DIP Episode 411 - The Clutch Sarcoidosis Podcast

Okay welcome my name is divine this is episode 411 of the divine intervention podcasts and into this podcast which we should hopefully be a short one we're talking about sarcoid doses this is gonna be called the clutch sarcoid doses podcast.

Sarcoid is one of those things that you're very likely gonna see on every US Emily exam on every complex exam and it's one of these wonderful things that you can see is like the classic prototypical topic that falls on the multi-systems processes and disorders because literally it affects many body systems so if you're wondering oh divine what are the things that constitute what is tested on their multi-systems processes and disorders something like sarcoid doses is a perfect example and you're gonna see why there are many integrations you can meet with many many different body systems so let's jump right into it right so we know that sarcoid doses you know many times it was granolaumas right more specifically non-key seeding granolaumas right and again we know that we live in an era where friends at the MBM is love to do this thing where again you'll put what I call derivative answers I will share in this with the people that took the test against strategies courses yesterday derivative answers right where it's something that you know the MBM is just just to put it in a different term so again remember instead of putting sarcoid doses as an answer they can put granolaumados long inflammation that's something they can put and again remember they are non-key seeding granolaumas and don't forget if you're you know for those that are taking step one you need to remember that the whole Markovar granolaumas is the presence of giant cells epitheliod macrophages right you're gonna see that those macrophages are very important for certain things as we as we go along and usually when people have sarcoid doses right like the two main organs that affect it don't get me wrong it can affect me any other things but in general it affects it affects the lungs the lungs are the most common organ of involvement in sarcoid doses so they are certain epidemiological related things you may

see me mentioned in this podcast or if you've listened to my other podcasts you've probably seen me mention these things are not low yields to know they are certain times the MBM is will ask what is the most likely cause of XYZ and they will give you multiple answers that are correct you have to pick the one that is the most common or they can see who was the most likely outcome of this or what is the most likely predictor of poor mortality or poor outcomes with this again those pieces of epidemiological data at things you should know or actually be mentioning some of them because sarcoid has quite a number of them that are very important so don't forget the most commonly involved organ in a person that has sarcoid doses is the lungs about 90% of people that have sarcoid doses will have some kind of long involvement right and if sarcoid doses of the lungs gets really severe it can lead to intestinal lung disease right which can cause preliminary hypertension obviously that intestinal lung disease or cause a restrictive pattern of lung disease right because again if you have a lot of the position of stuffing the interstitial right your lungs will not be able to expand very well so the compliance will be horrible the compliance will be decreased but the elastants will be increased they can snap back more and obviously you're gonna have reduced lung volumes as a typical for most restrictive lung diseases you're gonna have a normal or an elevated FEV1 to MVC ratio and then the second most commonly involved organ in the person in sarcoid doses is the skin and fact later in this podcast I'm gonna talk about some of the dermatologic manifestations of sarcoid doses again that's pretty important to know for exams and then obviously sarcoid also involves lymph nodes right sarcoid also involves lymph nodes although lymph nodes are not classically regarded as an organ so if for

example a person were to present with sarcoid doses on an MV and already look like well typically those people have like shortness or breath right they'll have dry cough they'll have lymphatic anopathy right they'll have a lot of fatigue many times people that show with sarcoid doses attire people they're very fatigued they have joint pain joint pain is a pretty prominent feature of sarcoid doses right and many times if you're listening to the lungs because they have intercicial lung disease you hear dry crackles remember whenever you hear dry crackles fine crackles those are pretty classic for a person having some kind of intercicial lung disease some kind of pulmonary fibrosis and besides these symptoms there's a triad I think I want to mention that you may actually find to come in pretty handy on exams right so it's a triad of bilateral hyalinemphadenopathy arthritis right that can involve like the knees the ankles whatever and erythema nodosa right so bilateral hyalinemphadenopathy arthritis and erythema nodosa is a triad when you see that triad together that's what's referred to as love green syndrome love green L-O-F-G-R-E-N love green syndrome it's pretty high you to know that actually for example and whenever people have love green syndrome whenever they have erythema nodosa in general is associated with a good prognosis right so if they give you a question about a patient with sarcoidosis and then they say oh which of the following historic factors in this patient's presentation is most likely associated with excellent outcomes think about the presence of love green syndrome or erythema nodosa now what are some labs you may see in a person with sarcoidosis well typically you're gonna see hypercalcemia because again those epithelioid macrophages that surround the granuloma they make very high left the express one of our hydroxylis in high quantity so that one

