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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 119-123

Clinico-radiological profile of pulmonary sarcoidosis: A study of 150 patients


1 Department of Chest Diseases and Tuberculosis, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Radiodiagnosis and Imaging, Government Medical College, Jammu, Jammu and Kashmir, India
3 Department of Internal Medicine, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Rahul Gupta
Department of Chest Diseases and Tuberculosis, Government Medical College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_25_17

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  Abstract 


Objective: The main aim of this study was to study the radiological, including radiographic and computed tomographic, histopathologic and clinical profiles in patients of pulmonary sarcoidosis. Materials and Methods: A prospective study of 150 patients suspected of having sarcoidosis was carried out with their routine chest radiographs and computed tomography scans performed followed by histopatholgical analysis of the lymph nodes. Results: Most of the patients evaluated belonged to the Stage-I sarcoidosis least number of patients were from Stage-IV disease. Conclusion: All the modalities should be combined with clinico-radiologico-pathological diagnosis of the disease to avoid inconvenience to the patient and misdiagnosis.

Keywords: Computed tomography, histopathology, radiography, sarcoidosis


How to cite this article:
Gupta R, Gupta A, Ilyas M, Kalsotra M. Clinico-radiological profile of pulmonary sarcoidosis: A study of 150 patients. Adv Hum Biol 2017;7:119-23

How to cite this URL:
Gupta R, Gupta A, Ilyas M, Kalsotra M. Clinico-radiological profile of pulmonary sarcoidosis: A study of 150 patients. Adv Hum Biol [serial online] 2017 [cited 2020 Apr 4];7:119-23. Available from: http://www.aihbonline.com/text.asp?2017/7/3/119/214889




  Introduction Top


A multisystem granulomatous disease of idiopathic origin which can involve any of the body organs but predominantly involves the lungs. Due to similar findings as that of the pulmonary tuberculosis, sarcoidosis can be misdiagnosed as pulmonary tuberculosis.[1] The primary organ system involved in the sarcoidosis include lungs and the lymphatics; however, it can involve any organ of the body such as liver, spleen and central nervous system. Sarcoidosis has global distribution and is prevalent in all the continents with slight epidemiological variations. We studied the clinic-radiological and histopathological profile of 150 patients who were diagnosed having sarcoidosis.


  Materials and Methods Top


This study included 250 patients suspected of having sarcoidosis based on clinical profile. We studied their detailed clinical, biochemical, radiologic (high-resolution computed tomography [HRCT] and chest radiography) and histopathologic profile. The biochemical evaluation included serum angiotensin-converting enzyme levels, serum calcium and 24-h urinary calcium. Haemogram including haemoglobin, total leucocyte count, differential leucocyte count and PBF was also obtained. The investigations for tuberculosis such as Mantoux test, sputum for acid-fast bacilli were also performed. The protocol investigations for the study that included posteroanterior view chest radiograph, pulmonary function tests and HRCT were then obtained and findings interpreted thereof.

The patients were classified based on the Siltzbach classification which defines the five stages of the sarcoidosis: Stage 0, which has normal appearance on chest radiograph; Stage 1, lymphadenopathy only; Stage 2, having lymphadenopathy and parenchymal disease; Stage 3, parenchymal disease only; and Stage 4, with parenchymal fibrosis.

Fibreoptic bronchoscopy and bronchoscopy-guided biopsy was done only in consenting patients.

The clinicoradiologic, histopathologic and biochemical profiles of the 150 patients finally labelled as having sarcoidosis were noted.


  Observations and Results Top


All the findings clinical, radiological (X-ray and HRCT), pulmonary function tests, bronchoscopy and histopathology, were analysed to diagnose sarcoidosis. Further demographic profile was also noted.

