01Approach to the Critical Patient/attcp58

Immediate stabilization

›Respiratory failure threats

›Severe hypoxemia

›SpO2 <90% on room air or escalating oxygen requirement

›Supplemental oxygen titrated to SpO2 >92%

›Ventilatory failure

›Rising PaCO2 with fatigue

›Early intubation planning for respiratory muscle exhaustion

›If SpO2 unresponsive to high-flow oxygen, escalate to HFNC or ICU

›Exclude superimposed infection before escalating immunosuppression

›Sputum and blood cultures prior to steroid boost

›Cardiac sarcoidosis threats

›High-grade AV block

›New heart block in patient <60 years is cardiac sarcoidosis until proven otherwise

›Transcutaneous pacing readiness if hemodynamically unstable

›Ventricular tachycardia

›Monomorphic VT most common sustained arrhythmia

›Defibrillation and ACLS if pulseless VT or VF

›If new AV block or VT, emergent cardiology consultation and cardiac monitoring

›AHA 2024 Class I recommendation for ICD implantation in cardiac sarcoidosis with sustained VT

›Temporary pacing bridge if symptomatic bradycardia

›Hypercalcemic crisis

›Altered mental status with polyuria and dehydration

›Serum calcium measured urgently

›IV normal saline 1-2 L bolus as initial treatment

›If corrected calcium >3.5 mmol/l or symptomatic, escalate management

›IV bisphosphonate or calcitonin

›Hydration and loop diuretic after volume replete

02History/hx80

Presenting symptoms

›Pulmonary symptom complex

›Dyspnea

›Baseline exertional tolerance vs. current limitation

›Dyspnea present as a baseline symptom in 29% of sarcoidosis patients

›Cough

›Cough present in >90% of acute pulmonary exacerbations

›Productive vs. dry character

›Chest pain

›Pleuritic vs. pressure type

›Chest pain reported in 23% at baseline

›Cardiac symptoms

›Palpitations or irregular heartbeat

›Atrial fibrillation present in up to 32% of cardiac sarcoidosis

›Ventricular ectopy or tachycardia

›Syncope or presyncope

›High-grade AV block most common manifestation of cardiac sarcoidosis (up to 42%)

