Pulmonary sarcoidosis

Rheumatologic Perspectives on Sarcoidosis: Predicting Sarcoidosis-Associated Arthritis Through Comprehensive Clinical and Laboratory Assessment

Background/Objectives: The primary aim of our study was to evaluate the demographic, clinical, and laboratory characteristics of sarcoidosis patients with musculoskeletal symptoms; investigate the relationship between arthritis development and various laboratory parameters (such as vitamin D, liver enzymes, and ACE levels); and compare the sarcoidosis-associated arthritis cases with those without. We also explored the factors influencing arthritis development and the role of biopsy in diagnosing sarcoidosis within rheumatology practice. Methods: This retrospective study analyzed 147 sarcoidosis patients from 2000 to 2024, categorized by the presence (n = 45) or absence (n = 102) of arthritis. Demographic, clinical, and laboratory data, including biopsy results, were collected and compared. Results: The mean age was 56.02 ± 11.21 years, with a mean disease duration of 134.33 ± 56.98 months. Females constituted 86.4% of the cohort. All of the patients presented musculoskeletal involvement. Pulmonary involvement was present in 93.7% of cases, and extrapulmonary involvement included the skin (21.20%), the eyes (14.30%), and peripheral lymphadenopathy (10.6%). Methotrexate was the most common treatment after corticosteroids. In the arthritis group, diabetes mellitus was more frequent (p = 0.024), the GGT levels were higher (p = 0.044), and the 25-hydroxyvitamin D levels (p = 0.002) and the DLCO Adj (p = 0.039) were lower. Multivariable regression showed diabetes mellitus (p = 0.028, OR: 4.805, 95% CI: 1.025-22.518) and low 25-hydroxyvitamin D levels (p = 0.034, OR: 0.914, 95% CI: 0.841-0.993) as factors influencing arthritis development. The other parameters showed no significant differences. Conclusions: This study identified significant clinical, demographic, and laboratory differences between sarcoidosis patients with and without arthritis. The patients with sarcoidosis-associated arthritis exhibited a higher frequency of diabetes mellitus, lower levels of 25-hydroxyvitamin D, and elevated GGT levels. Additionally, the lower DLCO values in the patients with arthritis indicate a more severe impact on pulmonary function, underscoring the importance of comprehensive pulmonary evaluation in this subgroup.

An expert overview of pulmonary fibrosis in sarcoidosis

INTRODUCTION

Advanced pulmonary sarcoidosis refers to phenotypes of pulmonary sarcoidosis that often lead to significant loss of lung function, respiratory failure, or death. Around 20% of patients with sarcoidosis may progress to this state which is mainly driven by advanced pulmonary fibrosis. Advanced fibrosis often presents with associated complications of sarcoidosis including infections, bronchiectasis, and pulmonary hypertension.

AREAS COVERED

This article will focus on the pathogenesis, natural history of disease, diagnosis, and potential treatment options of pulmonary fibrosis in sarcoidosis. In the expert opinion section, we will discuss the prognosis and management of patients with significant disease.

EXPERT OPINION

While some patients with pulmonary sarcoidosis remain stable or improve with anti-inflammatory therapies, others develop pulmonary fibrosis and further complications. Although advanced pulmonary fibrosis is the leading cause of death in sarcoidosis, there are no evidence-based guidelines for the management of fibrotic sarcoidosis. Current recommendations are based on expert consensus and often include multidisciplinary discussions with experts in sarcoidosis, pulmonary hypertension, and lung transplantation to facilitate care for such complex patients. Current works evaluating treatments include the use of antifibrotic therapies for treatment in advanced pulmonary sarcoidosis.

Diagnostic and Staging Value of Serum Angiotensin-Converting Enzyme in Sarcoidosis

Objective

To investigate the diagnostic and staging value of serum angiotensin-converting enzyme (sACE) in sarcoidosis.

