Sarcoidosis: Causes, Diagnosis, Clinical Features, and Treatments

Cutaneous Sarcoidosis Induced by Laser Therapy: Case Report and Review of the Literature

BACKGROUND

Sarcoidosis, characterized by non-caseating epithelioid granulomas, presents diagnostic and therapeutic challenges.

METHOD

Here we present a 38-year-old woman who exhibited erythematous and infiltrated skin lesions on her facial region following fractional laser treatment.

RESULTS

Histological analysis confirmed cutaneous sarcoidosis. Initial interventions with topical clobetasol and oral chloroquine provided transient relief. Subsequent outpatient management comprised topical tacrolimus and clobetasol, as well as systemic methotrexate, later substituted with prednisone. Gradual tapering resulted in lesion reduction.

CONCLUSIONS

This case underscores the intricate nature of cutaneous sarcoidosis and the necessity for personalized therapeutic approaches. The association with cosmetic procedures highlights the importance of understanding potential triggers. The presented case highlights and reminds the medical community that lasers are not only used for therapeutic purposes but can also induce specific responses through laser therapy. Notably, while laser therapy is frequently employed in treating cutaneous sarcoidosis, its role in inducing sarcoidosis warrants further investigation.

Occupational exposures and sarcoidosis: a rapid review of the evidence

BACKGROUND

Sarcoidosis is a rare, multisystem, inflammatory condition associated with the formation of granulomas. Diagnosis can be challenging because of non-specific symptoms complicating epidemiological investigations of its aetiology. Despite research efforts, a review of the current state of the evidence is needed.

AIMS

To assess the evidence for an association between occupational exposures and the development of sarcoidosis. To determine if workers in any occupation are at a greater risk of developing sarcoidosis.

METHODS

This rapid review follows the methodology suggested by the World Health Organization. Two electronic databases were systematically searched until April 2022. The methodological quality of the studies was critically appraised, and a best-evidence approach was used to synthesize the results.

RESULTS

Titles and abstracts of 2916 articles were screened, with 67 full-text articles reviewed for eligibility. Among the 13 studies eligible for this review, none were of high quality (i.e. low risk of bias). Six studies exploring the association between sarcoidosis and a range of occupations and exposures, and one previous systematic review were of low quality reporting inconsistent findings. Six studies examined the risk of sarcoidosis associated with occupational silica exposure, two of which were of acceptable quality. Overall, the study methodologies and results were inadequate to support causal relationships.

CONCLUSIONS

There is limited evidence of acceptable methodological quality to assess the risk of sarcoidosis associated with occupational exposures. There is a growing body of research examining occupational exposure to silica and sarcoidosis. Additional high-quality confirmatory research is needed.

Diagnosis and Management of Cardiac Sarcoidosis: A Scientific Statement From the American Heart Association

Cardiac sarcoidosis is an infiltrative cardiomyopathy that results from granulomatous inflammation of the myocardium and may present with high-grade conduction disease, ventricular arrhythmias, and right or left ventricular dysfunction. Over the past several decades, the prevalence of cardiac sarcoidosis has increased. Definitive histological confirmation is often not possible, so clinicians frequently face uncertainty about the accuracy of diagnosis. Hence, the likelihood of cardiac sarcoidosis should be thought of as a continuum (definite, highly probable, probable, possible, low probability, unlikely) rather than in a binary fashion. Treatment should be initiated in individuals with clinical manifestations and active inflammation in a tiered approach, with corticosteroids as first-line treatment. The lack of randomized clinical trials in cardiac sarcoidosis has led to treatment decisions based on cohort studies and consensus opinions, with substantial variation observed across centers. This scientific statement is intended to guide clinical practice and to facilitate management conformity by providing a framework for the diagnosis and management of cardiac sarcoidosis.

First Report of the Prevalence at Baseline and after 1-Year Follow-Up of Treatable Traits in Interstitial Lung Diseases

Different factors, not limited to the lung, influence the progression of ILDs. A "treatable trait" strategy was recently proposed for ILD patients as a precision model of care to improve outcomes. However, no data have been published so far on the prevalence of TTs in ILD. A prospective, observational, cohort study was conducted within the ILD Program at the IRCCS Humanitas Research Hospital (Milan, Italy) between November 2021 and November 2023. TTs were selected according to recent literature and assigned during multidisciplinary discussion (MDD) to one of the following categories: pulmonary, etiological, comorbidities, and lifestyle. Patients were further divided into four groups according to their post-MDD diagnosis: idiopathic ILD, sarcoidosis, connective tissue disease-ILD, and other ILD. The primary study outcome was the prevalence of each TT in the study population. A total of 116 patients with ILD [63.9% male; median (IQR) age: 69 (54-78) years] were included in the study. All the TTs identified in the literature were found in our cohort, except for intractable chronic cough. We also recognized differences in TTs across the ILD groups, with less TTs in patients with sarcoidosis. This analysis provides the first ancillary characterization of TTs in ILD patients in a real setting to date.

An Unusual Presentation of Neurosarcoidosis in a 64-Year-Old Man: A Case Report

Sarcoidosis is a multisystem granulomatous disorder with an unknown etiology that typically involves the lungs, skin, and lymph nodes, with neurological involvement being relatively rare. We discuss a case of neurosarcoidosis in a 64-year-old man who initially presented with unexplained cognitive impairment, insomnia, hyponatremia, paresthesias, and weight loss and later developed uveitis, diplopia, and dysphagia. Ultimately, findings of hilar and mediastinal lymphadenopathy on chest computed tomography (CT) resulted in bronchoscopy, which led to the diagnosis. This case highlights a rare presentation of sarcoidosis with an unusual constellation of symptoms. We discuss the difficulty involved in diagnosing this disorder as well as its highly variable course.

Diagnostic Value of Imaging and Serological Biomarkers in Pulmonary Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of an unknown aetiology. It can exist in many organs. Pulmonary and intrathoracic lymph nodes are most commonly involved. Lung sarcoidosis is uncommon in Asia. However, due to the large population of our country and the development of bronchoscopy, percutaneous lung puncture, and other medical technologies, the number of pulmonary sarcoidosis patients is on the rise. Pulmonary sarcoidosis patients have no obvious symptoms in the early stage, and the clinical manifestations in the later stage may vary from person to person. Eventually, the disease progresses to life-threatening pulmonary fibrosis. Therefore, patients with pulmonary sarcoidosis should receive a timely diagnosis. In recent years, the imaging features and serologic biomarkers of pulmonary sarcoidosis have been continuously studied. The diagnostic value of imaging and serologic biomarkers for pulmonary sarcoidosis is summarized below.

