pneumo stagiu sarcoidoza
TRANSCRIPT
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SARCOIDOZADEFINIIE:
- Granulomatoz multisistemic
- Cauz necunoscut
- Aduli tineri- Limfadenopatie hilar, infiltrat pulmonar i leziuni
cutanate i oculare
- Histologic - granulomul epitelioid necazeificat
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EPIDEMIOLOGIE
Prevalena 1 - 40 / 100.000 locuitoriAfecteaz n special vrsta 20-40 aniHeterogenitate epidemiologic prevalen i severitateMai frecventa n nordul Europei i la negrii americani
(1,15 % la suedezi i 2,4% la negrii americani)Afecteaz aproximatic egal ambele sexe
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ETIOLOGIE
Susceptibilitate genetic a gazdei(genotipul sarcoidozei)
Expunere la diferiiageni din mediu
SarcoidozFenotip clinic
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Etiologiefactori de mediu
Ageni infecioiVirui (herpes, Epstein-Barr, retrovirus,coxsackie B, cytomegalovirus)Borrelia burgdorferiPropionibacterium acnesM. tuberculosisMycoplasmaRickettsia
Substane anorganiceAluminiu
ZirconiuTalc
Substane organicePolen de pinRini
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Etiologiefactori genetici
Risc geneticpoligenicpredispoziie, clinic, evoluie,prognostic
Evoluie favorabil sindrom Lofgren
CW7DR3HLA-B8
Evoluie cronicHLAB13
Risc familial
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Celule T, Macrofage
Factori de cretereFactori chemoatractani
Proliferare celularGranulom
Fibroz
FIZIOPATOLOGIE
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MORFOPATOLOGIE
Alveolita - infiltraia peretelui alveolar predominant macrofage i limfocite T
Secundar neutrofile, eozinofile, bazofile, mastocite etc.
Granulom epitelioid necazeificat
Aglomerare de celule epitelioide pe fondul unei reele dereticulin care la periferie prezint o coroan de limfocite.
Prezena de celule gigante care conin incluziuni citoplasmatice(corpi Schauman):
Corpi asteroiziCorpi conchoizi
Corpi birefringenti
Granulomul nespecifictuberculoz, lepr, sifilis,bruceloz
Fibroza
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Sarcoid Granuloma
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Sarcoidosis Lung Gross
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LANGHANS' GIANT CELL
Langhans' giant cell in center of granuloma is
surrounded by epithelioid cells .
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ADVANCED COLLAGENOUS FIBROSIS
Elongated fibroblasts (FB) with extensive
collagenous tissue (C). Giant cells (arrows)
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CYTOPLASMIC INCLUSION BODY
Schaumann body (arrow) is common in
sarcoidosis but is nonspecific.
CASEOUS NECROSIS
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CASEOUS NECROSIS
Cellular destruction in TB granuloma appears
as clumped debris (arrows). This necrosis
does not occur in sarcoidosis.
M t b l i BACILLI
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M. tuberculos isBACILLI
Caseous necrosis is most common in TB, but
Gram negative, acid fast bacilli must be
identified to make the diagnosis.
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SUBPLEURAL GRANULOMA IN LUNG
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MECANISM IMUNOLOGIC
Deprimarea imunitii de tip celular
IDR la PPD
Exacerbarea imunitii de tip umoral Hipergammaglobulinemie, complexe imune circulante
Limfopenie absolut
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MANIFESTRI CLINICE
Simptomatologie de debut
50% asimptomatic
Simptomatologie general nespecific Simptomatologie dependent de organ
(polimorfism simptomatic)
30% debut acut
- Sindrom Lofgren
- Sindrom Heerfordt
- Sindrom Miculicz-Sjogren
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FORME CLINICE PARTICULARE
Sindrom Lofgren:
- adenopatie hilara bilaterala
- febra
- poliartralgii
- eritem nodos
Sindrom Heerfordt:
- febr- uveita (iridociclita)
- parotidit
- paralizie nerv facial
- Sindrom Miculicz-Sjogren:
- keratoconjunctivita uscat
- hiposecreie salivar, gastric, pancreatic- poliartrit cronic- eczeme.
