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Harper LJ, Farver CF, Yadav R, Culver DA. A framework for exclusion of alternative diagnoses in sarcoidosis. J Autoimmun 2024:103288. [PMID: 39084998 DOI: 10.1016/j.jaut.2024.103288] [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: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.
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Affiliation(s)
- Logan J Harper
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
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Abdelghaffar M, Hwang E, Damsky W. Cutaneous Sarcoidosis. Clin Chest Med 2024; 45:71-89. [PMID: 38245372 DOI: 10.1016/j.ccm.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is a multisystem disease that most commonly affects the lungs, lymphatic system, eyes, and skin but any organ may be involved. Cutaneous sarcoidosis most commonly presents as pink-red to red-brown papules and plaques that commonly affect the head and neck. With the skin being readily accessible for evaluation and biopsy, when sarcoidosis is suspected, dermatologic evaluation may be helpful for establishing a definitive diagnosis. Treatment strategy depends on the severity and distribution of skin lesions and should incorporate patient preference and treatment considerations for other organs that may be involved.
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Affiliation(s)
- Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, Ireland
| | - Erica Hwang
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, LCI 501 PO Box 208059, New Haven, CT 06520, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, LCI 501 PO Box 208059, New Haven, CT 06520, USA; Department of Pathology, Yale School of Medicine, 310 Cedar Street, LH 108, PO Box 208023, New Haven, CT 06520, USA.
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Lai J, Almazan E, Le T, Taylor MT, Alhariri J, Kwatra SG. Demographics, Cutaneous Manifestations, and Comorbidities Associated with Progressive Cutaneous Sarcoidosis: A Retrospective Cohort Study. MEDICINES (BASEL, SWITZERLAND) 2023; 10:57. [PMID: 37887264 PMCID: PMC10608652 DOI: 10.3390/medicines10100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/30/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
Background: Sarcoidosis is a multisystem granulomatous disease with a wide variety of presentations and clinical courses. Cutaneous manifestations and comorbidities associated with sarcoid prognosis remain understudied. Methods: An EPIC query was run for patients age 18+ at the Johns Hopkins Hospital with a diagnosis of sarcoidosis of the skin according to the ICD-10-CM code D86.3. Data were obtained from a population-based sample of 240 patients from 2015 to 2020. Results: A total of 240 patients were included in the cohort study. The mean (SD) age was 43.76 (11.72) years, and 30% of participants were male; 76.25% of patients identified as black, 19.58% as white, and 4.17% as other. The average age of onset in remissive patients was significantly higher than progressive (47 ± 12 vs. 40 ± 10, p = 0.0005); 49% of black patients experienced progressive sarcoid compared to 32.6% of white patients (p = 0.028). Progressive disease was associated with the presence of lupus pernio (aOR = 3.29, 95% CI, 1.60-6.77) and at least one autoimmune comorbidity (aOR 6.831, 95% CI 1.819-11.843). Conclusions: When controlling for patient demographics, lupus pernio and the presence of at least one autoimmune condition were associated with progressive cutaneous sarcoidosis.
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Affiliation(s)
| | | | | | | | | | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.L.); (T.L.); (M.T.T.); (J.A.)
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Sharma S, Kharel R, Parajuli S, Jha S, Parajuli S. A case of oculocutaneous sarcoidosis. Am J Ophthalmol Case Rep 2023; 30:101851. [PMID: 37168520 PMCID: PMC10165389 DOI: 10.1016/j.ajoc.2023.101851] [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] [Received: 11/26/2022] [Revised: 04/04/2023] [Accepted: 04/16/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To present a case of extrapulmonary sarcoidosis presenting with ocular and cutaneous involvement. Observations We report a 54-year-male who presented with bilateral redness of eyes, photophobia, and diminished vision for a week. The best corrected visual acuity in the right eye was 6/60 and the left eye was counting fingers close to face (CFCF). He also had multiple brown plaques on the nape of the neck, chest, back, and arms. Furthermore, he was on multiple antipsychotic drugs for schizophrenia for 3 years. Uveitis investigation workup revealed raised serum angiotensin converting enzyme (ACE), negative Mantoux, and other serological tests. The patient was treated for acute anterior uveitis secondary to sarcoidosis. Clinical improvement was seen after a few days following treatment. The patient presented a year later with multiple yellowish conjunctival nodules in the superior bulbar conjunctiva associated with hyperemia. A biopsy of the plaque like skin lesions was done, which suggested cutaneous sarcoidosis. Involvement of the skin and the eyes raised suspicion that the persistent psychotic episodes despite multiple antipsychotic drugs could be attributed to neurosarcoidosis. However, magnetic Resonance Imaging (MRI) of the brain and orbit showed normal findings. After treatment with corticosteroids and immunosuppressives (methotrexate), the conjunctival nodules as well as skin lesions drastically improved, and the psychosis also responded well to clozapine. Conclusion A high index of suspicion is needed in cases presenting with granulomatous uveitis with multisystem involvement. Long-term follow-up is crucial to monitor the disease progression and adverse effects of medications.
