A 36-year-old woman has a dry cough and mild exertional dyspnoea. Chest radiograph shows symmetric bilateral hilar lymphadenopathy with fine reticulonodular infiltrates. Transbronchial biopsy shows non-caseating granulomas. Pulmonary function tests are essentially normal and she has no ocular, cardiac, neurological, or cutaneous involvement, with normal calcium. What is the most appropriate management?
- A Methotrexate as steroid-sparing first-line therapy
- B Prednisolone 40 mg/day tapered over 12 months
- C Observation without treatment, with periodic reassessment ✓
- D Infliximab induction therapy
Explanation
Asymptomatic or minimally symptomatic pulmonary sarcoidosis with preserved lung function does not require treatment, because up to two thirds of patients undergo spontaneous remission and corticosteroids do not alter long-term outcome in this group. Oral corticosteroids are reserved for progressive symptoms, declining lung function, or involvement of eyes, heart, nervous system, or hypercalcaemia. Methotrexate and infliximab are second-line agents for refractory or chronic disease, never first-line. The key fact is that radiographic stage alone, even stage II, is not an indication for drugs.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.