Juvenile rheumatoid arthritis or childhood sarcoidosis?
Dudar A, Chaaban S, Lazar M, and Ouellette D. Juvenile rheumatoid arthritis or childhood sarcoidosis? Chest 2017; 152(4):A930.
Sarcoidosis (SC), a systemic disease that is characterized pathologically by non-caseating granulomas (NCG), has many different manifestations. The lungs and the lymphatic system are commonly involved by the disease process. Arthritis is present in 15-25% of patients with sarcoidosis. Co-existence of SC and Juvenile Rheumatoid Arthritis (JRA) is rare. CASE PRESENTATION: A 44 year old male with past medical history significant for morbid obesity and JRA presented to the pulmonary clinic with abnormal radiographic findings after being seen in the Emergency Department for chest pain. A chest radiograph had findings suggestive of paratracheal and hilar adenopathy. A computed tomography (CT) of the chest was ordered revealing multiple pulmonary nodules up to 8 mm in diameter, and enlarged hilar, subcarinal and paratracheal lymph nodes (LN). The patient reported that he had consulted with a rheumatologist regarding his JRA, and had been treated with various nonsteroidal anti-inflammatory drugs (NSAIDs), but not anti-tumor necrosis alpha (anti-TNF) inhibitors. On presentation to our clinic the patient reported no joint pain, though records described reports of previous bilateral ankle pain. Prior ankle radiographs demonstrated enthesitis of the Achilles tendon. The patient was referred for bronchoscopy for sampling of the LN. Pathology from all sampled mediastinal LN were positive for NCG suggestive of SC. DISCUSSION: The incidence of SC in children is reported to be rare, though this might be attributed to lack of clinical recognition. The earliest signs of SC in children are chronic arthritis and uveitis rather than respiratory complaints. The arthritis that develops in adolescent to pre-adolescent children can have a presentation similar to rheumatoid arthritis (RA). Early identification of uveitis may direct clinicians to the correct diagnosis. Symmetrical ankle arthritis had the highest diagnostic value when attempting to differentiate between SC arthritis and other types of arthritis. Anti-TNF-alpha inhibitors when used in the treatment of RA may lead to a syndrome similar to systemic SC by an unknown pathophysiologic mechanism. CONCLUSIONS: We speculate that our patient did not have both JRA and SC during his childhood, but rather had SC that masqueraded as JRA. SC was diagnosed during adulthood when findings were identified on chest CT leading to a bronchoscopy with biopsies.