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Simptomatologie
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Afectare organic
Organ %
Adenopatii mediastinale 95-98%
Plmni >90%
Ficat 50-80%Splin 40-80%
Ochi 20-80%
Adenopatii periferice 30%Cutanate 25%
Sistem nervos 10%
Cardiovascular 5%
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Simptomatologie
Pulmonar
90%
dispnea, tuse seac, dureri toracice difuze
Renal Nefrit interstiial,insuficien renal,
nefrocalcinozMetabolism
fosfocalcic
Hipercalcemie, hipercalciurie
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Neurologic
10%
Paralizii de nervi cranieni, convulsii, meningitgranulomatoas, leziuni hipotalamus sau hipofiz,hidrocefalie, polineuropatie periferic i afectare
psihiatricOcular
20%
Uveit, chorioretinit, keratoconjunctivit,glaucom, cataract, orbire
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Cardiac
5%
Palpitaii, sincop, durere toracic, aritmii, moartesubit cardiac
Endocrine Hipo/hipertiroidism, insuficien adrenalExocrin Tumefacia glandelor parotide, keratoconjunctivita
sicca
Hepatic Hepatalgii, hepatomegalie
Limfatic Limfadenopatii, splenomegalie
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Cutanate
25%
Eritem nodos, eritem polimorf sau vasculitic,
lupus pernio, noduli subcutanai,erupiemaculopapular, alopecie, hiper/hipopigmentare
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EN Lupus Pernio
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LUPUS PERNIO
Facial lesions are most common, but the
extremities and buttocks can be involved.
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LUPUS PERNIO
Indurated and violaceous range from a few
small lesions to large lesions
SMALL NODULES
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SMALL NODULES
Papules and nodular lesions, can be found
anywhere on the body. Papules are often
multiple while nodules are often solitary.
RAISED PLAQUES
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RAISED PLAQUES
These raised plaques are the result of
coalescence of nodules.
PSORIASIS LIKE LESIONS
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PSORIASIS LIKE LESIONS
These small white lesions closely
resemble psoriasis.
EARLY COLLAGEN FORMATION
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EARLY COLLAGEN FORMATION
Extracellular collagen (C) is being produced
by fibroblasts
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Adenopatii
Localizri adenopatii centrale:
Mediastinal 100 %
Hilar bilateral 75 %Adenopatii periferice: laterocervical i supraclavicular,epitrohleari, axilari, inghinali
Ganglionii sunt mobili, nedureroi, cu diametru variabil,
nu ulcereaz, nu fistulizeazSplenomegaliarar, poate cauza hiperslenism
E l d bil t l hil i ht t h l
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Enlarged bilateral hilar, right paratracheal
(arrow), and aortopulmonary window
(arrowhead) nodes.
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PARACARDIAC LYMPH NODE
ABDOMINAL LYMPHADENOPATHY
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ABDOMINAL LYMPHADENOPATHY
Multiple enlarged paraaortic, paracaval, and
porta hepatis lymph nodes (arrows).
GASTRIC SARCOID
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GASTRIC SARCOID
Granuloma involves the gastric antrum leading
to irregular nonspecific narrowing.
COLONIC SARCOID
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Irregular narrowing of the rectosigmoid has the
appearance of inflammatory disease or
malignancy.
PUNCHED OUT LYTIC LESIONS
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PUNCHED OUT LYTIC LESIONS
Focal osteolytic lesions in the fingers are most
common abnormality.
LACY TRABECULAR PATTERN
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LACY TRABECULAR PATTERN
Osteolysis has left a lacy trabecular pattern in
this phalanx (arrow)
DEFORMING LESIONS
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Advanced sarcoidosis with osteolytic lesions
of the distal forearm, wrist, and bones of the
hand
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SCLEROTIC LESION
Rare and often in the axial skeleton.
SCLEROTIC LESIONS,
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NONSPECIFIC
Focal sclerosis (arrows) of distal phalanges is
unusual
NASAL BONE LESION
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NASAL BONE LESION
Nasal sarcoidosis can lead to osteolysis of the
nasal bone (arrows).
T2-W MR IMAGE
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T2-W MR IMAGE
High signal intensity edema surrounding
biopsy proven sarcoid lesion.
