Pulmonary sarcoidosis

Question 1

What is sarcoidosis?

Answer 1

Systemic disorder of unknown causes characterised by formation of NON caseating granulomas

Question 2

Which organ is most commonly involved?

Answer 2

Lung - over 90%

Question 3

What cells are involved?

Answer 3

T cells accuumulate

Question 4

What evidence suggests that sarcoidosis is caused by infections?

Answer 4

Other granulomatous diseases have infectious causes

Can be transmitted via transplanted organs

Question 5

Which infectious organisms are linked to sarcoidosis?

Answer 5

Proponi bacteria acnes (but research was done in Japanese people)

Mycobacteria

Question 6

Risk factors

Answer 6

Agricultural exposures
Insecticides
Microbial bioaerosols
FH 
Northern europe, USA and India
African-americans

Question 7

What is the strange thing about cigarettes and sarcoidosis?

Answer 7

Cigarette smoking is a protective factor !!

Question 8

Sarcoid presentation differs by ethnicity. What is seen in Japanese?

Answer 8

Uveitis
Cardiac sarcoid
no ‘Lofgren’ ie bilateral hilar lymphadenopathy

Question 9

Where are the sarcoid granulomas found?

Answer 9

Follow lymphatic pathways along interlobular septa and around the pleura

Question 10

What are the characteristics of the pulmonary nodules?

Answer 10

bronchocentric

Question 11

Signs

Answer 11

Erythema nodosum
Bilateral hilar lymphadenopathy
Calcified egg shell lymph nodes (bilateral) - note this is unilateral in TB

Question 12

Staging name

Answer 12

Scadding staging on XRAY

Question 13

Stage 1

Answer 13

Bilateral hilar lymphadenopathy + Right paratrachea

Question 14

Classic signs of sarcoid on CT

Answer 14

Honeycomb - suggests end stage fibrosis
seen in UIP

usual interstitial pneumoniasis

Question 15

Stage 3 signs

Answer 15

Parenchymal disease

WITHOUT Bilateral hilar lymphadenopathy + Right paratrachea (these have receded or never been present)

Question 16

Stage 4 signs

Answer 16

Fibrosis

hilar being pulled up by hilar lymphosis

Question 17

Diagnosis of stages 1-2

Answer 17

EBUS-TBNA

Question 18

Diagnosis of stages 3-4

Answer 18

???

Question 19

Stage 4 signs

Answer 19

Fibrosis
hilar being pulled up by hilar
lymph ??

Question 20

Predictors of mortality

Answer 20

Pulmonary HTN

More than 20% fibrosis on CT

Question 21

Within fibrotic disease, what do you have to look for?

Answer 21

Stable or progressive?

Therefore you have to try to measure disease activity

Question 22

Assessing disease activity

Answer 22

HRCT
BAL 
Serum ACE 
Lung function
FDG-PET

Question 23

Nodules seen on HRCT are reversible or irreversible?

Answer 23

reversible

Question 24

Ground glass changes on HRCT is reversible or irreversible?

Answer 24

maybe reversible

Question 25

Complication of sarcoid

Answer 25

Chronic pulmonary aspergillosis

Question 26

Death in these patients with CPA is caused by?

Answer 26

Sarcoidosis rather than haemoptysis

Question 27

Treatment of sarcoidosis

Answer 27

NSAIDS for joint pain Low dose prednisolone or hydroxychloroquine + ???

Question 28

Risks

Answer 28

Respiratory failure | Cardiac arrythmias

Question 29

What's the problem with cardiac involvement?

Answer 29

Many patients are asymptomatic !!!!!!!!!!!!! Autopsy shows 25% of patients actually have cardiac involvement

Question 30

What questions would you ask to screen for cardiac involvement?

Answer 30

Palpitations Syncope SOB

Question 31

What would you look for on ECG to screen for cardiac involvement?

Answer 31

``` AV block Frequent premature vetnricular ectopics/tachycardia LBBB/RBBb Q waves ? ```

Question 32

Echo

Answer 32

??

Question 33

Treatment

Answer 33

Corticosteroids | Immunosuppressants

Question 34

What would you look for on ECG to screen for cardiac involvement?

Answer 34

``` AV block Frequent premature ventricular ectopics/tachycardia LBBB/RBBb Q waves ? ```

Question 35

Echo

Answer 35

Wall thinning, thickening etc | ??

Question 36

Why are second line agents used

Answer 36

Osteoporosis | Diabetes

Question 37

What do you use

Answer 37

Biologics e.g. inflixmab

Question 38

Why are second line agents used

Answer 38

Pt often have comorbidities which means they can't tolerate the corticosteroids e.g. Osteoporosis Diabetes

Question 39

What do you use if the other treatments don't work?

Answer 39

Biologics e.g. infliximab

Question 40

Symptoms

Answer 40

Ankle hurting Fatigue Resp symptoms

Question 41

What is eBUS-TBNA?

Answer 41

ultra sound guided endobronchial aspirate