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==Overview== | ==Overview== | ||
The diagnosis of [[sarcoidosis]] requires a tissue biopsy, with the exception of rare circumstances which the clinical findings are highly specific [[sarcoidosis]]. | The diagnosis of [[sarcoidosis]] requires a tissue biopsy, with the exception of rare circumstances which the clinical findings are highly specific for [[sarcoidosis]]. The evaluation of pulmonary disease in [[sarcoidosis]] patients relies on three major factors: pulmonary function, chest imaging, and symptoms. | ||
== | ==Tissue biopsy== | ||
The diagnosis of [[sarcoidosis]] requires a tissue [[biopsy]], with the exception of rare circumstances which the clinical findings are highly specific for [[sarcoidosis]]. It is ideal for [[biopsy]] to be minimally invasive and associated with the least [[morbidity]]. Thus, peripheral [[biopsy]] sites are preferred compared to [[visceral]] organs<ref>Teirstein AS, Judson MA, Baughman RP, et al: The spectrum of biopsy sites for the diagnosis of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 22(2):139 146, 2005.</ref>.When there is no evidence that a superficial peripheral site is involved by sarcoidosis, a [[biopsy]] is usually performed in organs which is very often the lung, because the lungs are involved in 90% of [[sarcoidosis]] patients<ref>Baughman RP, Teirstein AS, Judson MA, et al: Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 164:1885–1889, 2001.</ref>. | The diagnosis of [[sarcoidosis]] requires a tissue [[biopsy]], with the exception of rare circumstances which the clinical findings are highly specific for [[sarcoidosis]]<ref name="ex">Judson MA: The diagnosis of sarcoidosis. Clin Chest Med 29(3):415– 427, 2008.</ref>. It is ideal for [[biopsy]] to be minimally invasive and associated with the least [[morbidity]]. Thus, peripheral [[biopsy]] sites are preferred compared to [[visceral]] organs<ref name="sar">Teirstein AS, Judson MA, Baughman RP, et al: The spectrum of biopsy sites for the diagnosis of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 22(2):139 146, 2005.</ref>.When there is no evidence that a superficial peripheral site is involved by sarcoidosis, a [[biopsy]] is usually performed in organs which is very often the lung, because the lungs are involved in 90% of [[sarcoidosis]] patients<ref>Baughman RP, Teirstein AS, Judson MA, et al: Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 164:1885–1889, 2001.</ref>. | ||
===[[Bronchoscopy]]=== | |||
different samples can be taken with a bronchoscope: | |||
====Transbronchial biopsy(TBB)==== | |||
* 60-97% diagnostic for sarcoidosis<ref>Poe RH, Israel RH, Utell MJ, Hall WJ: Probability of a positive transbronchial | |||
lung biopsy result in sarcoidosis. Arch Intern Med 139(Jul):761–763, 1979.</ref><ref>Koerner SK, Sakowitz AJ, Appelman RI, et al: Transbronchinal lung | lung biopsy result in sarcoidosis. Arch Intern Med 139(Jul):761–763, 1979.</ref><ref>Koerner SK, Sakowitz AJ, Appelman RI, et al: Transbronchinal lung | ||
biopsy for the diagnosis of sarcoidosis. N Engl J Med 293(6):268–270, 1975.</ref><ref>Gilman MJ, Wang KP: Transbronchial lung biopsy in sarcoidosis. An | biopsy for the diagnosis of sarcoidosis. N Engl J Med 293(6):268–270, 1975.</ref><ref>Gilman MJ, Wang KP: Transbronchial lung biopsy in sarcoidosis. An | ||
approach to determine the optimal number of biopsies. Am Rev Respir Dis 122(5):721–724, 1980.</ref>. | approach to determine the optimal number of biopsies. Am Rev Respir Dis 122(5):721–724, 1980.</ref>. | ||
====Endobronchial biopsy==== | |||
sarcoidosis: a prospective study. Chest 120(1):109–114, 2001.</ref>< | * positive in 60% of patients with [[pulmonary sarcoidosis]]<ref>Shorr AF, Torrington KG, Hnatiuk OW: Endobronchial biopsy for | ||
sarcoidosis: a prospective study. Chest 120(1):109–114, 2001.</ref><ref>Kieszko R, Krawczyk P, Michnar M, et al: The yield of endobronchial | |||
biopsy in pulmonary sarcoidosis: connection between spirometric impairment and lymphocyte subpopulations in bronchoalveolar lavage luid. Respiration 71(1):72–76, 2004.</ref>. | biopsy in pulmonary sarcoidosis: connection between spirometric impairment and lymphocyte subpopulations in bronchoalveolar lavage luid. Respiration 71(1):72–76, 2004.</ref>. | ||
====Transbronchial needle aspiration(TBNA)==== | |||