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I Adenopatie hilar bilateral iparatraheal
55-90%
remisie
II Adenopatie mediastinal culeziuni ale parenchimului
pulmonar
40-70%
III Modificri parenchimul pulmonarfr adenopatii
10-20%
IV Fibroz pulmonar 0-5%
ASPECTE RADIOLOGICE
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Stadiile 14
Limfadenopatii +Infiltrate
infiltrate Fibroz
Stages
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Stages
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Stadiu I Stadiu II
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Tip 1
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Tip 1
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Tip 2
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Tip 2
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Stadiu III Stadiu IV
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Tip 3
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Atipice: - nodular-infiltrative
- pseudotumorale
- atelectazii
- caverne
ASPECTE RADIOLOGICE
STAGE IV
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STAGE IV
Broad bands of fibrosis in the upper lobes.
MILIARY SARCOIDOSIS
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CT shows well defined lung nodules less than
5mm in diameter. This pattern is rare.
ALVEOLAR SARCOIDOSIS
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Multiple lung masses are an unusual form of
sarcoidosis, resembles lung metastases.
ALVEOLAR SARCOIDOSIS
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Computed tomography shows a mass which
has air containing bronchi (arrows) within it.
CAVITARY SARCOIDOSIS
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Rare pattern of multiple cavitary sarcoid lung
lesions. Note lymphadenopathy.
RETICULONODULAR PATTERN
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Common appearance of sarcoidosis involving
the lung parenchyma.
RETICULONODULAR PATTERN CLOSEUP
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Well defined linear and nodular densities
characteristic of lung interstitial disease.
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NODULAR PATTERN
Small 5mm nodules are subpleural along fissures and
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Small 5mm nodules are subpleural, along fissures and
bronchovascular bundles. Give the vessels (arrow) and
fissures a beaded appearance.
SUBPLEURAL NODULES
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Cluster of small nodules looks like a tumor on
a radiograph.
MOST COMMON PATTERN
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Bilateral symmetric hilar and right paratracheal
mediastinal adenopathy.
LYMPHADENOPATHY ON CTPara-aortic and retrocaval lymphadenopathy
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Para-aortic and retrocaval lymphadenopathy.
CT shows enlarged lymph nodes not visible on
radiographs.
POSTERIOR MEDIASTINAL LYMPH NODE
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next to the aorta (A). Bilateral hilar adenopathy
was also shown.
STAGE IV
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STAGE IV
Permanent lung fibrosis. (20%)
ADENOPATHY AT TIME OF DIAGNOSIS
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Marked enlarged hilar and mediastinal lymph
nodes.
ADENOPATHY DECREASED 2 YRS LATER
L h d ll d th i
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Lymph nodes are smaller and there is
parenchymal lung disease.
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Aspecte funcionale
Corelaie imperfect cu aspectul clinico-radiologic Anomalii predominant de tip restrictiv
Tulburri ale transferului gazos Sindromul obstructiv distal 30-40 % din stadiile I si II Anomalii diverse la 74 % din pacieni n stadiul I
MODIFICARI BRONHOSCOPICE
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MODIFICARI BRONHOSCOPICE
ASPECTE
PATOLOGICE:
capilaritate crescut
proliferri de mucoas
stenoze bronice
granulaii sidefii-glbui
compresii extrinseci
TEHNICISUPLIMENTARE
Prelevri bioptice demucoasPuncia-biopsie
transbronicLavajul bronho-alveolar
ASPECT NORMAL LA 50 % DIN CAZURI !!