›Sudden cardiac death risk

›Orthopnea or paroxysmal nocturnal dyspnea

›Cardiac sarcoidosis with heart failure

›Pulmonary hypertension contribution

Triggers and context

›Exacerbation triggers

›Steroid taper or missed doses

›45% relapse rate within 12-18 months of stopping prednisone

›Recent dose reduction timeline

›Recent infection

›Opportunistic infection risk in immunosuppressed patients

›Superimposed bacterial pneumonia most important to exclude

›Medication changes

›Immune checkpoint inhibitors can cause sarcoid-like reactions

›Interferon and paradoxically anti-TNF agents can trigger exacerbations

›Medication history

›Current steroid dose and duration

›Adherence history

›Cumulative steroid exposure and complications

›Steroid-sparing agents

›Methotrexate, azathioprine, mycophenolate mofetil use

›Recent treatment failures or adverse reactions

›Prophylaxis status

›PJP prophylaxis with TMP-SMX

›Herpes zoster prophylaxis

Extrapulmonary symptoms review

›Neurologic symptoms

›Facial weakness or numbness

›CN VII palsy is the most common cranial nerve involvement

›Bilateral facial palsy strongly suggests sarcoidosis

›Headache, seizures, or cognitive changes

›Neurosarcoidosis in 5-15% of patients

›Leptomeningeal involvement pattern

›Ophthalmologic symptoms

›Eye pain or redness

›Anterior uveitis most common ocular manifestation

›Photophobia and blurred vision

›Visual loss

›Optic neuritis as emergency

›Glaucoma as steroid-related complication

›Dermatologic symptoms

›Skin lesions

›Erythema nodosum associated with acute Löfgren syndrome

›Lupus pernio (violaceous plaques on nose and cheeks) pathognomonic

›Renal and metabolic symptoms

›Polyuria and polydipsia

›Hypercalcemia in 3-12% of sarcoidosis patients

›Nephrolithiasis or nephrocalcinosis

›Fatigue and weight loss

›Constitutional symptoms of active disease

›Night sweats

Risk factors

›Demographic risk factors

›Age 25-45 years peak onset

›Black race: 2.4x higher mortality in Black women

›Female sex with higher rates of extrapulmonary involvement

›Adverse prognostic factors

›Age >=40 at onset

›Scadding stage III-IV at presentation

›Cardiac, neurologic, or renal organ involvement

›Genetic and family history

›First-degree relatives have 4-5x increased risk

›HLA region on chromosome 6 association

›HLA-DRB1*14 and DRB1*15 associated with adverse outcomes

›Occupational exposures

›Beryllium and silica exposure mimics sarcoidosis

›Mold exposure triggering hypersensitivity pneumonitis differential

03Physical Exam/exam70

Vital signs

›Stability assessment

›Respiratory rate

›>=24 per minute as severity marker

›Paradoxical breathing pattern

›Oxygen saturation

›Room air SpO2 baseline vs. current

›Ambulatory desaturation testing when stable

›Heart rate and rhythm

›Irregular rhythm suggesting arrhythmia

›Tachycardia as compensatory or infection marker

›Blood pressure

›Hypertension from hypercalcemia

›Hypotension suggesting advanced heart failure or sepsis

Pulmonary exam

›Lung auscultation

›Crackles

›Bilateral basilar crackles with parenchymal disease

›Diffuse vs. focal distribution

›Wheeze

›Endobronchial sarcoidosis causing obstruction

›Bronchospasm component

›Decreased breath sounds

›Pleural effusion

›Pulmonary fibrosis with volume loss

›Work of breathing

›Accessory muscle recruitment

›Scalene and sternocleidomastoid use

04Differential Diagnosis/ddx53

Life-threatening differentials

›Superimposed infection

›Bacterial pneumonia

›Most important to exclude before escalating immunosuppression

›ICD-10 J18.9 pneumonia unspecified

›Pneumocystis jirovecii pneumonia

›Immunosuppressed patients on combination therapy

›Diffuse ground-glass opacities on HRCT

›Invasive aspergillosis or aspergilloma

›Fibrocystic stage IV disease as risk factor

›Hemoptysis as presenting symptom

›Cardiac emergencies

›Cardiac sarcoidosis with complete heart block

›ICD-10 I42.5 other restrictive cardiomyopathy

›New AV block in patient <60 years is cardiac sarcoidosis until proven otherwise

›Ventricular tachycardia

›Sudden cardiac death risk in undiagnosed cardiac sarcoidosis

›Monomorphic VT most common pattern

›Sarcoidosis-associated pulmonary hypertension

›Progressive dyspnea out of proportion to parenchymal disease

›5-year mortality approximately 40% in advanced cases

›Pulmonary embolism

›ICD-10 I26.99

›Reduced mobility and active inflammation as risk factors

›Pleuritic pain and unexplained tachycardia

Sarcoidosis mimics

›Lymphoma

›Can coexist with or mimic sarcoidosis

05Laboratory Tests/lt60

Core laboratory evaluation

›Hematology

›Complete blood count with differential

›Lymphopenia common in active sarcoidosis

›Leukocytosis suggesting superimposed infection

›Eosinophilia if hypersensitivity pneumonitis in differential

›Coagulation screen when significant bleeding risk or hepatic involvement

›PT/INR with hepatic sarcoidosis

›Platelet count on methotrexate or azathioprine

›Comprehensive metabolic panel

›Serum calcium

›Hypercalcemia in 3-12% of sarcoidosis patients

›Granulomatous 1-alpha hydroxylase converts vitamin D to active form

›Renal function

›Nephrocalcinosis and renal sarcoidosis

›Drug dosing adjustment input for immunosuppressants

›Liver function tests

›Transaminitis with hepatic sarcoidosis

›Methotrexate hepatotoxicity monitoring (hepatotoxicity in ~25%)

Sarcoidosis-specific markers

›ACE level

›Elevated in 50-60% of active sarcoidosis

›Low sensitivity and specificity for diagnosis

›More useful for monitoring treatment response than diagnosis

›Limitations

›ACE inhibitor therapy causes false-negative results

›Elevated in diabetes, liver disease, hypothyroidism

›Soluble IL-2 receptor (sIL-2R)