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Affiliation(s)
- Sadhana Sharma
- B.P. Koirala Lions Center for Ophthalmic Studies (BPKLCOS), Institute of Medicine, Maharajgunj, Kathmandu, 44600, Nepal
- Corresponding author.
| | - Ranju Kharel
- B.P. Koirala Lions Center for Ophthalmic Studies (BPKLCOS), Institute of Medicine, Maharajgunj, Kathmandu, 44600, Nepal
| | | | - Saket Jha
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, 44600, Nepal
| | - Sudip Parajuli
- Department of Dermatology and Veneral Disease, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, 44600, Nepal
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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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Sarcoidal granuloma on exogenous ochronosis. Ann Dermatol Venereol 2022; 149:204-206. [DOI: 10.1016/j.annder.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/08/2021] [Accepted: 01/06/2022] [Indexed: 11/18/2022]
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Bae KN, Shin K, Kim HS, Ko HC, Kim B, Kim MB. Scar Sarcoidosis: A Retrospective Investigation into Its Peculiar Clinicopathologic Presentation. Ann Dermatol 2022; 34:28-33. [PMID: 35221592 PMCID: PMC8831309 DOI: 10.5021/ad.2022.34.1.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/24/2021] [Accepted: 07/25/2021] [Indexed: 11/08/2022] Open
Abstract
Background Scar sarcoidosis (SS), a rare form of cutaneous sarcoidosis, develops from pre-existing scars. Owing to its rarity, the clinicopathologic features and its significance in clinical prognosis have been obscure. Objective This study aimed to investigate clinical, laboratory and histopathologic findings and to clarify characteristics associated with the development of SS and systemic involvement. Methods We retrospectively assessed clinical, laboratory and histopathologic findings of SS. Clinical factors including demographics, anatomic area, number of lesion (single, multiple), presence of symptoms, latent period, injury types related to scar and the proportion of systemic involvement were investigated. Results Of the 21 patients with SS, skin lesions appeared predominantly in females (85.7%) and in the head and neck (57.1%). The mean latent period was 163.5 months and 13 patients (61.9%) had multiple lesions. Injury types were varied, with no specific type identified as associated with SS. Histologically, discrete sarcoidal granulomas surrounded by densely packed collagen bundles with a thickening of numerous fibers were observed. Ten patients (47.6%) had systemic involvement and showed significantly more of the multiple lesions, longer latent period and higher level of mean serum angiotensin-converting enzyme than those without systemic involvement. Conclusion Various causes of scar were related to SS, but no specific injury type was identified as leading to SS. Although the exact pathomechanism remains unclear, the possibility of systemic involvement could be considered when the patients have multiple lesions, longstanding scars, and elevated serum angiotensin-converting enzyme.
