Sarcoidosis in the aged: review and management:

Retrospective study of elderly onset sarcoidosis in Tunisian patients

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology. It affects mostly young adults. In the elderly, the presentation of this disease is different, often posing positive diagnosis problems.

OBJECTIVES

We intend to describe the various clinical features and the management of sarcoidosis in elderly patients (age ≥65 years) compared to the younger ones.

METHODS

We performed a retrospective, descriptive and comparative study in the Department of Internal Medicine in the University Hospital Hedi Chaker, Sfax, Tunisia, between 1996 and 2016.

RESULTS

From a series of 80 patients, we found sixteen patients (20%) with sarcoidosis diagnosed after the age of 65 years. A female preponderance (81,25%) was noted. Intrathoracic involvement concerned 13 patients (81,3%). Extrapulmonary signs were also frequent (93,8%). The main extrathoracic manifestations were ganglionar involvement (75%), an alteration of the general health (31,3%), hepatic involvement (31,3%), cutaneous involvement (25%) and ocular involvement (25%). Biological manifestations were hypercalcemia, hypercalciuria, lymphopenia and hypergammaglobulinemia noted in respectively 12,5%, 12,5%, 31,3% and 50% of the cases. Angiotensin-converting enzyme(ACE) level was elevated in 100% of the patients. Lymphadenopathy and cutaneous biopsies were important contributing factors to diagnosis (respectively: 100% and 75% were positive). Oral corticosteroid therapy was required in 50% of cases. Evolution was marked by pulmonary fibrosis in two cases. Satisfactory course of the disease was observed in the other patients.

CONCLUSION

Young and elderly subjects had common characteristics of sarcoidosis, except for more coexisting chronic morbidities, no erythema nodosum and more frequent high levels of ACE in the elderly group.

Elderly sarcoidosis: A comparative study from a 42-year single-centre experience

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.

CLINICAL PATHOLOGIC CORRELATION OF SARCOIDOSIS-ASSOCIATED MULTIFOCAL CHORIORETINITIS IN AN ELDERLY PATIENT

BACKGROUND/PURPOSE

To describe a case of histopathologic clinical correlation of sarcoidosis-related multifocal chorioretinitis in an elderly individual.

METHODS

This is a single case report and review of the pertinent literature. A 72-year-old white woman with a history of asthma was referred with bilateral asymmetric low-grade chronic panuveitis with advancing peripheral punched-out chorioretinal lesions despite systemic corticosteroid treatment.

RESULTS

Coalescent chorioretinal punched-out lesions on fundus examination in the more severely affected right eye did not respond to corticosteroid treatment, and the refractory nature resulted in a suspicion of intraocular lymphoma despite a previous inconclusive diagnostic vitrectomy result. A transvitreal chorioretinal biopsy in the vitrectomized eye demonstrated a chorioretinal noncaseating granuloma centered on the choriocapillaris and invading Bruch membrane and the outer retina. This case illustrates an example of the second peak of incidence in sarcoidosis that can occur in ages >50 in Caucasians and Japanese patients, as well as a tendency to develop chronic disease in Caucasians, and to have extrapulmonary sarcoidosis in the elderly.

CONCLUSION

This case emphasizes the differences in presentation of ocular sarcoid in older Caucasian women as well as the histopathologic findings in multifocal peripheral chorioretinitis associated with sarcoidosis.

Elderly-onset sarcoidosis: prevalence, clinical course, and treatment

Sarcoidosis is a systemic disorder of unknown cause characterized by its pathological hallmark, the non-caseating granulomas, and by variable clinical course. While most of the cases affect people aged between 25 and 40 years, approximately 30 % of cases occur in older patients. Elderly-onset sarcoidosis (EOS) is defined as the onset of sarcoidosis in people over 65 years of age. Specific studies on the incidence and prevalence of sarcoidosis in this subgroup are scarce. Several studies suggest that the clinical features of EOS differ from those of sarcoidosis in younger patients. Compared with younger patients, fatigue, uveitis and specific skin lesions are more common, while erythema nodosum and chest x-ray abnormalities are less frequent. The diagnosis of EOS is challenging and may be delayed for many months because of its insidious onset, low prevalence and similarity to other more common disorders. When there is a granulomatous reaction in the elderly, clinicians should doubt the diagnosis and first think of tuberculosis, neoplasia or rare settings such as granulomatosis with polyangiitis or granulomatous reaction due to interferon and tumour necrosis factor-α (TNFα) blockers. A minor salivary gland biopsy also has a higher accuracy for diagnosis in the elderly. The current management of EOS remains empiric because of the lack of randomized, controlled studies. However, the approach to treatment is similar, regardless of the age of the patient. The treatment may be complicated by co-morbidities and increased risk of toxicities from usual treatments, particularly steroids. This review discusses the epidemiology, clinical course, prognosis and treatment of EOS.