The most common affected gender was female. The commonly involved age-group was 40–50 years. Various results are tabulated as below:


  Discussion Top


Due to the high resemblance of the sarcoidosis clinical and radiological picture with the tuberculosis, its true prevalence remains uncertain. Earlier studies have shown the disease affects mostly patients below the age of 40 years.[2] In this study, most of the patients involved were between 40 and 50 years of age with 60% of them being females and least among <30 and >70 years of age [Table 1] and [Table 2].
Table 1: Distribution of patients according to gender

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Table 2: Distribution of patients according to age group

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It has been observed that sarcoidosis has propensity to affect non-smokers with this inverse relationship being observed in various studies.[3] In our study also, the disease was more common in non-smokers than smokers with non-smokers comprising 73.3% [Table 3].
Table 3: Distribution of patients according to their smoking habits

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The most common symptoms associated with sarcoidosis include dry cough, dyspnoea and chest pain.[4] In this study, the symptoms present were cough, breathlessness, chest pain and joints pain [Table 4].
Table 4: Distribution of patients based on their clinical profile (signs and symptoms)

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“Lofgren syndrome” (erythema nodosum, bilateral hilar lymphadenopathy and fever), a rare presentation, was seen in only two patients and “Heerfordt syndrome” (fever, enlarged parotid glands, anterior uveitis and facial nerve palsy)[5] was absent in our patients and also according to previous studies, this presentation is rare in India.

Although Stage 1 sarcoidosis is thought to be the most common but significant variability exists.[6] In this study also, Stage-I disease was the most common followed by Stage-II, combined aggregating around 80% of the patients.

Bilateral hilar lymphadenopathy is found in almost 75% of the patients with involvement of right paratracheal lymph nodes in some cases; however, computed tomography (CT) may demonstrate the enlarged left paratracheal, carinal and mediastinal lymph nodes.[7],[8]

In our study, on chest radiographs, 110 (73.3%) patients were having bilateral hilar lymphadenopathy and 60 patients had pulmonary infiltrates [Figure 1], [Figure 2] and [Table 5].
Figure 1: Posteroanterior view chest radiograph showing the bilateral hilar lymphadenopathy in a patient with Stage-I sarcoidosis.

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Figure 2: Posteroanterior view chest radiograph of a patient with Stage-II sarcoidosis showing diffuse bilateral pulmonary infiltrates without hilar lymphadenopathy.

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Table 5: Chest radiographic profile of patients diagnosed as having sarcoidosis

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On CT, bilateral hilar lymphadenopathy was found in 70% with 57% of patients having parenchymal abnormalities in the form of nodules with peribronchiolar distribution, ground glass haze, interlobular septal thickening, and military nodular pattern [Figure 3],[Figure 4],[Figure 5] and [Table 6].
Figure 3: Axial and coronal soft tissue window computed tomography images showing significant bilateral hilar lymphadenopathy.

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Figure 4: Axial and coronal lung window computed tomography image showing diffuse perilymphatic and peribronchovascular distribution of nodules with predominant involvement of upper and middle lung segments-typical of sarcoidosis.

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Figure 5: Axial computed tomography image lung window showing diffuse pulmonary infiltrates in both lungs without hilar lymphadenopathy Stage-III sarcoidosis.

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Table 6: High-resolution computed tomographic findings in patients diagnosed as having sarcoidosis

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The management approach towards sarcoidois should be cystal clear, especially regarding the use of corticosteroids. The drugs such as methotrexate, leflunomide, mycophenolate and azathioprine can be used in place of corticosteroids if contraindicated.[9]

In our study, we utilised steroids as the primary treatment modality for pulmonary disease in sarcoidosis resorting to antimetabolites only in cases of refractory treatment in view of their high toxicity.

The parenchymal abnormalities are better detected by the thoracic HRCT than chest radiographs. The degree of pulmonary involvement might be closely related to the loss of pulmonary function.[10] An important part of the sarcoidois management is the non-steroidal anti-inflammatory drugs.[11]

In our study, we also found that pulmonary function compromise was closely related to the degree of parenchymal involvement in sarcoidosis which usually manifested as restrictive pattern on spirometry.

Radiologic findings in the children with pulmonary sarcoidosis are similar to those in adults;[11] however, in our study, we did not have child group patient.

