This retrospective study is the first to evaluate sarcoidosis patients infected with SARS‑CoV‑2. Our results did not show a significant association between sarcoidosis and mortality. Yet, the risk of intubation and mechanical ventilation or in-hospital mortality was highest in patients with moderately and/or severely impaired pulmonary function (aOR 7.8). Interestingly, we were unable to identify in any other COVID-19 studies, data that correlate severity in pulmonary function with adverse COVID-19 outcomes.
In keeping with previous studies, [2,3,4] age, male sex, cardiovascular disease, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease and obesity were risk factors for intubation and mechanical ventilation or in-hospital mortality.
While it is not surprising that 95% of the sarcoidosis patients exhibited lung involvement,  it is intriguing that 35.1% of these patients manifested skin disease (excluding Erythema Nodosum). The scientific rationale for this finding is unclear. The finding may reflect that the Mount Sinai Health System is a tertiary referral center for sarcoidosis patients, most of whom suffer from chronic manifestations of disease, such as those in the skin.
Interestingly, nearly one half (48.6%) of the sarcoidosis patients were not taking systemic anti-inflammatory therapy at the time of their infection. Of the 19 patients who were receiving these medications, 29.7% were taking a daily dose of prednisone of ≤ 15 mg and 5 were taking a weekly dose of methotrexate (≤ 15 mg). Among the remaining 3 patients, one was taking Mycophenolate, Azathioprine and Infliximab (5 mg/kg every 6 weeks), respectively.
Unfortunately, our study was underpowered to determine whether the use of systemic anti-inflammatory therapies, which were received at the time of infection, was associated with an adverse outcome. It is remarkable to note, however, that the sarcoidosis cohort consisted of patients who were not our most clinically complex/severe or chronically ill patients. Only 9 patients were being treated for active pulmonary sarcoidosis and 14/37 (37.8%) demonstrated impaired pulmonary function. Similarly, only 4 patients exhibited cardiac involvement. Typically, cardiac sarcoidosis is treated with moderate or high doses of systemic anti-inflammatory therapy [9,10,11,12]. It is reasonable to hypothesize that treatment with higher doses of these therapies may predispose patients to infection with SARS-CoV-2.
There are several limitations to our study. First, it is a retrospective study and, therefore, subject to selection bias. The number of patients with sarcoidosis was small. As a result, it is debatable whether our conclusions may be generalizable to all sarcoidosis patients. While sarcoidosis is a rare disease, we expected that our cohort would be larger . The small size of our cohort could be attributed to several factors. It is conceivable that sarcoidosis, which is characterized by a hyperimmune, highly polarized Th1 response, may protect against the development of COVID-19. Alternatively, sarcoidosis patients, many of whom are medically underserved, did not have adequate access to COVID testing . Additional studies are needed to explore these hypotheses.
Our study is also hindered by missing pulmonary function data. Most of the sarcoidosis patients received their diagnosis more than 10 years prior to the diagnosis of COVID and, therefore, did not regularly undergo pulmonary function testing before the SARS-CoV-2 infection. Finally, the absence of pulmonary function data diminished the statistical power needed to precisely determine whether an adverse outcome was associated with moderate or severe deficits in obstruction, restriction and/or gas exchange.
These limitations notwithstanding, our study is the first to evaluate sarcoidosis patients infected with SARS‑CoV‑2. It confirms that sarcoidosis patients with COVID-19 are more likely to require mechanical ventilation and die if they have pre-existing moderate and/or severe impairment in pulmonary function. The results of our study may provide a foundation for future prospective studies, which further examine outcomes in sarcoidosis patients infected with SARS‑CoV‑2.