(Discordan ntre modificrile bronhoscopice i aspectul radiologic)
L j b h l l
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Lavaj bronhoalveolar
Alveolit limfocitarlimfocitoz 80-90% din cazuri,nespecific pentru sarcoidoz
Severitatea limfocitozei
> 28% - debut acut - evoluie favorabil< 28% debut insidiosevoluie cronic
PMN>3% i eozinofile >1% markeri ai progresieiraport LTh/ LTS (CD4/CD8) > 3,5
Alveolita neutrofilicsingurul element care indicnecesitatea tratamentului
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Transbronchial Needle Aspiration (TBNA) Cytology in
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Transbronchial Needle Aspiration (TBNA) Cytology in
Sarcoidosis
Smojver-Jezek S, et al. Cytopathology 2007; 18: 3
Multinucleated giant cell
of Langhans type
Scattered epithelioid cells
and lymphocytes
Linear Real-time Endobronchial Ultrasound-guidedTransbronchial Needle Aspiration Scope
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Transbronchial Needle Aspiration Scope
Herth FJF. Eur Respir J
(BF-UC160F-OL8; Olympus Medical Systems, Tokyo,
Japan)
Endobronchial Ultrasound
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in Sarcoidosis
Wong M et al. Eur Respir J 2007; 29: 1182
Right paratracheal
LN
Vena cava
superior
Endobronchial Ultrasound
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in Sarcoidosis
Wong M et al. Eur Respir J 2007; 29: 1182
Needle
BIOCHIMIE
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BIOCHIMIE
Cresc
.-VSH, PCR, globuline- Calcemia
- Calciuria
- Proteinemia
- Lizozim
- Angiotensin convertaza
seric
Scad
- Limfocite. CD4
COMPUTER TOMOGRAFIE
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COMPUTER TOMOGRAFIE
Tomografia computerizat evaluare extindere leziuni iprognostic:
- Micronoduli bronhovasculari i subpleuralireversibilitate crescut
- Imagini n fagure de miere sau reticularefibroz-ireversibil
- Sticl matcu evoluie variabil
Confirm prezen adenopatii
Nu este necesar de rutin, doar n cazuri atipiceradiologic sau clinic.
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Scintigrafia cu galiu
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Scintigrafia cu galiu
Extinderea i distribuia leziunilor inflamatorii
Captare n celulele mononucleare
Dou aspecte distincte:
- captare n lambdagg limfatici intratoracici
- captare n pandagl parotide i lacrimale
Examenul histologic
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Examenul histologic
Test Kveimcel mai specific test pentru sarcoidoz
Biopsii
Ganglionar prin mediastinoscopie
Pulmonar
Bronic
Ganglionii periferici
Leziuni cutanate
Leziuni hepatice Sediul leziunii
Investigaii specifice afectrii de organ
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Investigaii specifice afectrii de organ
RMNafectare cerebral, muscular, osoasAngiografia cu fluorescen - vascular retinian
Scintigrafia cu Thaliu, monitorizare Holter,
angiografie coronarian afectare cardiac
Biopsie miocardic
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Biopsie miocardic
Diagnostic
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Diagnostic
Diagnostic de excludereadenopatie hilarbilateral
IDR negativ
ACS crescut
Observaie ndelungat Ansamblu concordant de semne
Scopuri: - confirmare histologic, evaluare
extindere i severitate, progresie i necesitatetratamentPrezena granulomului epitelioid necazeificat
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ETAPE DIAGNOSTIC
Anamnez i examen clinicRadiografie toracicCT
Biopsie Diagnostic de certitudinebiopsie pulmonar transbronicExplorri funcionale respiratorii, gaze
arterialeAlte teste specifice: ecg, examenoftalmologic, etc
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Kveim Test
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Kveim test, or Kveim-Siltzbach test is a skin test usedto detect sarcoidosis:
Part of spleen of person with known sarcoidosis is
injected in the skin of the patient being tested
If granulomas are found, usually 4-6 weeks latertest is positive
It is named for the Norwegian pathologist Morten Ansgar
Kveim, who first reported the test in 1941 using lymphnode tissue from sarcoidosis patients
Diagnostic diferenial
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Pulmonare Adenopatii
Tuberculoz Tuberculoz
Pneumonii atipice Micobacterii atipice
Criptococcoz Bruceloz
Aspergiloz Toxoplasmoz
Histoplasmoz
Coccidioidomicoz tumorale
Blastomiocoz
Pneumocistic carini
Micoplasma
Pneumonii de hipersensibilitate
Pneumoconioz: Limfom Non-Hodgkin
berillium, titaniu, aluminiu
Aspiraie de corp strin
Granulomatoz Wegener
Pneumonie interstiiale
PROGNOSTIC
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PROGNOSTIC
Remisie 60% din cazuriDificil de prezis
Boal cronic progresiv10-20%
Mortalitate 1-5%
Prognostic bun:
Stadiu I 80% remisie spontan
sindrom Lofgren
Asimptomatic
Europeni
Prognostic nefavorabil:
Multisistemic (>3)Ras neagr
Infiltrate pulmonare
Neurologic, cardiac, uveitcronic
Vrst > 40 ani
Lupus pernio
Hipercalcemie
AG OS C SA CO O
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DIAGNOSTIC: SARCOIDOZ
TRATM PACIENTUL?
60%: rezoluie spontan!
Tratament: motive s nu-l administrm!
