Changing scenario of Sarcoidosis in India

There has been a rapid change in recognition and spectrum of sarcoidosis in India in the last decade. This was considered a rare disease almost till the end of the last century even though the disease was recognized and reported from different places. The change is remarkable considering the fact that the number of publications on the subject has suddenly jumped in the last decade. Of 340 total papers which are listed in PubMed since 1980, about two-third (228) have appeared in the last 10 years. There were only rare publications before 1980. The increase can be attributed to several different causes:

1. True increase in incidence
2. Increased awareness of disease among physicians. Many cases of sarcoidosis were dismissed as tuberculosis in the past.
3. Increased availability of diagnostic tests such as chest CT scanning, fiberoptic bronchoscopy and endo-bronchial ultrasound sound guided fine needle aspiration (EBUS-FNA)
4. Insistence of physicians as well as patients in making a confirmed diagnosis than starting anempiric treatment

Clinical spectrum of sarcoidosis: There is also a change in the spectrum of disease and organ involvement described in the reports of the recent past. Previously, it was mostly the pulmonary involvement i.e. hilar and mediastinal lymphadenopathy which was commonly described. Now, there is a greater recognition of extra-pulmonary involvement including that of the liver, spleen, nervous system and other organs. Moreover, atypical pulmonary presentations such as miliary involvement of lung parenchyma and pleural effusions are frequently reported. It is again a moot question whether this finding is a true change in the spectrum or only an increased recognition because of the factors already listed above.

Sarcoidosis tuberculosis enigma continues to bother physicians in India not only because of similar presentations of both diseases but also since the treatments are different for the two diseases. Corticosteroids, which are used for sarcoidosis may in fact precipitate tuberculosis and are necessarily avoided except in a few specific situations. There is no place to start the treatments for both conditions simultaneously as had been a common practice in the past. It is therefore important to make a firm diagnosis before starting treatment for either condition.

The other major shift which has happened relates to the more frequent use of non-steroidal drugs. Drugs such as methotrexate, hydroxy chloroquin and other immunosuppressants are now available for use for relapse and in the presence of co-morbidities with or without corticosteroid therapy, depending upon the clinical condition.  

S.K. Jindal

Medical Director, Jindal Clinics, Chandigarh

Steroids for treatment

Corticosteroids, also known simply as steroids constitute an important group of drugs used for a number of diseases especially of immunological or allergic origin. They are used to suppress immune responses of the body in these conditions. For the same reason, they are required in patients with transplantation of organs. 

Unfortunately, steroids are commonly misused for conditions for which they are not required. On the other hand, some patients tend to avoid their use when they are required. Problems are likely to arise in both situations.

Steroids are natural hormones produced in the body by adrenal (also known as supra-renal) glands. There are three types of steroid hormones produced by adrenal cortex:

1.  Mineralocorticoids
2. Glucocorticoids
3. Sex-hormones

Steroids used for treatment of diseases are the synthetic drugs based on the chemical structure of natural hormones.

Short-term use of steroidal drugs is generally required for acute, severe attacks of asthma, acute worsening of chronic obstructive pulmonary disease (COPD), acute allergic reactions of skin and eyes, drug reactions, insect bites and several other disorders. Longer use may be needed for interstitial lung diseases, rheumatoid arthritis and other connective tissue diseases, certain types of eczema, urticarial and eye diseases, etc. 

Steroids are also required for local use for skin and eye problems as creams, ointments and drops. For asthma and other respiratory problems they are frequently required as inhalers for their local action in the respiratory tract.  Local use is generally safe though minor local problems may sometimes occur.

Importantly, steroids should never be used without advice and prescription of your qualified doctor.

One should always know about their use whenever they are required for longer periods. Long-term use can produce several side-effects and other problems which should be adequately monitored.

 Following complications may occur:

1. Gastro-oesophageal reflux: Acidity, heart-burn and abdominal discomfort.
2. Facial swelling; later swelling over feet and abdomen.
3. Worsening of blood pressure
4. Worsening of blood sugar levels and diabetes control.
5. Weakening of bones due to calcium depletion.
6. Gain in weight due to increased appetite and fluid retention.
7. Redistribution of body fat over the back of neck and abdomen; early cataract in the eyes, other eye problems; acne over face and other parts of body.

There are some other side effects as well, but relatively uncommon.

It is important to know that steroids, when medically indicated need not be avoided. Side-effects should be monitored and controlled with supplementary drugs. Other corrective steps may be required in some cases which should be undertaken on advice of your consultant.

The misuse of steroids is common especially by medical quacks who add the steroidal drugs in every prescription. Some such quacks are known to dispense steroids as unlabelled tablets or powders. This is a highly risky proposition. It must be avoided at all costs.