Learn how to diagnose and radiograph your patients presenting with sarcoidosis

Sarcoidosis is a chronic disorder affecting a number of body systems. This granulomatous disorder commonly affects the cardiopulmonary, abdominal, ocular, dermatological, osseous, and neurological systems.¹

Epidemiology. Sarcoidosis predominantly affects young people, although patients of all age groups may be affected² with prevalence in the United States of approximately 10 to 40 cases per 100,000 of the population. Whilst there is no apparent gender predisposition, women in the child-bearing years may have an increased incidence. Patients of African origin are more commonly affected than whites or Asians, with an incidence of 10 to 20 times more than those who are not of African origin. However, the Swedish population has the highest incidence of sarcoidosis in the world with approximately 64 cases per 100,000 of the population. Overall, it is true that due to the number of African people, it is more common with them, but the Swedish population has the highest percentage of sarcoidosis.

The explanation of the cause of sarcoidosis is not fully understood, although suggestions have been made that it is linked to infection, heredity, or abnormalities in the immune system.

Symptoms and signs. Patients with sarcoidosis may present with acute, subacute, or chronic disease and therefore the clinical appearance of sarcoidosis is extremely variable, ranging from no symptoms to extensive system involvement, and fatality, affecting approximately 10% of patients. Presenting constitutional complaints may consist of malaise, symptoms of systemic infection, arthritis, parotid enlargement, or anorexia. Lesions on the skin may be painful, commonly about the tibia, characteristically described as erythema nodosum (though this may be seen in a variety of conditions). Chest symptoms may consist of a dry cough and dyspnea.

Diagnosis. The differential diagnosis of sarcoidosis is extensive depending on the presenting complaint. Common disorders to consider include rheumatoid arthritis and systemic lupus erythematosus as well as a variety of chest pathologies, including bronchitis, pneumonia, histiocytosis X, and pericarditis.

The diagnosis of sarcoidosis is based on the clinical, histologic, and radiologic findings. The laboratory tests that can be ordered to evaluate the patient include a complete blood count, where often leukocytosis, hypercalcemia, and immunologic markers, for example antinuclear antibodies.^3,4 Histological examination, though helpful at identifying the noncaseating granulomas, is not diagnostic since a variety of disorders may present a similar finding. Additional tests that may be ordered to evaluate the patient include skin biopsy and electrocardiogram studies, depending on the systems involved.

Imaging. The imaging of sarcoidosis depends on the region of the body involved, but for the purpose of this discussion, the chest will be addressed. The chest radiograph of a patient with sarcoidosis classically consists of enlarged lymph nodes in the region of the hilae, as well as the right paratracheal region. Parenchymal involvement may be evident, and in some cases though less common compared to the lymph node involvement, pulmonary fibrosis may be present.

Treatment. The treatment of sarcoidosis depends on the systems involved. In the case presented with pulmonary involvement, it is important to establish that the patient does not have any life-threatening complication, ensuring that oxygenation is adequate, cardiac function is monitored, and that assessment of the bodily systems has been complete.

If patients are symptomatic, glucocorticoids (prednisone) are used as well as other cytotoxic medications, including antineoplastic agents such as methotrexate.⁵ In some unusual situations, a lung transplant may be performed if the patient does not respond to conventional treatment.

Although no evidence in the medical literature is present as to the effectiveness of the chiropractic approach to the treatment of patients with sarcoidosis, two main areas are important. It is crucial to consider sarcoidosis in the differential diagnosis of common musculoskeletal complaints, since it is important to evaluate to determine the development of complications. It is also important consider treatment for these patients, including approaching the articulations affected. However, it is important to recall the association of sarcoidosis with a number of other important conditions and their complications, for example rheumatoid arthritis.

Prognosis. The prognosis for patients with sarcoidosis is variable, although about two thirds have spontaneous resolution. Although it is difficult to predict the outcome, those patients with an acute presentation, erythema nodosum or pulmonary lymphadenopathy (with no parenchymal involvement) have a more favorable outcome with resolution in 2 to 5 years.

Figure 1. PA chest view demonstrates enlargement of the bilateral hilar regions and of the right paratracheal region. The parenchyma is within normal limits.

Case History
A 28-year-old woman presented to the Institut Franco-Europeen de Chiropratique (IFEC) teaching clinic with a 6-week history of fever, dry cough, muscle aches, and fatigue. In particular, her wrist articulations were swollen and active and passive range of movement was reduced. She had consulted her general physician who prescribed anti-inflammatory medication that had not improved her symptoms following 2 weeks of use. Following her consultation in the clinic, a course of chiropractic treatment was suggested as well as another consultation with the general physician for further laboratory examination.

Figure 2. Lateral chest radiograph demonstrates enlargement of the hilar regions. The remaining chest is within normal limits.

Radiographs of her chest were ordered due to the continuation of fever and dry cough. These films were read as normal, but on her return to the clinic, clear evidence of hilar lymphadenopathy was noted (Figures 1 and 2). The films were returned to another radiologist who immediately scheduled the patient for a computed tomography chest examination. Following her imaging, and further laboratory tests, she was diagnosed with sarcoidosis and prescribed a short course of corticosteroid medication. Following 2 months of chiropractic and medical treatment, the patient reported a reduction in her systemic complaints, as well as a full and pain-free range of movement about her wrists. CP

Michelle A. Wessely, DC, DACBR, FCC (UK/Radiology), is the head of radiology and clinical director at Institut Franco-European de Chiropratique, Paris. She completed her fellowship in musculoskeletal radiology at the Department of Osteoradiology, Veterans Affairs Healthcare Center, San Diego, under Donald Resnick, MD, professor of radiology. Wessely travels throughout Europe lecturing to chiropractors on imaging and imaging-related subjects. She can be reached at: mwessely@ifec.net; michelle_wessely@yahoo.com; (033) (0)1 45 15 89 10.

References
1. Belfer MH, Stevens RW. Sarcoidosis: a primary care review. Am Fam Physician. 1998;58(9):2041-2050, 2055-2056
2. Chevalet P, Clement R, Rodat O, Moreau A, Brisseau JM, Clarke JP. Sarcoidosis diagnosed in elderly subjects: retrospective study of 30 cases. Chest. 2004;126 (5):1423-1430.
3. Wahlstrom J, Berlin M, Skold CM, Wigzell H, Eklund A, Grunewald J. Phenotypic analysis of lymphocytes and monocytes/macrophages in peripheral blood and bronchoalveolar lavage fluid from patients with pulmonary sarcoidosis. Thorax. 1999;54(4):339-346.
4. Young C, Burrows R, Katz J, Beynon H. Hypercalcaemia in sarcoidosis. Lancet. 1999;353 (9150):374.
5. du Bois RM. Corticosteroids in sarcoidosis: friend or foe? European Respiratory Journal. 1999;7(7):1203–1209.