From the Guidelines
To evaluate for sarcoidosis, a comprehensive approach is needed that includes clinical assessment, laboratory tests, imaging, and often tissue biopsy, prioritizing the detection of non-caseating granulomas and the assessment of organ involvement to guide management and improve outcomes. When evaluating for sarcoidosis, the initial step involves a thorough history and physical examination, focusing on symptoms like persistent cough, shortness of breath, skin lesions, eye problems, and fatigue 1. The laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Serum calcium
- Angiotensin-converting enzyme (ACE) levels, though ACE can be elevated in other conditions Chest X-ray is the initial imaging study, but high-resolution CT scan provides more detailed information about lung involvement and lymphadenopathy 1. Pulmonary function tests help assess lung function impairment. The gold standard for diagnosis is histopathological evidence of non-caseating granulomas, typically obtained through:
- Bronchoscopy with transbronchial biopsy
- Mediastinoscopy
- Biopsy of accessible affected organs like skin or lymph nodes Additional specialized tests may include:
- Bronchoalveolar lavage
- Gallium-67 scan
- PET scan in selected cases Cardiac and neurological involvement should be evaluated when suspected with appropriate tests like:
- ECG
- Echocardiogram
- MRI
- Lumbar puncture, as suggested by recent guidelines 1. This systematic approach helps confirm sarcoidosis while excluding other granulomatous diseases like tuberculosis, fungal infections, and malignancies. For patients with sarcoidosis who do not have symptoms or signs of hypercalcemia, baseline serum calcium testing is recommended to screen for abnormal calcium metabolism 1. In patients with a high clinical suspicion for sarcoidosis, lymph node sampling may not be necessary, but close clinical follow-up is required 1. The use of cardiac MRI with late gadolinium enhancement has emerged as a valuable imaging tool for the diagnosis of cardiac involvement in sarcoidosis, considered the imaging study of choice in patients suspected of having cardiac sarcoidosis 1. Overall, the evaluation of sarcoidosis requires a multifaceted approach that considers the patient's clinical presentation, laboratory findings, and imaging results to provide an accurate diagnosis and guide effective management.
From the Research
Evaluating for Sarcoidosis
- 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 2.
- The disease usually presents with persistent dry cough, eye and skin manifestations, weight loss, fatigue, night sweats, and erythema nodosum 2.
- Diagnosis can be difficult because of nonspecific symptoms and can only be verified following histopathological examination 2.
Diagnosis and Treatment
- Various factors, including infection, genetic predisposition, and environmental factors, are involved in the pathology of sarcoidosis 2.
- Exposures to insecticides, herbicides, bioaerosols, and agricultural employment are also associated with an increased risk for sarcoidosis 2.
- Corticosteroids are the drug of choice for the treatment of sarcoidosis, but alternative medications often need to be considered due to potential toxicities 3.
- Methotrexate is generally the preferred agent for treatment of chronic sarcoidosis when corticosteroids have inadequate efficacy and/or severe adverse effects 4.
Treatment Patterns
- A retrospective analysis of patients with sarcoidosis from 2016 to 2022 found that 42.5% of patients received treatment within 1 year of diagnosis, with 60% receiving steroids alone, 13% receiving nonsteroidal immunosuppressives alone, and 27% receiving both 5.
- Factors associated with higher odds of treatment were Black race, organ involvement at baseline, and comorbid diagnoses 5.
- Nonsteroidal immunosuppressives were used in 40% of treated patients, with hydroxychloroquine, adalimumab, and mycophenolate being commonly used as second-line medications 5.