Version May 2024
INTRODUCTION — Sarcoidosis, a multisystem disorder of unknown etiology, is characterized pathologically by the presence of noncaseating granulomas in affected organs (see "Pathology and pathogenesis of sarcoidosis"). It typically affects young adults, and, although any organ may be affected, the disorder commonly presents with one or more of the following three abnormalities:
●Bilateral hilar adenopathy
●Pulmonary infiltrates
●Skin and/or eye lesions
Musculoskeletal disease is a less common problem. However, joint manifestations may be clinically significant in patients with acute disease, such as acute arthritis with hilar lymphadenopathy and/or erythema nodosum [1]. Chronic arthritis and other musculoskeletal manifestations may also occur.
The articular manifestations of sarcoidosis and the diagnosis, differential diagnosis, and treatment of sarcoid arthropathy will be reviewed here. General issues related to sarcoidosis and its pathogenesis, as well as the muscular, skeletal, and other rheumatic manifestations of sarcoidosis, including discussions of diagnosis and treatment, are discussed separately. (See "Clinical manifestations and diagnosis of sarcoidosis" and "Pathology and pathogenesis of sarcoidosis" and "Sarcoid myopathy" and "Sarcoidosis of bone".)
CLINICAL MANIFESTATIONS
Frequency of musculoskeletal sarcoid — Approximately 10 to 15 percent of patients with sarcoidosis have an associated arthropathy [1]. One or more musculoskeletal manifestations, including arthropathy, bone lesions, muscular disease, and vasculitis, have been estimated to be present in up to 38 percent of patients with sarcoidosis [2]. However, the true incidence and prevalence are unclear since the diagnosis may be difficult when a patient presents with articular complaints alone; in this setting, the presence of sarcoidosis is established only after more commonly involved organs, such as the eye or lung, become affected.
Acute arthritis and Lofgren syndrome — Acute sarcoid arthritis presents most often as part of Lofgren syndrome, which is characterized by the triad of hilar adenopathy, acute arthritis, and erythema nodosum; the acute form of arthritis occurs less commonly in isolation or with parenchymal lung involvement. The acute polyarthritis most commonly involves ankles (>90 percent), often bilaterally, followed by other larger joints of lower extremity, and may be mistaken for a reactive arthritis [3]. The arthritis is mostly oligoarticular (87 percent), and involvement is typically symmetrical (76 percent) [3].
Lofgren syndrome is seen in less than 5 to 10 percent of sarcoidosis and is usually self-limiting [1,4,5]. The erythema nodosum typically disappears in a few months, but the joint symptoms may persist up to two years. Approximately one-third of patients have a more persistent arthritis [6]; rarely, the arthritic symptoms are recurrent [6]. A large retrospective study showed articular involvement, including isolated ankle involvement, and fever are more frequent in Lofgren compared with non-Lofgren sarcoidosis [7].
Joint involvement in Lofgren syndrome is the most common presentation of acute sarcoid arthritis. It most commonly presents as arthritis and/or periarthritis involving both ankles [8]. Hilar lymphadenopathy in these patients tends to resolve over time in up to 90 percent of patients, with only few reporting worsening of lung disease or lymphadenopathy [3]. Erythema nodosum is more often seen in female compared with male patients presenting with Lofgren syndrome [9]. Reports of seasonal clusters of this syndrome suggest that an infectious or environmental agent, as yet unknown, may be pathogenetically important [3,9].
Among a group of patients with arthritis of less than two years' duration, the prevalence of sarcoidosis was 4.4 percent [3]. In a prospective study of 189 patients presenting with symptoms suggestive of reactive arthritis, 17 (9 percent) were eventually diagnosed with acute sarcoid arthritis [10]. Ten had Lofgren syndrome, and all 17 had bilateral ankle involvement. A prospective cohort study of patients with recent-onset arthritis found that the presence of symptoms for less than two months, symmetrical ankle arthritis, and age less than 40 years had a high sensitivity (85 percent) and specificity (99 percent) for sarcoid arthritis [3]. Hence, the next step in the evaluation of a young adult presenting with acute, bilateral, ankle arthritis with or without tender red nodules on the shin is a chest radiograph to look for hilar lymphadenopathy. (See 'Diagnosis' below.)
