old man presented with a 3-year history of arthralgia and purple coloration of the skin of his fingers and feet. Hand and foot radiography showed cystic bone lesions on phalanges suggestive of sarcoidosis. Lab tests revealed increased liver enzymes. Liver MRI evidenced an enlarged liver and retroperitoneal lymphadenopathy. Histological analysis of the finger skin, lymph nodes and liver demonstrated the presence of granulomas, confirming the diagnosis of sarcoidosis. The patient started prednisolone with rapid improvement of the symptoms. Skin lesions are divided into two groups: specific for sarcoidosis (with granulomas, lupus pernio-like) and nonspecific (without granulomas, erythema nodosum-like). Specific cutaneous lesions usually cause no other symptoms beyond cosmetic changes. Lupus pernio stands out for having distinctive features but, to the best of our knowledge, the simultaneous involvement of both hands and feet has never been reported.

No impact of tumor necrosis-factor antagonists on the joint manifestations of sarcoidosis

Objective

The use of anti-tumor necrosis factor (TNF) agents to treat joint manifestations of sarcoidosis has not been described. We evaluated the efficacy and safety of three such biologics in patients with these symptoms refractory to conventional therapy (nonsteroidal anti-inflammatory drugs, corticosteroids, and/or disease-modifying antirheumatic drugs).

Methods

This retrospective study, covering January 2001 to September 2011, examined clinical–biological parameters collected before anti-TNF treatment (age, sex, duration of disease evolution, drugs taken), and at introduction and under anti-TNF therapy (number of painful and swollen joints, visual analog scale score of global disease activity, disease-activity score of 28 joints with erythrocyte sedimentation rate or C-reactive protein, TNF-antagonist duration). At 3, 6, and 12 months, anti-TNF impact on joints and the therapeutic response according to European League Against Rheumatism criteria used for rheumatoid arthritis were assessed.

Results

Ten patients’ data were evaluated; some of them had received several anti-TNF agents (median [range] duration on each biotherapy was 10 [4–30] months), which enabled analysis of 19 prescriptions. The total duration of anti-TNF exposure was 17.6 patient-years, which was started a median of 3 (0.33–17) years after sarcoidosis diagnosis. The median numbers of painful and swollen joints were 1 (0–28) and 0 (0–9), respectively. Despite rapid efficacy, after 1 year of treatment, clinical (especially joint) and biological parameters were comparable to pretreatment, and only the corticosteroid dose was significantly lower (P=0.03). One case of mild skin toxicity was noted.

Conclusion

TNF antagonists allowed significant steroid sparing and were well tolerated, but do not seem to be effective against sarcoidosis joint involvement.

[Maxillary bone sarcoidosis]

INTRODUCTION

Sarcoidosis is an unexplained systemic granulomatosis. Bone localizations of the disease are rare. We report a maxillary localization.

CASE

A 35-year-old patient consulted for facial dysmorphia first observed 2 years before. This swelling was associated to nodular panniculitis lesions and xerostomia. The facial asymmetry was due to maxillary gingival and alveolar swelling. It was associated with scarring in the legs and a purple nodular facial lesion. Lip and jaw biopsies revealed epithelioid and giant cell granulomas without caseous necrosis. The panoramic dental X-ray showed diffuse horizontal alveolar ridge lysis and CT scan revealed an osteolytic lesion of the right maxilla associated to a bone-condensing lesion of the left hemi-mandible.

DISCUSSION

The diagnosis of sarcoidosis is made in case of epithelioid and giant cell granulomas without caseous necrosis and the ruling out of other possible diagnoses, including tuberculosis. Bone involvement is rare; face and maxillary localization are extremely rare. The recommended treatment is corticosteroids. Facial remodeling surgery is not recommended.

[Sarcoidosis and ankylosing spondylitis: a rare association]

L’association spondylarthrite ankylosante et sarcoïdose est rare, seize cas ont été publiés dans la littérature, nous en rapportons un nouveau cas. Cette association qui pose des problèmes diagnostiques est probablement fortuite du fait de l’absence de facteurs génétiques prédisposant partagés et du petit nombre des cas publiés, mais elle suggère l’hypothèse d’une liaison physiopathologique entre eux.

Bilateral ankle edema with bilateral iritis

I report two patient presented to me with bilateral symmetrical ankle edema and bilateral acute iritis. A 42-year-old female of Indian origin and 30-year-old female from Somalia both presented with bilateral acute iritis. In the first patient, bilateral ankle edema preceded the onset of bilateral acute iritis. Bilateral ankle edema developed during the course of disease after onset of ocular symptoms in the second patient. Both patients did not suffer any significant ocular problem in the past, and on systemic examination, all clinical parameters were within normal limit. Lacrimal gland and conjunctival nodule biopsy established the final diagnosis of sarcoidosis in both cases, although the chest x-rays were normal.