06Diagnostic Tests/dt97

Scoring Systems

›Scadding staging system

›Stage 0: Normal chest radiograph

›Extrapulmonary disease possible

›26% spontaneous remission

›Stage I: Bilateral hilar lymphadenopathy alone

›60-90% spontaneous remission rate

›Favorable prognosis

›Stage II: Bilateral hilar lymphadenopathy plus pulmonary infiltrates

›40-70% spontaneous remission

›Intermediate prognosis

›Stage III: Pulmonary infiltrates without hilar lymphadenopathy

›10-20% spontaneous remission

›Poor prognosis

›Stage IV: Pulmonary fibrosis

›Irreversible disease

›Highest morbidity and mortality

›Disease severity assessment

›Organ involvement count

›Cardiac involvement dramatically worsens prognosis

›Neurologic involvement associated with persistent disability

›Pulmonary function test severity stratification

›FVC <50% predicted as severe disease threshold

›DLCO <40% predicted as severe impairment

MRI

›Cardiac MRI

›Gold standard for cardiac sarcoidosis

›Late gadolinium enhancement (LGE) identifies myocardial fibrosis and active inflammation

›Sensitivity 75-100% for cardiac sarcoidosis diagnosis

›Findings in cardiac sarcoidosis

›Patchy LGE in basal septum and lateral wall

›Mid-wall and epicardial enhancement pattern

›Myocardial wall motion abnormalities

›Clinical indications

›Unexplained AV block or bundle branch block in patient <60 years

›Sustained ventricular arrhythmia

›Unexplained cardiomyopathy

›AHA 2024 Class I recommendation for cardiac MRI in suspected cardiac sarcoidosis

›Preferred over echocardiography alone for tissue characterization

›Follow-up imaging for treatment response assessment

›Brain MRI with gadolinium

›Indications for neurosarcoidosis

›New cranial nerve palsies

›Seizures, altered mental status, or cognitive decline

›Leptomeningeal enhancement pattern on T1 post-contrast

›Findings

›Pachymeningeal or leptomeningeal enhancement

›White matter lesions

›Hypothalamic or pituitary involvement

›Spine MRI if myelopathy suspected

›Cervical or thoracic cord lesions

›Cauda equina involvement

CT

›HRCT chest

›Primary imaging for pulmonary sarcoidosis assessment

›Perilymphatic nodules along bronchovascular bundles pathognomonic pattern

›Upper and middle lobe predominance

›Active disease findings

›Ground-glass opacities indicating active inflammation

›Consolidation in alveolar sarcoidosis

›Enlarged mediastinal and hilar lymph nodes

›Chronic and fibrotic findings

›Traction bronchiectasis

›Honeycombing and architectural distortion (Stage IV)

›Conglomerate perihilar masses

›Comparison with prior imaging essential

›New ground-glass opacities suggest active inflammation amenable to steroids

›Fibrotic changes indicate irreversible disease

›FDG-PET/CT

›Most effective for detecting tissue-specific inflammatory activity

›Identifies metabolically active granulomas

›Useful in refractory disease to find biopsy targets

›Clinical applications

›Cardiac sarcoidosis when MRI contraindicated

›Monitoring treatment response

›Identifying extrapulmonary involvement

›AHA 2024 Class I recommendation for FDG-PET/CT in suspected cardiac sarcoidosis when MRI unavailable or contraindicated

›High sensitivity for active myocardial inflammation

›18F-FDG cardiac protocol requires cardiac preparation diet

Ultrasound

›Echocardiography

›Initial cardiac evaluation in all sarcoidosis exacerbations with cardiac symptoms

›LV systolic and diastolic function

›RV size and function for pulmonary hypertension

›Findings in cardiac sarcoidosis

›Wall motion abnormalities not following coronary distribution

›Septal thinning or thickening

›Pericardial effusion

›Pulmonary hypertension assessment

›Elevated RVSP estimation from tricuspid regurgitation jet

›RV dilation and septal flattening

›Point-of-care ultrasound

›Lung assessment

›Pleural effusion detection

›B-line pattern from interstitial disease

›Volume status assessment

›IVC collapsibility for fluid responsiveness

›Integration with clinical exam required

›ACEP Level B recommendation for point-of-care cardiac ultrasound in undifferentiated dyspnea