Role of triglyceride-glucose index in metabolic assessment of sarcoidosis patients

Sarcoidosis is a rare granulomatous disease that can affect any organ. It leads to an increased risk of metabolic syndrome and insulin resistance, due to biochemical pathways involved in low-grade inflammation in both diseases. The aim of our retrospective case-control study was to evaluate the utility of triglyceride-glucose (TyG) index, a surrogate of insulin resistance, for metabolic assessment of sarcoidosis patients. A cohort of 90 sarcoidosis patients and a cohort of 90 control subjects were enrolled. Clinical, anamnestic, and biochemical data were collected. Results showed that TyG index values were higher in the sarcoidosis cohort than in the control group (p < 0.001), even after excluding the influence of diabetes and metabolic syndrome (p = 0.018). In the sarcoidosis cohort, TyG index was not correlated with clinical phenotyping (p = 0.358), gender (p = 0.139), radiological stage (p = 0.656), glucocorticoids cumulative dose (p = 0.682) or treatment regimen (p = 0.093), while significant positive correlations with waist circumference (p < 0.001), systolic and diastolic pressure (p = 0.041 and p = 0.029, respectively), Framingham score (p = 0.007) were found. Receiving operating characteristics curve analysis identified a TyG index optimal cut-off value of 8.64 (66.7% sensitivity, 77.8% specificity, area under the curve -AUC- 75%, 95% confidence interval -CI- 65-85, p < 0.001) to detect metabolic syndrome and a cut-off value of 8.69 (64.1% sensitivity, 70.6% specificity; AUC 67%, 95% CI 55-78, p = 0.007) to detect an intermediate cardiovascular risk according to Framingham risk score. Concluding, TyG index can be considered a useful tool for the metabolic assessment of sarcoidosis patients, given its capacity to predict metabolic syndrome and cardiovascular risk.

An Analysis of the Readability of Online Sarcoidosis Resources

Introduction Sarcoidosis is an inflammatory disease characterized by the formation of noncaseating granulomas in multiple organ systems. The presentation can vary widely; although some patients with sarcoidosis can be asymptomatic, sarcoidosis can also present in others with symptomatic multiorgan system involvement. Considering the potential severity of the disease, patients need to be well-informed about sarcoidosis to better manage their health. This study aims to assess the readability levels of online resources about sarcoidosis. Methods We conducted a retrospective cross-sectional study. The term "sarcoidosis" was searched online using both Google and Bing to find websites written in English. Each website was categorized by type: academic, commercial, government, nonprofit, and physician. The readability scores for each website were calculated using six different readability tests: the Flesch-Kincaid reading ease (FKRE), Flesch-Kincaid grade level (FKGL), Gunning fog score (GFS), Simple Measure of Gobbledygook (SMOG), automated readability index (ARI), and Coleman-Liau index (CLI). FKRE gives a score that corresponds to the difficulty of the text, while the remaining tests give a score that corresponds to a grade level in terms of reading ability. A one-sample t-test was used to compare all test scores with the national recommended standard of a sixth-grade reading level. Our null hypothesis was that the readability scores of the websites searched would not differ statistically significantly from the sixth-grade reading level and that there would be no significant differences across website categories. To evaluate the difference between the categories of websites, ANOVA testing was used. Results Thirty-four websites were analyzed. Each of the six readability tests for the websites had an average score, which corresponded to being significantly harder to read than the nationally recommended sixth-grade reading level (p<0.001). None of the mean readability scores showed a statistically significant difference across the five different website categories. Conclusions This is the first study, to our knowledge, to examine the readability of online English resources on sarcoidosis and calculate standardized readability scores for them. It implies that the online English material for sarcoidosis is above the health literacy recommended reading levels for patients. There is a need to simplify the material to be easier to read for patients.

Sarcoidosis presenting as multiple osseous lesions

Sarcoidosis is a multisystem inflammatory condition presenting with the formation of noncaseating granulomas. These granulomas can be found in nearly every organ of the body, but in 90% of cases the lungs are involved. Osseous manifestations are seen in only 3% to 13% of cases and are typically seen alongside the more common pulmonary manifestations. These lesions can be misdiagnosed as metastatic cancer so biopsy, along with clinical correlation and exclusion of other diseases, is necessary to make the diagnosis. Most patients with primary osseous sarcoidosis remain asymptomatic but routine monitoring is necessary to identify progression to lesion growth, cardiac manifestations, and respiratory involvement.

Noninfectious Granulomatous Lung Disease: Radiological Findings and Differential Diagnosis

Granulomatous lung diseases (GLDs) are a heterogeneous group of pathological entities that can have different clinical presentations and outcomes. Granulomas are histologically defined as focal aggregations of activated macrophages, Langerhans cells, and lymphocytes, and may form in the lungs when the immune system cannot eliminate a foreign antigen and attempts to barricade it. The diagnosis includes clinical evaluation, laboratory testing, and radiological imaging, which especially consists of high-resolution computed tomography. bronchoalveolar lavage, transbronchial needle aspiration or cryobiopsy, positron emission tomography, while genetic evaluation can improve the diagnostic accuracy. Differential diagnosis is challenging due to the numerous different imaging appearances with which GLDs may manifest. Indeed, GLDs include both infectious and noninfectious, and necrotizing and non-necrotizing granulomatous diseases and the imaging appearance of some GLDs may mimic malignancy, leading to confirmatory biopsy. The purposes of our review are to report the different noninfectious granulomatous entities and to show their various imaging features to help radiologists recognize them properly and make an accurate differential diagnosis.

Sarcoidosis Associated Pulmonary Hypertension

In patients with sarcoidosis, the development of pulmonary hypertension is associated with significant morbidity and mortality. The global prevalence of sarcoidosis-associated pulmonary hypertension (SAPH) reportedly ranges between 2.9% and 20% of sarcoidosis patients. Multiple factors may contribute to the development of SAPH, including advanced parenchymal lung disease, severe systolic and/or diastolic left ventricular dysfunction, veno-occlusive or thromboembolic disease, as well as extrinsic factors such as pulmonary vascular compression from enlarged lymph nodes, anemia, and liver disease. Early diagnosis of SAPH is important but rarely achieved primarily due to insufficiently accurate screening strategies, which rely entirely on non-invasive tests and clinical assessment. The definitive diagnosis of SAPH requires right heart catheterization (RHC), with transthoracic echocardiography as the recommended gatekeeper to RHC according to current guidelines. A 6-min walk test (6MWT) had the greatest prognostic value in SAPH patients based on recent registry outcomes, while advanced lung disease determined using a reduced DLCO (<35% predicted) was associated with reduced transplant-free survival in pre-capillary SAPH. Clinical management involves the identification and treatment of the underlying mechanism. Pulmonary vasodilators are useful in several scenarios, especially when a pulmonary vascular phenotype predominates. End-stage SAPH may warrant consideration for lung transplantation, which remains a high-risk option. Multi-centered randomized controlled trials are required to develop existing therapies further and improve the prognosis of SAPH patients.

Extra-pulmonary Cutaneous Sarcoidosis Presenting With Granulomatous Cranial Lesions and Cardiac Complications: A Case Report

Sarcoidosis is a non-caseating granulomatous disorder affecting multiple organs. Although the lungs are the most common site of presentation, extra-pulmonary manifestations involving the skin and heart can occur. Sarcoidosis affecting skull bone is uncommon and involvement of skin, heart, and skull bone all together, without pulmonary manifestations, is extremely rare. We report a 63-year-old Caucasian woman with a past history of cutaneous sarcoidosis and granulomatous skull bone lesions who presented with recurrent syncope. An ambulatory cardiac monitor detected intermittent high-grade atrioventricular block and cardiac MRI confirmed the diagnosis of cardiac sarcoidosis. This case represents an extremely unique journey of sarcoidosis and suggests potential consideration for cardiac sarcoidosis screening in patients with a history of extra-cardiac manifestations.