alpha hydroxylis is going to cause them to make a lot of 125 dihydroxyl vitamin D that's what's known as calcium trial and that calcium trial is going to cause you to reabsorb more calcium in your guts so you're gonna have hypercalcemia right but many times these people that have sarcoidosis in the presence of that hypercalcemia the catheter of communists typically normal right the the hypercalcemia does not get to the point where it really cause I mean if obviously it's very severe that can lower the pt H but most times these people have normal pt H right and also they're gonna have a little bit of also fungiotensin converting enzyme right and the thing is in terms of sarcoid there's really not much you need to do with treatment if a person is not symptomatic at all we have like extremely mild disease and again they'll make it very obvious on the exam those people generally do not need treatment but if they're symptomatic the first-line treatment for sarcoidosis is gonna be steroids.

Stereoids are the first-line treatment for symptomatic sarcoidosis if you don't see that as an answer or steroids do not appear to be helping their symptoms then begin to consider drugs like methyl trexid remember methyl trexid works by inhibiting dihydrofully reductis and you remember it it's hepato toxic and it's pulmonary toxic rate and cause pulmonary fibrosis right is a thioprin's also another good circling agent for the management of or sarcoidosis and again in terms of one of these inoculars just strange bizarre questions to me see an exam to me see or what is the most likely outcome of a patient that has sarcoidosis well the most likely outcome is resolution without recurrence most people that have sarcoidosis they go into remission after a while it may vary by the amount of time necessary to go into remission but they'll go into remission for a while after they go into remission usually doesn't come back again it's literally less than 5% of people that have sarcoidosis like have a bottle sarcoidosis that end up having a having a recurrence right and again don't forget the geographical associations right the ethnic associations sarcoidosis is very common in African-Americans on exams but again we know that our friends at the NBM is they're really smart right again the fact that African Americans get sarcoidosis does not mean they're the only people that have a high incidence of sarcoidosis or high prevalence of sarcoidosis sarcoidosis is also very common in Scandinavians right sarcoidosis is also very common in Scandinavians and again if you're just comparing women and men women are way more common way more likely to have sarcoidosis on an exam than men don't get me wrong can men get sarcoidosis they absolutely can but is more likely a exam going to be found in a woman right it's more likely to be finding a woman so again just be careful don't just pigeonhole

yourself into learning or the one geographical association if a disease is very common in other populations they really think that you know you want to make sure that you you know right so like for example another classic one is like T-Sax disease many people have memorized T-Sax disease as Ashkenazi Ashkenazi Jewish population yes don't get me wrong very common in the Ashkenazi Jewish population or T-Sax disease is also found in French Canadians right T-Sax disease is found in the Cajun population in Louisiana right so these are not things you should ignore because again the MBME is every now and then they just slot in this new geographical association maybe a geographical association you don't know but it's actually a geographical association that actually makes a lot of sense giving the circumstances right so just kind of be careful of that on on exams right and and I think one thing that may be helpful is to maybe jump into looking at some of the grammatologic manifestations of sarcoidosis and before we do that if you're taking your USMLE step two CKL step three or complex level two or three exams anytime soon if you want to take it in time to get your scores before ERA scores out I'll encourage you to take the 20 hour review course I'm offering next week it's gonna be on the 25th and 26th it's 10 hours each day we'll have a one-hour break in between and we're very likely to take some small breaks as well for all the course so people can kind of refresh themselves on what not but basically it's gonna be 10 hours each day 25th 26th you'll learn a lot of internal medicine, pediatrics, surgery, OB-GYN, neurology, biostatistics, ethics, multi-systems, processes and disorders again many people have taken these courses and they found it to be profoundly helpful again I got a lot of good feedback even yesterday from people that took my course that got their scores back y

