ArticlesSarcoidosis: Clinical Presentation, Diagnosis, and Approach to Treatment
Section snippets
Natural Course
The natural course of pulmonary sarcoidosis is highly variable. Up to 60% of patients are asymptomatic such that pulmonary sarcoidosis is detected by an incidental finding on a chest radiograph.1 Radiographic abnormalities of patients with pulmonary sarcoidosis resolve, improve, or stabilize in 60% to 90% of cases.1., 2. Radiographic resolution is more frequent with hilar adenopathy alone on the initial chest radiograph (radiographic stage I) than with parenchymal infiltration (radiographic
Extrapulmonary Involvement
Sarcoidosis may affect any organ in the body, and extrapulmonary manifestations of the disease are often of major clinical importance. The clinician must be cognizant of the manifestations of sarcoidosis in all organs in order to deliver optimal care. The expertise of various subspecialists should be requested when appropriate. This section will outline the various extrapulmonary manifestations of the disease. Because of space limitations, this topic can only be briefly discussed. The
Diagnosis
The diagnosis of sarcoidosis requires compatible clinical findings, histologic demonstration of noncaseating granulomas, and exclusion of alternative diseases.16 Mycobacterial and fungal diseases must always be considered capable of producing a similar histologic and clinical picture. Therefore stains and cultures for fungi and mycobacteria should always be obtained when the diagnosis of sarcoidosis is considered.
Because sarcoidosis is a diagnosis of exclusion (granulomatous inflammation of
Initial Evaluation
Table 4 lists the recommended initial evaluation of a patient with diagnosed sarcoidosis.16 A medical history should be obtained to consider the exposures that may explain an alternative diagnosis such as tuberculosis, fungal diseases, chronic beryllium disease, and hypersensitivity pneumonitis (eg, significant bird exposure). A physical examination often reveals a normal chest examination66 and is most useful to detect signs of extrapulmonary sarcoidosis such as skin lesions or red eyes that
Treatment
Therapy is not mandated for sarcoidosis because the disease may remit spontaneously. Therapy is indicated for potentially dangerous disease including cardiac sarcoidosis, neurosarcoidosis, hypercalcemia unresponsive to dietary measures, any ocular involvement, and other life-threatening disease.68 Therapy should also be considered when the disease is progressive. In general, asymptomatic patients should not be treated with the exception of those with involvement of the eye and possibly the
Summary
Sarcoidosis is a granulomatous disease that usually affects the lungs but may affect any organ. The diagnosis is one of exclusion and requires elimination of all granulomatous diseases of known cause. All patients with sarcoidosis should be screened for disease in other organs, especially the lungs, eyes, and heart. Treatment of sarcoidosis is not mandated. Corticosteroids are the drug of choice in most instances.
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