›Rapid LV function assessment

›Pericardial effusion screen

07Disposition/dispo54

Admission criteria

›Inpatient admission required

›Respiratory criteria

›SpO2 <92% on room air or escalating oxygen requirement

›Significant exertional desaturation

›Cardiac criteria

›New AV block or bundle branch block

›Sustained or symptomatic arrhythmia

›Suspected cardiac sarcoidosis decompensation

›Metabolic and systemic criteria

›Symptomatic hypercalcemia

›Acute kidney injury related to sarcoidosis or hypercalcemia

›High-grade fever with immunosuppression requiring IV antibiotics

›Neurologic criteria

›New cranial nerve palsies

›Seizures or altered mental status

›ICU level care

›Ventilatory support requirement

›Intubation or HFNC with rising oxygen needs

›Hemodynamic instability requiring vasopressors

›Life-threatening arrhythmia

›Complete heart block requiring pacing

›Refractory VT requiring electrophysiology intervention

›Severe hypercalcemia with neurologic involvement

›Calcium >3.5 mmol/l with altered mental status

›Acute kidney injury with oliguria

Discharge criteria

›Safe discharge parameters

08Treatment/t98

Initial stabilization

›Supportive care

›Oxygen supplementation

›Titrate to SpO2 >92%

›HFNC for moderate to severe hypoxemia not responding to conventional oxygen

›IV access and continuous monitoring

›If hemodynamically unstable or arrhythmia suspected

›12-lead ECG on arrival for all cardiac symptom presentations

›Hydration for hypercalcemia

›IV normal saline 1-2 L bolus

›Reassess calcium and renal function after hydration

Corticosteroids

›Acute exacerbation management

›Prednisone oral 20-40 mg/day

›Standard first-line treatment for acute pulmonary exacerbation

›Duration 2-6 weeks initial course

›Taper over 6-18 months based on clinical and radiographic response

›Methylprednisolone IV for severe or inpatient cases

›0.5-1 mg/kg/day IV in divided doses

›Transition to oral prednisone when clinical improvement

›Löfgren syndrome

›NSAIDs first-line for arthritis and erythema nodosum

›Naproxen 500 mg PO twice daily or ibuprofen 400-600 mg PO three times daily

›NEJM 2025 RCT showed methotrexate comparable efficacy to prednisone as first-line therapy

