Background Sarcoidosis is characterized by multisystem granulomatous inflammation, predominantly of the lungs. Acute joint manifestations occur in 25–40% of cases and are usually self-limited with only 1–4% developing chronic arthritis. We previously reported a high incidence of sarcoidosis among Fire Department of New York (FDNY) firefighters, prior to 9/11/01, which further increased after World Trade Center (WTC) exposure. We now describe a series of FDNY firefighters who developed sarcoidosis following WTC rescue work, with severe chronic polyarthritis as a significant component of their disease.
Objectives To provide insight into the potential role of environmental exposures on the development of Sarcoidosis and chronic inflammatory polyarthritis.
Methods All FDNY WTC-exposed firefighters with Sarcoidosis and chronic inflammatory arthritis (n=11) are followed jointly by the WTC Health Program at FDNY and the Rheumatology Division at the Hospital for Special Surgery (HSS). Diagnosis of Sarcoidosis was based on clinical, radiographic and pathologic criteria. Alternative diagnoses were excluded. Patient demographics, WTC-exposure, smoking and pulmonary data were obtained from FDNY's WTC database. Data on arthritis characteristics, radiographic findings, treatments and response were obtained from HSS chart review. Descriptive analysis was performed.
Results 11 male firefighters (10 White and 1 Black) developed polyarthritis after WTC-exposure; 2 were diagnosed with sarcoidosis pre-9/11/01. All were never smokers and arrived at the WTC-site within 2 weeks after 9/11/01. Median age: 37.7 years (IQR=31.6–40.8), median firefighting service duration, pre-9/11/01: 6.9 years (IQR=4.4–13.2). All had biopsy-proven pulmonary sarcoidosis and normal pulmonary function tests at presentation. Duration from WTC-exposure to diagnosis of pulmonary sarcoidosis: 7.7 years (IQR=5.8–9.5). Polyarthritis was part of the initial presentation in 9 patients who developed sarcoidosis post-9/11/01. In 2 patients with pre-9/11/01 sarcoidosis, polyarthritis occurred after WTC exposure, 5 and 10 years after initial diagnosis. Polyarthritis was symmetrical, involving large (n=1), small and large (n=10), and ankle joints (n=10). No erosions on available Xrays (n=4). All had normal ESR and CRP, negative Quantiferon or PPD. All had negative anti-CCP and RF but one with low positive RF; all but two had normal ACE levels. All required steroid sparing agents (stepwise progression from hydroxychloroquine to methotrexate to TNF-blockers). Adequate disease control was obtained with hydroxychloroquine (n=1); methotrexate (n=2); no therapy (n=1); Infliximab (n=2); Adalimumab (n=4); Etanercept (n=1).
Conclusions Chronic polyarthritis is an important manifestation of sarcoidosis in FDNY firefighters with previous WTC exposure. Their arthritis is chronic and most did not respond adequately to oral DMARDs with 7/11 (64%) necessitating the addition of anti-TNF agents. Further studies are needed to determine the generalizability of these findings to other groups with varying levels of WTC exposure or with non-WTC environmental exposures.
Disclosure of Interest : None declared
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