Sarcoidosis in the elderly

Introduction to elderly sarcoidosis Sarcoidosis is an unknown cause. T lymphocytes and mononuclear macrophages in the lesions are activated, involving multiple systemic granulomatous diseases. Clinically, bilateral hilar lymphadenopathy and lung involvement are most common. , followed by eye and skin involvement. Lesions can also affect lymph nodes, liver, spleen, heart, parotid gland, bones and other organs in other parts. The diagnosis of this disease depends on histopathological confirmation, and excludes tuberculosis, fungal infections and other granulomatous lesions. Glucocorticoid is the main therapeutic drug that inhibits inflammation, the formation of granuloma, relieves clinical symptoms, and controls the progression of the disease. basic knowledge The proportion of illness: 0.005% Susceptible people: the elderly Mode of infection: non-infectious Complications: bronchiectasis hemoptysis respiratory failure pulmonary fibrosis iridocyclitis arrhythmias heart failure

Causes of sarcoidosis in the elderly

Infection factor (30%)

Bacteria enter the body from the respiratory tract, causing a systemic immune response, which leads to the occurrence and development of the disease. Thoracic sarcoidosis is the most common in clinical practice. Certain viruses, spirochetes, Propionibacterium acnes, Mycobacterium tuberculosis, non-tuberculous mycobacteria, and Mycoplasma genus may induce this disease.

Immune abnormality (15%)

The Th1/Th2 imbalance may be related to the onset of sarcoidosis. In most cases, the local helper T cells are mainly Th1 (CD4+) cells; only a few cases are dominated by Th2 (CD8+) cells. It has been suggested that abnormalities in the quality or quantity of T lymphocyte receptors (TCRs) are associated with the development of sarcoidosis.

Genetic factors (15%)

Sarcoidosis may be a polygenic genetic disease. It is currently recognized that HLA-A1, HLA-B8, and HLA-DR3 in leukocyte histocompatibility antigen (HLA) are closely related to the pathogenesis of sarcoidosis. US Teistein reports that about 10% of American patients with sarcoidosis have a family history. Moreover, the odds of single-oval twins suffering from sarcoidosis are much higher than those of double-oval twins.

Other factors (10%)

Cold stimuli, chemical pathogenic factors, and drugs can induce the disease.

Pathogenesis

Because sarcoidosis is very similar to the pathology of tuberculosis, foreign scholars have used polymerase chain reaction (PCR) to detect mycobacterial DNA in sarcoidosis specimens in recent years. The two PCR methods used are: specific complex IS986/ IS6100 detects Mycobacterium tuberculosis DNA and detects mycobacterial DNA other than Mycobacterium tuberculosis using the conserved sequence of mycobacterial groEL gene. As a result, DNA of these two bacteria can be detected in a considerable number of specimens, suggesting that the microorganism may be a knot. Pathogenic pathogens, but work in this area needs further verification. Genetic studies have also been carried out on certain sarcoidosis cases, often tending to multi-gene expression. Some studies have shown that HLA-B8 and the natural relief of the disease It is related to nodular erythema.

Formation of sarcoidosis granuloma: antigen-stimulated activation of T lymphocytes, resulting in the production of TH1 cytokines such as IFN- and IL-2, monocyte chemotactic factor (MCF) and monocyte migration factor (MIF), giant Lymphocytes are activated by irritations and IFN- stimulation, producing IL-12, INF-, IL-6 and cytokines that cause activation, proliferation and aggregation of other cells, and in addition to other effector cells such as fibroblasts. Local granuloma formation, CD4 T lymphocyte activation in the inflammation site increased, but the number of T lymphocytes in the surrounding blood decreased, and CD4 T lymphocytes in the bronchoalveolar lavage fluid (BALF) of active patients also increased significantly, while CD8 T cells were lower. Normally, the CIM/CD8 ratio is significantly higher.

Microscopic sarcoidosis lesions are characterized by non-caseal granuloma formation. Granuloma is composed of aggregated macrophages and epithelioid cells. Epithelioid cells fuse with each other to form Langerhans multinucleated cells. Lymphocytes are mostly infiltrated around the nodules. Granuloma tends to be distributed around blood vessels, bronchi, and especially lymphatic vessels. Schaumann's bodies containing calcium and iron are found in the cytoplasm of epithelioid cells. Ultrastructural lesions of the alveolar basement membrane can be seen in the inflammation site. Type I epithelial cell rupture, granuloma can be dissolved, healed, can also be merged into a large nodule, most of the intrapulmonary granuloma is located in the interstitial lung, which can lead to diffuse pulmonary interstitial damage, and can form interstitial fibers in the late stage. Sarcoidosis can affect the bronchial mucosa, causing swelling of the mucosa, narrowing of the lumen, pathological changes of sarcoidosis granuloma without specificity, in tuberculosis, leprosy, Crohn's disease, primary biliary cirrhosis, fungal infection, poisoning, etc. can also be seen, especially tuberculosis, because of the high incidence in China, more need to pay attention to identification, sarcoidosis in addition to granulomatous lesions, but also may have focal necrosis, but Tuberculosis granulomatous lesions are unevenly distributed in tissues, vary in size, and have caseous necrosis. Acid-fast bacilli can be found in acid-fast staining.

Elderly sarcoidosis prevention

1. Most of the sarcoidosis has a good prognosis, so early treatment should be sought to prevent complications.

2, pay attention to personal hygiene, protect water sources, do a good job in environmental sanitation, and develop good habits.

3, maintain a good mentality, stable mood, have a healthy eating habits, usually eat more fruits and vegetables, etc. to improve self-immunity.