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Affiliation(s)
- Kyung-Nam Bae
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kihyuk Shin
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
| | - Hoon-Soo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
| | - Byungsoo Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon-Bum Kim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Boda D, Cutoiu A, Bejenariu N, Caruntu C. Cutaneous sarcoidosis of the scalp unmasking systemic involvement: A case report. Exp Ther Med 2021; 22:1369. [PMID: 34659515 PMCID: PMC8515547 DOI: 10.3892/etm.2021.10803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Sarcoidosis is a multisystemic granulomatous disease of unknown cause that affects any organ, especially the lungs, eyes, lymph nodes and skin. Skin sarcoidosis occurs in about one-fourth of patients with systemic disease and may also arise in isolation. Skin lesions are divided into two groups, as follows: specific skin lesions where histologic examination shows the typical sarcoid granulomas and non-specific skin lesions. Specific lesions are lupus pernio, infiltrated plaques, maculopapular eruptions, subcutaneous nodules and scars. The most significant non-specific skin lesion seen in sarcoidosis is erythema nodosum. Cutaneous sarcoidosis is known as the ‘great imitator’ in dermatology, because it can mimic a vast variety of cutaneous lesions. The diagnosis of sarcoidosis is made by exclusion and is supported by the recognition of specific clinical features, the detection of classic histopathologic findings and the exclusion of other granulomatous diseases. We present a case report concerning a single, solitary and asymptomatic lesion on the scalp.
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Affiliation(s)
- Daniel Boda
- Department of Dermatology, 'Ponderas' Academic Hospital, 014142 Bucharest, Romania.,Department of Dermatology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ana Cutoiu
- Department of Dermatology, 'Colentina' Clinical Hospital, 020125 Bucharest, Romania
| | - Nona Bejenariu
- Department of Pathology, 'Santomar' Laboratory, 400350 Cluj Napoca, Romania
| | - Constantin Caruntu
- Department of Dermatology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Akram MJ, Khalid U, Abu Bakar M, Butt FM, Ashraf MB. Sarcoidosis: epidemiology, characteristics, and outcomes over 10 years - a single-center study in Pakistan. Expert Rev Respir Med 2021; 16:133-143. [PMID: 34402372 DOI: 10.1080/17476348.2021.1924062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Sarcoidosis is a multisystem granulomatous inflammatory disease which remains under-diagnosed in a tuberculosis endemic region such as Pakistan.Rationale: To determine the distribution, clinical characteristics, diagnostic and treatment modalities and the disease course in the Pakistani population.Methods: A cross-sectional review of sarcoidosis patients from Jan-1,2010 to Dec-31,2019 was done. Multivariable logistic and cox-regression models were used to identify the independent risk-factors associated with disease relapse. Kaplan-Meier curves were used to assess the DFS.Results: 222 patients, with mean age 44 ± 12 years, predominantly females (57.7%) and mean BMI 29 ± 6 were diagnosed sarcoidosis. Significant co-morbidities affected 36.5%, 90% were nonsmokers, and 50.3% belonged to moderate SES. Total 178 (80.2%) were symptomatic with 115 (51.8%) having multi-organ involvement. Stage-I radiological disease was predominant (52.5%). Histopathological diagnosis was obtained in 161 (72.5%) patients. Out of 113 mediastinal lymph-nodes, NNGI was present in 99, with highest yield in Station-07 (68.6%). Treatment was instituted in 108/178 (60.7%) symptomatic patients with steroids alone and in 26 (14.6%) with S+IS, with better clinical and radiological response duration in patients receiving steroid monotherapy (p-values=0.01 and 0.001,respectively, along with overall higher survival time (p-value = 0.04). Risk factors identified for relapse included high SES (AOR5.52;95%CI(1.10-28.40),0.04), steroid monotherapy (AOR0.22; 95%CI(0.10-0.87),0.03), symptomatic response after one year (AOR3.40; 95%CI(1.02-11.10),0.04), and radiological response duration (AOR1.10; 95%CI(1.05-1.20),0.04).Conclusion: Sarcoidosis is a dynamic disease with a variable clinical and geographical spectrum but good overall prognosis.
