Value of conjunctival biopsy in the diagnosis of sarcoidosis

PURPOSE: Retrospective study concerning the value of conjunctival biopsy in the diagnosis of sarcoidosis. PATIENTS AND METHODS: Between 1990 and 1996 we performed conjunctival biopsy in 11 patients (mean age 42.7 +/- 16.4 years) with suspect of sarcoidosis. RESULTS: In 8 of the 11 patients the diagnosis of sarcoidosis was established during the clinical course. In four of these eight patients conjunctival biopsy was positive. Five of the eight were under systemic steroids at the time of biopsy. Of the four patients with clinically established sarcoidosis and negative biopsy, three were under systemic steroids at the time of biopsy. In two patients diagnosis of sarcoidosis was established primarily by conjunctival biopsy. CONCLUSION: Conjunctival biopsy is a simple tool in the diagnostic of sarcoidosis. If possible, biopsy should be undertaken before systemic steroid treatment. We consider conjunctival biopsy to be useful as the first diagnostic tool before other invasive methods.     

Optic nerve enlargement and chronic visual loss

We present four patients with sarcoidosis of the anterior visual pathways. The first patient presented with unilateral visual loss, a mass lesion at the optic nerve head, and an enlarged orbital optic nerve. The second patient presented with bilateral progressive painless visual loss, associated with optic nerve pallor and visual field loss. In these two patients, optic nerve biopsy was diagnostic of sarcoidosis. The third patient developed optic nerve and chiasmal involvement after sarcoidosis was established by lacrimal gland biopsy. The fourth pateint had optic nerve, pulmonary, and lymph node involvement with sarcoidosis. A conjunctival and lung biopsy were diagnostic. Computed tomography and magnetic resonance imaging have greatly facilitated diagnosis of sarcoidosis of the anterior visual pathways. Sarcoidosis of the anterior visual pathways may occur alone or in association with other ocular or systemic manifestations. A conjunctival or lacrimal gland biopsy may be preferable as the initial diagnostic approach. Treatment of patients with this condition may require systemic immunosuppression, in addition to corticosteroids, to prevent permanent visual loss.     

Diagnostic value of bronchoalveolar lavage in ocular sarcoidosis

Bronchoalveolar lavage (BAL) is an investigation which has already proven its value in the diagnosis and follow-up of patients with pulmonary sarcoidosis. It also appears to be a valuable contribution to the diagnosis of patients presenting with ocular sarcoidosis. We evaluated the findings in BAL in 16 cases with suspected ocular sarcoidosis (14 cases of uveitis, one with eyelid-swelling and one with an inflammatory process of the lacrimal gland). BAL was positive in 11 cases e.g. showed a lymphocytosis with predominantly T4+ helper lymphocytes. There was one patient with ocular signs very suspect for sarcoidosis (a perivasculitis with candle wax infiltrates) with a normal percentage T lymphocytes (2%) in BAL. In two cases BAL was positive and showed a subclinical alveolitis, whereas no changes were seen on the chest X-ray and in Angiotensin Converting Enzyme (ACE) level.     

Conjunctival Biopsy as an Aid in the Evaluation of the Patient with Suspected Sarcoidosis

Conjunctival biopsy is an underused but simple technique in the evaluation of the patient with sarcoidosis and occasionally other systemic diseases. In 55% of patients with biopsy-proven sarcoidosis from other sites, a blind conjunctival biopsy was positive. Bilateral conjunctival biopsies and the examination of multiple sections of each biopsy were essential to obtain this high of a yield. There was no relationship between an anterior uveitis and a positive conjunctival biopsy.     

Conjunctival deposits as an initial manifestation of sarcoidosis.

PURPOSE: To report conjunctival deposits as an initial manifestation of sarcoidosis. METHODS: Case reports. RESULTS: Two patients with bilateral bulbar conjunctival white deposits underwent conjunctival biopsy. The biopsy specimens showed noncaseating granulomas with prominent Schaumann bodies. Serum angiotensin-converting enzyme levels were increased in both patients. The first patient had abnormal results of pulmonary function tests. Sarcoidosis was diagnosed in both patients. CONCLUSIONS: Conjunctival deposits may represent the initial clinical manifestation of sarcoidosis.     