It is necessary to evaluate the other systems possibly involved in a patient of sarcoidosis so that appropriate necessary action and management be done to prevent the irreversible damage to the organ.[12],[13]

On spirometry, most of the patients had restrictive pattern (60%) with only 20% having obstructive pattern with 10% normal spirometry [Table 7].
Table 7: Distribution of patients according to spirometry findings

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On Bronchoscopy, abnormal mucosa in the form of mucosal nodularity, erythema and plaques, was seen in 75% of patients [Table 8].
Table 8: Distribution of patients according to bronchoscopic findings

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On histopathology, after bronchoscpic-guided biopsy, majority of the patients had non-casseating granulomas [Figure 6] and [Table 9].
Figure 6: Histopathological slide showing the non-casseating granuloma in a patient of sarcoidosis.

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Table 9: Histopathologic findings in 80 patients who consented for bronchoscopic-guided biopsy

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In the present study, clinical, radiological and histopathological findings formed the main pillars for the diagnosis and staging of the sarcoidosis.


  Conclusion Top


Sarcoidosis has clinical, radiological and serological manifestations. Due to similar presentation as of tuberculosis, there are much chances of the misdiagnosis and our study conclude that the combination of the clinical data along with radiological, biochemical and histopathological analysis was very accurate in the diagnosis of sarcoidosis at different stages. All the modalities should be combined for proper and accurate diagnosis of the disease to avoid inconvenience to the patient and misdiagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nunes H, Soler P, Valeyre D. Pulmonary sarcoidosis. Allergy 2005;60:565-82.  Back to cited text no. 1
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2.
Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999;160:736-55.  Back to cited text no. 2
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Douglas JG, Middleton WG, Gaddie J, Petrie GR, Choo-Kang YF, Prescott RJ, et al. Sarcoidosis: A disorder commoner in non-smokers? Thorax 1986;41:787-91.  Back to cited text no. 3
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Lynch JP rd, Kazerooni EA, Gay SE. Pulmonary sarcoidosis. Clin Chest Med 1997;18:755-85.  Back to cited text no. 4
    
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Sinha R, Gaur SN. Sarcoidosis presenting as acute bilateral parotid swelling. Asian Pac J Allergy Immunol 2004;22:171-4.  Back to cited text no. 5
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Gupta SK, Mitra K, Chatterjee S, Chakravarty SC. Sarcoidosis in India. Br J Dis Chest 1985;79:275-83.  Back to cited text no. 6
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Hillerdal G, Nöu E, Osterman K, Schmekel B. Sarcoidosis: Epidemiology and prognosis. A 15-year European study. Am Rev Respir Dis 1984;130:29-32.  Back to cited text no. 7
    
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Brauner MW, Grenier P, Mompoint D, Lenoir S, de Crémoux H. Pulmonary sarcoidosis: Evaluation with high-resolution CT. Radiology 1989;172:467-71.  Back to cited text no. 8
    
9.
Baughman RP, Grutters JC. New treatment strategies for pulmonary sarcoidosis: Antimetabolites, biological drugs, and other treatment approaches. Lancet Respir Med 2015;3:813-22.  Back to cited text no. 9
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10.
Ors F, Gumus S, Aydogan M, Sari S, Verim S, Deniz O. HRCT findings of pulmonary sarcoidosis; relation to pulmonary function tests. Multidiscip Respir Med 2013;8:8.  Back to cited text no. 10
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Korsten P, Mirsaeidi M, Sweiss NJ. Nonsteroidal therapy of sarcoidosis. Curr Opin Pulm Med 2013;19:516-23.  Back to cited text no. 11
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12.
Sileo C, Epaud R, Mahloul M, Beydon N, Elia D, Clement A, et al. Sarcoidosis in children: HRCT findings and correlation with pulmonary function tests. Pediatr Pulmonol 2014;49:1223-33.  Back to cited text no. 12
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Rao DA, Dellaripa PF. Extrapulmonary manifestations of sarcoidosis. Rheum Dis Clin North Am 2013;39:277-97.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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