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Affiliation(s)
- Muhammad Junaid Akram
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Usman Khalid
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Muhammad Abu Bakar
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Faheem Mahmood Butt
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Mohammad Bilal Ashraf
- Pulmonology & Critical Care Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
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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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Hayati F, Zainudin SP, Abidin ZAZ. Cutaneous Sarcoidosis: A Case of the Great Imitator. Oman Med J 2020; 35:e184. [PMID: 33083042 PMCID: PMC7548049 DOI: 10.5001/omj.2020.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia
| | - Syaza Putri Zainudin
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia
| | - Zainal Adwin Zainal Abidin
- Department of General Surgery, Surgical Sciences Cluster, Faculty of Medicine, Universiti Teknologi MARA,Selangor, Malaysia
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Mathon B, Le Joncour A, Bielle F, Mokhtari K, Boch AL, Peyre M, Amoura Z, Cacoub P, Younan N, Demeret S, Shotar E, Burrel S, Fekkar A, Robert J, Amelot A, Pineton de Chambrun M. Neurological diseases of unknown etiology: Brain-biopsy diagnostic yields and safety. Eur J Intern Med 2020; 80:78-85. [PMID: 32654880 DOI: 10.1016/j.ejim.2020.05.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/04/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND For nonneoplastic neurological diseases, no recommendation exists regarding the place or appropriate timing of brain biopsy. The aim of this study was to evaluate the diagnostic yield and safety of brain biopsies from patients with neurological diseases of unknown etiology. METHODS We performed a retrospective cohort study from January 1, 2008 to December 31, 2018. We analyzed 1847 brain-biopsied patients, including 178 biopsies indicated for neurological diseases of unknown etiology. Specific histological and final diagnosis rates, positive diagnosis-associated factors, complication rate and complication-associated factors were assessed. RESULTS Specific histological diagnosis and final diagnosis rates were 71.3% and 83.1%, respectively, leading to therapeutic management change(s) for 75.3% of patients. Brain- biopsy-related mortality and permanent neurological morbidity occurred in 1.1% and 0.6% of the patients, respectively. The multivariable logistic-regression model retained (odds ratio [95% CI] only immunodepression (2.2 [1.1-4.7]; P=.04) as being independently associated with specific histological diagnosis, while supratentorial biopsy-targeted lesions (4.1 [1.1-15.2]; P=.04) were independently associated with a final diagnosis. Biopsies obtained from comatose patients were less contributive to the diagnosis (0.2 [0.05-0.7]; P=.01). Prebiopsy platelet count <100 G/L (28.5 [1.8-447]; P=.02), hydrocephalus (6.3 [1.2-15.3]; P=.02) and targeted lesions <1 cm (4.3 [1.2-15.3]; P=.03) were independently associated with brain biopsy-related complications. CONCLUSION For highly selected patients with neurological diseases of unknown etiology, brain biopsy has a high diagnostic yield and low frequency of severe complications. We advocate that this procedure be considered early in the diagnosis algorithm of these patients.
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Affiliation(s)
- Bertrand Mathon
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France.
| | - Alexandre Le Joncour
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Médecine Interne et d'Immunologie Clinique, F-75013, Paris, France
| | - Franck Bielle
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuropathologie, F-75013, Paris, France
| | - Karima Mokhtari
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuropathologie, F-75013, Paris, France
| | - Anne-Laure Boch
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France
| | - Matthieu Peyre
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France
| | - Zahir Amoura
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, F-75013, Paris, France
| | - Patrice Cacoub
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Médecine Interne et d'Immunologie Clinique, F-75013, Paris, France; INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Département d'Inflammation-Immunopathologie-Biothérapie (DHU i2B), UMR 7211, Sorbonne Université, F-75005, Paris, France
| | - Nadia Younan
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuro-Oncologie, F-75013, Paris, France
| | - Sophie Demeret
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Département de neurologie, Unité de Médecine Intensive Réanimation Neurologique, F-75013, Paris, France
| | - Eimad Shotar
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuroradiologie, F-75013, Paris, France
| | - Sonia Burrel
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Virologie, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), F-75013, Paris, France
| | - Arnaud Fekkar
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Parasitologie, F-75013, Paris, France
| | - Jérôme Robert
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Laboratoire de Bactériologie, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, and INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, F-75013, Paris, France
| | - Aymeric Amelot
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, F-75013, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, F-75013, Paris, France
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Young D, Kanuri SH, Akella K, Murtaza G, Gopinathannair R, Lakkireddy D. Cutaneous Conundrums in Cardiac Sarcoidosis: A Series on Skin Disease in Immunosuppression. J Atr Fibrillation 2020; 13:2247. [PMID: 34950287 DOI: 10.4022/jafib.2247] [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: 10/31/2019] [Revised: 11/05/2019] [Accepted: 03/25/2020] [Indexed: 11/10/2022]
Abstract
Sarcoidosis is a complex systemic condition resulting in formation of non-caseating granulomas. Infiltrative disease in cardiac sarcoidosis can have significant ramifications on mortality and is one of the few indications for systemic immunosuppressive therapy. In the patient on immunosuppressive medication, resultant sequelae such as skin and soft tissue infections are common and must be differentiated from cutaneous forms of sarcoidosis and other skin pathologies. Patients with humoral or cellular immunodeficiencies may have cutaneous lesions secondary to endemic fungi, mycobacterium, viral diseases, parasites, or encapsulated organisms. We report a rare case of cardiac sarcoidosis on immunosuppressive therapy, with a series of cutaneous sequelae due to opportunistic infection.