Gallium67 citrate scanning in patients with lacrimal gland and conjunctival sarcoidosis. A report on three cases

Gallium citrate Ga67 scanning of the head and thorax of 3 patients with sarcoidosis is presented. Two patients had a progressive pulmonary sarcoidosis of recent onset and in one patient, with a chronic course of the disease, the lung changes had resolved. All 3 patients had a conjunctival sarcoid change confirmed by biopsy and a lacrimal gland affection suggested by clinical examination. A highly increased Ga67 uptake in the lacrimal and parotid glands as well as in the nasopharynx was found in all patients, and an increased lung uptake was found in the newly detected cases. It is concluded that gallium scanning is a sensitive method for detecting minute ophthalmic changes in sarcoidosis. It also reveals chronic localized ocular affection in cases in which the lung changes are no longer detectable. The mechanism and specificity of gallium uptake in sarcoidosis is also discussed.     

Chest computerized tomography in the evaluation of uveitis in elderly women

PURPOSE: To describe the usefulness of chest computerized tomography (CT) in the evaluation of uveitis in elderly women and the clinical characteristics of patients with an abnormal chest CT scan. DESIGN: Prospective noncomparative case series. METHODS: We evaluated 30 elderly women, aged 61-83 years, with chronic iritis, vitritis, or choroiditis and with no definitive cause for their uveitis. All patients underwent a battery of diagnostic laboratory studies and chest CT. RESULTS: The diagnostic examination in most patients included serum angiotensin converting enzyme level, serum lysozyme, rapid plasma reagin level, fluorescent treponemal antibody-absorption test, purified protein derivative skin test, and chest x-rays. Chest CT performed on all patients showed parenchymal, mediastinal, and/or hilar adenopathy in 17 patients (57%). Histopathologic confirmation of sarcoidosis with noncaseating granulomas in the biopsy specimens was obtained in 14 patients: eight by mediastinoscopy, two by bronchoscopy, two by conjunctival biopsy, one by nasal biopsy, and one by vitreous biopsy. CONCLUSIONS: Chest CT can be useful in elderly female patients with chronic uveitis for identifying mediastinal lymphadenopathy and other lesions suggestive of sarcoidosis, as well as to help guide tissue confirmation and to rule out other diagnoses including lymphoma.     

Conjunctival non-caseating granulomas in a human immunodeficiency virus (HIV) positive patient attributed to sarcoidosis

PURPOSE: To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. DESIGN: Case report. METHODS: A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. RESULTS: A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. CONCLUSIONS: HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.     

Fuchs' heterochromic uveitis and sarcoidosis.

AIMS/BACKGROUND--The aetiology of Fuchs' heterochromic uveitis (FHU) is unknown although it can occur in combination with a number of different ocular conditions. Five patients with FHU who show an association with sarcoidosis were studied. METHODS--Four patients with clinical signs compatible with FHU who had elevated serum angiotensin converting enzyme levels (sACE), and a fifth case with a normal sACE and a positive Kveim test were described. RESULTS--All five cases had iris nodules, two later developed mutton fat keratic precipitates, and one had peripheral retinal periphlebitis. Of the four cases with elevated sACE, one had respiratory function test abnormalities and an abnormal chest x ray compatible with pulmonary sarcoidosis. Another had a chorioretinal scar and developed intermediate uveitis 2 years after presentation. CONCLUSIONS--In all of these cases a diagnosis of FHU may represent a specific secondary ocular response to sarcoidosis rather than a primary idiopathic uveitis syndrome. Although FHU remains a clinical diagnosis, routine uveitis investigations should still be performed in this group of patients.     

Conjunctival biopsy in the diagnosis of ocular sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that can affect almost every organ in the body, particularly the lungs, skin, eyes, and thoracic lymph nodes. A definitive diagnosis of sarcoidosis requires that a biopsy be performed. A specimen can be obtained from any affected ocular structure, including conjunctiva, lacrimal gland, eyelid skin, and orbit. Among them, conjunctival biopsy has been suggested as a sensible and safe procedure for confirming suspected sarcoidosis. We describe three patients in whom ocular symptoms were the sole initial manifestations of sarcoidosis and who were diagnosed based on the results of a conjunctival biopsy. We also discuss the efficacy of and indications for conjunctival biopsy.     

Ophthalmologic peculiarities of sarcoidosis

The present paper deals with the frequency of different ophthalmic sarcoid changes and their morphological and photographic characteristics. In addition, the diagnostic value of conjunctival biopsy is evaluated. The findings were based on repeated ophthalmological examinations of an unselected group of 281 patients with histologically confirmed sarcoidosis. Conjunctival (37/218) and lacrimal gland (33/254) changes were encountered more often than sarcoid uveitis (22/281), and a conjunctival granuloma was the most frequent single sarcoid ophthalmic finding. Sarcoid changes in the eyes and the adnexae were often characterized by a scarcity of symptoms and a typical outward appearance. In some cases of sarcoid uveitis fluorescein angiography revealed in the iris and the retina nodules which showed features suggesting the proliferative nature of the disease. The iris infrared transillumination technique illustrated the affinity of sarcoid nodules in the pupillary area. Conjunctival biopsy showed epithelioid cell granulomas compatible with sarcoidosis in nearly half of the patients in whom it was suspected in a slit-lamp examination of the conjunctivae. In the diagnosis of sarcoidosis, conjunctival biopsy is a procedure to be recommended before more demanding methods are tried.     

