Controversias en neuroinmunología: esclerosis múltiple, vacunación, SARS-CoV-2 y otros dilemas / Controversies in neuroimmunology: multiple sclerosis, vaccination, SARS-CoV-2 and other dilemas

La neuroinmunología es una disciplina que cada vez amplía más sus horizontes en la comprensión de las enfermedades neurológicas. Contemporáneamente, y a la luz de los nexos fisiopatológicos de las enfermedades neurológicas y la inmunología, se han planteado enfoques diagnósticos y terapéuticos específicos. A pesar de los importantes avances de esta disciplina, existen múltiples dilemas que le conciernen y se filtran en la práctica clínica. En esta revisión, se presentan y discuten 15 controversias, las cuales se construyen con la información clínica disponible más actualizada. Los temas incluidos son: disminución de esteroides en recaídas de esclerosis múltiple; recomendaciones terapéuticas en esclerosis múltiple a la luz de la pandemia por el SARS-CoV-2; evidencia de vacunación en esclerosis múltiple y en otras enfermedades desmielinizantes; panorama actual del síndrome clínico y radiológico aislado; y fallas terapéuticas en esclerosis múltiple; además, criterios para suspender las terapias modificadoras de la enfermedad; evidencia del manejo en recaídas leves; recomendaciones para la profilaxis contra Strongyloides stercolaris; utilidad de un segundo ciclo de inmunoglobulina en el síndrome de Guillain-Barré; criterios para diferenciar una polineuropatía crónica desmielinizante inflamatoria de inicio agudo de un síndrome de Guillain-Barré y, utilidad de la enzima convertidora de angiotensina en neurosarcoidosis. En cada una de las controversias, se presenta la problemática general y se ofrecen recomendaciones específicas que pueden adoptarse en la práctica clínica diaria.

Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time, and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis; therapeutic recommendations in MS in light of the SARS-CoV-2 pandemic; evidence of vaccination in multiple sclerosis and other demyelinating diseases; overview current situation of isolated clinical and radiological syndrome; therapeutic failure in multiple sclerosis, as well as criteria for suspension of disease-modifying therapies; evidence of the management of mild relapses in multiple sclerosis; recommendations for prophylaxis against Strongyloides stercolaris; usefulness of a second course of immunoglobulin in the Guillain-Barré syndrome; criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus Guillain-Barré syndrome; and, the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented, and specific recommendations are offered that can be adopted in daily clinical practice.

Reacción granulomatosa de tipo sarcoideo secundaria a biopolímeros: reporte de caso y revisión de la literatura / Biopolymer sarcoid-like foreign-body granulomas: Case report and literature review

La alogenosis iatrogénica es la enfermedad causada por la aplicación de biopolímeros con fines estéticos. Sus manifestaciones clínicas pueden presentarse entre las seis horas y los 30 años posteriores a la aplicación, con síntomas locales o sistémicos. El principal rasgo de la histopatología es la presencia de granulomas por cuerpo extraño con reacción de tipo sarcoideo, la cual es difícil de Interpretar por su asociación con la sarcoidosis. Se reporta aquí el caso de una paciente con lesiones granulomatosas de tipo sarcoideo por reacción a cuerpo extraño, secundaria a la aplicación de múltiples sustancias desconocidas en cara y glúteos.

Iatrogenic allogenosis is a disease caused by the injection of biopolymers with esthetic purposes. Clinical manifestations can occur between six hours and 30 years after the procedure with local and/or systemic symptoms. The pathological findings are characterized by the presence of foreign body granulomas with a sarcoid-like reaction. Its Interpretation Is difficult given Its association with sarcoidosis. We report the clinical case of a female patient with granulomatous lesions In reaction to a foreign body secondary to the multiple application of unknown substances on the face and buttocks.