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Affiliation(s)
- Daisy Young
- Internal Medicine Resident at Stony Brook Southampton Hospital, New York
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14
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Sarcoidosis: Causes, Diagnosis, Clinical Features, and Treatments. J Clin Med 2020; 9:jcm9041081. [PMID: 32290254 PMCID: PMC7230978 DOI: 10.3390/jcm9041081] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/04/2020] [Accepted: 04/08/2020] [Indexed: 12/19/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease with nonspecific clinical manifestations that commonly affects the pulmonary system and other organs including the eyes, skin, liver, spleen, and lymph nodes. Sarcoidosis usually presents with persistent dry cough, eye and skin manifestations, weight loss, fatigue, night sweats, and erythema nodosum. Sarcoidosis is not influenced by sex or age, although it is more common in adults (< 50 years) of African-American or Scandinavians decent. Diagnosis can be difficult because of nonspecific symptoms and can only be verified following histopathological examination. Various factors, including infection, genetic predisposition, and environmental factors, are involved in the pathology of sarcoidosis. Exposures to insecticides, herbicides, bioaerosols, and agricultural employment are also associated with an increased risk for sarcoidosis. Due to its unknown etiology, early diagnosis and detection are difficult; however, the advent of advanced technologies, such as endobronchial ultrasound-guided biopsy, high-resolution computed tomography, magnetic resonance imaging, and 18F-fluorodeoxyglucose positron emission tomography has improved our ability to reliably diagnose this condition and accurately forecast its prognosis. This review discusses the causes and clinical features of sarcoidosis, and the improvements made in its prognosis, therapeutic management, and the recent discovery of potential biomarkers associated with the diagnostic assay used for sarcoidosis confirmation.
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Ho B, Choi KS, Ochoa W, Torralba KD, Sandhu VK, Pakbaz Z. Atypical manifestations of sarcoidosis in a Hispanic male. J Community Hosp Intern Med Perspect 2019; 9:271-274. [PMID: 31258873 PMCID: PMC6586134 DOI: 10.1080/20009666.2019.1607503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 04/09/2019] [Indexed: 10/26/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown etiology that can present with nonspecific features, often resulting in delayed diagnosis. The diagnosis requires the demonstration of non-caseating granulomas on biopsy. While the prevalence of sarcoidosis in the USA is rare, the disease is rarer yet in Hispanics. It is for this reason that we report herein the case of a Hispanic gentleman with a unique clinical manifestations of sarcoidosis. With what began as a two-month history of joint pain and skin rash, this 55-year-old man was hospitalized with multiple joint pain, weight loss, fatigue and a pruritic rash with leonine facies in the setting of anemia, leukopenia, hypercalcemia, elevated serum creatinine, and urine Bence-Jones proteinuria. CT imaging of the chest was nonspecific, but skin biopsy revealed non-caseating granulomatous disease. After completing an infectious and malignancy evaluation, the patient was diagnosed with sarcoidosis, which was treated successfully with low-dose steroid therapy.