Occasionally, isolated involvement of the small joints of the hands may mimic the acute onset of rheumatoid arthritis [6,11]. Among such patients, the diagnosis of acute sarcoid arthritis is most frequently made in retrospect when other, more common features of the disease become apparent. Sarcoid arthritis can resemble rheumatic fever when the polyarthritis is migratory [11,12]. Therefore, acute sarcoidosis should be in differential for any young patient presenting with acute symmetric oligo- or polyarthritis. Young children presenting with both uveitis and arthritis may resemble patients with juvenile idiopathic arthritis [13].
Hilar adenopathy is uncommon in sarcoidosis in early childhood. Arthritis, however, is a prominent feature that is accompanied by uveitis and rash [8]. When this syndrome appears in the first decade of life (usually before age four), it may represent early-onset sarcoidosis, a sporadic form of Blau syndrome. (See "Autoinflammatory diseases mediated by NFkB and/or aberrant TNF activity", section on 'Blau syndrome'.)
Approximately 15 percent of patients with Lofgren syndrome have elevated angiotensin-converting enzyme (ACE) levels at presentation, and those with elevated ACE levels may tend to have a more persistent arthritis [14]. This presentation is associated with an increased prevalence of certain human leukocyte antigen (HLA)-DR and DQ alleles (DQ2 and DR3) [3,15] (see "Erythema nodosum"). Acute arthritis sometime presents with a rare (1 to 2 percent) febrile arthropathy in association with enlarged parotid glands, facial nerve palsy, and uveitis called uveoparotid fever (Heerfordt's syndrome) [5].
Lofgren syndrome has an association with the presence of HLA-DQB1*0201 and specific polymorphisms of C-C chemokine receptor 2 (CCR2) [16,17]. In a study of patients from the United Kingdom and the Netherlands, DQB1*0201 positivity was associated with a better outcome and greater likelihood of Lofgren syndrome than DQB1*0201 negativity [16]. DQB1*0201-negative patients took longer to recover and were more likely to need treatment at an early stage. In a series of 301 Swedish patients with Lofgren syndrome, DRB1*03 positivity was associated with a better outcome than DRB1*03 negativity [18]. (See "Human leukocyte antigens (HLA): A roadmap", section on 'Class II region'.)
Chronic arthritis — Chronic arthritis is an uncommon (1 to 2 percent) clinical manifestation of sarcoidosis [5,19], mostly presenting as oligoarthritis or polyarthritis, and frequently associated with parenchymal pulmonary and cutaneous manifestations [1]. Chronic arthritis (>2 years), especially that requiring treatment, is more common in non-Lofgren presentations [7]. Elevated serum concentrations of ACE are found in up to 50 percent of such patients [20]. The correlation between extremely high serum ACE levels and extrathoracic sarcoidosis, including chronic arthritis, probably reflects the high total body load of granulomas [14,21]. However, another report found no difference in the frequency of arthritis between those with normal and those with high ACE levels. The serum ionized calcium was significantly higher in the patients with elevated ACE levels.
Different forms of chronic arthritis can occur among patients with sarcoidosis [22-24]:
●Nondeforming arthritis with granulomatous synovitis
●Jaccoud's type deformity of the hands (nonerosive joint deformity)
●Joint swelling adjacent to a sarcoid bone lesion
●Dactylitis (sausage-like swelling of one or more digits)
Patients presenting with chronic arthritis are typically older than patients with acute arthritis or Lofgren syndrome [24]. The ankle, knees, hands, wrist, and metacarpophalangeal and proximal interphalangeal joints are the joints most frequently involved; more rarely, the sacroiliac joints may be affected [25,26]. The prevalence of spondyloarthropathies and inflammatory back pain is increased in sarcoidosis and may justify the use of magnetic resonance imaging (MRI) of the sacroiliac joint to evaluate these patients. There is an increased odds of sarcoidosis in patients with spondyloarthritis (odds ratio [OR] 1.52, 95% CI 1.16-2.01), specifically in ankylosing spondylitis and psoriatic arthritis [27,28]. Temporomandibular joints may also be affected [29]. The presentation of chronic arthritis (more than six months in duration) may be polyarticular or oligoarticular; it can be associated with joint erosions and osseous changes [24].