Differential Diagnoses of Diseases Involving the Extrinsic Ocular Musculature ­ A Pictorial Essay

Introduction There are some inflammatory, infectious, and neoplastic diseases affecting the extrinsic orbital musculature (EOM) that present with pain, decreased visual acuity, and proptosis. Imaging is fundamental to the differential diagnoses of these diseases with similar clinical presentations. The present case series report has as main objective to illustrate and discuss the main pathologies that affect the orbit. Material and Methods The present series of cases discusses the main pathologies that can affect the extraocular musculature that can be characterized by computed tomography (CT) or magnetic resonance imaging (MRI) using cases from our institution. Results and Discussion The present study compiled several cases of ophthalmopathy from our institution to illustrate and address some of these pathologies, such as orbital lymphoma, Grave disease, metastases, periorbital cellulitis, and idiopathic orbital inflammatory syndrome. The diseases are discussed according to the presentation of clinical cases with emphasis on the main imaging findings of each pathology. Conclusion Computed tomography and MRI can help in the diagnosis and follow-up of the diseases that affect the EOM. We must be conversant with the main characteristics of the pathologies presented in the present case series report, since such findings together with clinical data can confirm the diagnosis of these diseases or at least help to narrow the differential diagnoses.

Diagnóstico de sarcoidosis mediante el uso del Ultrasonido endoscópico bronquial (EBUS) / Diagnosis of sarcoidosis by use of bronchial endoscopic bronchial ultrasound (EBUS)

La sarcoidosis es una enfermedad multisistémica presente a nivel mundial que se caracteriza por el compromiso pulmonar y mediastinal en la mayoría de los pacientes. Para confirmar el diagnóstico, es importante contar con una biopsia que demuestre granulomas no caseificantes y la exclusión de otros diagnósticos diferenciales. Por lo tanto, la selección del método diagnostico para la confirmación histológica juega un rol fundamental en estos pacientes. Es así como, en los últimos años, el ultrasonido endoscópico bronquial (EBUS) ha mostrado ser un método seguro y con un alto rendimiento diagnóstico que debe considerarse en el abordaje de esta patología cuando existe compromiso mediastinal.

Sarcoidosis is a multisystemic disease present worldwide that is characterized by pulmonary and mediastinal involvement in most patients. To confirm the diagnosis, it is important to have a biopsy showing non-caseating granulomas and the exclusion of other differential diagnoses. Therefore, the selection of the diagnostic method for histological confirmation plays a fundamental role in these patients. Thus, in recent years, endoscopic bronchial ultrasound (EBUS) has shown to be a safe method with a high diagnostic yield that should be considered in the approach to this pathology when there is mediastinal involvement.

Pacientes con compromiso orbitario y renal: Diagnósticos diferenciales poco frecuentes / Patients with orbitary and kidney commitment: Rare differential diagnoses

Se comunica una serie de tres casos clínicos que consultaron al servicio de Reumatología por compromiso orbitario y renal. Uno de ellos presentó pseudotumor orbitario con proteinuria en rango nefrótico; se realizó biopsia y se encontró infiltrado linfoplasmocitario denso y fibrosis estoriforme con inmunohistoquímica: 15 células IgG4+ por campo de alto poder y relación IgG/IgG4 ≤40%, concluyendo diagnóstico de enfermedad relacionada por IgG4. El segundo y tercer caso presentaron compromiso ocular con "ojos de mapache" y lesiones amarillentas en párpados, ambos con proteinuria >500 mg/24 h, con biopsia de piel rojo Congo positiva y birrefringencia verde manzana con luz polarizada. Se discuten distintos diagnósticos diferenciales poco frecuentes a tener en cuenta en estos pacientes.

A series of three cases that consulted the rheumatology service due to orbital and renal involvement is reported. One of them presented orbital pseudotumor with proteinuria in the nephrotic range, a biopsy was performed, finding dense lymphoplasmacytic infiltrate and storiform fibrosis with immunohistochemistry: 15 IgG4 positive cells per HPF and IgG/IgG4 ratio ≤40%, concluding diagnosis of IgG4 related disease. The second and third cases presented ocular involvement with raccoon eyes and yellowish lesions on the eyelids, both with proteinuria greater than 500 mg/24 h, with apple-green birefringence of amyloid on congo red staining. Different rare differential diagnoses to take into account in these patients are discussed.