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Affiliation(s)
- Bao Ho
- Department of Internal Medicine, University of California, Riverside, School of Medicine, Riverside, CA, USA,Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Kristal S. Choi
- Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA,Division of Rheumatology, Loma Linda University, School of Medicine, Loma Linda, CA, USA,Department of Medicine, Loma Linda University, School of Medicine, Loma Linda, CA, USA
| | - William Ochoa
- Department of Internal Medicine, University of California, Riverside, School of Medicine, Riverside, CA, USA,Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Karina D. Torralba
- Department of Internal Medicine, University of California, Riverside, School of Medicine, Riverside, CA, USA,Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA,Division of Rheumatology, Loma Linda University, School of Medicine, Loma Linda, CA, USA,Department of Medicine, Loma Linda University, School of Medicine, Loma Linda, CA, USA
| | - Vaneet K. Sandhu
- Department of Internal Medicine, University of California, Riverside, School of Medicine, Riverside, CA, USA,Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA,Division of Rheumatology, Loma Linda University, School of Medicine, Loma Linda, CA, USA,Department of Medicine, Loma Linda University, School of Medicine, Loma Linda, CA, USA
| | - Zahra Pakbaz
- Department of Internal Medicine, University of California, Riverside, School of Medicine, Riverside, CA, USA,Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA,Department of Medicine, Loma Linda University, School of Medicine, Loma Linda, CA, USA,Hematology, Riverside University Health System Medical Center, Moreno Valley, CA, USA,CONTACT Zahra Pakbaz Department of Internal Medicine, University of California, Riverside, School of Medicine, 26520 Cactus Avenue, Moreno Valley, CA92555, USA
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Periocular cutaneous sarcoid: case series and review of the literature. Eye (Lond) 2019; 33:1590-1595. [PMID: 31048763 DOI: 10.1038/s41433-019-0448-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 02/24/2019] [Accepted: 04/04/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To illustrate the varying clinical presentations of cutaneous sarcoidosis affecting the periocular region, which may masquerade as other clinical entities such as basal cell carcinoma or seborrheic dermatitis. Furthermore, the authors present an unusual observation of lupus pernio involving the adnexal region with the rare presence of perineural granulomas on histology following incisional biopsy. METHODS We report a consecutive series of four cases with lesions involving the eyelids with varying clinical appearances. All four patients presented to our adnexal service undergoing incisional diagnostic biopsy. Histology following biopsy subsequently resulted in further investigation and management of both local cutaneous lesions and systemic sarcoidosis. RESULTS Three of our four cases had evidence of pulmonary involvement on chest X-ray. Over an 18-month period, one of two patients responded to intralesional triamcinolone and subsequently to oral methotrexate (15 mg/week). Two patients were observed with their periocular lesions remaining stable without therapy. CONCLUSIONS All four patients presented to the adnexal service with lesions of varying morphology and were diagnosed with sarcoidosis following incisional biopsy highlighting the vital role of oculoplastic surgeons in diagnosing this multisystem inflammatory disease. We describe our experience of intralesional triamcinolone, oral methotrexate and watchful observation in the management of such lesions.
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AlRyalat SA, Malkawi L, Abu-Hassan H, Al-Ryalat N. The impact of skin involvement on the psychological well-being of patients with sarcoidosis. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2019; 36:53-59. [PMID: 32476937 PMCID: PMC7247115 DOI: 10.36141/svdld.v36i1.7270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/16/2018] [Indexed: 06/11/2023]
Abstract
BACKGROUND Physicians frequently face challenges when screening and managing mental health impairment caused by different diseases, particularly those involving the skin. OBJECTIVE We aim to identify the major aspects of mental health impairment related to secondary skin involvement occurring in sarcoidosis patients. METHODS A total of 718 patients with a biopsy-confirmed diagnosis of sarcoidosis were included from the A Case Control Etiologic Study of Sarcoidosis (ACCESS) study. Sample was divided into two groups depending on presence or absence of skin involvement. Each recruited patient underwent mental health assessment using two measures: depression and mood scales. Demographic data of participants was obtained. RESULTS A total of 143 sarcoidosis patients had secondary skin involvement, and 575 had no skin involvement. Sarcoidosis patients with skin involvement had lost their appetite more frequently, experienced low mood more frequently, and had frequently encountered a significant loss of acceptance compared to patients without skin involvement. CONCLUSION A multidisciplinary approach including a focused psychological assessment for patients with sarcoidosis; particularly those with skin involvement, is encouraged.