There seemed to be an increased incidence of sarcoidosis and of sarcoidosis with arthritis in New York City firefighters who worked at the World Trade Center site [30]. Chronic sarcoid arthritis developed more frequently, was unresponsive to usual treatment, and required tumor necrosis factor (TNF)-alpha inhibitors more frequently.
Acute and chronic gouty arthritis was first described in association with sarcoidosis in the 19th century [31,32], but this is rare, and coincidental co-occurrence cannot be excluded [33-35]. Sarcoid manifested as podagra, mimicking gout, has also been reported [36].
Tenosynovitis — Tenosynovitis may occur in the absence of arthritis, and clinical swelling is frequently due to tenosynovitis (eg, at the ankle) rather than arthritis. Reported anatomic sites of tenosynovitis include the Achilles tendon and the flexor tendons of the fingers and wrist [37-39]. One ultrasonographic study of 24 patients with acute sarcoid arthritis, 16 of whom had Lofgren syndrome, found that six had joint effusions of the ankle that could be demonstrated only by ultrasound, while eight had findings of tenosynovitis, and 20 of the 24 had abnormalities (hypoechogenic structures) predominantly within the subcutis and periarticular tissues [40]. (See 'Imaging' below.)
Synovial fluid — Joint effusions may occur among patients with sarcoidosis but are uncommon. Although not required for diagnosis, synovial fluid in patients with arthritis is typically mildly inflammatory, with either neutrophilic or lymphocytic predominance, but may be noninflammatory in some patients with chronic arthritis [41,42].
Large joint effusions are infrequent. Synovial fluid analysis is most consistent with a mildly inflammatory effusion, which, on occasion, may be bloody [43]. (See "Synovial fluid analysis".)
Imaging — Plain radiographs of the hands and other joints are mostly normal, except that soft tissue swelling may be identified. No erosions or joint space narrowing are seen [1]. Cystic phalangeal lesions may be present but are not well-correlated with symptoms or with arthritis. An "apple core deformity" of the digit has been described (see "Sarcoidosis of bone"). Due to the acute self-limiting nature of Lofgren, radiologic stages are more advanced in non-Lofgren presentation of sarcoidosis [7].
Ultrasonography and MRI studies reveal that ankle swelling in most patients with Lofgren syndrome represents periarticular inflammation (soft tissue and tenosynovitis) rather than true joint swelling [40,44]. MRI can demonstrate tenosynovitis, tendonitis, bursitis, and joint effusion/synovitis but is nonspecific and cannot differentiate sarcoid arthritis from other forms of arthropathy [45]. Hypervascular subcutaneous edema is commonly seen in patients presenting with acute arthritis of Lofgren syndrome [44].
On gallium-67 scanning, the radioisotope is concentrated within the joints with varying intensity in patients with sarcoidosis and arthritis. However, the uptake of this radioisotope does not appear to correlate with the acuity or chronicity of the joint disease.
DIAGNOSIS
Diagnostic approach — The diagnosis of sarcoid arthropathy is based upon suggestive clinical, imaging, and synovial fluid findings, and in selected cases on synovial tissue biopsy. The diagnosis of sarcoidosis usually requires biopsy of the involved organ, with a major exception, which is in patients with classic Lofgren syndrome, where the diagnosis can be made based upon clinical features alone [46].
