Sarcoidosis
Sarcoidosis
Definition
Sarcoidosis is a disease which can affect many organs within the body. It causes the development of granulomas. Granulomas are masses resembling little tumors. They are made up of clumps of cells from the immune system.
Description
Sarcoidosis is a very puzzling disorder. In addition to having no clear-cut understanding of the cause of sarcoidosis, researchers are also puzzled by its distribution in the world population. In the United States, for example, 10-17 times as many African-Americans are affected as white Americans. In Europe, whites are primarily affected.
Prevalence is a way of measuring the number of people affected per 100,000 people in a given population. The prevalence figures for sarcoidosis are very unusual. In the United States, prevalence figures range from five (5/100,000 in the United States) for whites to 40 for blacks. In Europe, prevalence ranges from three in Poland, to 10 in France, to 64 in Sweden, to 200 for Irish women living in London. Furthermore, a person from a group with very low prevalence who leaves his or her native land for a second location with a higher prevalence will then have the same risk as anyone living in that second location.
Sarcoidosis affects both men and women, although women are more likely to have the disorder. The average age for diagnosis is around 20-40 years.
Causes and symptoms
The cause of sarcoidosis is not known. Because the granulomas are primarily made up of cells from the immune system (macrophages and lymphocytes), an immune connection is strongly suspected. One of the theories which has been put forth suggests that exposure to some toxic or infectious material starts up an immune response. For some reason, the body is unable to stop the response, and it spreads from the original organ to other organs.
Because sarcoidosis has been noted to occur in family groups, a genetic cause has also been suggested. Research shows that identical twins are more likely to both have sarcoidosis than are nonidentical twins or other siblings.
Some cases of sarcoidosis occur without the patient even noting any symptoms. These cases are often discovered by chance during routine chest x rays. Most cases of sarcoidosis, however, begin with very nonspecific symptoms, such as decreased energy, weakness, and a dry cough. Occasionally, the cough is accompanied by some mild pain in the breastbone (sternum). Some patients note that they are having unusual shortness of breath while exercising. Some patients develop fever, decreased appetite, and weight loss.
Virtually every system of the body has the potential to suffer the effects of sarcoidosis:
- tender reddish bumps (nodules) or patches often appear on the skin
- the eyes may become red and teary, and the vision blurry
- the joints may become swollen and painful (arthritis)
- lymph nodes in the neck, armpits, and groin become enlarged and tender, lymph nodes within the chest, around the lungs, also become enlarged
- fluid may accumulate around the lungs (pleural effusion), making breathing increasingly difficult
- nasal stuffiness is common, as well as a hoarse sound to the voice
- cysts in the bone may cause pain in the hands and feet, or in other bony areas
- the bone marrow may decrease the production of all blood cells; decreased number of red blood cells causes anemia, fewer white blood cells increases the chance of infections, fewer platelets can increase the chance of bleeding
- the body's ability to process calcium often becomes abnormal, so that excess calcium passes through the kidneys and into the urine; this may cause kidney stones to form
- the liver may become enlarged
- the heart may suffer a variety of complications, including abnormal or missed beats (arrhythmias), inflammation of the covering of the heart (pericarditis ), and an increasing tendency toward weak, ineffective pumping of the blood (heart failure)
- the nervous system may display the effects of sarcoidosis by hearing loss, chronic inflammation of the coverings of the brain and spinal cord (meningitis ), abnormalities of the nerve that is involved in vision (optic nerve dysfunction), seizures, and the development of psychiatric disorders
Any, all, or even none of the above symptoms may be present in sarcoidosis.
Diagnosis
Diagnosis depends on information from a number of sources, including the patient's symptoms, the physical examination, x-ray pictures of the chest, and a number of other laboratory examinations of blood or other tissue. None of these categories of information are sufficient to make the diagnosis of sarcoidosis. There is no one test or sign or symptom which clearly points to sarcoidosis, excluding all other types of diseases. This is because nearly all of the symptoms and laboratory results in sarcoidosis also occur in other diseases. Diagnosis, then, requires careful consideration of many facts.
The physical examination in sarcoidosis may reveal the characteristic skin lesions. Wheezes may be heard throughout the lungs. The liver may be enlarged. Examination of the eyes using a special light called a slit-lamp may reveal changes indicative of sarcoidosis.
The chest x ray will show some pattern of abnormalities, which may include enlargement of the lymph nodes which drain the lung, scarring and abnormalities to the tissue of the lungs, and fluid accumulation around the lungs.