Methods

Patients with suspected sarcoidosis treated in the Department of Pulmonary and Critical Care Medicine of the China-Japan Friendship Hospital from 2010 to 2020 were included. The data of sACE, erythrocyte sedimentation rate (ESR), complete blood count (CBC), lung function, bronchoalveolar lavage, and biopsy were collected. The differences between the sarcoidosis group and the nonsarcoidosis group and between different stages of sarcoidosis were compared. The receiver operating characteristic (ROC) curve analysis was used for the diagnostic test of sACE in sarcoidosis.

Results

A total of 84 cases with suspected sarcoidosis were included, among which 70 cases were confirmed to be sarcoidosis by biopsy. The mean value of sACE in sarcoidosis patients was 56.61 ± 30.80 U/L, which was significantly higher than that in nonsarcoidosis patients (28.07 ± 14.11 U/L, P = 0.001). The level of sACE in sarcoidosis patients with peripheral superficial lymph nodes and multiple system involvement was significantly higher than that in intrathoracic sarcoidosis patients (P = 0.009); the percentage of lymphocytes in bronchoalveolar lavage fluid (BALF) of sarcoidosis patients was 45.39 ± 22.87%, which was significantly higher than that of nonsarcoidosis patients (P < 0.001). There was no correlation between sACE and ESR (correlation coefficient = −0.167). According to ROC curve analysis, when sACE ≥ 44.0 U/L, the sensitivity of sarcoidosis diagnosis was 61.4%, the specificity was 92.9%, and the AUC was 0.819.

Conclusion

sACE has a good specificity in the diagnosis of sarcoidosis. sACE values in patients with sarcoidosis with systemic involvement were higher than those with simple intrathoracic sarcoidosis.

Efficacy and Tolerability of Methotrexate and Methylprednisolone in a Comparative Assessment of the Primary and Long-Term Outcomes in Patients with Pulmonary Sarcoidosis

Background: There is insufficient information in the literature on the comparative efficacy and tolerability of methotrexate (MTX) and methylprednisolone (MP) in patients with pulmonary sarcoidosis in assessing primary outcomes and the relapse rate. Purpose: The aim of our study was to evaluate primary and long-term outcomes of using MTX and MP in patients with pulmonary sarcoidosis. Methods: A total of 143 patients with newly diagnosed pulmonary sarcoidosis, verified by high-resolution computed tomography (CT) data, were examined. Corticosteroid (CS) therapy was used in 97 patients using MP at a dose of 0.4 mg/kg body weight for 4 weeks, followed by a dose reduction to 0.1 mg/kg by the end of the sixth month. The total duration of CS therapy was 12 months on average. Forty-six patients were treated with MTX at a dose of 10 mg/week (28) and 15 mg/week (18) per os for 6 to 12 months. The study of the relapse rate was conducted within 12 months after the CT data normalization in 60 patients after CS therapy and in 24 after MTX treatment. Results: MP treatment was successfully completed in 68 (70.1%), and MTX in 29 (60.4%) patients. In five MP patients (5.2%) and in five (10.9%) MTX, treatment was discontinued due to serious side effects. In seven (7.2%) MP patients and ten (21.7%) MTX patients, treatment required additional therapy due to the lack of efficacy. Progression with MP treatment (17–17.5%) was more common than with MTX (2–4.3%; Chi square = 4.703, p = 0.031). Relapses after MP therapy were observed in 26 (43.3%) patients, and after MTX therapy in 2 (8.3%; Chi square = 9.450, p = 0.003). Conclusion: In patients with pulmonary sarcoidosis, MTX monotherapy does not differ significantly from MP monotherapy in terms of the level of efficacy and the rate of serious side effects. Increasing the MTX dose from 10 to 15 mg/week accelerates the rate of regression of sarcoidosis, improves treatment efficacy, and does not affect the rate of serious side effects. When using MTX, there is a significant decrease in the incidence of treatment resistance and the relapse rate.

