COMMENTARY

Suspect Sarcoidosis? Here's What to Assess

Matthew F. Watto, MD; Paul N. Williams, MD

Disclosures

April 28, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: We are back. This is The Curbsiders. I'm Dr Matthew Watto, here with my good friend, Dr Paul Williams. We're going to talk about sarcoidosis. We had a wonderful conversation with two great experts, Dr Boltax and Dr Scholand from University of Utah. Paul, what was your top pearl from that episode?

Paul N. Williams, MD: It's always hard for me to pick out one specific pearl. But in terms of initially suspecting sarcoidosis, we talked about how it's often seen or picked up incidentally, when someone gets chest imaging for something else entirely (perhaps for a cough they've had), and then you see lymphadenopathy or something else suspicious. They made the point that we should be considering sarcoidosis as a diagnosis in anyone coming in with chronic dyspnea. It should be on your differential at the very least. Or if you have a patient with recurrent episodes of "pneumonia" and they've had multiple antibiotic courses, that should start to raise your suspicion a little and make you think of possible sarcoidosis in these patients.

And then, during the diagnostic workup, if you're trying to figure out whether this is sarcoidosis, one of the points they made is that you would not start with angiotensin-converting enzyme (ACE) levels, which I feel like everyone knows is a thing. It turns out that the evidence for those is not super-duper strong. So that's not where you would start, at least, to make the diagnosis. What did you like for this?

Watto: One thing that stuck with me is that they basically told us that the diagnosis of sarcoidosis is made when the probability of all other considered diagnoses is low enough. And, of course, a biopsy would help. But it can be a tricky diagnosis. And you made a comment that stuck with me. You said that writing "sarcoidosis" is like the bloodstain on Lady Macbeth's hands; it's impossible to remove from the patient's chart.

Now, some patients have symptoms at some point and then it never goes anywhere, and others have progressive symptoms. In primary care, if you're suspecting sarcoidosis, we talked about a good initial workup.

Pearls for Sarcoidosis. Infographic by Edison Jyang. Courtesy of The Curbsiders.

Sarcoidosis is a multisystem disease, so you have to ask about a lot of different things, like uveitis. Get an eye exam. Ask about palpitations, which is something that I had never really considered. If my patient has palpitations or has passed out, I should consider sarcoma in the differential and get an EKG. Ask about skin symptoms and pulmonary symptoms. Patients can have bone findings, so check 125(OH)vitamin D, 25(OH)vitamin D, and calcium levels. There's also neurosarcoidosis, and people can even have psychiatric symptoms. You really have to do a complete review of systems and get some basic testing. You don't have to jump right to high-res CT on everybody.

Williams: These experts work in a sarcoidosis clinic, and because sarcoidosis is a multisystem disease and affects so many organs in so many different ways, they have templated progress notes. They do structured interviews to elicit all of the potential diagnoses and things that this condition can affect, because it's so protean in its manifestations.

Watto: They have multidisciplinary teams to help them because it can get pretty confusing and hard to manage. So, if you have someone with this diagnosis and it's active, they should be followed by a specialist or at a specialized center if possible. High-res CTs are probably within the realm of an internist, but not necessarily for the first-line test. Things like cardiac MRIs and full-body PET scans I would probably leave to the specialists.

Williams: That's right, if only to avoid the prior-authorization fight. For that reason alone, referral is probably wise.

Watto: Another thing that we talked about was treatment. For a steroid starting dose, they gave a range of 20 mg-40 mg, which is a pretty wide range. And the taper is just over several months, so there's a lot of room for interpretation there.

Paul, you see people with sarcoidosis on steroids. What's the endgame? What was your takeaway from that as far as what Dr Boltax told us?

Williams: In terms of the endgame, we're trying to prevent disease progression, but let's be honest with ourselves: As internists, we're very rarely going to be managing the steroid dose alone. Our role is more in monitoring the sequelae of chronic steroid therapy. Sometimes that may be managed by the specialists and sometimes it may take a backseat to managing the active symptoms.

One thing we discussed is when to initiate prophylaxis for pneumocystis pneumonia in someone on chronic steroids. Should we be thinking about that? The answer is yes. If the patient is on a dose of prednisone > 30 mg for longer than 4 weeks, that might be time to start thinking about trimethoprim-sulfamethoxazole for pneumocystis prophylaxis for these patients. That was a nice reminder that we sometimes have to manage the therapies as well as the disease.

Watto: Absolutely. So watch their bone health, blood sugar, cataracts — all that stuff for chronic steroids. Dr Bolton said that he tries to get people below 10 mg of steroids daily. Some people can get by on 5 mg or less daily. If he can't get the patient below 10 mg, he starts adjunctive therapy such as methotrexate and some of the other immunomodulatory drugs.

Typically in primary care, we're just monitoring for the side effects of those meds. We're not going to be pulling the trigger ourselves on starting them. We had a really extensive discussion, even getting into the weeds on all things sarcoid with these two fantastic experts. If you'd like to hear the full episode and check out the show notes, click on Episode #256: Sarcoidosis with Drs. Boltax and Scholand.

And you can also join our mailing list and get a PDF copy of our show notes every week.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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