Pediatric uveitis secondary to probable, presumed, and biopsy-proven sarcoidosis

Sarcoid Uveitis in Children

Sarcoidosis is a multi-system granulomatous disease that often presents with uveitis. Although sarcoidosis and sarcoid uveitis typically occur in adulthood, children also may be affected. There are two distinct clinical presentations of the pediatric disease, associated with younger and older age groups, and having different causations. "Early-onset sarcoidosis", beginning at age 5 years or less, is an autosomal dominant genetic disease, caused by a mutation in the NOD2 gene. It is also known as sporadic Blau syndrome or Jabs syndrome. "Adult-type sarcoidosis", usually beginning between the ages of 8 and 15 years, is believed to represent an excessive response to an environmental antigen. There is limited literature on the management of pediatric sarcoidosis, and treatment follows an approach applied to other forms of pediatric non-infectious uveitis. When systemic immunomodulatory therapy is indicated, methotrexate and/or adalimumab are often employed. The condition may persist into adulthood, and thus long-term follow-up is indicated.

Ocular sarcoidosis in adults and children: update on clinical manifestation and diagnosis

Sarcoidosis-associated uveitis, is the predominant ocular sarcoidosis presentation, which affects both adults and children. For adults, international ocular sarcoidosis criteria (IWOS) and sarcoidosis-associated uveitis criteria (SUN) are defined. However, for children they are not yet established internationally. Due to the specificity of pediatric manifestations of sarcoidosis, this task is even more challenging. In children, sarcoidosis is subdivided into Blau syndrome and early-onset sarcoidosis (BS/EOS) affecting younger children (< 5 years) and the one affecting older children with clinical presentation resembling adults. Differential diagnosis, clinical work-up as well as diagnostic criteria should be adapted to each age group. In this article, we review the clinical manifestation of sarcoidosis-associated uveitis in adults and children and the sensitivity and specificity of various ocular sarcoidosis diagnostic modalities, including chest X-ray and CT, FDG PET-CT, gallium-67 scintigraphy, bronchoalveolar lavage fluid, genetic testing for NOD2 mutations and serum biomarkers, such as ACE, lysozyme and IL2R.

VASCULARIZED SARCOID GRANULOMA COMPLICATED BY PLACOID DISEASE IN A PEDIATRIC PATIENT

PURPOSE

To report a case of pediatric vascularized sarcoid choroidal granuloma complicated by placoid-like inflammation.

METHODS

Case report.

RESULTS

A 10-year-old girl presented with blurry vision in her right eye and a yellowish macular lesion that had been diagnosed as fibrotic choroidal neovascular membrane and observed for several months. On referral to our clinic, optical coherence tomography revealed a homogeneous hyperreflective lesion obliterating the choroidal vasculature and protruding under the retina with associated subretinal and intraretinal fluid. Optical coherence tomography angiography revealed vascularization of this granulomatous lesion, and the girl underwent six intravitreal injections of anti-vascular endothelial growth factor, with reabsorption of the fluid and consolidation of the lesion. A sudden, abrupt decrease in the visual acuity of the right eye 3 months after the last injection was accompanied on optical coherence tomography by hyperreflective inflammatory lesions breaking from the retinal pigment epithelium and involving the outer nuclear layer, all around the fibrotic granulomatous lesion. The girl was treated with oral steroids, and an extensive systemic evaluation revealed hilar adenopathy, thus posing the diagnosis of pediatric sarcoidosis complicated by placoid chorioretinopathy.

CONCLUSION

Atypical presentations of typical uveitic diseases are quite common in children. The presence of a foveal vascularized granuloma complicated by a placoid disorder should prompt the exclusion of infectious etiologies such as tuberculosis, to establish a therapy to preserve the child's vision.

Serum Angiotensin-Converting Enzyme Has a High Negative Predictive Value in the Investigation for Systemic Sarcoidosis

PURPOSE

To examine whether measurement of serum angiotensin-converting enzyme (ACE) is useful in diagnosing sarcoidosis in undifferentiated uveitis.

DESIGN

Evaluation of a diagnostic test.

METHODS

Data collection was performed from 1035 consecutive subjects presenting with uveitis to Moorfields Eye Hospital undergoing measurement of serum ACE as part of baseline investigations for underlying systemic disease. The main outcome measures were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of elevated serum ACE.