A rare case of atypical bone marrow sarcoidosis without pulmonary involvement in a Japanese woman

Sarcoidosis is a systemic granulomatous disease of unknown origin characterised by the presence of non-caseating granulomatous lesions. Extrapulmonary sarcoidosis with bone marrow involvement is rare and even more so without pulmonary involvement. Here, we describe a case of 69-year-old woman diagnosed as having bone marrow and hepatic sarcoidosis without pulmonary involvement based on ¹⁸F-fluorodeoxyglucose positron emission tomography findings. She was successfully treated with systemic glucocorticoid therapy.

A Rare Case Study About Necrotizing Granulomatous Sarcoidosis

Sarcoidosis is a granulomatous disorder with an elusive etiology and pathogenesis. Classically, sarcoidosis is associated with non-caseating granulomas composed of mononuclear phagocytes, lymphocytes, and multinucleated giant cells. Necrotizing granulomas can also be associated with sarcoidosis but is scarcely reported in the medical literature. Necrotizing sarcoid granulomatosis is challenging to diagnose due to its rarity and similarity with other necrotizing disorders. Therefore, it is mainly considered a diagnosis of exclusion. We report one such case study, which could prompt further research to lay the course of treatment strategies for this disease. Moreover, our patient had a family history of sarcoidosis, which raises questions regarding possible genetic predisposition, and future work might help solve this medical mystery.

Renal manifestations of sarcoidosis: from accurate diagnosis to specific treatment

Sarcoidosis is a multisystem granulomatous disease characterized by epithelioid noncaseating granulomas associated with clinical and radiologic findings. The cause of this disease is still uncertain. Sarcoidosis affects mostly lungs and lymph nodes and is not usually considered a urological disease, therefore, this etiology may be overlooked in several urological disorders, such as hypercalcemia, hypercalciuria and nephrolithiasis. It affects all races and genders. This review aims to describe the urological manifestations of sarcoidosis and to elucidate how the disease may affect the management of numerous urological conditions.

Sarcoidosis: muchas caras, una enfermedad. Revisión narrativa de la literatura

La sarcoidosis es una enfermedad granulomatosa sistémica de etiología desconocida. Esta puede afectar a pacientes de todas las latitudes y edades, siendo más frecuente entre la tercera y cuarta década de la vida con un segundo pico alrededor de los 50 años en las poblaciones escandinava y japonesa. Es más frecuente en mujeres y grave en la población afrodescendiente.Los antígenos que inician esta respuesta granulomatosa son desconocidos, pero se presume que son aerotransportados por la alta frecuencia de compromiso pulmonar en esta enfermedad. Su presentación clínica abarca una amplia gama de manifestaciones, desde formas agudas y limitadas hasta el compromiso crónico con daño orgánico progresivo y muerte. Su diagnóstico se basa en la existencia de los granulomas no caseificantes en los tejidos, con la exclusión de otras enfermedades, entre ellas infección por micobacterias. 

Sarcoidosis in the Middle East

Sarcoidosis, a systemic granulomatous disease of unknown cause, has been described worldwide and in all populations with notable differences in clinical characteristics, organ involvement, disease severity, and prognosis among different ethnic and racial groups. While the exact prevalence of sarcoidosis in the Middle East is unknown, studies from various countries in the region have reported the clinical characteristics of affected patients, along with a few anecdotal reports. A search of the MEDLINE and Google Scholar databases was conducted for relevant English-language articles using the terms “sarcoidosis” and “Middle East” or “sarcoidosis” and “Arabs.” Subsequently, the names of individual countries were used as search terms, replacing “Middle East.” Overall, the clinical picture of patients with sarcoidosis in the Middle East is similar to that reported elsewhere; for example, the disease was more frequent among females and respiratory complaints were the predominant symptoms. Within the region, most patients from Oman were older and female, with arthralgia, hypercalcemia, and eye involvement being more common. Constitutional symptoms were frequent, especially among patients from Iran. Cough was more common among patients from Kuwait and Iran, while dyspnea was the predominant symptom for Saudi patients. Erythema nodosum was more common in the Turkish population. Clustering was seen in patients with Stage I and II of the disease in all countries except Oman. Apart from those in Iran, the prognosis of most patients from the Middle East was excellent.