Sarcoidosis con compromiso cutáneo casuística del Servicio de Dermatología del Hospital Nacional- período 2010-2020 / Sarcoidosis with skin engagement casuistics of the National Hospital Dermatology Service - period 2010-2020

Introducción: La sarcoidosis es una enfermedad inflamatoria, granulomatosa de etiología desconocida. Puede afectar cualquier órgano siendo la afectación pulmonar la más frecuente. La piel se compromete en aproximadamente 30% de los casos, pudiendo ser inicial o único. La sarcoidosis es muy rara en el Paraguay. Objetivos: Realizar una revisión de los casos de sarcoidosis observados en el Servicio de Dermatología del Hospital Nacional en el periodo 2010-2020; determinando sus características demográficas, clínicas, laboratoriales y evolutivas. Materiales y métodos: Estudio retrospectivo, descriptivo y observacional. Resultados: Se diagnosticaron 5 casos, todas mujeres de raza blanca, con edades que oscilaban de 41 a 63 años. Las formas clínicas fueron papulosa en 3 casos, en placa 1 y mixta 1. Las lesiones cutáneas eran asintomáticas y estaban ubicadas preferentemente en rostro (4 casos). El compromiso sistémico se objetivó en las primeras consultas en 2 casos (pulmonar, ocular y ganglionar en 1 y del aparato lagrimal en otro). En todos los casos el diagnóstico se fundamentó en la correlación clínico-histológica, con el hallazgo de los granulomas sarcoides. Todos recibieron clobetasol tópico, 3 pacientes ciclos de prednisona y 2 hidroxicloroquina. La evolución fue favorable en 3 casos y 2 no volvieron a sus controles. Conclusión: La sarcoidosis con manifestaciones cutáneas es rara en nuestro Servicio, pero representa un desafío diagnóstico, que debe ser oportuno para diferenciarla de otras patologías más prevalentes en nuestro medio

Introduction: Sarcoidosis is an inflammatory, granulomatous disease of unknown etiology. It can affect any organ, lung involvement being the most frequent. The skin is compromised in approximately 30% of the cases, and can be initial or unique. Sarcoidosis is very rare in Paraguay. Objectives: To carry out a review of the sarcoidosis cases observed in the Dermatology Service of the National Hospital in the period 2010-2020; determining their demographic, clinical, laboratory and evolutionary characteristics. Materials and methods: Retrospective, descriptive and observational study. Results: 5 cases were diagnosed; all white women; with ages ranging from 41 to 63 years. The clinical forms were papular in 3 cases, in plate 1 and mixed 1. The skin lesions were asymptomatic and were preferably located on the face (4 cases). Systemic involvement was observed in the first consultations in 2 cases (pulmonary, ocular and lymph node in 1 and the lacrimal apparatus in another). In all cases the diagnosis was based on the clinical-histological correlation, with the finding of sarcoid granulomas. All received topical clobetasol, 3 patients received prednisone cycles and 2 hydroxychloroquine. The evolution was favorable in 3 cases and 2 did not return to their controls. Conclusion: Sarcoidosis with skin manifestations is rare in our Service, but it represents a diagnostic challenge that must be timely to differentiate it from other more prevalent pathologies in our setting

Sarcoidosis Mimicking Skull Base Meningioma

Sarcoidosis is a systemic disease characterized by granulomatous inflammation. Pulmonary and lymphatic granulomatous involvement are common.We present a rare case report of involvement of the central nervous system affecting the ocular region and mimicking optic nerve sheath meningioma. We report the case of a 79-year-old female patient with progressive visual impairment with an evolution of 4 years. Amagnetic resonance imaging scan of the cranium with gadolinium and intense homogeneous contrast enhancement revealed an expansive lesion in the right optic nerve, at the height of the optic canal. The patient was submitted to the neurosurgical approach with lesion biopsy, which showed sarcoidosis of the central nervous system. Due to the rarity of central nervous system involvement, the diagnosis of this pathologymay unfortunately be postponed. The present article aims to elucidate this pathology as a differential diagnosis of retro-orbital tumors.

