Sarcoidosis: Review of Diagnosis and Treatment

Background: Sarcoidosis is a systemic heterogenous granulomatous disease of unknown etiology that results in inflammation of pulmonary and extrapulmonary sites. In a minority of patients it can result in fibrosis and permanent organ damage. Most commonly mentioned causes of sarcoidosis include atypical mycobacterium, proprionobacterium and inorganic dusts. Once exposed to an organic or inorganic, an Antigen Presenting Cell (APC) prepares and presents the antigen to a T cell and its respective HLA locus. In a susceptible person, this provides cytokine production, differentiation into T helper cells and provokes an immune response that in its early stages is allayed by corticosteroids or other immunomodulatory agents. In the majority of patients appropriate immunomodulatory therapy will control the disease and prevent progression. However, in 20-25 % the disease can progress and lead to organ damage or compromise and fibrosis. Sarcoidosis is a relatively common disease with an incidence of 2.3-17.8 per 100,000. It is 2-4 times more common in African Americans than Caucasian Americans with the mean age of onset of 45-50 years of age. Unlike autoimmune rheumatic disease the disease occurs almost as commonly in men than women. Sources: A Medline, Pub Med review from 1999-2021. Spectrum of Disease: Sarcoidosis occurs in 90-98 % of patients during the course of their disease. Eleven to twenty two percent of patients have involvement of either the liver, Skin, ocular (uveitis), Lymph nodes and spleen. The upper airway, liver, CNS and heart comprise <10% of cases each and the bone, joints/ muscle, and hypercalcemia < 5%. Diagnosis: With the exception of Lofgren’s and Heerfordt’syndromes the presence of non-caseating/necrotizing granuloma must be present on biopsy of at least one site and mycobacterial or fungal infections or malignancy must be ruled out. If clinically suspicious, Skin and peripheral lymph nodes are the least invasive areas for biopsy and if hilar or mediastinal nodes are suggestive, an EBUS approach is recommended. In organs such as the heart and CNS where biopsy is either insensitive or invasive, a Cardiologist and Neurologist in concert with a Rheumatologist can make a probable diagnosis based on clinical presentation, PET or MRI and exclusion of alternative diseases.

Polyadenopathy - A Multidisciplinary Approach

Introduction. Sarcoidosis is a multisystemic disease, that can basically affect any organ of the body, the lungs and the intrathoracic lymph nodes being the most affected. Despite the attempts to understand the exact pathogenic mechanism of the disease, this continues to remain uncertain. Histopathologically, the trademark of sarcoidosis is the presence of nonnecrotizing granuloma.Case presentation. We report the case of a 33-year-old man without significant past medical history, who is admitted to our clinic for bilateral supraclavicular and axillary adenopathies, progressive asthenia for the last three months and pain in the latero-thoracic region. The patient denies weight loss, odynophagia and fever.Clinically, the patient is afebrile and has supraclavicular, bilateral laterocervical and axillary adenopathies which are painless, elastic and mobile with a maximum diameter of 1.5 cm. The prehepatic diameter is 16 cm, with rounded inferior edge and the spleen in not palpable.The laboratory tests reveal moderate inflammatory syndrome, with C-reactive protein (CRP) of 1.4mg/dL (N<0.5mg/dL) and the erythrocyte sedimentation rate (ESR) 65mm/h (N<40mm/h). There is no lymphocytosis or neutrophilia. The ENT (Ear Nose Throat) consultation found no evidence of angina and, combined with the paraclinical investigations, excluded mononucleosis.Thus, the presumptive diagnosis was difficult because of the non-specific symptomatology and included the following: lymphoma, mononucleosis, sarcoidosis, tuberculosis and systemic vasculitis.The chest X-ray reveals enlarged pulmonary hilums, diffuse outlined-adenopathic/tumoral aspect, diffuse changes in the pulmonary interstitium and micronodular opacities of medium intensity, being diffusely outlined with the tendency of basal merging on the left side and slight asymmetrical enlargement of the superior mediastinum on the right side, para trachealadenopathic aspect.The lymph node biopsy reveals the aspect of non-necrotizing granuloma, which suggests the diagnosis of sarcoidosis.We used the dosage of angiotensin convertase, which reveals high values of 108.20U/L (N 13.3-63.9 U/L). Therefore, a pulmonary clinical evaluation was recommended.Conclusion. Case of 33-year-old man with sarcoidosis. The diagnosis was difficult, considering the non-specific symptomatology and the numerous pathologies that can be included in the differential diagnosis.

Assessment of Clinically Suspected Tubercular Lymphadenopathy by Real-Time PCR Compared to Non-Molecular Methods on Lymph Node Aspirates

Background: The diagnosis of tubercular lymphadenitis (TBLN) is challenging. This study assesses the role of diagnostic intervention with real-time PCR in clinically suspected tubercular lymphadenopathy in relation to cytology and microbiological methods. Methods: The cross-sectional study involved 214 patients, and PCR, cytology, and Ziehl-Neelsen (ZN) staining was performed on aspirates. The findings were compared with culture on Lowenstein-Jensen medium. The overall concordance of cytology and PCR, both individually and combined, was calculated. χ2 and Phi values were assessed between cytology, PCR, and culture. Results: A cytological diagnosis of tuberculosis (TB), reactive lymphoid hyperplasia, and suppurative lymphadenitis was made in 71, 112, and 6 patients, respectively. PCR and culture were positive in 40% of the cases. Among the TBLN patients, PCR showed higher positivity in necrosis and culture showed higher positivity in necrotizing granuloma. Positive ZN staining was observed in 29.6% of the TBLN cases, with an overall positivity of 11%. PCR could additionally detect 82 cases missed by ZN staining. The overall concordance rate for either diagnostic modality, i.e., PCR or cytology, was highest (75%), and for PCR alone was 74%. Phi values were observed to be 0.47 between PCR and culture. Conclusion: Real-time PCR for Mycobacterium tuberculosis complex on aspirates offers a definitive and comparable diagnosis of TBLN. Including this approach as the primary investigation in the work-up of TBLN could reduce the burden of TB.