Differential Diagnosis of Asthma

Asthma is one of the most common chronic syndromes worldwide (Moorman et al., Vital Health Stat 3(35), 2012). It is not a diagnosis but a clinical syndrome based on a constellation of signs and symptoms (Li et al., Ann Allergy Asthma Immunol 81:415–420(IIa), 1998). The classic symptoms of asthma include chest tightness, wheeze, cough, and dyspnea (Moorman et al., Vital Health Stat 3(35), 2012). The term asthma encompasses a spectrum of pulmonary diseases sharing the hallmark of reversible airway obstruction and can be classified as allergic or non-allergic (Löwhagen, J Asthma. 52(6):538–44, 2015). Asthma designated allergic is due to an immunoglobulin E (IgE)-mediated process, but as noted not all asthma is allergic in etiology (Romanet-Manent et al., Allergy 57:607–13, 2002). The differential diagnosis for asthma is broad and requires a detailed history with supportive pulmonary function tests to be properly diagnosed.

Diagnostic Yield of Transbronchial Biopsy in Comparison to High Resolution Computerized Tomography in Sarcoidosis Cases

This study aimed to evaluate the diagnostic yield of fiberoptic bronchoscopic (FOB) transbronchial biopsy and its relation with quantitative findings of high resolution computerized tomography (HRCT). A total of 83 patients, 19 males and 64 females with a mean age of 45.1 years diagnosed with sarcoidosis with complete records of high resolution computerized tomography were retrospectively recruited during the time period from Feb 2005 to Jan 2015. High resolution computerized tomography scans were retrospectively assessed in random order by an experienced observer without knowledge of the bronchoscopic results or lung function tests. According to the radiological staging with HRCT, 2.4% of the patients (n=2) were stage 0, 19.3% (n=16) were stage 1, 72.3% (n=60) were stage 2 and 6.0% (n=5) were stage 3. This study showed that transbronchial lung biopsy showed positive results in 39.7% of the stage I or II sarcoidosis patients who were diagnosed by bronchoscopy. Different high resolution computerized tomography patterns and different scores of involvement did make a difference in the diagnostic accuracy of transbronchial biopsy (p=0.007).

Stroke Presenting as a Complication of Sarcoidosis in an Otherwise Asymptomatic Patient

A stroke occurring in young patients in the absence of common risk factors needs a thorough investigation of the underlying cause to prevent its recurrence. Herein, we discuss a case of stroke with rare etiology in a 28-year-old male presenting within 30 minutes of speech difficulty and right-sided weakness. The initial triage workup showed an abnormal configuration of the P wave in the 12 lead echocardiograph (ECG) and his chest x-ray (CXR) showed mediastinal widening. His echocardiogram and chest computed tomography (CT) confirmed bilateral enlargement with restrictive cardiomyopathy and mediastinal lymphadenopathy, raising a suspicion of sarcoidosis. A cardiac positron emission tomography (PET) scan confirmed the diagnosis by showing a non-caseating granuloma. The patient was put on intravenous (IV) tissue plasminogen activator (TPA) and his National Institute of Health Stroke Scale (NIHSS) came down from 14 on admission to zero within 48 hours. Cardiac involvement in sarcoidosis is not uncommon but it presenting as stroke is extremely rare. For a young, previously healthy patient presenting as a stroke without risk factors, sarcoidosis should be considered as a differential diagnosis.