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Affiliation(s)
- Saif Aldeen AlRyalat
- Department of Ophthalmology, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Lna Malkawi
- Department of Radiology, Jordan University Hospital, The University of Jordan, Amman Jordan
| | - Hana Abu-Hassan
- Department of Family medicine, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Nosaiba Al-Ryalat
- Department of Radiology, Jordan University Hospital, The University of Jordan, Amman Jordan
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Hudson AD, Klimas NK, Stetson CL. Filiform Verrucous Sarcoidosis of the Face: A Warty Report. J Cutan Med Surg 2018; 22:424-426. [PMID: 29502440 DOI: 10.1177/1203475418763590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sarcoidosis is a multisystem inflammatory condition of unknown etiology. Variability in the cutaneous features of sarcoidosis is profound, and its protean manifestations affirm the condition's designation as one of dermatology's "great mimics." Cutaneous phenotypes of sarcoidosis include but are by no means limited to ichthyosiform, alopecic, erythrodermic, angiolupoid, and verrucous variants. Verrucous sarcoidosis is an exceedingly rare manifestation, and previous reports of this phenotype are limited to 15 cases. Most cases in the extant literature presented on the extremities, with clinical features mimicking that of a common wart, or as verrucous crateriform nodules, ulcers, or cutaneous horns. Only 4 previous reports of facial verrucous sarcoidosis exist in the literature, and to our knowledge, no prior cases have demonstrated filiform lesion morphology. Here we present a case of filiform verrucous sarcoidosis in an otherwise healthy, middle-aged African American man, devoid of internal organ involvement and limited to the face, histopathologically confirmed by the presence of characteristic granulomata devoid of lymphocytic infiltrates.
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Affiliation(s)
- Andrew D Hudson
- 1 Department of Dermatology, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Natasha K Klimas
- 1 Department of Dermatology, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Cloyce L Stetson
- 1 Department of Dermatology, Texas Tech Health Sciences Center, Lubbock, TX, USA
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Huang HW, Wong LS, Lee CH. Sarcoidosis with bilateral leg lymphedema as the initial presentation: a review of the literature. DERMATOL SIN 2016. [DOI: 10.1016/j.dsi.2015.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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21
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Janegova A, Janega P, Kovac O, Dragun J, Zakutansky A, Mihalova R, Marinova P, Babal P. Plantar subcutaneous sarcoidosis - a rare form of skin sarcoidosis: unusual plantar aponeurosis location of sarcoidosis as primary manifestation of asymptomatic systemic disease. J Cutan Pathol 2016; 43:475-7. [PMID: 26865475 DOI: 10.1111/cup.12662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/02/2015] [Accepted: 12/06/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Andrea Janegova
- Faculty of Medicine, Institute of Pathology, Comenius University, Bratislava, Slovakia
| | - Pavol Janega
- Faculty of Medicine, Institute of Pathology, Comenius University, Bratislava, Slovakia. .,Institute of Normal and Pathological Physiology, Slovak Academy of Science, Bratislava, Slovakia. .,Medirex Group Academy, Bratislava, Slovakia.
| | - Ondrej Kovac
- Faculty Hospital with Polyclinic, Skalica, Slovakia
| | - Juraj Dragun
- Faculty Hospital with Polyclinic, Skalica, Slovakia
| | | | | | - Petya Marinova
- Division of Pathology, Alpha Medical Patologia, Ltd, Bratislava, Slovakia
| | - Pavel Babal
- Faculty of Medicine, Institute of Pathology, Comenius University, Bratislava, Slovakia.,Medirex Group Academy, Bratislava, Slovakia.,Faculty Hospital with Polyclinic, Skalica, Slovakia
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23
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Shah A, Lakhani R, Panesar J. Lupus pernio--a patient case study. J Vis Commun Med 2014; 37:19-23. [PMID: 24802044 DOI: 10.3109/17453054.2014.911153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
An 80 year old female patient was seen in the Otolaryngology department with a skin manifestation of her sarcoidosis, known as lupus pernio. Around 25% of patients with sarcoidosis have skin disease and the presence of lupus pernio may suggest a more aggressive form of the disease. Photography of this relatively rare presentation not only helped us diagnose her underlying medical condition but also served as a baseline during treatment.
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Affiliation(s)
- Aadarsh Shah
- Department of Otolaryngology, Luton and Dunstable University Hospital , Luton, LU4 0DZ , England . E-mail:
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