›Different side-effect profile may favor methotrexate in selected patients

›Shared decision-making regarding steroid vs. methotrexate initiation

Steroid-sparing agents

›Second-line immunosuppression

›Methotrexate

›5-25 mg per week orally or subcutaneously

›Folic acid 1 mg daily to reduce toxicity

›LFTs and CBC monitoring monthly initially

›Hepatotoxicity in approximately 25% with long-term use

›Azathioprine

›50-200 mg per day orally

›TPMT genotyping before initiation to assess metabolizer status

›CBC monitoring for myelosuppression

›Mycophenolate mofetil

›500-3000 mg per day in divided doses

›GI side effects common dose-limiting

›Teratogenic: contraception required

›Leflunomide

›10-20 mg per day orally

›Hepatotoxicity and hypertension monitoring

›Long half-life requiring cholestyramine washout if discontinued

Biologic therapy

›Third-line anti-TNF therapy for refractory disease

›Infliximab IV

›3-5 mg/kg IV at weeks 0 and 2, then every 4-8 weeks

›Class IIb recommendation for refractory pulmonary sarcoidosis

›Screening for TB and hepatitis B before initiation

›Adalimumab SC

›40 mg subcutaneously every 1-2 weeks

›Alternative if infliximab intolerance

›Biologic safety monitoring program required

›Anti-TNF agents caution in bronchiectasis

›Increased risk of acute worsening events

›Aspergilloma risk assessment before initiation

›Hydroxychloroquine

›200-400 mg per day orally

›Useful for cutaneous sarcoidosis and hypercalcemia

›Some neurosarcoidosis indications

›Annual ophthalmologic monitoring for retinopathy

Complication-specific treatment

›Hypercalcemia management

›IV normal saline hydration

›1-2 L bolus, then guided by urine output and symptoms

›Loop diuretic (furosemide 20-40 mg IV) after volume replete

›Calcitonin

›4 units/kg IM or SC every 12 hours

›Rapid onset within hours

›Tachyphylaxis limits use beyond 48 hours

›Bisphosphonates

›Zoledronic acid 4 mg IV over 15 minutes

›Onset 2-4 days

›Renal function assessment before use

›Hydroxychloroquine or chloroquine for granulomatous hypercalcemia

›Inhibits 1-alpha hydroxylase in macrophages

›Adjunct to steroid therapy

›Cardiac sarcoidosis management

›Corticosteroids for active myocardial inflammation

›Prednisone 0.5 mg/kg/day initial dose

›FDG-PET or cardiac MRI to guide response

›ICD implantation

›AHA 2024 Class I recommendation for sustained VT or VF

›Class IIa recommendation for LVEF <35%

›Pacemaker implantation

›Symptomatic high-grade AV block

›Transcutaneous pacing bridge in ED setting

›Pulmonary hypertension treatment

›PDE-5 inhibitors

›Sildenafil 20 mg PO three times daily

›Tadalafil 40 mg PO daily

›Prostacyclin analogues for WHO Group 5 PH assessment

›Specialist rheumatology and pulmonology guidance

›Right heart catheterization required before initiation

›Infection prophylaxis

›TMP-SMX for PJP prophylaxis on combination immunosuppression

›TMP-SMX single strength daily or double strength three times weekly

›Dapsone 100 mg daily as alternative if sulfa allergy

›Herpes zoster prophylaxis

›Consider acyclovir 400 mg PO twice daily on high-dose steroids

›Varicella zoster vaccination before immunosuppression if non-immune

09Special Populations/sp58

Pregnancy

›Sarcoidosis in pregnancy

›Disease course variability

›Many patients improve during pregnancy due to elevated cortisol

›Postpartum flare risk increased in first 3 months after delivery

›Medication safety

›Prednisone generally safe in pregnancy at lowest effective dose

›Methotrexate absolutely contraindicated (teratogenic, category X)

›Mycophenolate mofetil contraindicated (teratogenic)

›Hydroxychloroquine considered safe throughout pregnancy

›Monitoring and imaging

›Chest X-ray with abdominal shielding when clinically indicated

›MRI without gadolinium preferred over CT when possible

›Gadolinium crosses placenta, avoid unless essential

›Delivery considerations

›SpO2 target >=95% for fetal oxygenation

›Steroid stress dosing if on chronic steroids peripartum

›Neonatal adrenal suppression awareness if high-dose steroid exposure

›Hypercalcemia in pregnancy

›Increased risk with granulomatous disease

›Avoid high calcium and vitamin D supplementation

›Hydration and corticosteroids safe first-line management

Geriatric

›Sarcoidosis in older adults

›Atypical presentation

›Fatigue and weight loss may predominate over respiratory symptoms

›Cardiac manifestations more common in older patients

›Higher comorbidity burden masking sarcoidosis diagnosis

10Background/b78

Epidemiology

›Incidence and prevalence

›Incidence 5-40 per 100,000 depending on population and geography

›Higher rates in Scandinavian countries (64 per 100,000 in Sweden)

›African Americans: 35-80 per 100,000 (3x higher than White Americans)

›Peak age of onset 25-45 years

›Second smaller peak in women aged 50-65 years

›Rare before age 15 years

›Sex distribution

›Slight female predominance overall

›Black women have 2.4x higher mortality than White women

›Mortality and prognosis

›Overall 5-year mortality approximately 7%

›>60% of deaths attributable to advanced cardiopulmonary disease

›Cardiac sarcoidosis with pulmonary hypertension: ~40% 5-year mortality

›Spontaneous remission rates by Scadding stage

›Stage I: 60-90% remission

›Stage II: 40-70% remission

›Stage III-IV: <20% remission

›Exacerbation frequency

›73% of patients with sarcoidosis-associated pulmonary fibrosis report >=2 acute worsening events per year

›Relapse rate 13-75% depending on stage and population

›45% relapse within 12-18 months of stopping prednisone

Pathophysiology

›Granuloma formation

›Trigger antigens

›Environmental antigens including mycobacterial antigens and organic dusts

›Genetic susceptibility determines individual response to antigenic exposure

›Immune activation cascade

›Antigen presenting cells activate CD4+ T-helper lymphocytes

›Th1-polarized immune response with IFN-gamma and TNF-alpha production

›Macrophage activation and epithelioid cell transformation

›Noncaseating granuloma structure

›Epithelioid macrophages and giant cells

›Surrounding CD4+ T lymphocytes

›Central zone lacks caseating necrosis (distinguishes from tuberculosis)

›Organ-specific pathophysiology

›Pulmonary involvement

›Perilymphatic distribution along bronchovascular bundles

›Airway involvement causes obstruction and wheeze

›Fibrosis pathway leads to irreversible Stage IV disease

›Cardiac involvement

›Patchy granulomatous infiltration of myocardium

›Conduction system involvement causing AV block and bundle branch blocks

›Ventricular scarring as substrate for reentrant tachycardia

›Hypercalcemia mechanism

›Macrophages within granulomas express 1-alpha hydroxylase

›Unregulated conversion of 25-OH vitamin D to 1,25-dihydroxyvitamin D

›Increased intestinal calcium absorption and bone resorption

Therapeutic Considerations

›Corticosteroid therapy principles

›Indications for treatment

›Symptomatic pulmonary disease with functional impairment

›Cardiac, neurologic, ocular, or renal organ involvement

›Hypercalcemia unresponsive to conservative measures

›Dose and duration evidence

›Initial dose 20-40 mg prednisone daily

›Duration 6-24 months; shorter courses associated with higher relapse rates

›Taper guided by symptoms, PFTs, and imaging response

›Steroid-related complications

›Mean weight gain +5 kg at 24 weeks on prednisone

›Diabetes, osteoporosis, cataracts, hypertension, psychiatric effects

›Preventive strategies: bone protection, glucose monitoring, BP control

›Steroid-sparing strategy

›Indications

›Steroid dependence (unable to taper below 10 mg/day without relapse)

