Thoracic sarcoidosis

Thoracic involvement is seen in >90% of patients with sarcoidosis (1)

• parenchymal and airway involvement (larynx, trachea and bronchi)
  • lung involvement may vary from alveolitis and granulomatous infiltration (in early stages of sarcoidosis) to fibrosis with bronchiolectasis (in a later stage of the disease) (2,3)
    
    
• intrathoracic lymphadenopathy
  • bilateral hilar lymphadenopathy is the commonest thoracic manifestation
  • unilateral hilar lymphadenopathy is present in 3% to 5% of patients
  • mediastinal lymphadenopathy in the absence of hilar lymph node enlargement indicates an alternative diagnosis (1)
    
    
• rarely the pleura maybe affected as well - pleural thickening, pleural effusion and chylothorax (3)

Patients may present with dyspnoea, dry cough and chest pain. Most patients with massive hilar and/or mediastinal lymphadenopathy are asymptomatic but some may have fatigue, retrosternal pain and/ or dysphagia (3).

Physical finding are usually minimal or absent:

• crackles are seen in less than 20% of patients - usually these are fine interstitial crackles in the upper lobes
• clubbing is rarely seen - if present suspect an alternative diagnosis (4,5)

Secondary complications may be seen in patients who develop pulmonary fibrosis e.g. - infection (aspergilloma, mycobacterial), pneumothorax, respiratory failure, and pulmonary hypertension (5)

Prognosis is generally good, but a few patients die due to progressive disease (6)

Reference:

• 1. Iannuzzi MC, Fontana JR. Sarcoidosis: clinical presentation, immunopathogenesis, and therapeutics.JAMA. 2011;305(4):391-9
• 2. Turchin I et al. Cough, fever, joint pain and tender nodules: what is your call?CMAJ. 2008 Jan 15;178(2):151-2.
• 3. Grutters JC et al. Chapter 9 - Sarcoidosis. Eur Respir Mon 2009;46:126-154
• 4. Lynch JP 3rd et al. Pulmonary sarcoidosis.Semin Respir Crit Care Med. 2007;28(1):53-74
• 5. Dempsey OJ et al. Sarcoidosis. BMJ. 2009 Aug 28;339:b3206
• 6. Bradley B et al.Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008;63 Suppl 5:v1-58