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Tratament: motive s nu l administrm!
Cauza bolii necunoscutMoment optim de iniiere a terapiei greu destabilit
Vindecare spontan frecventCorticosteroizii prezint efecte secundare multiple
Recidivele dup vindecarea spontan sunt rare
Tratamentul nceput trebuie s fie de lung durat
TRATAMENT
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TRATAMENT
Corticosteroizi sistemicmanifestri cardiace, neurologice,afectare pulmonar progresiv sau n cazul hipercalcemieiPrednison = 20 - 40 mg/zi
Indicaii absolute:afectarea organelor vitale
tendina la fibrozDurata: aproximativ 1 an
Monitorizare la 3 luniCorticosteroizi topici-afectare cutanat sau oftalmic
TRATAMENT
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TRATAMENT
TRATAMENT
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TRATAMENT
TRATAMENT
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TRATAMENT
Monitorizare
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Monitorizare
ClinicRadiologic
Adesea rezorbie lezional
Uneori: imagine adenopatii inghetateFuncional
Cretere ACS = puseu evolutiv
Efecte adverse ale corticoterapiei
Alternative terapeutice la corticoterapie
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Medicament, dozaj Utilizare n sarcoidoz Efecte adverse
Metotrexat 10-25 mg/sptmn, maxim 1-2 g/an
Sarcoidoz sever, cronicMedicaie de linia II Greuri, neutropenie,
toxicitate hepatic
Azatioprin 50-200mg/zi
Fibroz pulmonarSarcoidoz sever, cronic
Medicaie de linia II
Greuri, neutropenie
Ciclofosfamid 50-150mg/zi sau 500-2000 mg
la 2 sptmni IV
Sarcoidoz refractar lacorticoterapie
Greuri, neutropenie
Hidroxiclorochin 200-400 mg/zi
Manifestricutanate,hipercalcemie,
fibroz pulmonar
Retinopatie, depozite
corneene.
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Bilateral hilar lymphadenopathy :
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A 30 - year - old man with
bilateral lymph node
enlargement and fine
reticulations in both lung fields
Judges wig appearance
Deepak D and Shah A. Indian J Radiol Imag
2001 ; 11 : 191 198
Bilateral asymmetrical hilar nodes
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A 50 - year - old man with
bilateral asymmetrical hilar
lymph nodes with lobulated
border on the right side .
Bilateral reticulonodular
opacities are also visible
Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 198
Asymmetrical mediastinal lymphadenopathy
in a 32 - year - old man with sarcoidosis
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Radiograph shows striking
asymmetric enlargement of
mediastinal lymph nodes
potato nodes
y
HRCT of the same patient shows
bilateral multiple mediastinal
lymphadenopathy
Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 198
1 - 2 - 3 sign orGarlands / pawnbrokers sign
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p g
Radiograph of 34 - year - old
man shows bilateral hilar and
right paratracheal lymph nodesenlargement ( 1 - 2 - 3 sign ).
Also visible is bilateral
parenchymal involvement with
reduced lung volumes
Deepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198
Unilateral hilar adenopathy
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Postero - anterior chest
radiograph in a 42 - year - old
man with sarcoidosis shows
a left hilar lymph node and
consolidation in right upper
and mid zones mistaken for
tuberculosis
Deepak D and Shah A . Indian J Radiol Imag2001 ; 11 : 191 - 198
Regression of lymphadenopathy and
progression of pulmonary lesion
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p g p y
Deepak D and Shah A. Ind ian J Radiol Imag2001 ; 11 : 191 198
2 years later
Bilateral hilar lymph
nodes with prominent
reticulonodular shadows
regression of the hilar lymph
nodes with calcification ( arrow )
and honeycombing
Unilateral disease
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Radiograph of 49 - year - old
woman shows predominantly
unilateral disease involving left
side with cavities ( arrows )
and features of parenchymal
fibrosis in the left upper zone
as evidenced by the pulled - up
left hilum & tracheal deviation
Deepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198
Parenchymal nodules
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CECT of a 52 - year - old
woman through the level
of left upper lobe
bronchus shows bilateral
nodular opacities
Deepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198
Reticulations
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Chest radiograph in a
40 - year - old man shows
bilateral reticulations.
