Background/Purpose: Sarcoidosis is a multisystem disease characterized by the formation of non-caseating granulomas with lungs being predominantly affected and the joints in up to 40%. Acute joint manifestations occur in 25-40% of patients and are often self-limited with only 1-4% of patients developing a more chronic arthritis, requiring more aggressive therapy, due to persistence or progression. We previously reported an increased incidence of sarcoidosis among Fire Department of the City of New York (FDNY) firefighters prior to 9/11/01 and an even higher incidence after World Trade Center (WTC) exposure. We now describe a series of FDNY firefighters who developed sarcoidosis following WTC rescue/recovery work with severe chronic polyarthritis as a significant component of their disease.

Methods: All FDNY WTC-exposed firefighters with polyarticular sarcoidosis are followed jointly by the WTC Health Program at FDNY and the Rheumatology Division at the Hospital for Special Surgery (HSS). Patient demographics, WTC-exposure information, smoking status, date of diagnosis, and pulmonary findings were obtained from FDNY’s WTC database. Joint findings (symptoms, duration, distribution of joints involved, treatments, and response) were obtained from HSS chart review.

Results: 11 male firefighters developed polyarticular arthritis after WTC-exposure; 2 had been diagnosed with sarcoidosis pre-9/11/01. All were never smokers and arrived at the WTC-site within 2 weeks after 9/11/01. Their median age was 37.7 years (IQR = 31.6-40.8), with a median of 6.9 years (IQR=4.4-13.2) of FDNY firefighting service pre-9/11/01. All had biopsy-proven pulmonary sarcoidosis, 9 by transbronchial or mediastinal lymph node biopsy, 1 by liver and bone biopsy and 1 by Kveim testing. All had normal pulmonary function tests at presentation. Duration from WTC-exposure to diagnosis of pulmonary sarcoidosis was 7.7 years (IQR=5.8-9.5). Polyarticular arthritis 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, polyarticular arthritis occurred after WTC exposure, 5 and 10 years after their initial diagnosis.  Polyarthritis was symmetrical, involving large joints (n=1), small and large joints (n=10) and ankles (n=10). All had normal ESR and CRP; negative anti-CCP and Quantiferon or PPD. Only one had a positive RF and all but two had normal ACE levels. All required additional disease modifying agents for steroid sparing (stepwise progression from hydroxychloroquine->methotrexate->TNF-blocking agent). Adequate disease control was obtained with hydroxychloroquine (n=1); methotrexate (n=3); and anti-TNF agents (n=6).

Conclusion: Chronic polyarthritis appears to be an important manifestation of sarcoidosis in FDNY firefighters with sarcoidosis and WTC-exposure. Their arthritis appears to be chronic and most have not responded adequately to oral DMARDs, generally necessitating the addition of anti-TNF agents. Further studies are needed in order to determine the generalizability of these findings to other groups with varying levels of WTC-exposure or with non-WTC environmental/occupational exposures.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/sarcoid-arthritis-in-world-trade-center-exposed-new-york-city-firefighters-presenting-as-a-unique-clinical-subset/