In this episode of Hospital Medicine Unplugged, we tackle sarcoidosis—recognize the classic presentations, screen aggressively for silent organ involvement, and treat the patients at highest risk for irreversible damage or sudden death.

Diagnosis requires three things: compatible clinical presentation, non-caseating granulomas, and exclusion of alternative granulomatous disease like TB, fungal infection, or malignancy. Some syndromes are classic enough to skip biopsy, including Löfgren syndrome (bilateral hilar adenopathy, erythema nodosum, arthritis, fever) and lupus pernio. Most hospitalized patients, though, need tissue confirmation—typically via EBUS-guided transbronchial needle aspiration for intrathoracic lymphadenopathy.

Once diagnosed, the mission shifts to multisystem screening: • Pulmonary: chest imaging + PFTs with DLCO • Cardiac: ECG for all patients; cardiac MRI or FDG PET for symptoms, arrhythmias, or conduction disease • Ophthalmologic: slit-lamp examination • Labs: CBC, creatinine, calcium, alkaline phosphatase, vitamin D metabolites when indicated

Cardiac sarcoidosis is a major killer and can present with AV block, ventricular arrhythmias, syncope, or unexplained cardiomyopathy. Neurosarcoidosis can cause cranial neuropathies, meningitis, seizures, or spinal cord disease—both require aggressive recognition and treatment.

Not all sarcoidosis needs therapy. Treat when there’s risk of organ damage, death, or severe symptoms: • Cardiac sarcoidosis • Neurosarcoidosis • Progressive pulmonary disease • Ocular disease • Symptomatic hypercalcemia

Treatment backbone: • Prednisone 20–40 mg/day for most disease • Higher-dose steroids for cardiac/neuro involvement • IV methylprednisolone for life-threatening presentations

Steroid-sparing therapy matters early: • Methotrexate is the preferred second-line agent • Azathioprine, mycophenolate, and leflunomide are alternatives • Infliximab or other biologics for refractory disease

Cardiac sarcoidosis often needs more than immunosuppression: • ICDs for ventricular arrhythmia risk • Pacemakers for conduction disease • Catheter ablation for refractory VT

Key inpatient pearls: • Monitor calcium and steroid toxicity • Use telemetry if cardiac involvement suspected • Watch for progressive hypoxemia or arrhythmias • Involve pulmonology, cardiology, ophthalmology, and neurology early

We close with the system moves: build a standardized sarcoidosis screening pathway, default to ECG + pulmonary testing + ophthalmology evaluation at diagnosis, escalate rapidly to cardiac imaging when red flags appear, and initiate steroid-sparing therapy early for chronic disease.

Granulomas are only the start—screen every organ, respect cardiac sarcoidosis, and treat before inflammation becomes permanent fibrosis.