Sarcoidosis / Sacoidosis

Introducción: La sarcoidosis es un desorden multisistémico de causa desconocida. El curso de la enfermedad es variable, puede ser asintomático con resolución espontánea o progresar con fallo orgánico llegando incluso a la muerte. Objetivo: Describir el protocolo diagnóstico ante la sospecha de sarcoidosis. Presentación del caso: Se presenta un caso clínico con varios síntomas y signos aparentemente no relacionados entre sí, en el que se implementa un algoritmo descrito en la literatura foránea. Conclusiones: La interdisciplinariedad fue necesaria para el correcto manejo de este caso, en la cual los internistas como moderadores fueron fundamentales pues permitió una visión integral del enfermo(AU)

Introduction: Sarcoidosis is a multisystemic disorder of unknown cause. The course of the disease is variable, it can be asymptomatic with spontaneous resolution or progress with organ failure, even death. Objective: To describe the diagnostic protocol for suspected sarcoidosis. Case report: A clinical case is report here with several apparently unrelated symptoms and signs, in which an algorithm described in foreign literature is implemented. Conclusions: Interdisciplinarity was necessary for the correct management of this case, in which internists as moderators were fundamental because it allowed a comprehensive vision of the patient(AU)

Sarcoid-like granulomatous myositis-associated hypercalcemia. An infrequent case to consider / Hipercalcemia asociada a miositis granulomatosa sarcoidea simil- sarcoidea. Un caso infrecuente a considerar

Abstract PTH-independent hypercalcemia due to granulomatous disease is well-documented and sarcoidosis is the most characteristic disease, although there are others. We describe a case of sarcoid-like granulomatous myositis. An 87-year-old man was referred with tetraparesis and hypercalcemia (albumin-corrected calcium of 13.4 mg/dl) following a trip to the Caribbean. The evaluation showed a suppressed PTH, 25-hydroxy vitamin D of 7.5 ng/ml, 18F-FDG PET/CT showed markedly increased uptake in intercostal, back, shoulder, but tock and thigh muscles and a deltoid biopsy confirmed extensive granulomatous myositis. He was prescribed glucocorticoids which resulted in normalized plasma calcium levels and complete recovery from tetraparesis. Sarcoid-like granulomatous myositis should be incorporated into the differential diagnosis of PTH-independent hypercalcemia, especially in the absence of clinical features of sarcoidosis and with special emphasis on the use of 18F-FDG PET/CT to ensure a correct approach.

Resumen La hipercalcemia PTH-independiente asociada a enfermedades granulomatosas está bien documentada y la sarcoidosis es la enfermedad más característica, a pesar de que existen otras. Des cribimos un caso de miositis granulomatosa simil-sarcoidea. Un hombre de 87 años consultó por tetraparesia e hipercalcemia (calcio corregido por albúmina 13.4 mg/dl) luego de un viaje al Caribe. La evaluación mostró una PTH suprimida, 25-hidroxivitamina D 7.5 ng/ml, 18F-FDG PET/CT mostró marcado aumento de captación a nivel de musculatura intercostal, dorsal, deltoidea, glúteos y muslos. Una biopsia deltoidea confirmó una miositis granulomatosa extensa. Se prescribieron glucocorticoides, resultando en normalización del calcio plasmático y completa recuperación de la tetraparesia. La miositis granulomatosa simil-sarcoidea debe ser incorporada den tro del diagnóstico diferencial de la hipercalcemia PTH-independiente, especialmente en ausencia de hallazgos clínicos de sarcoidosis y con especial énfasis en el uso de 18F-FDG PET/CT para su correcta aproximación.