Pleural thickening ( arrow )
is also seen in the left
upper zone
Deepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198
Pulmonary sarcoidosis : alveolar pattern
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areas of consolidation with
irregular borders preferentially
involving central areas
Deepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198
HRCT showing bilateral
consolidation with air
bronchogram ( arrow )
Alveolar pattern : 11 years post treatmentDeepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198
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bilateral bullous areas
pleural thickening
clearing of consolidation
HRCT :
bronchiectasis and bullae
Alveolar sarcoidosis with subpleural nodules
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HRCT of a 30 year old man
through the level of left lower
lobe bronchus showing
alveolar pattern of
involvement on the left side.
Also visible are bilateral
sub - pleural nodules (arrows)
Deepak D and Shah A. Ind ian J Radiol Imag2001; 11 : 191 198
Stage IV sarcoidosis : 50 - year - old womanDeepak D and Shah A. Indian J Radiol Imag2001; 11 : 191 198
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- beaded appearance of
bronchovascular bundles with
- perihilar concentration of
fibrosis and lobular distortion
Left side : cystic spaces & fibrosis
Pulmonary sarcoidosis :simultaneous ground glass & honeycombing
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HRCT through right lower lobe
bronchus shows :
- air bronchogram ( arrow )
- ground glass opacities
Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 - 198
HRCT through apical region :
- honeycombing on right side
Pleura : a 35 - year - old man with
a non - resolving pleural effusion
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a non resolving pleural effusion
Panjabi C et al. Indian J Tuberc2004 ; 51 ; 37 - 41
B / l mediastinal lymphadenopathy & thickening of both fissures
Merci lessly received second l ine ant i tuberculou s therapy
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Well circumscribed noncaseating granuloma consisting of
epitheloid cells and multinucleated giant cells ( H & E 100 )Panjabi C et al. Indian J Tuberc2004 ; 51 : 37 - 41
Spontaneous pneumothorax
R 2 4 %
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Chest radiograph in a
45 - year - old woman with
sarcoidosis shows
pneumothorax ( arrows )
along with b / l hilar
prominence, reticular
opacities in lower zones
Deepak D and Shah A. Indian J Radiol Imag2001 ; 11 : 191 198
Rare : 2 - 4 %
Mihailovic - Vucinic V and Jovanovic D . Clin Chest Med2008 ; 29 : 459 - 473
Sarcoidosis : miliary pattern in
a 40 - year - old man
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Deepak D and Shah A . Indian J Radiol Imag2001; 11 : 191 - 198
a 40 year old man
A 65 - year - old lady with cavitation9 months pr ior to referral
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Bilateral diffuse
non - homogeneous opacities
Bilateral hilar enlargement
Acinar pattern seen in the
right mid and lower zones
A well - defined cavitary lesion
in the anterior segment of the
right upper lobe
Panjabi C et al. Brazi l ian J Pulmonol2009 ( in press )
Aspergilloma formation in a sarcoid cavity
1 - year after commencement o f therapy for sarcoidos is
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C T in prone position
showing positional change
of the fungal ball
C T in supine position
showing fungal ball
within the cavity
Panjabi C et al. Brazi lian J Pulmono l2009 ( in press )
Mediastinal lymphadenopathy in a
35 - year - old lady
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A 35 - year - old lady
presented with a history
of dry cough , fever and
weight loss for one month
Chest X - ray showed
bilateral symmetrical
hilar lymphadenopathy
FOB done elsewhere :
inconclusive
35 year old lady
On presentation :investigated for pulmonary sarcoidosis
Spirometry : mixed obstruction with restriction
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Spirometry : mixed obstruction with restriction ,
diffusion per unit volume normal
Serum ACE : 25.7 IU / ml ( 8 52 IU / ml )
Mantoux test : 20 mm x 22 mm ( 1 TU )
Bilateral extensive
mediastinal lymphadenopathy
Bilateral ground glass haze with
right upper lobe consolidation and
peri - bronchial cuffing
Six weeks later
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Patient went out of town and
reported later with persistent
fever and productive cough
Chest X - ray revealed a cavity
in the right middle zone
All three consecutive samples for
AFB were positive
Sputum culture : positive
Bronchial aspirate culture by
BACTEC : positive
cavity
After six months of ATT
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She complained of dyspnoeaChest X- ray :
shrunken lung fields
Bilateral multiple mediastinal
lymphadenopathy
Ground glass haze