* positive in 80% of patients with [[pulmonary sarcoidosis]]<ref>Agarwal R, Srinivasan A, Aggarwal AN, Gupta D: Eficacy and safety of convex probe EBUS-TBNA in sarcoidosis: a systematic review and meta-analysis. Respir Med 106(6):883–892, 2012.</ref> | |||
====Bronchoalveolar lavage(BAL)==== | |||
* is a complementary test for the diagnosis of pulmonary sarcoidosis<ref>Meyer KC, Raghu G, Baughman RP, et al: An oficial American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar | |||
lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 185(9):1004–1014, 2012.</ref>. BAL lymphocytosis(>15% lymphocytes) has a 90% sensivity<ref>Drent M, van Nierop MA, Gerritsen FA, et al: A computer program using BALF-analysis results as a diagnostic tool in interstitial lung diseases. Am J Respir Crit Care Med 153(2):736–741, 1996.</ref>. BAL CD4/CD8 ratio is increased more than 3.5 in 50% of patients with pulmonary sarcoidosis<ref>Welker L, Jorres RA, Costabel U, Magnussen H: Predictive value of BAL cell differentials in the diagnosis of interstitial lung diseases. Eur Respir J 24(6):1000–1006, 2004.</ref><ref>Drent M, Wagenaar SS, Mulder PH, et al: Bronchoalveolar lavage fluid proiles in sarcoidosis, tuberculosis, and non-Hodgkin’s and Hodgkin’s disease. An evaluation of differences. Chest 105(2):514– | |||
519, 1994.</ref><ref>Winterbauer RH, Lammert J, Selland M, et al: Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis. Chest | |||
104(2):352–361, 1993</ref>. | |||
===Extrapulmonary tissue biopsy=== | |||
Granulomas can be detected in any organ which is involved by sarcoidosis<ref name="sar">Teirstein AS, Judson MA, Baughman RP, et al: The spectrum of biopsy sites for the diagnosis of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 22(2):139 146, 2005.</ref> | |||
==When the diagnosis can be made without performing a tissue biopsy?== | |||
in some clinical scenarios, the presentation is so specific that the diagnosis can be made without a confirmatory tissue biopsy<ref name="ex">Judson MA: The diagnosis of sarcoidosis. Clin Chest Med 29(3):415– 427, 2008.</ref>. | |||
*[[Lupus pernio]] | |||
*[[Lofgren syndrome]] | |||
*[[Heerfordt syndrome]] | |||
*[[Bilateral hilar adenopathy]] on [[CXR]] '''without''' symptoms | |||
*Positive [[panda]] and/or [[lambda sign]] on [[gallium scan]] | |||
==[[Pulmonary Function Tests]]== | |||
* Significant amount of patients with pulmonary [[sarcoidosis]] will have a normal [[spirometry]] and [[lung volumes]] at the time of diagnosis, but over time some of these individuals will develope a [[restrictive pattern]], with reduction of [[lung volumes]]<ref>Baughman RP, Teirstein AS, Judson MA, et al: Clinical characteristics | |||
of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 164:1885–1889, 2001.</ref><ref>Loddenkemper R, Kloppenborg A, Schoenfeld N, et al: Clinical indings in 715 patients with newly detected pulmonary sarcoidosis–results of a cooperative study in former West Germany and | |||
Switzerland. WATL Study Group. Wissenschaftliche Arbeitsgemeinschaft fur die Therapie von Lungenkrankheitan. Sarcoidosis Vasc Diffuse Lung Dis 15(2):178–182, 1998.</ref><ref>Baughman RP, Winget DB, Bowen EH, Lower EE: Predicting respiratory failure in sarcoidosis patients. Sarcoidosis 14:154–158, 1997.</ref><ref>Judson MA, Baughman RP, Thompson BW, et al: Two year prognosis of sarcoidosis: the ACCESS experience. Sarcoidosis Vasc Diffuse Lung Dis 20(3):204–211, 2003.</ref>. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Roshan Dinparasti Saleh M.D.
Overview
The diagnosis of sarcoidosis requires a tissue biopsy, with the exception of rare circumstances which the clinical findings are highly specific for sarcoidosis. The evaluation of pulmonary disease in sarcoidosis patients relies on three major factors: pulmonary function, chest imaging, and symptoms.
Tissue biopsy
The diagnosis of sarcoidosis requires a tissue biopsy, with the exception of rare circumstances which the clinical findings are highly specific for sarcoidosis[1]. It is ideal for biopsy to be minimally invasive and associated with the least morbidity. Thus, peripheral biopsy sites are preferred compared to visceral organs[2].When there is no evidence that a superficial peripheral site is involved by sarcoidosis, a biopsy is usually performed in organs which is very often the lung, because the lungs are involved in 90% of sarcoidosis patients[3].
Bronchoscopy
different samples can be taken with a bronchoscope:
Transbronchial biopsy(TBB)
Endobronchial biopsy
- positive in 60% of patients with pulmonary sarcoidosis[7][8].
