Pulmonology focuses on diagnosing and treating lung and airway conditions such as asthma, COPD, and pneumonia, as well as overall respiratory health.
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Diagnosing sarcoidosis means ruling out other diseases and confirming certain findings. There is no single blood test that can confirm it. Instead, doctors use a mix of symptoms, scans, and tissue samples. The best way to diagnose sarcoidosis is to have symptoms and scan results that fit, find non-caseating granulomas in a biopsy, and make sure no other disease explains the findings. At Liv Hospital, a team of specialists works together to ensure the diagnosis is correct and to rule out other conditions, such as tuberculosis or lymphoma.
Imaging tests are very important for finding and tracking sarcoidosis.
Chest X-ray Staging
The chest X-ray (sarcoidosis CXR) is often the first tool used. Sarcoidosis is classically staged based on chest X-ray patterns:
Computed Tomography (CT)
A high-resolution CT scan of the chest provides much greater detail than an X-ray. It can reveal the characteristic distribution of granulomas along the lymphatic vessels (perilymphatic distribution) and detect subtle fibrosis or airway involvement. It is crucial to evaluate patients with respiratory symptoms using regular chest X-rays.
To be sure of the diagnosis, doctors usually need a tissue sample.
Bronchoscopy and EBUS
Bronchoscopy is the most common method for obtaining tissue in pulmonary sarcoidosis. The physician inserts a flexible tube into the airways to obtain lung tissue biopsies (transbronchial biopsy) or lymph node biopsies. Endobronchial Ultrasound (EBUS) allows the physician to visualize and sample the mediastinal lymph nodes through the bronchial wall with high precision and safety.
Other Biopsy Sites
If the disease presents with skin lesions or enlarged peripheral lymph nodes, these are often easier and safer biopsy sites than the lungs. The key finding the pathologist looks for is the non-caseating granuloma, a tight collection of immune cells without a necrotic center—and the absence of foreign bodies or infectious organisms within the sample.
Testing how well the lungs work is important to see how much the disease is affecting them.
Spirometry and Diffusion Capacity
Spirometry measures how much air a patient can inhale and exhale. Sarcoidosis typically causes a restrictive pattern (reduced lung volume) due to stiffness from granulomas or fibrosis. Occasionally, it can cause obstruction when granulomas block the airways. The diffusing capacity of the lung for carbon monoxide (DLCO) is often reduced, indicating that the transfer of oxygen from the air sacs to the blood is impaired.
Exercise Testing
Cardiopulmonary exercise testing can uncover limitations in gas exchange that may not be apparent at rest. It helps evaluate the cause of unexplained dyspnea in patients with seemingly normal resting lung function.
Blood tests help doctors diagnose sarcoidosis and monitor disease activity.
ACE Levels
Angiotensin-Converting Enzyme (ACE) is produced by the granulomas. Elevated serum ACE levels are found in about 60-70% of patients with active disease. However, a normal ACE level does not rule out sarcoidosis, and an elevated level is not diagnostic on its own; it is a marker of disease burden rather than a definitive diagnostic tool.
Calcium and Organ Function
Blood tests check for hypercalcemia (high calcium) and kidney function (creatinine, BUN). Liver enzyme tests (AST, ALT, Alkaline Phosphatase) evaluate liver involvement. A complete blood count may show lymphopenia (low lymphocyte count) or anemia.
Because heart sarcoidosis can be life-threatening, it is very important to check for heart involvement.
ECG and Echocardiogram
All patients should have an electrocardiogram (ECG) to look for conduction abnormalities or arrhythmias. An echocardiogram assesses the heart’s structure and pumping function.
Advanced Cardiac Imaging
If symptoms or initial tests suggest heart involvement, a Cardiac MRI or a PET scan (FDG-PET) is performed. These advanced imaging modalities can visualize inflammation and scarring in the heart muscle, confirming the diagnosis of cardiac sarcoidosis.
Since sarcoidosis can affect the eyes without causing symptoms, everyone with the disease should have a thorough eye exam.
Slit-Lamp Examination
An ophthalmologist uses a slit-lamp microscope to examine the front and back of the eye for signs of uveitis, iris nodules, or inflammation. This screening should be done at the time of diagnosis and annually thereafter.
To diagnose sarcoidosis of the nervous system, doctors use specialized scans and tests of the cerebrospinal fluid.
MRI of the Brain and Spine
Magnetic Resonance Imaging (MRI) with contrast is the test of choice for detecting granulomas in the brain, meninges, or spinal cord. It can show enhancement of the meninges or lesions within the brain parenchyma.
Lumbar Puncture
A spinal tap may be performed to analyze the cerebrospinal fluid (CSF) for signs of inflammation, such as elevated protein or white blood cells, and to rule out infections.
Ruling out other possible diseases is a careful and important part of diagnosing sarcoidosis.
Ruling Out Infection
Stains and cultures for tuberculosis and fungi must be negative. In some cases, molecular testing (PCR) is used to ensure no genetic material from these pathogens is present.
Ruling Out Environmental Disease
A detailed occupational history is taken to rule out berylliosis (caused by beryllium exposure) or hypersensitivity pneumonitis (caused by organic dusts), which can look identical to sarcoidosis under the microscope.
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CT scans use X-rays to create detailed cross-sectional images and are excellent for visualizing kidney stones, detecting tumors, and evaluating traumatic injuries. They are fast and widely available. MRI uses strong magnetic fields and radio waves to produce detailed images of soft tissues, making it superior for staging prostate cancer, evaluating bladder wall invasion, and assessing pelvic floor disorders without ionizing radiation.
Contrast dye, usually iodine-based, is injected into a vein to highlight the blood vessels and urinary tract organs. As the kidneys filter the dye from the blood, it opacifies the urine. This allows the radiologist to see the internal structure of the kidneys, the ureters, and the bladder clearly, revealing blockages, tumors, or structural abnormalities that would be invisible on a non-contrast scan.
Multiparametric MRI is an advanced imaging technique that combines standard anatomical sequences with functional sequences like Diffusion-Weighted Imaging and Dynamic Contrast-Enhanced imaging. This provides a comprehensive assessment of the prostate, allowing doctors to distinguish between benign conditions like BPH and significant prostate cancer, and to guide targeted biopsies.
CT scans do involve exposure to ionizing radiation, which carries a small theoretical risk of cellular damage over time. However, modern CT scanners use dose-modulation technology to minimize this exposure to the lowest level necessary for a diagnostic image. The benefit of an accurate and timely diagnosis for serious urological conditions typically far outweighs the minimal risk of radiation.
Many modern orthopedic implants are MRI-safe, although they may cause some image distortion. However, older pacemakers, defibrillators, and certain metal clips may be unsafe in the strong magnetic field. It is critical to inform the imaging team of any metallic implants so they can verify their safety compatibility or recommend an alternative test like a CT scan.
