Sarcoidosis of the lungs: symptoms

The clinical symptoms of sarcoidosis of the lungs and the severity of manifestations are very diverse. It is characteristic that most patients can note a completely satisfactory general condition, despite mediastinal lymphadenopathy and a fairly extensive lung injury.

MM Ilkovich (1998), AG Khomenko (1990), IE Stepanian, LV Ozerova (1998) describe three variants of the onset of the disease: asymptomatic, gradual, acute.

The asymptomatic onset of sarcoidosis is observed in 10-15% (and according to some data in 40%) patients and is characterized by the absence of clinical symptoms. Sarcoidosis is detected accidentally, as a rule, with prophylactic fluorography and lung radiography.

The gradual onset of the disease is observed in approximately 50-60% of patients. At the same time, patients complain of such symptoms of lung sarcoidosis as: general weakness, increased fatigue, decreased efficiency, marked sweating, especially at night. Quite often there is a cough dry or with the separation of a small amount of mucous sputum. Sometimes patients notice pain in the chest, mainly in the interscapular area. As the disease progresses, shortness of breath appears during exercise, even moderate.

When examining the patient, any characteristic manifestations of the disease are not detected. In the presence of dyspnea, you can see a small cyanosis of the lips. With percussion of the lungs, it is possible to detect an increase in the roots of the lungs (percussion of the roots of the lungs, see the chapter "Pneumonia"), if there is mediastinal lymphadenopathy. Over the remaining sections of the lungs, percussion is determined by a clear pulmonary sound. Auscultatory changes in the lungs are usually absent, however, severe vesicular breathing and dry wheezing may be heard in some patients.

The acute onset of sarcoidosis (acute form) is observed in 10-20% of patients. For the acute form of sarcoidosis, the following main symptoms are characteristic:

• short-term increase in body temperature (within 4-6 days);
• joint pain (mostly large, most often ankle) migrating;
• dyspnea;
• pain in the chest;
• dry cough (in 40-45% of patients);
• decreased body weight;
• an increase in peripheral lymph nodes (in half of patients), and the lymph nodes are painless, not soldered to the skin;
• mediastinal lymphadenopathy (more often bilateral);
• nodosum erythema (according to MMIlkovich - in 66% of patients). Nodular erythema is an allergic vasculitis. It is localized mainly in the region of the shins, thighs, extensor surface of the forearm, however it can appear in any part of the body;
• Löfgren's syndrome - simtomocompuls, including mediastinal lymphadenopathy, fever, erythema nodosum, arthralgia, increased ESR. Lefgren's syndrome occurs mainly in women under 30;
• Heerford-Valdenstrem syndrome - a symptom complex including mediastinal lymphadenopathy, fever, parotitis, anterior uveitis, facial nerve paresis;
• dry wheezes with auscultation of the lungs (in connection with the lesion of the bronchi by the sarcoidosis process). In 70-80% of cases, the acute form of sarcoidosis ends with the reverse development of the symptoms of the disease, i.e. Almost comes recovery.

The subacute onset of sarcoidosis has, in general, the same signs as acute, but the symptoms of lung sarcoidosis are less pronounced and the timing of the onset of symptoms is more prolonged in time.

And yet the most characteristic for sarcoidosis of the lungs is the primary chronic course (in 80-90% of cases). Such a form for a while can be asymptomatic, hidden or manifested only not by an intense cough. Over time, dyspnea appears (with dissemination of the pulmonary process and bronchial injury), as well as extrapulmonary manifestations of sarcoidosis

With auscultation of the lungs dry scattered wheezing, hard breathing are heard. However, with this course of the disease in half of patients, the reverse development of symptoms and almost recovery are possible.

The most unfavorable prognostic attitude is the secondary chronic form of respiratory sarcoidosis, which develops due to the transformation of the acute course of the disease. The secondary chronic form of sarcoidosis is characterized by the developed symptomatology - pulmonary and extrapulmonary manifestations, the development of respiratory insufficiency and complications.