Advances in cellular and tissue-based imaging techniques for sarcoid granulomas

Sarcoidosis embodies a complex inflammatory disorder spanning multiple systems, with its origin remaining elusive. It manifests as the infiltration of inflammatory cells that coalesce into distinctive noncaseous granulomas within afflicted organs. Unraveling this disease necessitates the utilization of cellular or tissue-based imaging methods to both visualize and characterize the biochemistry of these sarcoid granulomas. Although hematoxylin and eosin stain, standard in routine use alongside cytological stains have found utility in diagnosis within clinical contexts, special stains such as Masson's trichrome, reticulin, methenamine silver, and Ziehl-Neelsen provide additional varied perspectives of sarcoid granuloma imaging. Immunohistochemistry aids in pinpointing specific proteins and gene expressions further characterizing these granulomas. Finally, recent advances in spatial transcriptomics promise to divulge profound insights into their spatial orientation and three-dimensional (3-D) molecular mapping. This review focuses on a range of preexisting imaging methods employed for visualizing sarcoid granulomas at the cellular level while also exploring the potential of the latest cutting-edge approaches like spatial transcriptomics and matrix-assisted laser desorption ionization mass spectrometry imaging (MALDI-MSI), with the overarching goal of shedding light on the trajectory of sarcoidosis research.

Immunopathology of herpes simplex virus-associated neuroinflammation: Unveiling the mysteries

The immunopathology of herpes simplex virus (HSV)-associated neuroinflammation is a captivating and intricate field of study within the scientific community. HSV, renowned for its latent infection capability, gives rise to a spectrum of neurological expressions, ranging from mild symptoms to severe encephalitis. The enigmatic interplay between the virus and the host's immune responses profoundly shapes the outcome of these infections. This review delves into the multifaceted immune reactions triggered by HSV within neural tissues, intricately encompassing the interplay between innate and adaptive immunity. Furthermore, this analysis delves into the delicate equilibrium between immune defence and the potential for immunopathology-induced neural damage. It meticulously dissects the roles of diverse immune cells, cytokines, and chemokines, unravelling the intricacies of neuroinflammation modulation and its subsequent effects. By exploring HSV's immune manipulation and exploitation mechanisms, this review endeavours to unveil the enigmas surrounding the immunopathology of HSV-associated neuroinflammation. This comprehensive understanding enhances our grasp of viral pathogenesis and holds promise for pioneering therapeutic strategies designed to mitigate the neurological ramifications of HSV infections.

Large Lung Consolidation: A Rare Presentation of Pulmonary Sarcoidosis

Sarcoidosis is a complex inflammatory disease of uncertain origin, characterized by non-necrotizing epithelioid cell granulomas (NNEGs) affecting multiple organ systems. Although many different clinical and pathological phenotypes can be present, with different organs involved, the lung is the most common site described. In this case report, we (a) present and discuss the broad differential diagnosis of a patient presenting with a solitary lung mass with clinical and imaging features of lung cancer that ultimately was confirmed with a rare manifestation of stage II pulmonary sarcoidosis, and (b) analyze and compare similar cases from the literature.

The role of the host-microbiome and metabolomics in sarcoidosis

Sarcoidosis is a complex inflammatory fibrotic disease that affects multiple organ systems. It is characterized by the infiltration of lymphocytes and mononuclear phagocytes, which form non-caseating granulomas in affected organs. The lungs and intrathoracic lymph nodes are the most commonly affected organs. The underlying cause of sarcoidosis is unknown, but it is believed to occur in genetically predisposed individuals who are exposed to pathogenic organisms, environmental contaminants, or self and non-self-antigens. Recent research has suggested that the microbiome may play a role in the development of respiratory conditions, including sarcoidosis. Additionally, metabolomic studies have identified potential biomarkers for monitoring sarcoidosis progression. This review will focus on recent microbiome and metabolomic findings in sarcoidosis, with the goal of shedding light on the pathogenesis and possible diagnostic and therapeutic approaches.

Corticosteroid Use and Adherence in Patients Treated with Acthar Gel for Advanced Sarcoidosis

INTRODUCTION

Long-term corticosteroid use in immune-mediated diseases is associated with increased risk of adverse events (AEs) and worsened health-related quality of life (HRQoL). Previous studies report chronic high-dose corticosteroid therapy results in higher rates of healthcare resource use and AE-related medical costs. Recent studies suggest Acthar® Gel (repository corticotropin injection) is an effective steroid-sparing therapy for sarcoidosis. This study compares the corticosteroid-sparing effect between Acthar Gel and comparators and evaluates the impact of Acthar Gel adherence on reduction of corticosteroid burden.

METHODS

A retrospective analysis of a large administrative pharmacy and medical claims database (Symphony Health Solutions) was conducted. Patients were included with confirmed ICD-9/10 diagnosis for sarcoidosis in the study period (2014-2020), followed by ≥ 2 Acthar Gel claims or comparators (janus kinase inhibitor (JAKi)/rituximab), ≥ 18 years old, with 12 months coverage pre/post index. Outcomes were compared as change from baseline. Acthar Gel adherence was determined by proportion of days covered in the follow-up period.

RESULTS

The Acthar Gel (n = 735) and comparator (n = 626) cohorts were mostly female (68-72%) between 55 and 58 years old. Compared to the comparator cohort at baseline, Acthar Gel patients had greater any corticosteroid use (80% vs. 56%, p < 0.001), extended use (61% vs. 32%, p < 0.001), and mean average daily dose (6.72 vs. 3.03, p < 0.001). After treatment, Acthar Gel patients had greater reduction from baseline in any corticosteroid use (- 9.0% vs. - 3.2%) and extended use (- 10.0% vs. - 3.0%). In the Acthar Gel adherence cohorts, patients with above average adherence had greater reduction in both measures (- 11.2% vs. - 6.1%; - 11.6% vs. - 7.6%, respectively) than patients with below average adherence. Acthar Gel patients had greater reduction of extended use at all dose levels.

CONCLUSION

Acthar Gel is associated with reductions in corticosteroid use compared to alternatives. Better adherence is associated with greater reduction in corticosteroid exposure. Key Summary Points.

Bilateral Dacryoadenitis As the First Presentation in an Undiagnosed Sarcoidosis Patient

Sarcoidosis is an idiopathic multisystem disorder associated with hilar lymphadenopathy and noncaseating granulomas that can affect any organ. Ocular involvement is less common; however, sarcoidosis is a known cause of uveitis, dry eye, and conjunctival nodules. We report a case of a 36-year-old male with an occupational history of dust exposure presenting to the ophthalmology clinic with bilateral painless upper eyelid swelling of one-week duration. The diagnosis of sarcoidosis was suspected based on clinical examination, laboratory analysis, and imaging showing mediastinal lymphadenopathy, further confirmed by pathologic examination showing noncaseating granulomas with the presence of some asteroid and Schaumann bodies. A treatment plan consisting of prednisone, folic acid, and azathioprine was effective for the patient, though azathioprine was eventually changed to methotrexate due to an allergic reaction. The patient is on a maintenance dose of methotrexate and is asymptomatic after a year of careful management and follow-up. This case emphasizes the significance of considering sarcoidosis as a differential diagnosis in patients presenting with bilateral dacryoadenitis.