esterday which was Wednesday and then I also have a biostatistics boot camp right so the thing is biostatistics is something these days on all the USMLE exams step one to step three that are not really based on how much do you know the formula so have you memorized the formulas no most of the biostat questions we see on exams these days almost exclusively based on understanding like many MVME biostat questions these days do not depend on your ability to regurgitate formulas and regurgitate numbers so to be perfectly honest with you if you want to learn biostat at a deep level and say you know what I'm not just gonna be memorizing formulas for relative raise blah blah blah blah but I want to see applied biostatistics which is the way we'll show up on your exam I will encourage you to attend the biostatistics boot camp but really have it today from 5 to 9 pm specific standard time there's still some spots if you want to sign up but again it's gonna be something that's gonna meet when you're done with the course you're gonna feel very confident in your abilities to manipulate biostatistics and we're gonna use a lot is not gonna be giving lectures you're gonna see a lot of scenarios that's how we're gonna buttress our points so let's jump into the dramatologic and also by the way I also have a integrated pathophysiology review is targeted towards step one but if you're taking step two and step three and you have a very poor foundation I have that class in October actually made a podcast on that recently okay so let's go jump into the dermatological manifestations of sarcoidosis so the dermatological manifestations as I've mentioned right the first classic one is the arithea monodosum right that usually involves like the lower extremities on exams although it can really be even in your upper extremities we usually see your lower extremities and it'll be a red it'll be a te

nder lesion right again I said that arithea monodosum is classically found in association with love grain syndrome and again it's a predictor of a good prognosis and a person that has sarcoidosis now why is this important to know well compared contrast this with lupus per new right lupus per new typically is a published lesion is typically a raised lesion and we typically find it in a lupus in a lupoint distribution right so we know that lupus commonly causes a Miller rash well this has a lupoint distribution see it around the cheeks around the nose around the forehead right and this is what's called lupus per new lupus per new is actually a predictor of poor outcomes so people that have sarcoidosis with lupus per new these people likely not do well long-term or they will just do worse than a person that has the arithea monodosum as the as the dermatological manifestation and then one of the thing about sarcoidosis that you may want to keep in mind as a dermatological manifestation is something called granuloma granuloma anulary a granuloma g-r-a-n-u l-o-m-a that's easy anulary is n-a-w-n-u-l-a-r-e granuloma granuloma anulary right it's basically like a ringed like distribution of like bumps is like in a ring anulary right anulary ring and typically that affects the hands and the feet again it's pretty common to people that have sarcoidosis now the thing is most people that have sarcoidosis that involves the skin usually need no treatment most of those things will result spontaneously within about two to four weeks but if they give you a question we're pressing has a dermatological manifestation of sarcoidosis and they want you to treat pick the answer that says to use hydroxychloroquine that's very important to know pick the answer that says to use hydroxychloroquine it's really helpful in the dermatological manifestations of sarcoidosis don't forget hydroxychloroqui

ne can cause problems with the retina so if you're gonna be taking hydroxychloroquine chronically then it's probably not a terrible idea to get like an anulary exam now sarcoidosis can obviously also torch the heart right many times when a person has cardiac sarcoidosis right they tend to have conduction problems in the heart because the granulomas can infiltrate the heart walls they can even have like an aneurysmol like dilation of the heart right of the ventricles right that's something you can certainly see in sarcoidosis and again remember sarcoidosis causes a restrictive pattern of cardiac disease like a restrictive cardiomyopathy remember most of the things that Indian ulces cause a restrictive disease of the organ the effect that will works really well for the heart right like look at all the causes of restrictive cardiomyopathy ameloidosis sarcoidosis right all those things and then also if you look at the lungs right the things that cause restrictive lung disease sarcoidosis, pneumoconylosis you know so that's like a useful rule to keep in mind for exams and then don't forget sarcoidosis can also involve the heart I mean the eyes right many times it causes U Vitis U Vitis is the most common manifestation of sarcoidosis in the eye and then sarcoidosis can even torch your nervous system or you can affect your central nervous system the probably the most common presentation you would ever see on exams for neuro sarcoidosis is a bilateral Bell's pausing right remember that's a cranium or seven problem right and you know so for those is lost to cause like a sensory like a sensory neuropathy like so cause a sensory neuropathy right and also sarcoidosis on exams can actually present us central diabetes insipidus so again those granulums can deposit in your brain if they deposit in your brain they can damage the neurons that produce it each so you're gonna have a centr