RESULTS

Mean age of the sample was 41.7 years and 56.1% of subjects were female. Sarcoidosis was the underlying cause for the uveitis in 110 subjects (10.6%) and was more common in adults, female subjects, black subjects, and subjects with intermediate uveitis or panuveitis. ACE was elevated in 196 subjects (18.9%) and elevated levels were observed in 85 subjects eventually diagnosed with underlying sarcoidosis (true positive 77.3%) and in 111 subjects with an alternate diagnosis (false positive 12.0%). In adult subjects, sensitivity of serum ACE was 78.1%, specificity 90.0%, and PPV 43.6%, but the NPV was 97.0%. The test performed well, with area under curve (AUC) 0.897 (95% confidence interval [CI] 0.854-0.941). Serum ACE performed less well in distinguishing sarcoid uveitis in pediatric subjects, with sensitivity 60.0%, specificity 78.5%, and PPV 10.0%, but again NPV was high at 96.9% and AUC was 0.828 (95% CI 0.571-1.000).

CONCLUSIONS

Serum ACE had a very high negative predictive value for sarcoid uveitis, eliminating the need for further screening tests in subjects with normal serum ACE, unless clinical suspicion was high.

Urinary β2-Microglobulin Testing in Pediatric Uveitis: A Case Report of a 9-Year-Old Boy with Renal and Ocular Sarcoidosis

We present here a case of a 9-year-old boy with bilateral anterior uveitis and an extremely elevated urinary β₂-microglobulin level (25,400 μg/l). The normal range for urinary excretion of β₂-microglobulin is 0–300 μg/l. In patients with tubulointerstitial nephritis and uveitis syndrome (TINU), elevations typically range from 1,260 to 5,160 μg/l. Renal biopsy was pursued, and significant granulomatous interstitial nephritis consistent with sarcoidosis was identified. Systemic immune modulation was required for control of ocular inflammation. This case highlights the importance of urinary β₂-microglobulin testing in the pediatric patient uveitis population, and additionally the need to pursue kidney biopsy in the presence of extreme elevations in urinary β₂-microglobulin to differentiate between TINU and sarcoidosis.

Directed conjunctival biopsy and impact of histologic sectioning methodology on the diagnosis of ocular sarcoidosis

Background

Sarcoidosis is an idiopathic, multi-system, granulomatous disease with well-described ocular manifestations. However, other uveitic etiologies can manifest in a similar fashion, and ocular disease may precede systemic manifestations. Definitive diagnosis requires histologic confirmation of non-caseating granulomatous inflammation. This study reports the diagnostic yield of directed biopsy of conjunctival follicles in patients with uveitis suspected to be secondary to sarcoidosis, and compares an institutional standard tissue sectioning method to a multi-plane technique.

Results

A retrospective analysis was performed of all patients who underwent directed conjunctival biopsy for suspected ocular sarcoidosis. A total of eight patients were identified; all were females. Directed conjunctival biopsy was positive in three of seven patients using standard histologic processing method, a yield of 43%. Using the multi-plane technique increased the cumulative yield to 63%.

Conclusions

Directed conjunctival biopsy is a minimally invasive, cost-effective, and moderately high yield method of diagnosing ocular sarcoidosis. Using a multi-plane sectioning method may increase biopsy yield when standard sectioning techniques are negative.

Current perspectives on ophthalmic manifestations of childhood rheumatic diseases

Inflammatory eye diseases are an important manifestation of many pediatric rheumatologic conditions. Early screening and diagnosis are imperative as these illnesses can not only result in significant visual morbidity but are also an indicator of systemic inflammation. Time to presentation of ocular inflammation varies significantly and can range from many years prior to the onset of systemic symptoms to well after the diagnosis of the rheumatologic disorder. Due to this variability in presentation, careful monitoring by an ophthalmologist is vital to preventing ocular complications and preserving vision. Both local and systemic immunosuppressive medications have been effective in the management of ocular disease. In this review, we will focus on the known ophthalmologic manifestations of common pediatric rheumatologic diseases and discuss recent advances in therapeutic considerations for these conditions.