Ventricular Tachycardia as a Presentation of Isolated Cardiac Sarcoidosis: How to Manage It When We Do Not See Granulomas

A 47-year-old male was referred for rapid palpitations and an electrocardiogram compatible with sustained monomorphic ventricular tachycardia (VT) that required synchronized electrical cardioversion due to hemodynamic instability. After the initial clinical certainty, an etiological search is carried out. The transthoracic echocardiogram (TTE) revealed moderate dilatation and left ventricular systolic dysfunction due to global hypokinesia. Coronary angiography did not show significant coronary stenosis. Cardiac magnetic resonance (CMR) guarantees a nonischemic dilated cardiomyopathy with moderate systolic dysfunction and a pattern of subepicardial and intramyocardial late gadolinium enhancement (LGE) in medial-lateral and median inferolateral segments. Lastly, a positron emission tomography-computed tomography (PET-CT) scan showed diffuse fixation of the radiotracer in the left ventricular (LV) walls, with greater uptake on the lateral and inferolateral surfaces of inflammatory origin. After ruling out other alternative pathologies and according to current diagnostic criteria, the clinical judgment of probable isolated cardiac sarcoidosis (ICS) is established. An implantable cardioverter-defibrillator was implanted as secondary prevention of the acute arrhythmic event. Specific treatment for systolic dysfunction was prescribed, as well as immunosuppressive therapy with corticosteroids and methotrexate, after which the patient remained in clinical remission, with disappearance of active inflammation on cardiac imaging tests and progressive ventricular systolic function. The initial diagnosis of isolated cardiac sarcoidosis can be complex and challenging, especially in those patients in whom the diagnosis of extracardiac sarcoidosis has not been previously established. The limitations of endomyocardial biopsy in this entity make it necessary to have a high index of clinical suspicion with the early use of new cardiac imaging techniques and to include this picture in the differential diagnosis of patients with sustained ventricular arrhythmias or left ventricular systolic dysfunction of nonspecific etiology clarified. Early initiation of aggressive immunosuppressive therapy has been shown to prevent disease progression and limit its potential cardiac complications.

Diagnosing Extrapulmonary Sarcoidosis and the Implications of Diagnosis on Military Service

Sarcoidosis is a systemic inflammatory disease that can cause granulomatous infiltration of almost all organs and tissues which allows for a wide variety of presentations that may overlap with other disease processes. Renal sarcoidosis is a much rarer site of extrapulmonary involvement and may present as hypercalcemia, tubular or glomerular dysfunction, and/or granulomatous interstitial nephritis. Prompt diagnosis of sarcoidosis is crucial for initiating appropriate treatment and avoiding organ dysfunction. Herein, we describe a case of an armed forces service member who developed extrapulmonary sarcoidosis and renal sarcoidosis with acute complications refractory to glucocorticoids requiring adalimumab. The case highlights and emphasizes a rare manifestation of extrapulmonary sarcoidosis, the importance of avoiding premature closure of the differential diagnosis to avoid diagnostic delay and treatment imitation, and the unique clinical reasoning that occurs in active-duty personnel where diagnoses and subsequent treatments can have career implications and affect the ability of the service member to maintain the ability to deploy worldwide.

A single-center rheumatology experience of sarcoidosis: observations from 70 patients

BACKGROUND

The aim of this study is to determine the demographic, clinical and laboratory characteristics of the patients who followed up with the diagnosis of sarcoidosis, to investigate the distribution frequency of rheumatological findings and to examine the disease management from the perspective of rheumatology.

METHODS

Patients who were followed up with the diagnosis of sarcoidosis in the rheumatology clinic of Ankara City Hospital between November 2019 and November 2022 were evaluated. Demographic, clinical, radiological, serological, laboratory, and histopathological findings, and rheumatological, systemic, and locomotor system examination findings of the patients were obtained from the medical data registered in the hospital.

RESULTS

A total of seventy sarcoidosis patients (48.98 ± 11.78 years, %75 female) were included in the study. Joint involvement was observed in 64.3% of cases, skin involvement in 48.6% of cases, and ocular involvement in 25.7% of cases. The ankle was the most frequently involved joint, followed by the knee and small joints in the foot. Corticosteroids were the most used therapeutic agent, and pulmonary and joint findings were the most common reasons for starting treatment.

CONCLUSIONS

Sarcoidosis is a disease that mimics many diseases, misdiagnosis and treatment should be avoided with a good and fast differential diagnosis. Clinicians, especially rheumatologists, should remember sarcoidosis more frequently and keep it in mind in the differential diagnosis.

Organ involvement and assessment in sarcoidosis

PURPOSE OF REVIEW

In recent years new recommendations have been published about organ assessment in the diagnosis of sarcoidosis.

RECENT FINDINGS

Screening for pulmonary, cardiac, ocular, neurologic and renal involvement and hypercalcemia is recommended in the work-up for sarcoidosis, additionally, screening for hypercalciuria at the time of the diagnosis might be beneficial.

SUMMARY

One of the goals in the work-up of sarcoidosis is to assess the extent and severity of organ involvement. Timely and accurate assessment leads to determination of treatment indication. Screening for pulmonary involvement should include pulmonary imaging and pulmonary function tests. Screening for cardiac involvement should include a clear history including palpitations and collapse and a baseline electrocardiogram or 24-h Holter monitoring. At diagnosis, ophthalmological assessment is recommended. Furthermore, serum calcium level and serum creatinine level should be obtained. Although routine 24-h urinary calcium excretion is not included in the guidelines, performing this test routinely can be considered. On indication, neurologic, rheumatologic or dermatologic assessment can be performed.

Sarcoidosis presenting as a loss of weight with preserved appetite

Sarcoidosis is a multisystem inflammatory disorder of unknown aetiology affecting a wide range of organs and is characterised by the presence of noncaseating granulomas. It has rarely been reported in Sri Lanka. This case describes a 36-year-old male presenting with a loss of weight despite a preserved appetite. He had evidence of sarcoidosis with pulmonary, lymph node, eye, hepatosplenomegaly, thyroid and parotid gland involvement with hypercalcaemia. He was successfully treated with glucocorticoids.

Cardiovascular risk in rare diseases: a prognostic stratification model in a cohort of sarcoidosis patients

Sarcoidosis is a rare granulomatous disease that can affect any organ; as other chronic diseases, it leads to increased risk of atherosclerosis and cardiovascular (CV) disease. The aim of our observational study was to define a prognostic stratification model of sarcoidosis patients based on the evaluation of CV risk through common carotid Doppler ultrasound and cardiovascular risk scores assessment; for this reason, a clinical phenotyping of sarcoidosis patients in four subgroups was done, based on the different organ involvement. A cohort of 53 sarcoidosis patients and a cohort of 48 healthy volunteers were enrolled. Results showed that CV risk was higher in sarcoidosis cohort than in the control group when evaluated through CV risk scores and Doppler parameters: peak-systolic velocity (PSV) and end-diastolic velocity (EDV) were significantly lower in sarcoidosis cohort (p = 0.045 and p = 0.017, respectively), whereas intima media thickness (IMT) showed higher values in sarcoidosis group than in controls (p = 0.016). The analysis of sarcoidosis phenotypes showed no significative differences of CV risk among them when CV risk scores were considered, while partial differences emerged by evaluating subclinical atherosclerosis. Results also highlighted a relationship between CV risk score and carotid Doppler ultrasound parameters: EDV showed an inverse correlation with Framingham score (R = - 0.275, p = 0.004), whereas IMT showed a direct one (R = 0.429; p = 0.001); furthermore, an inverse correlation between PSV and EDV and illness duration (R = - 0.298, p = 0.030 and R = - 0.406, p = 0.002, respectively) was found, so suggesting a higher CV risk in patients with a longer story of disease.