Transbronchial needle aspiration(TBNA)
- positive in 80% of patients with pulmonary sarcoidosis[9]
Bronchoalveolar lavage(BAL)
- is a complementary test for the diagnosis of pulmonary sarcoidosis[10]. BAL lymphocytosis(>15% lymphocytes) has a 90% sensivity[11]. BAL CD4/CD8 ratio is increased more than 3.5 in 50% of patients with pulmonary sarcoidosis[12][13][14].
Extrapulmonary tissue biopsy
Granulomas can be detected in any organ which is involved by sarcoidosis[2]
When the diagnosis can be made without performing a tissue biopsy?
in some clinical scenarios, the presentation is so specific that the diagnosis can be made without a confirmatory tissue biopsy[1].
- Lupus pernio
- Lofgren syndrome
- Heerfordt syndrome
- Bilateral hilar adenopathy on CXR without symptoms
- Positive panda and/or lambda sign on gallium scan
Pulmonary Function Tests
- Significant amount of patients with pulmonary sarcoidosis will have a normal spirometry and lung volumes at the time of diagnosis, but over time some of these individuals will develope a restrictive pattern, with reduction of lung volumes[15][16][17][18].
References
- ↑ 1.0 1.1 Judson MA: The diagnosis of sarcoidosis. Clin Chest Med 29(3):415– 427, 2008.
- ↑ 2.0 2.1 Teirstein AS, Judson MA, Baughman RP, et al: The spectrum of biopsy sites for the diagnosis of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 22(2):139 146, 2005.
- ↑ Baughman RP, Teirstein AS, Judson MA, et al: Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 164:1885–1889, 2001.
- ↑ Poe RH, Israel RH, Utell MJ, Hall WJ: Probability of a positive transbronchial lung biopsy result in sarcoidosis. Arch Intern Med 139(Jul):761–763, 1979.
- ↑ Koerner SK, Sakowitz AJ, Appelman RI, et al: Transbronchinal lung biopsy for the diagnosis of sarcoidosis. N Engl J Med 293(6):268–270, 1975.
- ↑ Gilman MJ, Wang KP: Transbronchial lung biopsy in sarcoidosis. An approach to determine the optimal number of biopsies. Am Rev Respir Dis 122(5):721–724, 1980.
- ↑ Shorr AF, Torrington KG, Hnatiuk OW: Endobronchial biopsy for sarcoidosis: a prospective study. Chest 120(1):109–114, 2001.
- ↑ Kieszko R, Krawczyk P, Michnar M, et al: The yield of endobronchial biopsy in pulmonary sarcoidosis: connection between spirometric impairment and lymphocyte subpopulations in bronchoalveolar lavage luid. Respiration 71(1):72–76, 2004.
- ↑ Agarwal R, Srinivasan A, Aggarwal AN, Gupta D: Eficacy and safety of convex probe EBUS-TBNA in sarcoidosis: a systematic review and meta-analysis. Respir Med 106(6):883–892, 2012.
- ↑ Meyer KC, Raghu G, Baughman RP, et al: An oficial American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 185(9):1004–1014, 2012.
- ↑ Drent M, van Nierop MA, Gerritsen FA, et al: A computer program using BALF-analysis results as a diagnostic tool in interstitial lung diseases. Am J Respir Crit Care Med 153(2):736–741, 1996.
- ↑ Welker L, Jorres RA, Costabel U, Magnussen H: Predictive value of BAL cell differentials in the diagnosis of interstitial lung diseases. Eur Respir J 24(6):1000–1006, 2004.
- ↑ Drent M, Wagenaar SS, Mulder PH, et al: Bronchoalveolar lavage fluid proiles in sarcoidosis, tuberculosis, and non-Hodgkin’s and Hodgkin’s disease. An evaluation of differences. Chest 105(2):514– 519, 1994.
- ↑ Winterbauer RH, Lammert J, Selland M, et al: Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis. Chest 104(2):352–361, 1993
- ↑ Baughman RP, Teirstein AS, Judson MA, et al: Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 164:1885–1889, 2001.
- ↑ Loddenkemper R, Kloppenborg A, Schoenfeld N, et al: Clinical indings in 715 patients with newly detected pulmonary sarcoidosis–results of a cooperative study in former West Germany and Switzerland. WATL Study Group. Wissenschaftliche Arbeitsgemeinschaft fur die Therapie von Lungenkrankheitan. Sarcoidosis Vasc Diffuse Lung Dis 15(2):178–182, 1998.
- ↑ Baughman RP, Winget DB, Bowen EH, Lower EE: Predicting respiratory failure in sarcoidosis patients. Sarcoidosis 14:154–158, 1997.
- ↑ Judson MA, Baughman RP, Thompson BW, et al: Two year prognosis of sarcoidosis: the ACCESS experience. Sarcoidosis Vasc Diffuse Lung Dis 20(3):204–211, 2003.