MRI-based differentiation between lymphoma and sarcoidosis in mediastinal lymph nodes / Diferenciação entre linfoma e sarcoidose em linfonodos mediastinais por RMN

ABSTRACT Objective: Evaluation of enlarged mediastinal lymph nodes is crucial for patient management. Malignant lymphoma and sarcoidosis are often difficult to differentiate. Our objective was to determine the diagnostic accuracy of MRI for differentiating between sarcoidosis and malignant lymphoma. Methods: This was a retrospective study involving 47 patients who underwent chest MRI and were diagnosed with one of the diseases between 2017 and 2019. T1, T2, and diffusion-weighted signal intensity were measured. Apparent diffusion coefficients (ADCs) and T2 ratios were calculated. The diagnostic performance of MRI was determined by ROC analysis. Results: Mean T2 ratio was significantly lower in the sarcoidosis group than in the lymphoma group (p = 0.009). The T2-ratio cutoff value that best differentiated between lymphoma-related and sarcoidosis-related enlarged lymph nodes was 7.1, with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 58.3%, 95.6%, 76.5%, 93.3%, and 68.7%, respectively. The mean ADC was significantly lower in the lymphoma group than in the sarcoidosis group (p = 0.002). The ADC cutoff value that best differentiated between lymphoma-related and sarcoidosis-related enlarged lymph nodes was 1.205, with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 87.5%, 82.6%, 85.1%, 84.0% and 86.3%, respectively. No significant differences were found between the two groups regarding T1 signal intensity, T2 signal intensity, and lymph node diameter. Conclusions: MRI parameters such as ADC, diffusion, and T2 ratio can be useful in the differentiation between sarcoidosis and lymphoma in the evaluation of enlarged lymph nodes.

RESUMO Objetivo: A avaliação de linfonodomegalias mediastinais é crucial para o manejo dos pacientes. O linfoma maligno e a sarcoidose costumam ser difíceis de diferenciar. Nosso objetivo foi determinar a precisão diagnóstica da RMN para diferenciar sarcoidose de linfoma maligno. Métodos: Estudo retrospectivo com 47 pacientes submetidos a RMN de tórax e diagnosticados com uma das doenças entre 2017 e 2019. Foi medida a intensidade do sinal em T1, T2 e difusão. Foram calculados o coeficiente de difusão aparente (ADC, do inglês apparent diffusion coefficient) e a razão T2. O desempenho diagnóstico da RMN foi determinado pela análise da curva ROC. Resultados: A média da razão T2 foi significativamente menor no grupo sarcoidose que no grupo linfoma (p = 0,009). A razão T2 = 7,1 foi o melhor valor de corte para diferenciar linfonodomegalias relacionadas com linfoma daquelas relacionadas com sarcoidose, com sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e precisão de 58,3%, 95,6%, 76,5%, 93,3% e 68,7%, respectivamente. A média do ADC foi significativamente menor no grupo linfoma que no grupo sarcoidose (p = 0,002). O ADC = 1,205 foi o melhor valor de corte para diferenciar linfonodomegalias relacionadas com linfoma daquelas relacionadas com sarcoidose, com sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e precisão de 87,5%, 82,6%, 85,1%, 84,0% e 86,3%, respectivamente. Não houve diferença significativa entre os grupos quanto à intensidade do sinal em T1, intensidade do sinal em T2 e diâmetro dos linfonodos. Conclusões: Parâmetros de RMN como ADC, difusão e razão T2 podem ser úteis na diferenciação entre sarcoidose e linfoma na avaliação de linfonodomegalias.