Thus, the diagnosis of acute sarcoid arthritis can be made in a patient under the age of 40 with suspected Lofgren syndrome or acute bilateral ankle arthritis or periarthritis based upon the combination of the bilateral acute ankle changes and hilar adenopathy, with or without the tender red nodules of erythema nodosum; such findings have a high degree of specificity for the diagnosis of acute sarcoid arthritis (see 'Acute arthritis and Lofgren syndrome' above). In general, acute sarcoid arthritis should be included in the differential diagnosis of any patient presenting with acute oligo- or polyarthritis.
In patients with a negative chest radiograph, a computed tomography (CT) scan of the chest may be helpful to identify hilar lymphadenopathy. The finding of sterile noncaseating granulomatous inflammation on synovial biopsy is supportive but is not pathognomonic of sarcoidosis. (See 'Synovial biopsy' below.)
A diagnosis of chronic sarcoid arthritis can be made in a patient with sarcoidosis and one of the characteristic manifestations of chronic sarcoid arthropathy (eg, nondeforming arthritis with granulomatous synovitis, Jaccoud's type deformity of the hands, joint swelling adjacent to a sarcoid bone lesion, or dactylitis), after exclusion of other conditions with similar musculoskeletal features (see 'Chronic arthritis' above and 'Differential diagnosis' below). Rarely, patients may present with clinical features of chronic sarcoid arthritis before the diagnosis of sarcoidosis is established.
The utility of laboratory testing and of other diagnostic procedures in patients suspected of having sarcoidosis is discussed in more detail elsewhere. (See "Clinical manifestations and diagnosis of sarcoidosis".)
Synovial biopsy — A paucity of data exists concerning the characteristics of synovial tissue in acute or chronic sarcoid arthritis. Synovial cysts with typical noncaseating granulomas have been observed on arthroscopically obtained synovial biopsies from chronic sarcoid arthritis [41,47,48]; however, closed synovial membrane needle biopsies are not helpful [49]. Tissue confirmation is typically not obtained in classic acute arthritis of Lofgren syndrome. The increasing use of needle arthroscopes which permit the performance of a synovial biopsy under direct vision may eventually provide additional useful information but are not routinely done.
When indicated for diagnostic purposes (eg, in patients with oligo- or polyarthritis in whom the diagnosis remains unclear despite extensive clinical, laboratory, serologic, and imaging evaluations), several samples of synovial tissue obtained by arthroscopically directed biopsy may be submitted for the following studies:
●Fresh (unfixed) tissue for microbiologic studies, including mycobacterial and fungal stains and cultures
●Absolute alcohol fixed tissue for processing with water-free stains (eg, Wright-Giemsa) and examination under polarizing microscopy to exclude urate or calcium pyrophosphate dihydrate (CPPD) tophi
●Formalin fixed tissue for routine light microscopy
Differential diagnosis — The differential diagnosis of sarcoid arthropathy includes several rheumatic diseases, including reactive arthritis, crystal-induced disorders, and rheumatoid arthritis; and infectious mimics of pulmonary sarcoidosis that sometimes have associated joint manifestations, particularly those due to Mycobacterium tuberculosis (TB) and Histoplasma capsulatum. (See "Clinical manifestations and diagnosis of sarcoidosis", section on 'Differential diagnosis'.)
In the presence of typical pulmonary or other nonpulmonary features of sarcoidosis, a synovial biopsy that reveals multiple noncaseating granulomas offers additional support for the diagnosis of sarcoidosis. (See 'Synovial biopsy' above.)
●Reactive arthritis – Reactive arthritis is a type of seronegative spondyloarthritis that commonly leads to inflammation of the spine and oligoarthritis involving lower-extremity joints, especially the ankles. Involvement of spine and asymmetrical lower-extremity joint involvement, as well as joint swelling rather than periarthritis can help to differentiate it from sarcoid arthropathy. The absence of hilar lymphadenopathy on chest radiograph also helps to differentiate it from Lofgren syndrome. Reactive arthritis, unlike sarcoid, occurs soon following one of a set of infectious illnesses that causes enteritis or urethritis. (See "Reactive arthritis".)