[1], [2], [3], [4], [5]

Lymph node involvement in sarcoidosis

The first place in the frequency is the lesion of the intrathoracic nodes - mediastinal lymphadenopathy - 80-100% of cases. The predominantly radical bronchopulmonary, tracheal, upper and lower tracheobronchial lymph nodes increase. Less marked increase in the anterior and posterior lymph nodes of the mediastinum.

Patients with sarcoidosis also increase peripheral lymph nodes (25% of cases) - cervical, supraclavicular, less often - axillary, ulnar and inguinal. The enlarged lymph nodes are painless, not soldered to each other and to the underlying tissues, of a dense elastic consistency, they never ulcerate, do not overtake, do not disintegrate or form a fistula.

In rare cases, damage to peripheral lymph nodes is accompanied by damage to the tonsils, the hard palate, the tongue - dense nodules appear with hyperemia along the periphery. It is possible to develop sarcoidosis with multiple granulomas on the gums.

The defeat of the bronchopulmonary system in sarcoidosis

Lungs are involved in the pathological process in sarcoidosis quite often (in 70-90% of cases). In the early stages of the disease, changes in the lungs begin with the alveoli - alveolitis develops, alveolar macrophages accumulate in the alveolar lumen, lymphocytes infiltrate, interalveolar septa infiltrate. Further granulomas are formed in the parenchyma of the lungs, and in the chronic stage there is marked development of fibrous tissue.

Clinically, the initial stages of lung injury may not be manifested in any way. As the pathological process progresses, cough appears (dry or with a small discharge of mucous sputum), pain in the chest, shortness of breath. Dyspnea becomes particularly pronounced in the development of fibrosis and pulmonary emphysema, accompanied by a significant weakening of vesicular breathing

Bronchi are also affected in sarcoidosis, sarcoid granulomas are subepithelial. Involvement of the bronchi is manifested by a cough with the separation of a small amount of sputum, scattered by dry, rarely small bubbling rales.

The defeat of the pleura is manifested by a clinic of dry or exudative pleurisy (see "Pleurisy"). Often, pleurisy is an inter-partisal, parietal and can be detected only with radiographic examination. In many patients, pleurisy is not clinically manifested, and only with pulmonary radiography it is possible to find a local thickening of the pleura (pleural layers), pleural adhesions, and interlobar cords - the consequence of the transferred pleurisy. In pleural effusion, there are usually many lymphocytes.

The defeat of the digestive system in sarcoidosis

The involvement of the liver in the pathological process in sarcoidosis is often observed (according to various data in 50-90% of patients). The patients are disturbed by a feeling of heaviness and fullness in the right hypochondrium, dryness and bitterness in the mouth. Jaundice does not usually happen. When palpation of the abdomen is determined by the increase in the liver, the consistency of it can be dense, the surface is smooth. The functional capacity of the liver, as a rule, is not disturbed. The diagnosis is confirmed by puncture liver biopsy.

The defeat of other organs of the digestive system is considered a very rare manifestation of sarcoidosis. There are indications in the literature about the possibility of affecting the stomach, duodenum, ileocecal section of the small intestine, sigmoid colon. The clinical symptomatology of the defeat of these organs does not have any specific signs and it is possible to reliably recognize the sarcoidosis of these parts of the digestive system only on the basis of a complex examination and histological examination of biopsy specimens.

A typical manifestation of sarcoidosis is the defeat of the parotid gland, which is expressed in its increase and soreness.

Spleen involvement in sarcoidosis

The involvement of the spleen in the pathological process in sarcoidosis is observed quite often (in 50-70% of patients). However, there is usually no significant increase in the spleen. Often, the enlargement of the spleen can be detected by ultrasound, sometimes the spleen is palpable. A significant increase in the spleen is accompanied by leukopenia, thrombocytopenia, hemolytic anemia.