Immunology repertoire study of pulmonary sarcoidosis T cells in CD4+, CD8+ PBMC and tissue

Sarcoidosis is a systemic granulomatous disorder highly related with immune response. The diversity and stability of the immune system could be measured by hypervariable complementarity-determining region 3 (CDR3) segments of the T cell receptor (TCR). Here we used a combination of multiplex PCR and next-generation sequencing to conduct a good quality analysis of the T-cell receptor BV complementarity-determining region 3 (TCR BV CDR3) gene in peripheral blood mononuclear cells (PBMCs) from 7 sarcoidosis patients and lung sarcoidosis tissue from 6 patients. The length distribution of CDR3 sequences identified a significant difference among CD4+, CD8+ and tissue samples. The analysis of Gini coefficient, Shannon entropy and HEC number showed that they all presents in sarcoidosis tissue group clones in a more skewed manner than that of in PMBCs groups. 2 nucleotide sequences and 2 amino acid sequences were shared by all samples. The comparison of TRBV, TRBJ usage and VJ combination frequency identified 2 TRBV genes, 2 TRBJ genes differentially expressed among different groups and different higher usage and lower usage of V-J combinations between each group.

Efficacy of additional treatment with azathioprine in a patient with prednisolone-dependent gastric sarcoidosis

Gastric sarcoidosis with noncaseating granuloma is rare. Although corticosteroid produces a dramatic clinical response, it is unknown whether azathioprine show efficacy in prednisolone-dependent cases. Here, we report a case of gastric sarcoidosis in a 25-year-old man with severe epigastlargia. Gastroendoscopy revealed multiple map-like ulcerations. Histological examination showed multiple noncaseating granulomatous lesions in gastric mucosa, which were incompatible with diagnoses of Crohn's disease or tuberculosis. He was started on prednisolone at 30 mg/d, and his symptoms improved within 7-d. The prednisolone was gradually tapered by 5 mg every 2-wk, but oral azathioprine at 50 mg was added after symptoms recurred at tapered dose of 10 mg. Endoscopy 4-wk later showed healing ulcers, and, lymphocytic infiltration was absent. The efficacy of additional azathioprine in gastric sarcoidosis is not well defined. Here, we report a case of prednisolone-dependent gastric sarcoidosis that improved after additional azathioprine, and also review the literature concerning the treatment, especially for prednisolone-dependent cases.

Exhaled breath markers of alveolar macrophage activity in sarcoidosis

OBJECTIVE

Granuloma formation in sarcoidosis is dependent upon the interaction between alveolar macrophages (AMs) and a CD4+-driven TH1 response. This study aimed to measure TNF-α and calcium ion concentrations as markers of AM activity, in addition to total protein as a non-specific inflammatory marker in the exhaled breath condensate (EBC) of patients with sarcoidosis as well as control subjects.

METHODS

EBC was collected from 17 sarcoidosis patients and 23 healthy volunteers. Protein was measured by the bicinchoninic acid assay, TNF-α concentration was measured by ELISA and Ca(2+) concentration was measured by inductively coupled plasma-mass spectrometry. Conductivity of EBC was assessed using a conductivity probe.

RESULTS

Total protein concentration was significantly elevated in EBC from patients with sarcoidosis compared to control subjects (19.51 ± 4.52 vs. 10.60 ± 1.31 µg/ml, p = 0.020), as was TNF-α (3.37 ± 0.38 vs. 2.59 ± 0.40 pg/ml, p = 0.037) and conductivity (66.68 ± 16.73 vs. 36.85 ± 3.070 µS/cm, p = 0.044). EBC Ca(2+) concentration was significantly higher in healthy controls compared to patients with sarcoidosis (116.50 ± 12.19 vs. 73.88 ± 13.35 µmol/l, p = 0.018), although this was in the context of normal serum Ca(2+) in the sarcoidosis cohort.

CONCLUSIONS

Total protein and TNF-α concentrations were elevated in EBC from patients with sarcoidosis and could indicate disease activity. The reduction in EBC Ca(2+) concentrations could represent granulomatous activity in the lung.