●Tuberculous arthritis and Poncet's disease – Mono- or oligoarthritis of lower-extremity joints, especially knees, is seen in patients with pulmonary TB. Tuberculous joint infection is typically monoarticular, while inflammatory arthritis associated with TB, known as Poncet disease, in which the organism typically cannot be identified in the joint, is commonly an acute, symmetrical polyarthritis of large and small joints. Diagnosis of pulmonary TB with symptoms of productive cough, evidence of TB on chest radiograph, weight loss, a high erythrocyte sedimentation rate (ESR), and confirmation by the identification of the organisms on histopathology or culture can help to distinguish the two conditions. (See "Bone and joint tuberculosis".)
●Histoplasmosis – Histoplasmosis is usually seen in immunocompromised hosts and regions where histoplasmosis is endemic. It typically presents with pneumonia with mediastinal or hilar lymphadenopathy, pulmonary nodules, and/or cavitary lesions. It can cause arthritis or arthralgia as well as erythema nodosum, which can closely mimic sarcoid arthritis. Diagnosis of histoplasmosis can be made by detection of Histoplasma antigen by enzyme immunoassay in the urine, blood, or bronchoalveolar lavage fluid. (See "Pathogenesis and clinical features of pulmonary histoplasmosis" and "Diagnosis and treatment of pulmonary histoplasmosis".)
●Crystal-induced arthritis – Gout and pseudogout (acute calcium pyrophosphate deposition arthritis) can cause acute monoarthritis and occasional oligoarthritis of the great toes and/or ankles, including podagra which may look similar to sarcoid arthropathy. The key clinical differentiation from sarcoid is that gout and pseudogout are typically intensely inflammatory (with severe redness, tenderness and swelling) and they resolve within a few days to a week with conservative treatment. Confirmation of these diagnoses is by the demonstration of characteristic crystals in the synovial fluid using polarizing light microscopy. (See "Clinical manifestations and diagnosis of gout" and "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease".)
●Rheumatoid arthritis – Rheumatoid arthritis can involve joints of the lower extremity, including the ankles, knees, and metatarsophalangeal joints; however, it can be differentiated from sarcoid arthropathy by characteristic history and examination findings, including the typical hand involvement seen in rheumatoid arthritis and positive testing for rheumatoid factor and anti-citrullinated peptide antibodies. (See "Clinical manifestations of rheumatoid arthritis" and "Diagnosis and differential diagnosis of rheumatoid arthritis".)
●Granulomatous synovitis – Multiple conditions, like sarcoid, can be associated with granulomatous histopathologic changes in synovial tissue. A detailed discussion of each of these other conditions is beyond the scope of this discussion, but the distinction from sarcoid is generally made by history, physical examination, and routine laboratory findings that demonstrate features characteristic of these other conditions. The following disorders are among the many causes of granuloma formation in the synovium, other than sarcoidosis (see appropriate topic reviews):
•Heritable disorders, such as Blau syndrome
•Mycobacterial infection
•Fungal infections, such as histoplasmosis, sporotrichosis, others
•Foreign body granulomas, including those resulting from plant thorns, sutures, sea urchin fragments, and others
•Tophi, as in gout and infrequently calcium pyrophosphate deposition (pseudogout)
•Other idiopathic granulomatous disorders, such as Crohn disease, granulomatosis with polyangiitis (GPA), and lymphomatoid granulomatosis
TREATMENT — Treatment of acute sarcoid arthropathy includes the use of antiinflammatory pharmacotherapy, such as nonsteroidal antiinflammatory drugs (NSAIDs) or low-dose glucocorticoids, and is usually sufficient to alleviate the symptoms, which tend to resolve spontaneously. Drug choices in chronic arthritis are influenced by treatment requirements for extraarticular disease manifestations that may be present; in patients with chronic arthritis that is clinically problematic despite the use of antiinflammatory therapies and medications used for pulmonary or other major manifestations, treatment with disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX) or a tumor necrosis factor (TNF) inhibitor is usually of benefit in controlling the joint symptoms [50]. Fatigue is also a common symptom that needs to be assessed in sarcoid patients [51,52]; there is limited evidence from well-designed studies, but some patients may benefit from TNF inhibitor therapies.
