Sarcoidosis

Guidance for medical examiners when assessing a patient for either a general topic or condition - sarcoidosis.

Definition

This guidance applies to applicants Sarcoidosis affecting any organ system, whether active or quiescent.

Aeromedical implications 

Effect of aviation on condition

• Fatigue
• Sleep deprivation
• Increased cardiac workload during stressful phases of flight
• Hypoxic, hypobaric, low relative humidity flight environment

Effect of condition on aviation

• Overt incapacitation
  • distracting pain
  • acute shortness of breath
  • pulmonary embolism
  • heart failure
  • arrhythmia
  • seizure
  • sudden death
• Cognitive impairment
• Vision impairment
• Fatigue.

Effect of treatment on aviation

• Neuropsychological impairment secondary to steroid treatment
• Risk of infection

Approach to medical certification

Based on the condition

• Confirmed diagnosis
• Absence of significantly impaired respiratory, ocular, neurological, renal or cardiac involvement
• Reports and investigations will be dependent upon if primarily pulmonary sarcoidosis or if there is extrapulmonary involvement

Based on treatment

• Acceptable, stable treatment without significant side effects

Demonstrated stability

• Adequate period of grounding before new aviation medical assessment until demonstrated stability and absence of symptoms or complications
• Absence of symptoms eg shortness of breath

Risk assessment protocol - information required

New cases

CASA requires a report from the treating specialist(s) - eg. Respiratory physician, Cardiologist, Ophthalmologist etc, depending on organ involvement. The report(s) should detail:

• Confirmed diagnosis
• Clinical status
  • symptoms such as breathlessness, pain, palpitations, visual disturbance, neurological symptoms, etc.
  • progress
• Investigation reports (for relevant affected organ systems)
  • Respiratory
    • chest x-ray
    • spirometry
    • histopathology report
    • blood test results
    • If clinically indicated, full pulmonary function testing, diffusion capacity, blood gases
  • Cardiac
    • ECG
    • Echocardiogram with ejection fraction
    • 24 or 48 hour Holter
    • If clinically indicated, stress test
  • Ophthalmic
    • slit lamp examination
    • tonometry
    • results of computerised visual field plot
• Other investigations if clinically indicated
  • cardiac MRI
  • cardiac stress test
  • CT-KUB
  • montreal Cognitive Assessment (MOCA)
  • high resolution CT of lungs
• Management
  • treatment
  • side-effects
• Proposed monitoring and follow-up plan. Please detail periodic investigations required.

Renewal for confirmed disease

CASA requires a report from the doctor monitoring the applicant's sarcoidosis. CASA will require further reports from other specialists if other organs are involved. The specialist report should detail:

• Clinical status
  • symptoms such as breathlessness, pain, palpitations, visual disturbance, neurological symptoms, etc.
  • involvement of critical target organs e.g. brain, heart, lungs, kidneys
  • progress
• Investigations conducted as recommended by specialist, e.g.
  • pulmonary function test, including spirometry and DLCO
  • chest x-ray, if clinically indicated
  • relevant blood tests
  • ECG
  • 24 or 48 hour Holter
  • DAO or CO report with slit lamp examination, tonometry and results of computerised visual field plot
• Management
  • treatment
  • side-effects
• Proposed monitoring and follow-up plan.

Indicative outcomes

• Initial notification to CASA and grounding until demonstrated stability and absence of symptoms or complications
• Unrestricted certification is possible if asymptomatic with absence of or risk of significant impairment

Favourable

• Absence of significant symptoms
• Disease control. (NB Prednisolone equivalent daily dose acceptable at 10mg or less if tolerated)
• Absence of side-effects from treatment
• Absence of cardiac, ocular, neurological or renal involvement

Unfavourable

• Dyspnoea at rest
• Pulmonary hypertension
• Any calculi in the collecting system (irrespective of location) or ureteric obstruction
• Visual disturbance
• Overlapping visual field defect.
• Headache, seizure, ataxia, cognitive impairment, etc
• Evidence of rhythm disturbance
• LV ejection fraction <50% or significant abnormality of wall motion on echocardiogram
• Implantable Cardiac Defibrillator
• Treatment

Pilot and controller information

• Annual review will be required for a minimum of 3 years after diagnosis (as >50% remission during this period). Ongoing annual review after 3 years will be dependent upon extent of organ involvement
• Multi-crew restriction may be required for pilots
• An Implantable Cardiac Defibrillator is considered safety relevant
• Treatment may impact the ability to exercise the privileges of your medical certificate. Be advised that Prednisolone up to 10mg daily may be acceptable on a case by case basis