Sarcoidosis, well you need,
well you need to do biopsy
in which tissues are
almost always required
Now, I told you about that hypertension,
what the heck is going on
To understand, lung normally houses
an enzyme called ACE, doesn't it?
In sarcoidosis, you might find an
increased serum level of your ACE
Next, there may be hypercalcemia
Every once in a while with sarcoid, you
might have a patient that has an increased
increased level of what's
known as 1-alpha hydroxylase
Dr. Raj, i think I've heard that
enzyme, of course you have.
That 1-alpha hydroxylase activates
Vitamin D, welcome to calcitriol
And that calcitriol
is going to do what?
reabsorption of calcium
welcome to hypercalcemia.
I'll tell you what you're gonna
find in tissues soon enough.
The pulmonary function
test will be restrictive,
That's where we are. So we have a
PFT definitely not less than 80
We have adenopathy, interstitial
infiltrate, what does that mean to you?
This then represents your reticular
and the caviterial disease
in severe type of cases
And looking for what is known as a
non-caseating type of granuloma
and within the non-caseating granuloma,
what are you then going to find?
You're going to find, you HAVE to find
what's known as multinucleated giant cells
In multinucleated giant cell, you then refer
to it as being Langhan's cell
Also referred to as epithelioid, I will
then go into this in further detail
And in granuloma formation, we'll
take a look at this as well
in which you will then find a particular
pattern where for the most part,
think of it as being imprisonment of whatever
antigen that might be giving rise to this
What we'll find here, on
this CT, on the right side
an arrow that's then pointing
to a lymphadenopathy
What we're looking at here upon
your biopsy of the tissue,
that arrow is showing you a horseshoe
pattern of a multinucleated giant cell
In other words, these
are fused macrophages.
Now, this is a non-caseating granuloma
if you take a look at the middle
of this granuloma. This whole thing
that you're seeing is a granuloma.
Inside the granuloma, you'd
find an epithelioid cell.
An epithelioid cell is a multinucleated
giant cell, welcome to Langhan.
a horseshoe type of pattern that
you see here, peripheral nuclei.
And well, what is it that the
T-helper1 cell is releasing
that then activates your macrophage?
Good, Interferon-Gamma, you
learned that in immunology.
That IFN-gamma is also called
the macrphage activating factor
So if you have so much of this MAF or
IFN-gamma, you're going to take these
macrophages, fuse them and form
a multinucleated giant cell.
You must, I repeat, you must find at least
3 of these multinucleated giant cell
or epithelioid cell in order for you
to diagnose or describe a granuloma
Well, what about your patient?
In terms of therapy,
well kinda difficult.
Patients with advanced disease are
treated with systemic corticosteroids
And then for those individuals
that are refractory such cases,
then you start getting
You have such drugs such as methotrexate,
leflunamide, azathioprine and anti-TNF therapy
With anti-TNF therapy, you're
always worried about what?
Good, you're worried about those
patients that may then have
what is known as reactivation TB
Think of etanercept, think of infliximab
reserved for patients with
So you really wanna be careful about
when to use such immunosuppresive agents
Really, the complications from
the medications could be worse
than the actual
disease as you know..