Lung function tests measure such things as the amount of air an individual can breathe in and breathe out, the speed at which the air flows in and out, and the amount of air left in the lung after blowing out as much as possible in one second. A variety of lung function tests may show abnormal results in sarcoidosis.
Other types of tests may be abnormal in sarcoidosis. The abnormal test results may also indicate other diseases. They include an elevation of a substance called angiotensin-converting enzyme in the blood, and an increased amount of calcium present in 24 hours worth of urine.
Bronchoscopy is a very helpful diagnostic test. This involves passing a tiny tube (bronchoscope) through the nose or mouth, down the trachea, and into the airways (bronchial tubes). The bronchial tubes can be inspected through the bronchoscope. The bronchoscope is also designed in such a way as to allow biopsies to be obtained. Bronchoalveolar lavage involves washing the surfaces with a sterile saltwater (saline) solution. The saline is then retrieved and examined in a laboratory. Cells and debris from within the bronchial tubes and the tiny sacs of the lung (the alveoli) will be obtained in this way, and can be studied for the presence of an abnormally large number of white blood cells. A tiny piece of the lung tissue can also be obtained through the bronchosocope. This can be studied under a microscope to look for the characteristic granulomas and inflammation of sarcoidosis.
A gallium 67 scan involves the injection of a radioactive material called gallium 67. In sarcoidosis, areas of the body which are inflamed will retain the gallium 67. These areas will then show up on the scan.
Treatment
Many cases of sarcoidosis resolve without treatment. If treatment is needed, the most effective one for sarcoidosis is the administration of steroid medications. These medications work to decrease inflammation throughout the body. The long-term use of steroid medications has serious potential side-effects. Patients are only treated with steroids when the problems caused by sarcoidosis are particularly serious. Many cases of sarcoidosis resolve without treatment.
Prognosis
The prognosis for sarcoidosis is quite good. About 60-70% of the time, sarcoidosis cures itself within a year or two. In about 20-30% of patients, permanent damage occurs to the lungs. About 15-20% of all patients go on to develop a chronic, relapsing form of sarcoidosis. Death can be blamed on sarcoidosis in about 10% of all sarcoidosis cases.
Prevention
Until researchers are able to pinpoint the cause of sarcoidosis, there will be no available recommendations for how to prevent it.
KEY TERMS
Granuloma— Masses made up of a variety of immune cells, as well as fibroblasts (cells which make up connective tissue).
Immune system— The system of specialized organs, lymph nodes, and blood cells throughout the body which work together to prevent foreign invaders (bacteria, viruses, fungi, etc.) from taking hold and growing.
Resources
PERIODICALS
Zitkus, Bruce S. "Sarcoidosis: Varied Symptoms Often Impede Diagnosis of this Multisystem Disorder." American Journal of Nursing 97, no. 10 (October 1997): 40+.
Sarcoidosis
Sarcoidosis
Sarcoidosis is an inflammatory disease with no known cause and no known cure.
Description
Sarcoidosis is a disease in which inflammatory cells (granulomas) form usually in the lungs but it can affect the heart, liver, lymph nodes, skin, and eyes. Granulomas may collect and grow larger or form groups of granulomas. Granulomas usually affect more than one organ.
During the active phase of the disease, granulomas form and grow and symptoms may develop. Scar tissue may form in the affected organ(s). Sometimes the granulomas change an organ's structure and function.
During the nonactive phase, the inflammatory response decreases and the granulomas may shrink. Scars may remain and continue to cause symptoms.
The disease may resolve spontaneously within two to three years or there may be only an occasional flare-up of symptoms. In some people, the disease may get worse and cause permanent damage.
Demographics
Women ages 20–40 are more likely to develop sarcoidosis. Sarcoidosis occurs more often in people of African or Scandinavian descent (in particular Swedes and Danes). It occurs more often in nonsmokers than in smokers. In the United States certain groups have a higher percentage of cases of sarcoidosis including health care workers, naval aircraft servicemen, and firefighters.
African Americans have a four to seventeen time chance of developing sarcoidosis compared to Caucasians. Having a brother or sister or parent with sarcoidosis increases the risk of developing the disease five fold.
Causes and symptoms
The cause of sarcoidosis is unknown. It is theorized that sarcoidosis develops when the body's immune system responds abnormally to bacteria, viruses , dust, or chemicals in the environment. Sarcoidosis may also develop as a result of overactivity of the body's immune system (autoimmune response). There may also be a genetic predisposition to developing sarcoidosis.