Sarcoidosis asociada a panuveítis en el área de un tatuaje: Reporte de caso / Sarcoidosis associated with panuveitis in the area of a tattoo: Case report

RESUMEN Antecedentes: la sarcoidosis es una de las reacciones cutáneas asociadas con los tatuajes. Lo más frecuente es que se presente una afección sistémica; dentro de ésta, el compromiso por uveítis y las reacciones sarcoidales asociadas a los tatuajes han sido poco descritas. Caso clínico: hombre de 27 años con cuadro clínico de seis meses de evolución constituido por malestar general, fiebre subjetiva, escalofríos, mialgias, artralgias, tos con expectoración hemoptoica y edema en los miembros inferiores. Se encontró ojo izquierdo rojo, disminución de la agudeza visual y pápulas que infiltraban uno de los tatuajes que se había realizado seis meses antes en el brazo derecho y antebrazo izquierdo. Conclusión: la sarcoidosis asociada a los tatuajes es una condición que requiere de un alto índice de sospecha; donde la infiltración del tatuaje debe hacer pensar al clínico en el diagnóstico para realizar la búsqueda activa del daño orgánico visceral, mucho más en un paciente con uveítis que puede llevar a la ceguera. Aunque inusual, existe esta triple asociación: tatuaje, sarcoidosis sistémica y panuveítis.

SUMMARY Background: One of the cutaneous reactions associated with tattoos is sarcoidosis and the most frequent presentation is systemic involvement; within this, the manifestation of uveitis and sarcoidal reactions associated with tattoos is little described. Clinical case: A 27-year-old man with a clinical picture of six months of evolution consisting of general malaise, subjective fever, chills, myalgias, arthralgias, cough with hemoptysis, edema in lower limbs, and in whom red eye, diminution of visual acuity, and papules that infiltrated one of the tattoos that were placed, six months earlier, on the right arm and left forearm, were found. Conclusion: Sarcoidosis associated with tattooing is a disease that requires a high index of suspicion, where its infiltration should make the clinician suspect the disease and make an active search for systemic involvement, especially in a patient with a uveal compromise that can lead to blindness. It must keep in mind that, although rare, this triple association is possible (tattoo, systemic sarcoidosis, and panuveitis).

Sarcoidose como diagnóstico diferencial de mieloma múltiplo / Sarcoidosis as a differential diagnosis of multiple myeloma

A sarcoidose caracteriza-se como doença granulomatosa que acomete diferentes órgãos humanos, especialmente os pulmões, sendo sua patogênese pouco conhecida. No caso em questão, a paciente iniciou com sintomas inespecíficos, como fraqueza, perda ponderal e tosse seca esporádica, sendo internada para extensão da propedêutica. Sugeriu-se como hipótese diagnóstica inicial possível quadro de mieloma múltiplo, tendo em vista a anemia, a disfunção renal, a hipercalcemia e, sobretudo, as lesões osteolíticas apresentadas pela paciente. Todavia, o diagnóstico de sarcoidose foi selado a partir das biópsias de medula óssea e de linfonodo inguinal, que evidenciaram mielite e linfadenite granulomatosas, respectivamente. A terapêutica instituída baseou-se na administração de corticosteroides e em medidas de redução da calcemia. A paciente recebeu alta, com melhora do quadro clínico, para acompanhamento ambulatorial da doença. Conclui-se que a sarcoidose não possui tratamento curativo, mas a terapêutica imunossupressora é eficaz no controle da progressão da enfermidade, fazendo com que o paciente tenha um prognóstico favorável.

Sarcoidosis is characterized as a granulomatous disease that affects different human organs, especially the lungs, and its pathogenesis is little known. In this case, the patient started with nonspecific symptoms, such as weakness, weight loss, and sporadic dry cough, being hospitalized for extension of the propaedeutics. The initial diagnostic hypothesis suggested was a possible case of multiple myeloma, based on the anemia, renal dysfunction, hypercalcemia and, above all, the osteolytic lesions presented by the patient. However, the diagnosis of sarcoidosis was made after bone marrow and inguinal lymph node biopsies that showed granulomatous myelitis and lymphadenitis, respectively. The therapy instituted was based on the administration of corticosteroids and on measures to reduce the level of calcium. The patient was discharged, with clinical improvement, for outpatient follow-up of the disease. It is concluded that sarcoidosis has no curative treatment, but immunosuppressive therapy is effective in controlling the progression of the disease, giving the patient a favorable prognosis.