The Elusive Sarcoidosis, an Eight-Year Journey to the Diagnosis of Sarcoidosis: A Case Report

We present a unique case of a patient coming to our internal medicine clinic with intermittent diffuse lymphadenopathy and non-specific symptoms for the past eight years. Initially, the patient was thought to have carcinoma of unknown primary origin, given the abnormalities seen in her imaging. The diagnosis of sarcoidosis was also dismissed, given that the patient had not responded to steroids with negative laboratory support. The patient was referred to several specialists, and only after a pulmonary biopsy was a non-caseating granuloma revealed after multiple prior failed biopsies. The patient was placed on infusion therapy and responded positively. This case demonstrates a challenging diagnosis and treatment which emphasizes the importance of considering alternative treatments if the initial therapy fails.

A Rare Case of Relapsed Sarcoidosis Presenting As Severe Thrombocytopenia Associated With Intracerebral Hemorrhage Due to Bone Marrow Involvement

Sarcoidosis is a systemic granulomatous disease characterized by the hyperactivation of CD4 T cells, CD8 T cells, and macrophages. Clinical presentations of sarcoidosis are highly variable. Sarcoidosis is unknown in its etiology, but it suggests it may result from exposure to specific environmental agents in genetically susceptible people. Sarcoidosis commonly involves the lungs and lymphoid system. Bone marrow involvement in sarcoidosis is uncommon. Sarcoidosis rarely results in intracerebral hemorrhage due to severe thrombocytopenia secondary to bone marrow involvement. We present the case of a 72-year-old woman who has been in remission from sarcoidosis for 15 years and developed intracerebral hemorrhage secondary to severe thrombocytopenia due to sarcoidosis recurrence in the bone marrow. The patient presented to the emergency department with a generalized, non-blanching petechiae rash and nose and gum bleeding. Her labs showed a platelet count of less than 10.000/mcL, and computed tomography (CT) showed intracerebral hemorrhage. A bone marrow biopsy revealed a small, non-caseating granuloma indicative of a sarcoidosis relapse in the bone marrow.

A Case of Coexistent Sarcoidosis and Tuberculosis: A Diagnostic Dilemma

Sarcoidosis and tuberculosis (TB) are chronic granulomatous diseases with similar radiological, clinical, and histopathological presentations. Although rare, both conditions can coexist together. Case reports of concomitant incidence have been published in the literature. The classic manifestations of both diseases overlap, making it difficult for clinicians to reach a final diagnosis. While TB is responsible for the majority of necrotizing granuloma cases, necrotizing sarcoidosis should be considered a possible diagnosis, especially in the absence of mycobacterial antigen isolation or when a remarkable improvement isn't achieved after administering anti-tb medications. We report a rare case of a 12-year-old female exhibiting an atypical form of the granulomatous disease (concomitant incidence of tuberculosis and sarcoidosis), who presented with respiratory distress, cough, fever, weight loss, and generalized fatigue that was initially diagnosed as Tuberculosis which was supported by radiological and biological findings. Initially, the patient had shown some clinical improvement with anti-tubercular treatment, but nonetheless, she experienced progressively increasing mediastinal lymphadenopathy. Subsequently, she developed new granulomatous skin findings. Further investigations supported the diagnosis of coexisting sarcoidosis.

Role of anti-tumor necrosis factor-alpha agents in treatment of sarcoidosis: A meta-analysis

IMPORTANCE

Anti-tumor necrosis factor-alpha agent (anti-TNF-α) is considered an effective third-line therapy for refractory sarcoidosis,studies observing the efficacy of anti-TNF-α agents show conflicting results.

OBJECTIVE

We performed an up-to-date systemic meta-analysis to determine effectiveness and further elucidate the role of anti-TNF-α in the treatment of sarcoidosis.

DATA SOURCES

A systematic search was carried out in PubMed/Medline, EMBASE, and Cochrane Library for studies reporting the therapeutic effects of anti-TNF drugs on patients with pulmonary and extra-pulmonary sarcoidosis, published up to April 10, 2022. The study was registered in the international prospective register of systematic reviews (PROSPERO) under ID: CRD42022364614.

STUDY SELECTION

Clinical trials written reporting the therapeutic effects of anti-TNF drugs on patients with pulmonary and extra-pulmonary sarcoidosis were included.

DATA EXTRACTION AND SYNTHESIS

Statistical analyses were performed with Comprehensive Meta-Analysis software, and the random-effects model was used. The combined overall treatment success was determined for patients with pulmonary and extrapulmonary sarcoidosis.

MAIN OUTCOMES AND MEASURES

Overall treatment success rate wasdefined as no disease progression or improvement in symptoms.

RESULTS

Eight clinical trial articles were included in the meta-analysis; four used Infliximab, two Etanercept, one Adalimumab, and one Ustekinumab and Golimumab. The mean age of participants was 48.5 years. The duration of drug therapy ranged from 14 to 45 weeks. We found a combined overall treatment success rate, defined as no disease progression or improvement in symptoms, of 69.9% (95% CI 35.0-90.9, I2: 70%) in the pulmonary sarcoidosis group and 74.5% (95% CI 36.3-93.7, I2: 90%) in the extrapulmonary sarcoidosis group. There was no evidence of publication bias in either group.

CONCLUSION AND RELEVANCE

Treatment of refractory sarcoidosis with anti-TNF-α agents was effective in both pulmonary and extrapulmonary sarcoidosis, with a slightly higher efficacy seen in extrapulmonary sarcoidosis. Further randomized controlled trials should be conducted to determine the effects of anti-TNF-α agents as a part of the management strategy of sarcoidosis. Patients with pulmonary sarcoidosis should be studied separately from patients with extrapulmonary sarcoidosis to adjust for confounding results.

Respiratory disease in workers handling cross-linked water-soluble acrylic acid polymer

Eight workers involved in packing cross-linked water-soluble acrylic acid polymer, an organic substance, developed pulmonary fibrosis, and the upper lobe was the most affected. The dust concentration in the polymer packing workstation was measured. Chest computed tomography (CT) was obtained for 82 individuals, including the 8 workers mentioned above. Three workers were histopathologically examined. In six of these eight workers, central pulmonary fibrosis and secondary bulla formation caused pneumothorax. Histopathologically, multiple centrilobular fibrotic foci were observed. Chest CT revealed centrilobular nodular opacity and interlobular septal thickening, suggesting early lesions in the workers because the dust concentration was remarkably high. Although the pathogenesis of the disease is unclear, we reported the occurrence of pulmonary fibrosis caused by the exposure to cross-linked water-soluble acrylic acid polymers in humans as it has not been reported earlier.