Granulomatous Conjunctivitis Secondary to Treponema pallidum

A 41-year-old black man presented with bilateral iritis, conjunctivitis, and pulmonary and dermatologic manifestations, which were initially thought to be secondary to sarcoidosis. The patient’s serology was markedly positive and the definitive diagnosis of secondary syphilis was established by the identification of spirochetes consistent with Treponema pallidum in a conjunctival biopsy.     

Sarcoidosis presenting with facial palsy and uveitis

A 43-year-old woman presented with peripheral facial palsy and bilateral anterior uveitis. The diagnosis of sarcoidosis was established by an elevated serum angiotensin-converting enzyme level, hilar adenopathy on chest x-ray film, restrictive ventilatory impairment on pulmonary function testing, and a transbronchial biopsy specimen showing noncaseating epithelioid granulomas with Langhans giant cells. A complete ophthalmic examination is important in patients with peripheral facial palsies to search for signs of systemic disease. Presented at the 91st Annual Scientific Assembly of the Southern Medical Association, Charlotte, N.C., November 8, 1997. The views in this article are those of the authors and do not reflect the official policy or position of the U.S. Department of the Air Force, the U.S. Department of Defense, or the U.S. Govemment.     

Conjunctival Non-Caseating Granulomas in a Human Immunodeficiency Virus (HIV) Positive Patient Attributed to Sarcoidosis

Purpose: To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. Design: Case report. Methods: A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. Results: A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. Conclusions: HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.     

Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease with an unknown etiology, characterized by the presence of noncaseating granulomas in involved organs. It has a worldwide prevalence, but variable incidence among different geographical regions. The disease affects adults between 20 and 40 years of age, and it is slightly more common in women than men. Sarcoidosis is 3 to 4 times more prevalent in US blacks than whites. It usually presents with bilateral hilar adenopathy, pulmonary infiltrates and skin or eye involvement. The eye or adnexa are affected in 25 to 80% of the sarcoidosis patients. The disease can involve the orbit, lacrimal gland, anterior and posterior segments of the eye. Typical sarcoid uveitis presents with bilateral mutton-fat keratic precipitates, cells, flare, iris nodules, anterior and posterior synechia, and increased ocular pressure. Posterior involvement includes vitreitis, vasculitis, choroidal lesions, and optic neuropathy. Long term complications are common, and cystoid macular edema is the most important and sight-threatening consequence. Laboratory tests for the diagnosis of sarcoidosis include chest radiography or CT scan, bronchoscopy with bronchoalveolar lavage, angiotensin converting enzyme (ACE), Lysozyme, serum and urinary calcium, gallium scintigraphy, and biopsy. The only confirmatory test is biopsy showing classic noncaseating granulomas. Oral corticosteroids are the mainstay of treatment of sarcoidosis. Systemic cytotoxic agents like methrotrexate, azathioprine, and chlorambucil may be used in refractory cases. The visual prognosis of sarcoidosis is usually good.     

Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease with an unknown etiology, characterized by the presence of noncaseating granulomas in involved organs. It has a worldwide prevalence, but variable incidence among different geographical regions. The disease affects adults between 20 and 40 years of age, and it is slightly more common in women than men. Sarcoidosis is 3 to 4 times more prevalent in US blacks than whites. It usually presents with bilateral hilar adenopathy, pulmonary infiltrates and skin or eye involvement. The eye or adnexa are affected in 25 to 80% of the sarcoidosis patients. The disease can involve the orbit, lacrimal gland, anterior and posterior segments of the eye. Typical sarcoid uveitis presents with bilateral mutton-fat keratic precipitates, cells, flare, iris nodules, anterior and posterior synechia, and increased ocular pressure. Posterior involvement includes vitreitis, vasculitis, choroidal lesions, and optic neuropathy. Long term complications are common, and cystoid macular edema is the most important and sight-threatening consequence. Laboratory tests for the diagnosis of sarcoidosis include chest radiography or CT scan, bronchoscopy with bronchoalveolar lavage, angiotensin converting enzyme (ACE), Lysozyme, serum and urinary calcium, gallium scintigraphy, and biopsy. The only confirmatory test is biopsy showing classic noncaseating granulomas. Oral corticosteroids are the mainstay of treatment of sarcoidosis. Systemic cytotoxic agents like methrotrexate, azathioprine, and chlorambucil may be used in refractory cases. The visual prognosis of sarcoidosis is usually good.     