Our approach to treatment of sarcoid arthropathy (algorithm 1) is based upon case reports, small uncontrolled studies, and our clinical experience [31,53-56]; there have been no well-designed randomized trials of treatments for the arthropathy seen in these patients.
Initial therapies
Initial therapy with an NSAID — In most patients with acute sarcoid arthritis and periarthritis, we suggest initial therapy with an NSAID in antiinflammatory doses (eg, ibuprofen 600 to 800 mg three to four times daily or naproxen 375 to 500 mg twice daily) rather than glucocorticoids or other therapies. An NSAID is often sufficient to control symptoms, and the acute arthritis is usually self-limiting (see 'Acute arthritis and Lofgren syndrome' above), precluding the need for prolonged therapy with NSAIDs in the majority of patients.
Resistant to NSAIDs — We take the following approach in patients resistant to NSAIDs:
●In patients with an inadequate response to a trial of NSAID therapy for at least two weeks at antiinflammatory doses, we suggest oral glucocorticoid therapy (prednisone 10 to 20 mg orally once daily initially, then gradually tapered as tolerated over two to four weeks) rather than continued trials of different NSAIDs.
●In patients with an inadequate response to glucocorticoids or who are unable to prevent flares of arthritis with tapering of glucocorticoids (flare with prednisone less than 7.5 mg daily), we add hydroxychloroquine (HCQ; up to 400 mg daily, not to exceed 5 mg/kg per day based upon real body weight) [50,57,58]. In a retrospective case series of patients with sarcoid, 52.2 percent were able to taper completely off of glucocorticoids after treatment with HCQ 200 mg twice daily [59]. Small case series indicate that HCQ may be particularly effective for the cutaneous and neurologic manifestations of this disease [60,61].
The dosing, adverse effects, and monitoring of HCQ are described in detail separately. (See "Antimalarial drugs in the treatment of rheumatic disease".)
Resistant to initial therapies
Add a conventional synthetic DMARD (eg, methotrexate) — In patients who have continued symptoms of arthritis despite treatment for at least three months with prednisone plus HCQ, we add a conventional nonbiologic disease-modifying antirheumatic drug (DMARD). We start with low-dose MTX (7.5 to 15 mg once weekly). For those who do not respond, we increase to full-dose MTX (15 to 25 mg once weekly). Alternatively, we add leflunomide (10 to 20 mg once daily) to low-dose MTX in patients who cannot tolerate higher doses of MTX [62].
●Methotrexate – MTX is used for sarcoid arthropathy in the regimen employed for rheumatoid arthritis (with a maximum dose of 25 mg/week, which may be given by subcutaneous administration if oral dosing is inadequate); the use and adverse effects of MTX are described in detail separately. (See "Use of methotrexate in the treatment of rheumatoid arthritis" and "Major side effects of low-dose methotrexate".)
The use of MTX for patients with sarcoid arthropathy is supported by limited case series and our clinical experience [53,56,63].
●Leflunomide – We use leflunomide as an adjunctive or alternative DMARD when patients cannot tolerate MTX. In a retrospective case series of 76 patients with sarcoidosis, 83 percent of patients with extrapulmonary manifestations of sarcoidosis (including cutaneous, ocular, and sinonasal) had a complete or partial response to treatment with leflunomide [62]. Patients with pulmonary sarcoidosis experienced a small improvement in forced vital capacity following treatment with leflunomide.
Add a TNF inhibitor for persistent symptoms — In patients with an inadequate response to a conventional synthetic DMARD, we add infliximab (5 mg/kg administered by intravenous infusion every four to eight weeks). Infliximab is used in a similar fashion to that employed for the treatment of rheumatoid arthritis; the adverse effects of TNF inhibitors are described in detail separately. Dose is titrated up to 10 mg/kg in refractory disease every four to eight weeks. (See "Treatment of rheumatoid arthritis in adults resistant to initial conventional synthetic (nonbiologic) DMARD therapy", section on 'Methotrexate plus TNF inhibitor' and "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects".)