PD1, CTLA4 and TIGIT Expression on T and NK Cells in Granulomatous Diseases: Sarcoidosis and ANCA-Associated Vasculitis

Sarcoidosis is a granulomatous diseases affecting the lungs. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a histologically granulomatous B-mediated disorder characterized by activated T cells. The expression of immune checkpoint (IC) molecules (PD1, CTLA4, TIGIT) on T- and NK-cells negatively regulate the T-cell immune function. The present study aimed to explore the peripheral distribution of IC molecules to better elucidate their peripheral tolerance failure, which might reflect the development of diseases. Patients referred to Respiratory Diseases and Rheumatology Unit of Siena University Hospital were prospectively and consecutively enrolled. Healthy subjects were also enrolled as a control group. Multicolor flow cytometric analysis was performed to detect IC molecules in the peripheral blood of patients. Twenty-three patients were consecutively and prospectively enrolled in the study: 11 patients had an AAV diagnosis and 12 had sarcoidosis. CD4⁺PD1⁺ cells were higher in sarcoidosis and GPA than in HC (p = 0.0250 and p = 0.0253, respectively). CD56⁺CTLA4⁺ were higher in sarcoidosis than GPA, MPA and HC (p = 0.0085, p = 0.0042 and p = 0.0004, respectively). CTLA4⁺NK cells clustered for 100% of sarcoidosis patients according to decision tree analysis, while PD1⁺CD4 and CD8 cells for clustered for 100% of GPA patients. Our analyses showed substantial differences between sarcoidosis and AAV, further confirming the immunological peculiarity of this disease. Despite these advances, the pathogenesis remains incompletely understood, indicating an urgent need for further research to reveal the distinct immunological events in this process, with the hope to open up new therapeutic avenues and, if possible, to develop preventive measures.

Sarcoidosis in Johannesburg, South Africa: A retrospective study

Background

Sarcoidosis is a multisystem granulomatous condition of uncertain aetiology that most frequently affects the lungs. Because of clinical and radiological similarities with tuberculosis (TB), particularly in high-prevalence regions, sarcoidosis is frequently misdiagnosed as TB.

Objectives

To review the clinical features of sarcoidosis patients in a South African (SA) population, adding clinical information to the relatively few studies that have been conducted in SA patients with sarcoidosis.

Methods

This was a retrospective study of 102 sarcoidosis patients conducted between 2002 and 2006 at the Charlotte Maxeke Johannesburg Academic Hospital.

Results

Of 102 sarcoidosis patients, there were 69 (67.6%) females and 33 (32.4%) males. The majority (85.3%) were non-smokers. The mean age of the group was 44.6 years. One-third of patients had chronic comorbid diseases. Almost 17% had been treated initially for TB, prior to being diagnosed as having sarcoidosis. Two patients developed active TB while receiving corticosteroid treatment for sarcoidosis. The salient clinical manifestations were dry cough (the most common presenting symptom in 82.4%), dyspnoea in 53.9%, cutaneous lesions other than erythema nodosum in 33.3%, and on lung examination crackles were noted in 37.3% of patients. Raised angiotensin-converting enzyme (ACE) levels were found in 56.8% of patients. The majority (48%) of patients had stage II chest radiographic changes. Cutaneous (28.4%), mediastinal lymph node (25.5%) and transbronchial lung (25.5%) biopsies were the most frequent sites confirming granulomatous inflammation. Overall, 21.2% of patients had obstructive airway disease. Systemic corticosteroids were indicated in 87.3% of patients and the relapse rate was 60.7%.

Conclusion

Sarcoidosis is often initially misdiagnosed as TB in SA. The most common biopsy sites for histological confirmation were the skin and mediastinal lymph nodes, and transbronchial lung biopsies were also frequently taken. Stage II chest radiographic changes were most common. Overall, systemic corticosteroids were administered in 87.3% of cases and the relapse rate was 60.7%.

Prothrombotic state, endothelial injury, and echocardiographic changes in non-active sarcoidosis patients

Sarcoidosis is a multisystem inflammatory granulomatous disease of unknown cause that most commonly affects lungs and lymph nodes, with frequent yet asymptomatic cardiac involvement. The epidemiologically associated cardiovascular risk suggests an underlying prothrombotic state and endothelial dysfunction, currently understudied in the available literature. Therefore, we aimed to investigate prothrombotic plasma properties together with selected echocardiographic and laboratory biomarkers of cardiovascular injury in that disease. N = 53 patients with pulmonary sarcoidosis in clinical remission and N = 66 matched controls were assessed for inflammatory and endothelial injury biomarkers, plasma thrombin generation profile, and echocardiographic and lung function parameters. Sarcoidosis cases had impaired systolic and diastolic left ventricular function, higher concentrations of inflammatory markers, D-dimer and factor VIII activity compared to the controls. The coexistence of extrapulmonary disease was associated with elevated circulating vascular cell adhesion molecule 1, while cases with hypercalcemia had higher thrombomodulin concentration. Sarcoidosis was characterized by the unfavorably altered thrombin generation profile, reflected by the 16% higher endogenous thrombin potential (ETP), 24% increased peak thrombin concentration, and 12% shorter time to thrombin peak in comparison to the control group. ETP was higher in cases with proxies of pulmonary restriction, extrapulmonary-extracutaneous manifestation, and need for corticosteroids use. Despite the clinical remission, sarcoidosis is related to prothrombotic plasma properties and signs of endothelial injury, likely contributing to the higher risk of cardiovascular events. In addition, subclinical cardiac involvement may play an additional role, although further clinical and experimental studies are needed to verify these findings.

Sarcoidosis and autoimmunity: In the depth of a complex relationship

Sarcoidosis is a chronic granulomatous disease that can virtually affect any organ. Its etiology is unknown, although it has been proposed that environmental or biological agents can act as triggers, ultimately leading to chronic inflammation in genetically predisposed individuals. The main component of sarcoid inflammation is represented by an exaggerated T- lymphocytic cellular response to a putative antigen that could not be efficiently cleared in the patient. However, several clinical and immunological observations, such as the association of sarcoidosis to autoimmune diseases or the presence of autoantibodies in the serum of patients with sarcoidosis, suggest that humoral-mediated immune response might also play a role in the pathogenesis of sarcoidosis. The aim of this review is to deepen the relationship between sarcoidosis and autoimmunity, by analyzing the most recent advances and proposing new fields of research.

Perspective of sarcoidosis in terms of rheumatology: a single-center rheumatology clinic experience

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.

Potential Composite Digenic Contribution of NPC1 and NOD2 Leading to Atypical Lethal Niemann-Pick Type C with Initial Crohn’s Disease-like Presentation: Genotype-Phenotype Correlation Study

Niemann–Pick disease type C (NPC) is an autosomal recessive neurovisceral disease characterized by progressive neurodegeneration with variable involvement of multisystemic abnormalities. Crohn’s disease (CD) is an inflammatory bowel disease (IBD) with a multifactorial etiology influenced by variants in NOD2. Here, we investigated a patient with plausible multisystemic overlapping manifestations of both NPC and CD. Her initial hospitalization was due to a prolonged fever and non-bloody diarrhea. A few months later, she presented with recurrent skin tags and anal fissures. Later, her neurological and pulmonary systems progressively deteriorated, leading to her death at the age of three and a half years. Differential diagnosis of her disease encompassed a battery of clinical testing and genetic investigations. The patient’s clinical diagnosis was inconclusive. Specifically, the histopathological findings were directed towards an IBD disease. Nevertheless, the diagnosis of IBD was not consistent with the patient’s subsequent neurological and pulmonary deterioration. Consequently, we utilized a genetic analysis approach to guide the diagnosis of this vague condition. Our phenotype–genotype association attempts led to the identification of candidate disease-causing variants in both NOD2 and NPC1. In this study, we propose a potential composite digenic impact of these two genes as the underlying molecular etiology. This work lays the foundation for future functional and mechanistic studies to unravel the digenic role of NOD2 and NPC1.

