Late-Onset Sarcoidosis in a 77-Year-Old Man

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.

Management of sarcoidosis in clinical practice

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.