We prefer infliximab in such patients for several reasons. Infliximab has been found effective for sarcoid arthropathy, as described in case reports, and benefit was suggested in one randomized trial which evaluated extrapulmonary manifestation as a secondary outcome, although the number of patients with resolution of bone and joint involvement in the treatment group did not achieve statistical significance compared with the placebo group at week 24 (8 of 19 versus 0 of 8) [64-66]. Although several case reports showed benefit from TNF inhibitor therapy for treatment-resistant sarcoid arthropathy [64,65,67], relapse has been observed with discontinuation of therapy [67,68]. This phenomenon has been observed with other granulomatous diseases. There have been no randomized trials with any of the available anti-TNF agents for sarcoid arthropathy, nor has there been any head-to-head comparison between the different agents.
TNF-alpha is important in granuloma formation [69], and use of inhibitors of TNF alpha to treat articular sarcoid is biologically plausible. Etanercept has not been useful in the treatment of sarcoid pulmonary [70] or eye disease [71]. By contrast, infliximab appeared to be effective in the treatment of some patients with resistant sarcoidosis in two randomized trials [72,73].The use of TNF inhibitors in pulmonary sarcoidosis is reviewed in detail separately. (See "Treatment of pulmonary sarcoidosis refractory to initial therapy", section on 'Tumor necrosis factor-alpha antagonists'.)
There are a few case reports of benefit from etanercept in chronic sarcoid arthropathy that was not responsive to conventional treatments [64,65]. However, given the lack of benefit for this agent in randomized trials in pulmonary sarcoidosis, we discourage its use in sarcoid arthropathy. There have been no reports regarding the use of adalimumab in sarcoid arthritis; however, there are positive trials for pulmonary and cutaneous sarcoidosis and occasionally authors have extrapolated those findings to sarcoid arthritis, given its similar mechanism of action to infliximab [74,75]. There is no evidence regarding other anti-TNF agents or rituximab, which depletes B cells, in sarcoid arthropathy.
Despite the possible benefit of anti-TNF agents in some patients with pulmonary or extrapulmonary sarcoidosis, the apparently paradoxical development of granulomatous pulmonary disease consistent with sarcoidosis has been reported as a rare complication of treatment with these agents for other conditions [76]. In most patients, there was resolution of both the symptoms and the radiographic findings following withdrawal of the drug. (See "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects", section on 'Pulmonary disease'.)
Duration of therapy — We generally continue the effective treatment regimen for approximately one year before initiating a gradual taper of medications over the subsequent 6 to 12 months. Some patients may require only six to nine months of a stable regimen before beginning to taper, depending upon their clinical response to treatment.
Resistant to medical therapy — In the very infrequent patient resistant to medical therapy, synovectomy is a treatment option. Because the diffuse synovitis observed in sarcoidosis does not appear to cause surface cartilage erosions, arthroscopic synovectomy is usually straightforward, and synovitis is recurrent only in joints where synovectomy is not complete [77].
PROGNOSIS — Acute and chronic sarcoid arthritis usually both have a good prognosis. Acute arthritis is typically self-limiting, and chronic arthritis generally responds to usual treatments for sarcoidosis. Joint damage is generally not seen in sarcoid arthropathy [8,10,30].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sarcoidosis".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Approximately 10 to 15 percent of patients with sarcoidosis have an associated arthropathy. Acute arthritis often involves the joints of the lower extremities, is mostly accompanied by hilar adenopathy and erythema nodosum (Lofgren syndrome), and usually resolves spontaneously, although it may persist in one-third of affected patients. Chronic arthritis, which is less common than the acute form, is frequently associated with parenchymal lung disease and other extrapulmonary manifestations like cutaneous disease. (See 'Frequency of musculoskeletal sarcoid' above and 'Acute arthritis and Lofgren syndrome' above and 'Chronic arthritis' above.)