Heart involvement in sarcoidosis

The incidence of heart failure in sarcoidosis varies according to the data of different authors from 8 to 60%. The defeat of the heart is observed in systemic sarcoidosis. All the membranes of the heart can be involved in the pathological process, but most often the myocardium is observed sarcoid infiltration, granulomatosis, and then fibrotic changes. The process can be focal and diffuse. Focal changes may manifest electrocardiographic signs of transmural myocardial infarction with the subsequent formation of an aneurysm of the left ventricle. Diffuse granulomatosis leads to the development of severe cardiomyopathy with dilatation of the heart cavities, which is confirmed by ultrasound. If sarcau granulomas are localized mainly in papillary muscles, mitral valve insufficiency develops.

Quite often, with the help of ultrasound of the heart, an effusion is found in the pericardial cavity.

In the majority of patients with sarcoidosis, intravital heart damage is not recognized, as it is usually taken for the manifestation of any other diseases.

The main symptoms of heart failure in sarcoidosis are:

• shortness of breath and pain in the heart with moderate physical activity;
• feeling of palpitations and irregularities in the heart;
• frequent, arrhythmic pulse, decreased pulse filling;
• widening the border of the heart to the left;
• deafness of heart sounds, often arrhythmias, most often extrasystoles, systolic murmur in the apex of the heart;
• the appearance of acrocyanosis, edema on the legs, the increase and soreness of the liver with the development of circulatory insufficiency (with severe diffuse myocardial damage);
• ECG changes in the form of a decrease in the T wave in many leads, various arrhythmias, most often extrasystoles, cases of atrial fibrillation and flutter, various degrees of atrioventricular conduction disturbance, block blocking of the bundle's legs; in some cases, ECG-signs of myocardial infarction are revealed.

To diagnose the heart lesions in sarcoidosis, use ECG, echocardiography, heart scintigraphy with radioactive galium or thallium, in rare situations - even lifetime ekdomiokardialnuyu biopsy. Intravital biopsy of the myocardium allows revealing epithelioid-cell granulomas. The cases of detection of extensive Rubtsovy areas in the myocardium during a sectional study in sarcoidosis with heart damage are described.

The defeat of the heart can be the cause of death (severe violations of heart rhythm, asystole, circulatory insufficiency).

Μ. Μ. Ilkovich (1998) reports on individual observations of obstruction of the femoral artery, upper vena cava, pulmonary artery, and the formation of an aortic aneurysm.

Kidney damage in sarcoidosis

Involving the kidneys in the pathological process in sarcoidosis of the kidneys is a rare situation. Only isolated cases of development of sarcoidosis glomerulonephritis are described. As mentioned earlier, sarcoidosis is characterized by hypercalcemia, which is accompanied by calcicuria and the development of nephrocalcinosis - the deposition of calcium crystals in the renal parenchyma. Nephrocalcinosis may be accompanied by intensive proteinuria, a decrease in the reabsorption function of the renal tubules, which is manifested by a decrease in the relative density of urine. However, nephrocalcinosis develops rarely.

Changes in bone marrow in sarcoidosis

This pathology in sarcoidosis is not fully understood. There are indications that lesions of the bone marrow in sarcoidosis are observed in approximately 20% of cases. Reflection of the involvement of bone marrow in the pathological process in sarcoidosis is a change in peripheral blood - anemia, leukopenia, thrombocytopenia.

[6], [7], [8]

Changes in the osteoarticular system in sarcoidosis

Bone lesion is observed in approximately 5% of patients with sarcoidosis. Clinically, this is manifested by non-intensive pain in the bones, very often there are no clinical symptoms at all. Significantly more often bone damage is detected in radiography in the form of multiple foci of rarefaction of bone tissue, mainly in the phalanges of hands and feet, rarely in the bones of the skull, vertebrae, and long tubular bones.

Joint damage is observed in 20-50% of patients. The pathological process involves mainly large joints (arthralgia, aseptic arthritis). Deformation of the joints is extremely rare. If such a sign appears, rheumatoid arthritis should be excluded first.