Late-onset sarcoidosis: a comparative study

Sarcoidosis is not rare in patients aged more than 65 years, but studies of elderly patients with sarcoidosis are scarce. We analyzed the characteristics and outcomes of patients in a French teaching hospital with late-onset sarcoidosis, defined as sarcoidosis diagnosed in patients aged 65 years or older, and compared them with those of younger patients with sarcoidosis. From 2002 to 2006, 30 patients were identified as having late-onset sarcoidosis and were compared to 70 patients randomly selected aged younger than 65 years. We compared clinical characteristics, laboratory data at diagnosis, severity, therapy, and outcome. The female to male ratio was higher in the late-onset sarcoidosis group than in the younger group (5:1 vs. 1:1, respectively; p = 0.003). Asthenia (30% vs. 10%; p = 0.012), uveitis (33.3 vs. 8.6%; p = 0.002), and specific skin lesions (36.7% vs. 15.7%; p = 0.002) occurred more frequently in patients with late-onset sarcoidosis than in younger patients. On the contrary, asymptomatic chest radiograph abnormalities (p = 0.031) and erythema nodosum (p = 0.016) were not reported in the group of elderly patients. The 2 groups were similar with regard to race, other organ systems involved, pulmonary function, radiographic stage, laboratory values, and severity. The proportion of patients with accessory salivary glands (p = 0.002) and skin (p = 0.023) biopsies was more often contributory to the diagnosis in the late-onset group.After a mean follow-up of 50 months, 1 death related to pulmonary mycetoma and 2 others unrelated to sarcoidosis occurred in the late-onset sarcoidosis group. The 5-year survival rate was 93.3% in the late-onset group compared with 100% in the young-onset group (p = 0.03), while overall mortality was not significantly different. The 2 groups were similar with regard to oral corticosteroid therapy and immunosuppressive use, although steroid-related adverse events were more common in the elderly group.In conclusion, we found certain clinical and diagnostic peculiarities in patients with late-onset sarcoidosis. Asthenia, uveitis, and specific cutaneous lesions were more frequent in this group, whereas erythema nodosum and disclosure on a routine chest roentgenogram were not observed. Biopsy of the minor salivary glands appears to be particularly pertinent for the diagnosis. Evolution and therapeutic management were not different in the 2 groups. However, the patients aged more than 65 years had more side effects related to the corticosteroid therapy.

Fatigue in patients with sarcoidosis, compared with the general population

OBJECTIVE

Fatigue is a significant symptom in sarcoidosis patients. The causes for this symptom are unclear. The aims of this study were to analyze age and gender differences in fatigue, compared with the general population, and to test the psychometric properties of two questionnaires measuring fatigue in sarcoidosis.

METHOD

A sample of 1197 patients diagnosed with sarcoidosis was examined in Germany with the Fatigue Assessment Scale (FAS) and the Multidimensional Fatigue Inventory (MFI).

RESULTS

The percentages of patients exceeding the fatigue cut-offs were 70% (FAS) and 68% (MFI), respectively. While in the general population there is a nearly linear age trend (high fatigue scores with increasing age), among the patients there is only a very slight and nonlinear age trend. Female patients are more affected by fatigue than male patients, but this relationship is also true in the general population. Both questionnaires (FAS and MFI) are equally suited to test fatigue; their psychometric properties are good. They should not be replaced with a single question concerning tiredness.

CONCLUSION

The comparison to norm data is highly recommended for the evaluation of age and gender differences. Compared with the general population, young sarcoidosis patients are especially affected by fatigue.