Cutaneous sarcoidosis: an intriguing model of immune dysregulation

Sarcoidosis is a systemic granulomatous disease characterized by the presence of non-caseating granulomas. Its etiology remains obscure. A plausible hypothesis suggests that a complex interplay of host factors, infectious processes, and non-infectious environmental factors, matched with a susceptible genetic background, results in a pathway that leads to systemic granulomatous inflammation. Although presentations of sarcoidosis vary enormously, multi-organ involvement is a common feature. Cutaneous involvement occurs in about 25% of patients with protean manifestations and variable prognoses. Skin manifestations are divided into specific lesions with histopathologically evident non-caseating granulomas and nonspecific lesions arising from a reactive process that does not form granulomas. A peculiar form of cutaneous sarcoidosis is represented by sarcoidal lesions at sites of trauma that has caused scarring. The pathogenesis of scar sarcoidosis remains unknown. Scar sarcoidosis is also associated with herpes zoster infection, surgery, and tattooing. Such heterogeneous events, along with those at the sites of chronic lymphedema, thermal burns, radiation dermatitis, and vaccinations, occur on areas of vulnerable skin labeled "immunocompromised districts". Numerous options are available for the treatment of cutaneous sarcoidosis. Although corticosteroids remain the treatment of choice for initial systemic therapy, other nonsteroidal agents have proven effective and therefore useful for long-term management. Tumor necrosis factor-α antagonists such as infliximab may have a role in the treatment of cutaneous sarcoidosis, especially in refractory cases that are resistant to standard regimens. Elucidation of the relationship of sarcoidal granulomas with malignancy and immunity may facilitate a better understanding of some pathomechanisms operating in neoplastic and immunity-related disorders.

Sarcoidosis-associated pulmonary hypertension and lung transplantation for sarcoidosis

Pulmonary hypertension (PH) is a significant complication of sarcoidosis, occurring in approximately 6 to > 20% of cases, and markedly increases mortality among these patients. The clinician should exercise a high index of suspicion for sarcoidosis-associated PH (SAPH) given the nonspecific symptomatology and the limitations of echocardiography in this patient population. The pathophysiology of PH in sarcoidosis is complex and multifactorial. Importantly, there are inherent differences in the pathogenesis of SAPH compared with idiopathic pulmonary arterial hypertension, making the optimal management of SAPH controversial. In this article, we review the epidemiology, diagnosis, prognosis, and treatment considerations for SAPH. Lung transplantation (LT) is a viable therapeutic option for sarcoid patients with severe pulmonary fibrocystic sarcoidosis or SAPH refractory to medical therapy. We discuss the role for LT in patients with sarcoidosis, review the global experience with LT in this population, and discuss indications and contraindications to LT.

Diagnostic criteria for sarcoidosis

Sarcoidosis is a multiorgan system disease that often presents insidiously. The diagnosis is often made fortuitously upon routine chest radiography or that done for other reasons. Blacks are more commonly affected than whites and age of onset is typically adolescents to young adults. Lung involvement is common and symptoms may include cough, dyspnea and chest pain. Extrapulmonary symptoms may include the skin, joint and eye findings. Bilateral hilar adenopathy is the classic finding on chest radiograph. Anemia or other cell line deficiencies, elevated liver enzymes, hypercalciuria, and EKG abnormalities may also be present. Angiotensin converting enzyme levels may be elevated but are not diagnostic. Histopathological confirmation of noncaseating granulomas is essential for diagnosis. It is generally performed through a biopsy of the most peripheral site possible, although transbronchial biopsy is commonly required. Finally, other possible etiologies must be evaluated and differentiated with a particular emphasis on tuberculosis due to the multiple overlapping symptoms and findings. Newer techniques such as proteomics and transcriptional gene signatures may contribute to the understanding of the pathophysiology of sarcoidosis, and may even serve as diagnostic tools in the future.

Cutaneous sarcoidosis in a chronic hepatitis C patient receiving pegylated interferon and ribavirin therapy

