## Diagnosis: Pulmonary Sarcoidosis The clinical presentation of bilateral hilar lymphadenopathy, non-caseating granulomas on biopsy, elevated ACE, and hypercalcemia is pathognomonic for sarcoidosis—a systemic granulomatous inflammatory disorder of unknown etiology. ## First-Line Treatment **Key Point:** Corticosteroids (prednisolone or prednisone) are the gold standard first-line therapy for symptomatic sarcoidosis with pulmonary or systemic involvement. **High-Yield:** Indications for corticosteroid therapy in sarcoidosis include: - Progressive pulmonary disease (declining FEV₁, worsening symptoms) - Systemic manifestations (hypercalcemia, neurological involvement) - Symptomatic disease affecting quality of life **Clinical Pearl:** Prednisolone 0.5–1 mg/kg/day (typically 20–40 mg/day) is initiated, then gradually tapered over weeks to months based on clinical and radiological response. Most patients show improvement within 4–8 weeks. ## Why Prednisolone Is Superior | Feature | Prednisolone | Azathioprine | Methotrexate | Infliximab | |---------|--------------|--------------|--------------|------------| | **Onset** | Rapid (days–weeks) | Slow (weeks–months) | Slow (weeks–months) | Rapid but reserved | | **Evidence** | Level 1A (RCTs) | Second-line steroid-sparing | Second-line steroid-sparing | Refractory cases only | | **Role** | First-line monotherapy | Adjunct/steroid-sparing | Adjunct/steroid-sparing | Refractory/TNF-driven | **Mnemonic:** **SARCOID** management = **S**teroids first, **A**zathioprine/MTX add-on, **R**efractory → **C**ytokine inhibitors, **O**ther causes ruled out, **I**nvestigate systemic, **D**rug-sparing taper. [cite:Harrison 21e Ch 329]
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