Síndrome sarcoidosis-linfoma. Presentación de 2 casos clínicos / Sarcoidosis-lymphoma syndrome. Presentation of 2 clinical cases

RESUMEN La combinación de sarcoidosis y linfoma (síndrome sarcoidosis-linfoma) es una asociación poco frecuente pero reconocida en el ámbito clínico. Algunas manifestaciones pueden ser comunes entre estas entidades, por lo que es un reto para el clínico diferenciar cada enfermedad por separado o si coexisten en un mismo individuo. En este último escenario, ni las manifestaciones clínicas ni los parámetros de laboratorio son específicos, por lo que es necesario un análisis minucioso de cada caso, apoyado de laboratorios, imágenes e histopatología para llegar a un diagnóstico certero. Se presentan 2 casos de síndrome sarcoidosis-linfoma y se analizan los aspectos clave en el diagnóstico de esta forma clínica.

ABSTRACT The combination of sarcoidosis and lymphoma (sarcoidosis-lymphoma syndrome) is a rare but recognised clinical condition. Some manifestations may be common among these conditions, making it a challenge for the clinician to differentiate each disease separately, or if they coexist in the same individual. In this latter scenario, neither the clinical manifestations nor the laboratory parameters are specific, so a meticulous analysis of each case is necessary, supported by laboratory and imaging tests, and histopathology in order to obtain an accurate diagnosis. Two cases of sarcoidosis-lymphoma syndrome are presented, and an analysis is presented on the key aspects in the diagnosis of this clinical condition.

Symptomatic cholelithiasis may be the first sign of sarcoidosis

SUMMARY Sarcoidosis is a multisystemic noncaseating granulomatous disease that rarely affects the gastrointestinal system. The initial diagnosis of sarcoidosis with gallbladder/gallbladder-associated lymph node involvement is a very rare condition in the literature. Herein, we aimed to report a case of newly diagnosed sarcoidosis with lymph node involvement associated with the gallbladder.

RESUMO A sarcoidose é uma doença granulomatosa multissistêmica não-caseosa que raramente afeta o sistema gastrointestinal. O diagnóstico inicial de sarcoidose com envolvimento de linfonodo da vesícula biliar ou associado à vesícula biliar é muito raro na literatura. Aqui, o nosso objetivo foi relatar um caso de sarcoidose recém-diagnosticado com envolvimento de linfonodos associados à vesícula biliar.

PET-CT: Signos radiológicos en el Síndrome Sarcoidosis-Linfoma: Reporte de un caso y revisión / PET-CT: Radiologic signs in Sarcoidosis-Lymphoma Syndrome: Case Reporte and review

El síndrome sarcoidosis-linfoma es una entidad clínica a la cual se puede llegar de distintas formas a su diagnóstico. Algunas de las mismas suelen ser atípicas. Para estos casos complejos, la tomografía por emisión de positrones (PET) combinado con un escáner de tomografía computarizada de rayos X (CT), (PET-CT) es definitorio para llegar posteriormente a la biopsia. Se presenta un caso clínico de nuestro grupo que da lugar a la revisión/puesta al día correspondiente.

Sarcoidosis-lymphoma syndrome is a clinical entity that can be diagnosed in different ways. Some of them are atypical. For these complex cases, positron emission tomography (PET) combined with an X-ray computed tomography (CT) scanner (PET-CT) is definitive for subsequent biopsy. A clinical case of our group is presented, which leads to the corresponding revision/update.