Conjunctival lymphocytic infiltrates associated with Epstein-Barr virus

PURPOSE: To describe the clinicopathologic features of two patients with Epstein-Barr virus (EBV) associated conjunctival lymphocytic infiltrates. DESIGN: Two case reports. METHODS: The clinical histories and pathologic findings of two patients with salmon-colored conjunctival infiltrates are described. MAIN OUTCOME MEASUREMENTS: Clinical observation and pathologic examination of conjunctival biopsy specimens with accompanying immunohistochemical staining, flow cytometric immunophenotyping, and polymerase chain reaction analysis when appropriate. RESULTS: One patient had ipsilateral preauricular lymphadenopathy, elevated serum EBV titers, and a unilateral reactive lymphocytic infiltrate resulting in a conjunctival mass. The other patient had bilateral conjunctival lymphocytic infiltrates causing conjunctival masses. There was an expanded clonal population of B lymphocytes in the conjunctival mass in the second patient. Both patients had EBV antigen in their conjunctival lymphocytic infiltrates. CONCLUSIONS: Conjunctival lymphocytic lesions associated with EBV represent a spectrum of reactive infiltrates to monoclonal populations.     

Ocular sarcoidosis in Kuwait with a review of literature

Objective: To study 18 cases of sarcoidosis, the hall mark of which was uveitis. Setting: Referrals from peripheral eye clinics. Patients: 18 patients with bilateral almost symmetric uveitis, negative Mantoux test and positive gallium scan were enrolled in the study. Preliminary bronchoscopy and bronchial lavage were not done due to social habits. Results: Age ranged between 7–48 years with median 15 and mean 19 years. Although the patients were multinational, yet all of them were residents of Kuwait. A father and son were affected within 8 months period. 78% were strictly ocular, associated pulmonary and salivary gland affection 11% each. Sole anterior uveitis was found in 28%,associated with intermediate uveitis in 55% and with posterior in16.6% of cases. Clinically detectable dry eyes associated 33% of cases. All our patients developed glaucoma which resolved with treatment of uveitis in 88% of them. Gallium uptake of the eye balls was found in 22%, of the lacrimal glands (panda sign) in 67%, and of the salivary glands or chest 11% each. Positive biopsy was found in 72%, 22% of which was conjunctival. Chest X-ray and SACE were positive in 11%.61% had hypergammaglobulinaemia and all had negative ANA and RF. Conclusions: (1) 61% of ocular sarcoidosis presented below sarcoid age. (2) Multinationality together with father‘s and son‘s affection indicate aclimatic or environmental insult in an already predisposed person. (3) Routine chest X-ray and SACE may not be adequate for diagnosis of ocular sarcoidosis. Gallium should be done in suspected cases. (4)Follow-up for prospects is emphasized. This revised version was published online in July 2006 with corrections to the Cover Date.     

Retinal cotton-wool spots as the first sign of systemic sarcoidosis.

Isolated retinal cotton-spots have not yet been reported as the sign of ocular sarcoidosis. We describe three patients with retinal cotton-wool spots of initially unknown etiology in whom systemic sarcoidosis was diagnosed 6-16 months later. The diagnosis was confirmed by conjunctival biopsy. These observations indicate that sarcoidosis should be included in the differential diagnosis of retinal cotton-wool spots and patients with these lesions should be followed for the development of this disease.     

Conjunctival sarcoidosis

A biopsy from the lower conjunctival fornix, whether or not taken from follicles, is a method which yields a positive result in ± 25% of cases of suspected sarcoidosis. We saw a patient with chronic recurrent follicular conjunctivitis of the upper eyelid, without further ocular symptoms. He was known to suffer from allergy and chronic respiratory disease. As the conjunctivitis did not improve a biopsy was taken from the conjunctiva of the upper eyelid. The specimen showed non-necrotizing epithelioid-cell granulomata with multinucleate giant cells and asteroid bodies, and an increase in reticular fibres. The diagnosis of sarcoidosis was confirmed by finding parabronchial granulomata and a raised level of angiotensin-converting enzyme in the serum.Prolonged local corticoid therapy then gradually cleared up the conjunctival condition.