Reliable Sarcoidosis Detection Using Chest X-rays with EfficientNets and Stain-Normalization Techniques

Sarcoidosis is frequently misdiagnosed as tuberculosis (TB) and consequently mistreated due to inherent limitations in radiological presentations. Clinically, to distinguish sarcoidosis from TB, physicians usually employ biopsy tissue diagnosis and blood tests; this approach is painful for patients, time-consuming, expensive, and relies on techniques prone to human error. This study proposes a computer-aided diagnosis method to address these issues. This method examines seven EfficientNet designs that were fine-tuned and compared for their abilities to categorize X-ray images into three categories: normal, TB-infected, and sarcoidosis-infected. Furthermore, the effects of stain normalization on performance were investigated using Reinhard’s and Macenko’s conventional stain normalization procedures. This procedure aids in improving diagnostic efficiency and accuracy while cutting diagnostic costs. A database of 231 sarcoidosis-infected, 563 TB-infected, and 1010 normal chest X-ray images was created using public databases and information from several national hospitals. The EfficientNet-B4 model attained accuracy, sensitivity, and precision rates of 98.56%, 98.36%, and 98.67%, respectively, when the training X-ray images were normalized by the Reinhard stain approach, and 97.21%, 96.9%, and 97.11%, respectively, when normalized by Macenko’s approach. Results demonstrate that Reinhard stain normalization can improve the performance of EfficientNet -B4 X-ray image classification. The proposed framework for identifying pulmonary sarcoidosis may prove valuable in clinical use.

Sarcoidosis With Bilateral Testicular Involvement Resembling Testicular Cancer: A Rare Case Report

Sarcoidosis is a granulomatous inflammatory disease that could potentially involve multiple organ systems. It causes noncaseating granulomas in tissues, and at least two organs must be involved to make a diagnosis. In sarcoidosis patients, if there is a mass in the testicles, a testicular biopsy should be performed to exclude malignancies because of infrequent testicular involvement. We present a 23-year-old male diagnosed with sarcoidosis who had a bilateral testicular mass. A testicular biopsy was performed because of bilateral involvement. The biopsy revealed a diagnosis of sarcoidosis. After high-dose steroid treatment, the lesions regressed. This paper presents a sarcoidosis case with testicular involvement that imitates testicular tumors. Testicular tumors and testicular involvement of sarcoidosis are two different pathologies that may mimic each other, confuse clinicians, and/or lead to misdiagnosis and mistreatment.

Electrical monitoring of infection biomarkers in chronic wounds using nanochannels

Chronic wounds represent an important healthcare challenge in developed countries, being wound infection a serious complication with significant impact on patients' life conditions. However, there is a lack of methods allowing an early diagnosis of infection and a right decision making for a correct treatment. In this context, we propose a novel methodology for the electrical monitoring of infection biomarkers in chronic wound exudates, using nanoporous alumina membranes. Lysozyme, an enzyme produced by the human immune system indicating wound infection, is selected as a model compound to prove the concept. Peptidoglycan, a component of the bacterial layer and the native substrate of lysozyme, is immobilized on the inner walls of the nanochannels, blocking them both sterically and electrostatically. The steric blocking is dependent on the pore size (20-100 nm) and the peptidoglycan concentration, whereas the electrostatic blocking depends on the pH. The proposed analytical method is based on the electrical monitoring of the steric/electrostatic nanochannels unblocking upon the specific degradation of peptidoglycan by lysozyme, allowing to detect the infection biomarker at 280 ng/mL levels, which are below those expected in wounds. The low protein adsorption rate and thus outstanding filtering properties of the nanoporous alumina membranes allowed us to discriminate wound exudates from patients with both sterile and infected ulcers without any sample pre-treatment usually indispensable in most diagnostic devices for analysis of physiological fluids. Although size and charge effects in nanochannels have been previously approached for biosensing purposes, as far as we know, the use of nanoporous membranes for monitoring enzymatic cleavage processes, leading to analytical systems for the specific detection of the enzymes has not been deeply explored so far. Compared with previously reported methods, our methodology presents the advantages of no need of neither bioreceptors (antibodies or aptamers) nor competitive assays, low matrix effects and quantitative and rapid analysis at the point-of-care, being also of potential application for the determination of other protease biomarkers.

A young man with transitory hemiparesis and lung infiltrates

In patients with neurological symptoms when other neurological causes are excluded, a differential diagnosis of neurosarcoidosis should be considered taking into account the clinical picture, radiological and laboratory findings.https://bit.ly/3oMSBap

Longitudinal follow-up of Choroidal Granulomas with Indocyanine Green Angiography And Optical Coherence Tomography Angiography: a lesion-based analysis

PURPOSE

To investigate choroidal granulomas visualized by indocyanine green angiography (ICGA) and Optical Coherence Tomography Angiography (OCTA) in response to treatment.

METHODS

Ten eyes of eight patients with tubercular, sarcoid or Vogt-Koyanagi-Harada associated choroidal granulomas were evaluated in this multicentric study. All patients underwent ICGA and OCTA at baseline, 1 and 3 months after treatment onset. Granulomas were identified as hypofluorescent lesions on intermediate ICGA phases. Late ICGA behavior and OCTA visualization were assessed.

RESULTS

On baseline intermediate ICGA, 222 choroidal granulomas were detected. Overall, 174/222 granulomas were detected on baseline OCTA images. At 1 month, 28% of lesions were healed and 48 late ICGA hyper-fluorescent lesions were identified. At 3 months, 63% of baseline lesions were healed, with 33 persistent late hyper-fluorescent lesions. OCTA sensitivity was reduced at 1 and 3 months compared to baseline. Some flow-voids detected on OCTA at 1 and 3 months did not correspond to any visible lesion on ICGA.

CONCLUSIONS

Different healing behaviors of choroidal granulomas were identified combining ICGA and OCTA analysis. Late ICGA hyper-fluorescent lesions may be the consequence of a possible fibrotic shift. Structural changes in the choroid may persist after active granulomas resolution resulting in persistent flow voids on OCTA.

Sarcoidosis - A review article

Sarcoidosis is a granulomatous disorder of multiple organs, with lungs and lymphatic systems being the most frequently affected sites of the body. It was first reported in 1877 and has continued to engross both clinicians and scientists since that time. Because sarcoidosis being a diagnosis of exclusion, it demands the physician to rule out all the possible diagnosis. Most of the patients remain asymptomatic and this makes the disease remain unnoticed for a prolonged period. Later after years, the disease could be diagnosed after witnessing the patient being symptomatic or suffering from organ failures. It could affect middle aged people of any sexes, often its clinical features correlate with tuberculosis. On immunological and histopathological examination, it reveals noncaseating granuloma in simple terms. Glucocorticoids remain the standard drug now and then. Further research has to be done to know the exact pathogenesis, early detection and betterment in treatment plan of sarcoidosis. The current review article gives a brief knowledge about etiopathogenesis, Clinical features, upgraded diagnostic methods such as biomarkers detection and the organized treatment plan to treat sarcoidosis.

