ATS: Guideline for Sarcoidosis Diagnosis and Detection

The American Thoracic Society has developed its first official clinical practice guideline for the diagnosis and detection of sarcoidosis. 

Included in the guideline are 14 recommendations and 1 best practice statement on lymph node sampling, screening for extrapulmonary disease, and diagnostic evaluation of suspected extrapulmonary disease.

“The diagnosis of sarcoidosis is not standardized but is based on 3 major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in 1 or more tissue samples, and the exclusion of alternative causes of granulomatous disease,” the authors wrote. “There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure.”

After conducting systemic reviews and meta-analyses of the best available evidence, the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability of various diagnostic tests for patients with suspected or known sarcoidosis. In turn, the panel made 1 strong recommendation, 13 conditional recommendations, and 1 best practice statement.

The strong recommendation is that baseline serum calcium testing should be used to screen for abnormal calcium metabolism among patients with sarcoidosis who do not have symptoms or signs of hypercalcemia.

The best practice statement is that the need for right heart catheterization should be determined on a case-by-case basis for patients with sarcoidosis in whom pulmonary hypertension (PH) is suspected and a transthoracic echocardiogram is not suggestive of PH.

The 13 conditional recommendations include the following:

  • Do not sample lymph nodes in patients for whom there is a high clinical suspicion for sarcoidosis. 
  • Consider using endobronchial ultrasound-guided lymph node sampling rather than mediastinoscopy as the initial mediastinal and/or hilar lymph node sampling procedure for patients with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy for whom it has been determined that tissue sampling is necessary.
  • Perform a baseline eye examination to screen for ocular sarcoidosis among patients with sarcoidosis who do not have ocular symptoms.
  • Perform a baseline complete blood cell count test to screen for hematological abnormalities among patients with sarcoidosis.
  • Use cardiac magnetic resonance imaging rather than positron emission tomography or transthoracic echocardiography (TTE) to obtain both diagnostic and prognostic information for patients with extracardiac sarcoidosis and suspected cardiac involvement.
  • Conduct initial testing with TTE in patients with sarcoidosis in whom PH is suspected.


All evidence was very-low quality. According to the authors, this reflects the need for additional high-quality research to guide clinical practice.

—Colleen Murphy


Crouser ED, Maier LA, Wilson KC, et al; American Thoracic Society Assembly on Clinical Problems. Diagnosis and detection of sarcoidosis. an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;201(8). doi:10.1164/rccm.202002-0251ST