●Diagnosis – A diagnosis of chronic sarcoid arthritis can be made in a patient with sarcoidosis and one of the characteristic manifestations of chronic sarcoid arthropathy (eg, nondeforming arthritis with granulomatous synovitis, Jaccoud's type deformity of the hands, joint swelling adjacent to a sarcoid bone lesion, or dactylitis) after exclusion of other conditions with similar musculoskeletal features, such as tuberculosis (TB). The diagnosis of sarcoid arthritis can be made without a tissue biopsy in most patients with classic Lofgren syndrome, where the diagnosis can be made based upon clinical features alone unless there is a strong suspicion of an infectious etiology. An inflammatory but sterile joint aspirate further supports the diagnosis. (See 'Diagnostic approach' above and 'Imaging' above and 'Synovial biopsy' above.)
●Differential diagnosis – The differential diagnosis of sarcoid arthropathy includes several rheumatic diseases, including reactive arthritis, crystal-induced disorders, and rheumatoid arthritis; and infectious mimics of pulmonary sarcoidosis that sometimes have associated joint manifestations, particularly those due to Mycobacterium TB and Histoplasma capsulatum. Synovial biopsy is sometimes necessary, principally to exclude other causes of arthritis, particularly infectious diseases such as TB and histoplasmosis. (See 'Differential diagnosis' above.)
●Treatment – Treatment of acute sarcoid arthropathy includes the use of antiinflammatory pharmacotherapy and is usually sufficient to alleviate the symptoms, which tend to resolve spontaneously. Drug choices in patients with more chronic arthritis are influenced by treatment requirements for extraarticular manifestations of sarcoid, such as pulmonary disease, that may also be present (see 'Treatment' above). Our approach is as follows (algorithm 1):
•In most patients with acute sarcoid arthritis and periarthritis, we suggest initial therapy with a nonsteroidal antiinflammatory drug (NSAID) in antiinflammatory doses (eg, ibuprofen 600 to 800 mg three to four times daily or naproxen 375 to 500 mg twice daily), rather than glucocorticoids or other therapies (Grade 2C). An NSAID is often sufficient to control symptoms, and the acute arthritis is usually self-limiting, precluding the need for prolonged therapy with NSAIDs in the majority of patients. (See 'Initial therapy with an NSAID' above.)
•In patients with an inadequate response to a trial of NSAID therapy for at least two weeks at antiinflammatory doses, we suggest oral glucocorticoid therapy (prednisone 10 to 20 mg orally once daily initially, then gradually tapered as tolerated over two to four weeks) rather than continued trials of different NSAIDs (Grade 2C). (See 'Resistant to NSAIDs' above.)
•In patients with an inadequate response to glucocorticoids or who are unable to prevent flares of arthritis with tapering of glucocorticoids (eg, flare with prednisone less than 7.5 mg daily), we add hydroxychloroquine (HCQ; up to 400 mg daily, not to exceed 5 mg/kg per day, calculated based upon real body weight). In patients with continued symptoms after another three months, we then add low dose methotrexate (MTX; 7.5 to 15 mg weekly). (See 'Resistant to NSAIDs' above.)
•For patients with continued symptoms despite treatment with prednisone combined with HCQ and/or low-dose MTX, or for those who are unable to taper prednisone to less than 5 to 7.5 mg, we continue HCQ, and add higher-dose MTX (usually 15 to 20 mg once weekly, maximal dose of 25 mg once weekly by subcutaneous administration) or add leflunomide (20 mg daily). In patients with an inadequate response to a three-month trial of this combination, we add infliximab (5 mg/kg administered by intravenous infusion every four to eight weeks) to the regimen. (See 'Add a conventional synthetic DMARD (eg, methotrexate)' above and 'Add a TNF inhibitor for persistent symptoms' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Winston Sequeira, MD, who contributed to an earlier version of this topic review.
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