Many people have no symptoms. Symptoms depend on which organs are affected. The most common symptoms include shortness of breath, persistent dry cough, wheezing, and reddish bumps or rashes on the skin. Eye symptoms may include vision problems and dry eyes. Other symptoms rarely occur but may include a generalized sick feeling (malaise), loss of appetite, weight loss , and fatigue. Blacks tend to have the more severe and chronic form of the disease.
Diagnosis
Evaluation to diagnose sarcoidosis begins with a complete medical history and physical examination. Diagnostic testing may include a chest x-ray, pulmonary function testing, tissue biopsy, an eye examination , the Serum Angiotensin Converting Enzyme (S.A.C.E.) blood test, computed axial tomography (C.A.T. scan), Gallium scanning, and calcium blood and urine level testing.
Chest x-ray is used to detect the presence of enlarged lymph nodes and granulomas. Pulmonary testing using a special instrument called a spirometer evaluates lung volumes and assesses the lungs' ability to exchange oxygen and carbon dioxide. Tissue biopsy is used to obtain tissue samples to confirm a diagnosis of sarcoidosis. Tissue samples are obtained during a bronchoscopy to examine for the presence of granulomas. Bronchoscopy is an outpatient procedure during which a specially trained physician inserts a narrow tube through the nose into the lungs. Bronchoalveolar lavage may also be done during bronchoscopy. During bronchoalveolar lavage, part of the lung is washed (lavaged) then the fluid is examined for cell inflammation characteristic of sarcoidosis. If the physician suspects that other parts of the body are affected by sarcoidosis, e.g. the skin, lymph nodes, or eyes, a tissue sample for biopsy may be taken from these areas.
Eye examination is conducted by an ophthalmologist to evaluate for inflammation or damage to the eyes from sarcoidosis. If the S.A.C.E. blood test result is elevated, it may indicate the presence of sarcoidosis. This blood test may be used at periodic intervals to determine if the disease is getting worse or improving. For some people with sarcoidosis, calcium levels are elevated in the blood and urine therefore, calcium blood and urine testing may be done.
C.A.T. scanning may reveal enlarged lymph nodes and lung scarring that a chest x-ray cannot. During Gallium scanning, a small amount of radioactive material is injected into the bloodstream. The radioactive material collects in inflamed areas of the body which can help to show sarcoidosis in the lungs and other organs.
Treatment
Treatment may be unnecessary if symptoms are mild. If treatment is needed it usually consists of corticosteroids to decrease inflammation. Prednisone is the corticosteroid used most often. The length of time medication is needed is dependent on how severe the disease is and how quickly the symptoms improve. Corticosteroids can reduce symptoms, improve lung function, decrease S.A.C.E. levels, decrease granuloma formation, and may reduce lung scarring.
Corticosteroids can cause serious side effects especially when taken for an extended period of time. These side effects include osteoporosis (a disease in which bones become thin and brittle), high blood pressure , cataracts , diabetes, increased risk of infection, and weight gain with redistribution of body fat. Benefits of using corticosteroids outweigh medication side effects.
Lung function testing and chest x-ray should be done every six to twelve months. An annual eye examination and electrocardiogram (E.C.G.) are recommended.
Nutrition/Dietetic concerns
Maintain a healthy weight. It is important to eat a balanced diet and drink adequate amounts of water daily. Foods high in calcium should be avoided. Foods high in calcium include dairy products, oranges, and canned salmon with bones.
Therapy
Don't smoke. Remain physically active without overexertion. Get adequate rest. Avoid exposure to chemicals, dust, toxic fumes, and other environmental lung irritants. Get recommended follow-up testing and regular medical care. Self-help groups are available for people diagnosed with sarcoidosis. Medication should be taken as prescribed.
Prognosis
Many people diagnosed with sarcoidosis do not require treatment and improve spontaneously. Those with advanced lung disease or heart or neurological involvement have a poorer prognosis.
Prevention
Because there is no definitive cause for sarcoidosis, there is no way to prevent it.
Caregiver concerns
Regular follow-up care is vital as new symptoms may occur unexpectedly and the disease may worsen without notice. It is important to remember that sarcoidosis is not contagious.
QUESTIONS TO ASK YOUR DOCTOR
- Will I need treatment?
- What are some of the treatments that may be recommended?
- How will I know if the treatments are working?
- Are there any side effects to the treatment?
- Do I need to see a specialist?
Ensure that medication is taken as prescribed. Some medications used to treat sarcoidosis can have side effects so it is important to be aware of potential adverse effects. Report them to your health care provider as indicated.
June G. Borazjani R.N., M.S.N., C.P.H.Q.