[9], [10], [11], [12], [13], [14]

Lesion of skeletal musculature in sarcoidosis

The involvement of muscles in the pathological process is rare and manifests itself mainly with pain. Objective changes in skeletal musculature and a significant decrease in muscle tone and muscle usually do not. Very rarely there is severe myopathy, according to the clinical course resembling polymyositis.

The defeat of the endocrine system in sarcoidosis

Significant violations of the endocrine system in sarcoidosis, as a rule, no. An increase in the thyroid gland with phenomena of hyperthyroidism, a decrease in sexual function in men, menstrual cycle disorders in women are described. Very rarely there is a deficiency of the adrenal cortex. There is an opinion that pregnancy can lead to reduction of symptoms of lung sarcoidosis and even recovery. However, after the delivery, a resumption of the clinic for sarcoidosis is possible.

The defeat of the nervous system in sarcoidosis

The most common is peripheral neuropathy, manifested by a decrease in sensitivity in the region of the feet and legs, a decrease in tendon reflexes, a feeling of paresthesia, and a decrease in muscle strength. Mononeuritis of individual nerves can also occur.

A rare, but severe complication of sarcoidosis is the defeat of the central nervous system. There is sarcoidosis of meningitis, manifested by headaches, neck stiffness, positive Kernig symptom. The diagnosis of meningitis is confirmed by the study of cerebrospinal fluid - characteristic increase in the content of protein, glucose, lymphocytes. It should be remembered that in many patients sarcoidosis of meningitis almost does not give clinical manifestations and the diagnosis is possible only with the help of the analysis of cerebrospinal fluid.

In some cases, the spinal cord is affected with the development of paresis of motor muscles. The defeat of the optic nerves with reduced visual acuity and limitation of the visual fields is also described.

Skin lesion in sarcoidosis

Skin changes in sarcoidosis are observed in 25-30% of patients. The acute form of sarcoidosis is characterized by the development of erythema nodosum. It is an allergic vasculitis, localized mainly in the region of the shins, rarely - the hips, extensor surfaces of the forearms. Nodular erythema is characterized by painful, reddish, never ulcerated nodes of different sizes. They arise in the subcutaneous tissue and involve the skin. Nodular erythema is characterized by a gradual change in skin color over the nodes - from red or red-violet to greenish, then yellowish. Nodular erythema disappears spontaneously after 2-4 weeks. For a long time knotty erythema was considered a manifestation of tuberculosis. Now it is considered as a nonspecific reaction, which is most often observed in sarcoidosis, as well as in tuberculosis, rheumatism, drug allergies, streptococcal infection, sometimes with malignant tumors.

In addition to erythema nodosum, true sarcoidosis of the skin can also be observed - granulomatous sarcoidosis of the skin. A characteristic feature is small or large focal erythematous plaques, sometimes it is hyperpigmented papules. On the surface of plaques can be telangiectasia. The most common localization of sarcoidosis lesions is the skin of the dorsal surfaces of the hands, feet, face and area of old scars. In the active phase of sarcoidosis skin manifestations are more pronounced and extensive, lesions bulge above the surface of the skin.

Very rarely in sarcoidosis there is an appearance in the subcutaneous tissue of dense, painless, spherical-shaped nodes from 1 to 3 cm in diameter-the sarcoid of Daria-Rousseau. In contrast to erythema nodosum, the appearance of nodes is not accompanied by skin color changes, besides the nodes are painless. Histological examination of nodes is characterized by typical changes in sarcoidosis.

Lesion of the eye in sarcoidosis

Eye damage in sarcoidosis is observed in 1/3 of all patients and is manifested by anterior and posterior uveitis (the most common type of pathology), conjunctivitis, corneal opacity, cataract development, iris changes, glaucoma development, lacrimation, photophobia, visual acuity reduction. Sometimes, eye damage gives small symptoms of sarcoidosis of the lungs. All patients with sarcoidosis must have an ophthalmological examination.