4, people who must work in heavy oil fume should try to protect themselves, such as wearing a mask, regularly go out to breathe some fresh air, do an inspection every year.

Elderly sarcoidosis complications Complications bronchiectasis hemoptysis respiratory failure pulmonary fibrosis iridocyclitis arrhythmia heart failure

Common complications of repeated lung infection, late bronchiectasis, hemoptysis, pulmonary fibrosis, respiratory failure, ocular lesions such as: iridocyclitis, uveitis, heart involvement, arrhythmia, heart failure, nodular joints Inflammation and so on.

Symptoms of sarcoidosis in the elderly Common symptoms Tired, weak nodules, loss of appetite, low fever, papules, joint pain, subcutaneous nodules, dry cough, congestion

Because of the different organs invading the disease, the symptoms of sarcoidosis vary. More than 90% of the sarcoidosis involves the lung and intrathoracic lymph nodes. About 2/3 of the patients may have no clinical symptoms, and even some have bilateral hilar lymph nodes. Infiltrates also appear asymptomatic, pulmonary nodule disease is more slowly onset, beginning with chest tightness and shortness of breath, shortness of breath after exercise, may have cough, mostly dry cough, other common systemic symptoms are fatigue, loss of appetite, joint pain, low fever Etc., advanced patients due to granulomatous fibrosis or bronchiectasis, recurrent lung infection and cough, hemoptysis, 20% of patients with sarcoidosis can affect the eyes and skin, ocular lesions including iridocyclitis, grapes Membrane inflammation, combined with membranous inflammation and keratoconjunctivitis, skin is most common with nodular erythema. Chronic patients have rash and subcutaneous nodular lesions. A few sarcoidosis can cause acute onset, which is characterized by fever and lower limbs. Skin nodular erythema, etc., severe polyarthritis, known as Lofgren syndrome, this syndrome is more common in Europe, the Caucasian, the prognosis is better, sarcoidosis often involving the liver, accounting for 50%, but rarely a single organ damage, so the diagnosis is not difficult, the nervous system is involved, myocardial sarcoidosis is <5%, but the latter can cause arrhythmia, conduction block and congestive heart failure It has become an important cause of death in young sarcoidosis. In patients with sarcoidosis, due to inflammation of granuloma in tissues, secretion of macrophages and epithelial cells promotes the conversion of vitamin D to activated 1,25-(OH)2 vitamin D, increasing the small intestine. Calcium absorption, but also reduce serum parathyroid hormone, resulting in hypercalcemia and hypercalciuria, hypercalciuria is more common than hypercalcemia, kidney stones are the most common manifestations of renal sarcoidosis, According to statistics, the incidence of hypercalcemia in patients with sarcoidosis is high, and the proportion of hyperuricemia is low.

Elderly sarcoidosis examination

1. The blood lymphocyte count can be decreased in the active period.

2. Serum globulin and specific immunoglobulin can be increased.

3. Some patients may have high urinary calcium and hypercalcemia.

4. In patients with active sarcoidosis, serum angiotensin I converting enzyme (SACE) is mostly increased. When the condition is relieved, it can gradually decline and return to normal. When recurrence, it can be increased again, but SACE can also be used in other granulomatous diseases. Increased as a non-specific diagnostic indicator.

5. Patients with sarcoidosis have increased BALF lymphocytes and increased CD4/CD8 ratio. These changes are of great value in the diagnosis of sarcoidosis and disease activity.

6.67Ga scan: It is a sensitive index reflecting sarcoidosis activity. In the active stage of sarcoidosis, the amount of 67Ga intake is significantly increased, but in other granulomatous diseases, pneumonia patients can also be raised because the examination is expensive and specific. Poor sex, rarely used now.

7. Chest X-ray: sarcoidosis is divided into 3 stages according to the chest radiograph, stage I: double hilar lymphadenopathy, stage IIa: double hilar lymphadenopathy with pulmonary infiltration, stage IIb: pulmonary interstitial infiltration, There is no enlargement of hilar lymph nodes, stage III: pulmonary fibrosis, cystic changes in clusters, CT and HRCT can accurately estimate the type of sarcoidosis, degree and size of lymph nodes, HRCT sensitivity to lung lesions More sexual.

8. Pulmonary function test: early lung function can be normal, diffuse dysfunction can occur in the future, ventilatory dysfunction; to pulmonary fibrosis due to further reduction of lung capacity, there may be restrictive ventilatory dysfunction, when there is severe diffuse dysfunction, Hypoxemia can occur when ventilation is dysfunctional.

Diagnosis and diagnosis of sarcoidosis in the elderly

Diagnostic criteria

The diagnosis should be based on clinical manifestations and biopsy of the living tissue to confirm the formation of non-caseous epithelioid granuloma.

1 Obtaining bronchial mucosal biopsy specimens through fiberoptic bronchoscopy has a certain positive rate; transbronchial lung biopsy (TBLB) also has a higher positive rate.

2 swollen superficial lymph node biopsy can also be diagnosed. If there is no superficial lymph node enlargement, it can be used for anterior scalene lymph node biopsy.

The 3Kveim skin test is of great significance for diagnosis, but because it is not easy to obtain a suitable antigen (spleen or lymph node tissue), the skin test needs to wait for 4 to 6 weeks before taking the nodule of the skin for biopsy, which takes a long time. It has rarely been used in recent years.

Differential diagnosis

Sarcoidosis should be differentiated from lymphoma, lung cancer, bronchial lymph node tuberculosis, and pulmonary fungal disease.

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