What are the clinical signs of sarcoidosis?

Clinical Signs of Sarcoidosis

Sarcoidosis presents with a wide spectrum of clinical signs, ranging from highly specific features like lupus pernio and Löfgren's syndrome to more common manifestations including bilateral hilar adenopathy, skin lesions, and ocular involvement. 1

Highly Probable Clinical Features

The following physical examination findings are considered highly probable indicators of sarcoidosis and carry significant diagnostic weight:

Dermatologic Signs

• Lupus pernio: Chronic violaceous skin lesions, typically on the nose, cheeks, and ears—this is a highly specific finding 1
• Erythema nodosum: Tender, raised nodules typically on the shins, often associated with Löfgren's syndrome 1

Ocular Manifestations

• Uveitis: Inflammation of the uveal tract, one of the most common extrapulmonary manifestations 1
• Optic neuritis: Inflammation of the optic nerve 1

Classic Syndrome

• Löfgren's syndrome: The triad of bilateral hilar adenopathy, erythema nodosum, and/or periarticular arthritis—this presentation is so specific that it does not require histological confirmation 1, 2

Probable Clinical Features

These signs support the diagnosis but are less specific than the highly probable features:

Skin Manifestations

• Maculopapular, erythematous, or violaceous skin lesions 1
• Subcutaneous nodules 1

Ocular Signs

• Scleritis and retinitis 1
• Lacrimal gland swelling 1

Neurologic Findings

• Seventh cranial nerve paralysis (facial nerve palsy) 1
• Seizures due to parenchymal brain involvement 3
• Neurosarcoidosis occurs in approximately 5-15% of patients 3

Cardiac Manifestations

• New-onset third-degree AV block in young or middle-aged adults—this is a critical finding that requires immediate evaluation 1
• Treatment-responsive cardiomyopathy or AV node block 1
• Spontaneous or inducible ventricular tachycardia without traditional risk factors 1
• Reduced left ventricular ejection fraction without other risk factors 1

Head and Neck Signs

• Symmetrical parotid gland enlargement 1
• Granulomatous lesions on direct laryngoscopy 1

Abdominal Findings

• Hepatomegaly and/or splenomegaly 1
• Hepatic involvement presents with elevated liver enzymes and imaging showing enlargement or nodules 3

Renal Manifestations

• Treatment-responsive renal failure 1
• Nephrolithiasis with calcium stones 1

Systemic Signs

The most common systemic symptoms include:

• Persistent dry cough and dyspnea—present in the majority of pulmonary cases 4, 2
• Fatigue, weight loss, and fever 5, 2
• Night sweats 5, 6
• Arthralgia and myalgia 6
• Chest discomfort 4

Imaging Findings as Clinical Signs

While not physical examination findings, these imaging features are critical clinical signs:

• Bilateral hilar adenopathy: The most characteristic radiographic finding, present in approximately 90% of cases 1, 2
• Perilymphatic nodules on chest CT 1
• Upper lobe or diffuse pulmonary infiltrates 1

Critical Pitfalls to Avoid

Failure to recognize cardiac involvement is particularly dangerous, as cardiac sarcoidosis carries significant mortality risk and may present subtly with conduction abnormalities before progressing to life-threatening arrhythmias 7, 8. Any young or middle-aged patient with unexplained AV block should be evaluated for sarcoidosis 1.

Insufficient monitoring for extrapulmonary manifestations can lead to delayed diagnosis, particularly for neurosarcoidosis which affects 5-15% of patients and requires aggressive treatment 8, 3. The multisystem nature of sarcoidosis means that seemingly unrelated symptoms (such as skin lesions, seizures, and hepatomegaly) may represent a single unifying diagnosis 3.

Inadequate exclusion of infections is the most common cause of misdiagnosis, as granulomatous diseases from tuberculosis, fungal infections, and other causes can mimic sarcoidosis exactly 8. Every case requires rigorous exclusion of alternative diagnoses before confirming sarcoidosis 7, 8.