al diabetes insipidus obviously you're pressing the heart central diabetes insipidus when you give them this more pressing you're in a small lala or small lala till horizon response right because the problem the reason why they have the ADHD problem is because they have a deficiency not because they have a resistance as we see in the virtually diabetes insipidus and also it's pretty high up to know that many people that have sarcoidosis they have granulums in the liver right many people sarcoidosis have liver granulums most of those liver granulums tend to be asymptomatic right but again if the person is symptomatic and they have a liver granuluma or so dial or so deoxycolic acid it's not a horrible idea in those people right and just as again as a quick said we don't forget the things that use or so dial for an endemic exam so we said liver sarcoidosis that is symptomatic response to or so dial if a person has primary billary colonjides right remember those antimicric control antibodies that also respond to or so dial and they don't forget if a person has intra hepatic holostasis of pregnancy right that holostasis of pregnancy that also the drug of choice in that circumstance is or so dial and bread or something for or so dial is or so deoxycolic acid and then the final tip it I will just say in conclusion so I can wrap up this sarcoid discussion is that people that have sarcoidosis they can have they can have like false positive PPD tests right like their PPD tests are not particularly reliable let's just put it that way right instead of saying false positive false negative let me just say this people that have sarcoidosis may not have reliable PPD tests that's just something we want to keep out the back of your mind for exams okay so I'm gonna go ahead and stop here again I do offer one or one tutoring for all the USMAD exams step one two three complex level one tw

o three I just don't tutor OMM and then I also offer a view courses I have a 20 hour view course for step two and step three complex level two and three I teach an MBME test against strategy scores as a wildly perpure I teach a four-er by statistics board camp we actually have one to do if you want to sign up and then I also have an integrated path of physiology review for step one and for people taking step two or step three or complex two or three and obviously the class also applies to complex one if they have like poor foundations from the abysix sciences that's gonna be held in October and then I have these podcasts on the on Apple podcast Google podcasts on Spotify at least the most recent 150 if you want everything from episode one go on the website divine intervention podcasts.com if you actually have a Word Press account and subscribe you'll follow my website you get an email notification whenever I make a new podcast and then I also have a You Tube channel divine intervention USMAD podcast and videos that's where I post the videos that I make and then I also help with ER As applications done this for years I've worked with many people that are some of them are now attendants many residents in many different programs all across the country I have a pretty big network of people that I've worked with people have marching to internal medicine dermatology ENT orthopedic surgery general surgery radiology anesthesia family medicine many different disciplines I've worked with lots of IM Gs that are now successful residents so if you're interested in any of those especially like work with like rec letters personal statements the supplemental application the ER As application itself mock interviews just shoot me an email and I'll give you some more information on that and then I also have a new website so many of you listen to this podcast on a Christian and you know I've

always put I've tried at least in many of my podcast to put life lessons so many people say divine I really love your life lessons so instead of make a new website called divine intervention life lessons dot com in fact there's an Apple podcast associated with it is called the divine intervention life lessons podcast I post about two podcasts every week they were 10 or 20 minutes long each in fact we have more than a hundred right now and basically the usually post them on Friday and on Sunday usually Friday and Sunday mornings and typically you know it just uses the Bible to address a life lesson just a common problem that people face and gives a perspective on understanding the problem and also executing through that problem to conquer it and to thrive through it so hopefully you found these podcasts to be helpful thank you for listening to me I'll see you in the next podcast episode 412 have a wonderful weekend God bless you thank you

Bilateral hilar lymphadenopathy, erythema nodosum, and acute polyarthritis.

The lungs.

A restrictive pattern of lung disease.

Sarcoidosis can cause false positive or non-reliable PPD test results.

Uveitis.

Deficiency (meaning the problem is in the production of ADH, not the kidney's response).

Non-caseating granulomas.

1-$\alpha$-hydroxylase (leading to excess calcitriol).

Löfgren syndrome.

Corticosteroids (e.g., Prednisone).

Granuloma annulare.

Restrictive cardiomyopathy.

Non-caseating granulomas.

1-$\alpha$-hydroxylase (leading to excess calcitriol).

Löfgren syndrome.

Corticosteroids (e.g., Prednisone).

Granuloma annulare.

Restrictive cardiomyopathy.