Clinicopathological Characteristics Related to Etiologies of Erythema Nodosum: A 10-Year Retrospective Study

Background

Erythema nodosum (EN) is the most common panniculitis associated with a wide variety of conditions. Updated studies regarding the clinicopathological manifestations related to etiologies of EN and its prognosis are limited.

Objective

We aimed to explore the clinicopathological features in relation to the etiologies of EN and determine characteristics of disease recurrence and its predictive factors.

Methods

A total of 169 patients with biopsy-proven EN or septal panniculitis from January 2008 to September 2018 were retrospectively reviewed. Patients were classified as either idiopathic or secondary EN. Patients’ general information, clinical manifestations, investigations, and recurrence of EN were recorded. The details on histopathological findings were reviewed by a blinded dermatopathologist.

Results

The mean age at diagnosis of EN was 40.6 ± 17.3 years. The majority of patients (85.2%) were female. Idiopathic EN was found in 62.7% of patients. Tuberculosis (23.8%) and drugs (23.8%) were the leading causes of secondary EN. In univariate logistic regression analysis, lesions on upper extremities (p = 0.018), fever (p = 0.003), clinical lymphadenopathy (p < 0.001) favored secondary EN. Histopathologically, the presence of focal peripheral lobular panniculitis with eosinophils was linked to idiopathic EN (p = 0.03). However, multivariable logistic regression analysis failed to demonstrate factors associated with secondary EN. Recurrence was found in 46.6% of patients with no identifiable predictive factors.

Conclusion

Although no clinical risk factors were associated with the etiology of EN, the histopathological presence of eosinophils in focal peripheral lobular panniculitis suggested idiopathic EN.

T Lymphocyte Maturation Profile in the EBUS-TBNA Lymph Node Depending on the DLCO Parameter in Patients with Pulmonary Sarcoidosis

Sarcoidosis (SA) is a systemic granulomatous disorder of unknown etiology with lung and mediastinal lymph nodes (LNs) as the main location. T lymphocytes play important role in the formation of granulomas in SA, but still little is known about the role of maturation profile in the development of inflammatory changes. The aim of this study was to determine the CD4+ and CD8+ T cells maturation profile in LNs and in peripheral blood (PB) and its relation to disease severity expressed by diffusing capacity of the lung for carbon monoxide (DLCO). 29 patients with newly pulmonary SA were studied. Flow cytometry was used for cells evaluation in EBUS-TBNA samples. We observed lower median proportion of T lymphocytes, CD4+ T and CD8+ T cells in patients with DLCO< 80% than in patients with normal diffusion (DLCO > 80%). Patients with DLCO < 80% had lower median proportion of effector and higher median proportion of central memory CD4+ and CD8+ T cells than patients with DLCO > 80%. We reported for the first time that LNs CD4+ and CD8+ T cells maturation differs depending on the DLCO value in sarcoidosis. Lymphocytes profiles in LNs may reflect the immune status of patients with SA and can be analysed by flow cytometry of EBUS-TBNA samples.

Imaging of Biliary Involvement in Sarcoidosis: Computed Tomography, Magnetic Resonance Cholangiopancreatography, and Gadolinium Ethoxybenzyl Diethylenetriamine Pentaacetic Acid-Enhanced Magnetic Resonance Imaging Findings

Sarcoidosis is a multisystem disease usually affecting the chest, hilar lymph nodes, and lungs, but can potentially involve any organ; therefore, its clinical presentation may vary. Hepatobiliary involvement is rare, and typically asymptomatic; however, it can lead to cirrhosis, and may require liver transplantation. In this report, we present a rare case of a patient affected by sarcoidosis with hepatobiliary involvement. He presented to our hospital complaining of dyspnea triggered by moderate efforts and oppressive thoracic discomfort. Chest X-ray showed multiple bilateral nodular opacities and enlargement of both hilar regions, confirmed by a subsequent total-body computed tomography scan and positron emission tomography, which also revealed cardiac, splenic, and hepatic involvement. Liver function was studied via gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging, and magnetic resonance cholangiopancreatography (MRCP) was also performed. The diagnosis of sarcoidosis was finally achieved via liver biopsy, revealing non-necrotizing granulomas in the periportal space. The patient was treated with prednisone per os, with regression of all lesions at all levels. Although other cases of biliary sarcoidosis have been described, this report provides a complete image set of Gd-EOB-DTPA-enhanced magnetic resonance and MRCP images that is lacking in the English literature, and which may be useful for diagnosis.

Atrial tachyarrhythmia as a presenting symptom leading to the diagnosis of pulmonary sarcoidosis treated with catheter-based ablation

A 55-year-old woman was referred for recurrent palpitations. A 48-hour ambulatory cardiac monitor revealed an atrial tachycardia rate up to 170 beats per minute. A subsequent electrophysiology study revealed atrial fibrillation and both typical and atypical atrial flutter. Computed tomography revealed multiple pulmonary nodules, and an endobronchial ultrasound-guided fine-needle aspiration confirmed the diagnosis of pulmonary sarcoidosis. The patient underwent radiofrequency ablation of the cavotricuspid isthmus and left common, right superior, and right inferior pulmonary vein isolation via cryoablation, without recurrent symptoms.

Effect of genotype on the disease course in idiopathic pulmonary fibrosis despite antifibrotic treatment

A genetic predisposition has been identified in 30% of idiopathic pulmonary fibrosis (IPF) cases. Although it is highly probable that the genotype affects the disease susceptibility and course in almost all patients, the specific genotype goes undetected. The aim of the present study was to explore the effects of variants of the genes encoding interleukin-4 (IL-4), mucin 5B (MUC5B), toll interacting protein (TOLLIP), surfactant protein A (SFPTA), transforming growth factor-β (TGF-β) and transporters associated with antigen processing (TAP1 and TAP2) on the course of IPF. A total of 50 patients with IPF were enrolled, and variants of these genes were assessed. Lung function at the time of diagnosis and after 6, 12 and 18 months, and the number of acute exacerbations and deaths in each observation period were measured. ANOVA was used to test the association between gene polymorphisms and the decrease in lung function. There was no significant effect of the gene polymorphisms on the outcomes of patients up to 6 months during the observation period. After 12 months, an effect of an IL-4 single nucleotide polymorphism (SNP) (rs 2070874) on patient outcomes was observed [relative risk (RR) for T allele: 5.6; 95% confidence interval (CI), 0.79-39.0; P=0.053]. The RR of progression in patients with the IL-4 SNP (rs 2243250) and the CT and TT genotypes was 4.3 (95% CI, 1.1-17.5; P=0.046). A total of 18 months after the diagnosis of IPF, an effect of the TOLLIP polymorphism on patient outcome was detected (rs 111521887; risk allele GC; RR: 7.2; 95% CI, 0.97-53.6; P=0.052). Thus, IL-4 and TOLLIP gene polymorphisms may represent disease course-modifying factors, but not drivers of IPF.

Lofgren syndrome in close temporal association with mild COVID-19 - Case report

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.