›Steroid toxicity requiring dose reduction

›Steroid-refractory disease

›Agent selection considerations

›Methotrexate: best evidence and NEJM 2025 RCT data for first-line equivalence

›Azathioprine: alternative with different toxicity profile

›Mycophenolate: preferred in renal sarcoidosis or post-transplant settings

›Refractory disease approach

›Biologic therapy consideration

›Anti-TNF agents (infliximab, adalimumab) have evidence for refractory disease

›Third-line after failure of two steroid-sparing agents

›Screening for opportunistic infection before initiation

›Lung transplant

›Stage IV with FVC <50% predicted or 6MWT <250 meters

›Sarcoidosis recurrence in transplanted lung reported

›Referral to transplant center when approaching end-stage criteria

11Patient Discharge Instructions/pdi39

copy discharge instructions

›Sarcoidosis exacerbation home care

›Take all medications exactly as prescribed

›Do not stop or reduce steroids without physician guidance

›Stopping steroids suddenly is dangerous

›Steroid precautions

›Take prednisone in the morning with food to minimize GI upset

›Monitor blood sugar if diabetic or on higher doses

›Avoid close contact with people who are sick

›Activity and rest

›Pace activities to breathing tolerance

›Rest if short of breath

›Avoid strenuous activity until cleared by physician

›Return to emergency department immediately for

›Breathing difficulty at rest or sudden severe shortness of breath

›Chest pain

›Fainting, blackout, or severe lightheadedness

›Racing or irregular heartbeat

›New weakness or numbness in face or extremities

›Sudden vision change or eye pain

›Confusion, new severe headache, or seizure

›Fever above 38.5 degrees Celsius

›Excessive thirst, urination, or confusion (signs of high calcium)

›Follow-up instructions

›Pulmonologist appointment within 1-2 weeks

›Bring list of all current medications

›Steroid taper schedule to be reviewed at this visit

›Repeat blood tests as directed

12References/r27

Guidelines and key sources

›Society guidelines

›American Thoracic Society Clinical Practice Guideline: Diagnosis and Detection of Sarcoidosis (AJRCCM 2020)

›Crouser ED, Maier LA, Wilson KC, et al.

›Evidence-based diagnostic recommendations

›AHA Scientific Statement: Diagnosis and Management of Cardiac Sarcoidosis (Circulation 2024)

›Cheng RK, Kittleson MM, Beavers CJ, et al.

›Class I/IIa/IIb recommendations for cardiac sarcoidosis management

›JACC State-of-the-Art Review: Challenges in Cardiac and Pulmonary Sarcoidosis (JACC 2020)

›Trivieri MG, Spagnolo P, Birnie D, et al.

Landmark trials and reviews

›Key clinical evidence

›Kahlmann V, et al. First-Line Treatment of Pulmonary Sarcoidosis with Prednisone or Methotrexate. NEJM 2025

›RCT demonstrating comparable efficacy of methotrexate and prednisone as first-line therapy

›Supports shared decision-making for initial steroid-sparing strategy

›Drent M, Crouser ED, Grunewald J. Challenges of Sarcoidosis and Its Management. NEJM 2021

›Comprehensive review of treatment challenges and relapse rates

›45% relapse within 12-18 months of stopping prednisone

›Belperio JA, Shaikh F, Abtin FG, et al. Diagnosis and Treatment of Pulmonary Sarcoidosis: A Review. JAMA 2022

›ACE utility, Scadding staging, and BAL CD4:CD8 ratio evidence

›Spagnolo P, Rossi G, Trisolini R, et al. Pulmonary Sarcoidosis. Lancet Respir Med 2018

›Epidemiology, pathophysiology, and treatment ladder review

Coding standards

›Diagnostic codes

›ICD-10 D86.0 Sarcoidosis of lung

›D86.1 Sarcoidosis of lymph nodes

›D86.85 Sarcoid myocarditis

›D86.82 Multiple cranial nerve palsies in sarcoidosis

Evidence & Review