A 61-year-old Japanese woman suffered from a small, painful, subcutaneous nodule on the sole of her foot that was 10 mm across in diameter during pegylated interferon (PEG IFN) and ribavirin (RBV) combination therapy for chronic hepatitis C. Skin biopsy revealed multiple non-caseating granulomas composed of epithelioid histiocytes with multinucleate giant cells, which was consistent with sarcoidosis. Ophthalmologic examination revealed uveitis. Thoracic computed tomography (CT) showed multiple bilateral hilar lymphadenopathies and a diffuse micronodular interstitial pattern of the lungs. Genetic analysis indicated a probable homozygous haplotype of A*02:01-C*15:02-B*51:01-DRB1*16:02-DQB1*05:02 in human leukocyte antigen regions. The patient was observed carefully without any additional medication because no significant systemic symptoms were noted. Combination therapy was continued for 2 months afterwards. She was asymptomatic for over 3 years of follow up, and repeated hematological and biological investigations and chest CT showed improvement. In conclusion, clinicians should bear sarcoidosis in mind as a complication during PEG IFN and RBV combination therapy. They should also be aware of the usually good prognosis of PEG IFN-induced cutaneous sarcoidosis in order not to prematurely discontinue a treatment necessary for liver disease; maintenance of PEG IFN treatment may be advised with careful follow up.

Nicotine treatment improves Toll-like receptor 2 and Toll-like receptor 9 responsiveness in active pulmonary sarcoidosis

BACKGROUND

New evidence links nicotine to the regulation of T cell-mediated inflammation via a 7 nicotinic cholinergic receptor activation, and chronic nicotine exposure (smoking) reduces the incidence of granulomatous diseases. We sought to determine whether nicotine treatment was well tolerated while effectively normalizing immune responses in patients with active pulmonary sarcoidosis.

METHODS

Consenting adults with symptomatic sarcoidosis (n 5 13) were randomly assigned to receive 12 weeks of nicotine treatment plus conventional therapy or conventional therapy alone. Obtained blood cells were evaluated for their responsiveness to selected Toll-like receptor (TLR) and nucleotide oligomerization domain-like receptor ligands and T cell surface marker expression before and after nicotine treatment. Asymptomatic patients (n 5 6) and disease-free subjects (n 5 6) served as comparative control subjects. Adverse events were monitored for the duration of the study.

RESULTS

Compared with the asymptomatic group, symptomatic patients had impaired peripheral responses to TLR2, TLR4, and TLR9 ligands (anergy) and reduced peripheral populations of CD4 1 FoxP3 1 regulatory T cells (Tregs). Nicotine treatment was associated with restoration of TLR2 and TLR9 responsiveness, and expansion of Tregs, including the CD4 1 CD25 2 FoxP3 1 phenotype. There were no serious adverse events or signs of nicotine dependency.

CONCLUSIONS

Nicotine treatment in active pulmonary sarcoidosis was well tolerated and restored peripheral immune responsiveness to TLR2 and TLR9 agonists and expansion of FoxP3 1 Tregs, including a specific “preactivated” (CD25 2 ) phenotype. The immune phenotype of patients with symptomatic sarcoidosis treated with nicotine closely resembled that of asymptomatic patients, supporting the notion that nicotine treatment may be beneficial in this patient population.

Sarcoidosis manifesting as a pseudotumorous renal mass

A 53 year-old African American woman with a three-year history of pulmonary sarcoidosis had a follow-up computed tomographic scan to evaluate the status of her disease and response to treatment. On the scan, an abnormal, hypodense mass on the left renal superior pole, which was not present on previous scans, was incidentally discovered. The initial concern was of carcinoma, despite her lack of any urinary symptoms. She underwent further evaluation with magnetic resonance, and the enhancement pattern and the shape of the mass were more suggestive of lymphoma or infarction than a carcinoma. A review of literature revealed sparse case reports demonstrating sarcoidosis presenting as infiltrative granulomatous masses resembling tumors with nonspecific imaging qualities. This diagnosis was entertained and then proven by biopsy. Pseudotumorous renal sarcoid should be in the differential of renal masses, especially in patients with a history of sarcoidosis, as it alters clinical management.

Therapeutic approach of hepatic sarcoidosis

PURPOSE OF REVIEW

Surveillance of hepatic involvement in sarcoidosis has not been standardized. Therefore, management of hepatic involvement is a clinical challenge. This review analyses published data on the pharmacological treatment of hepatic sarcoidosis.

RECENT FINDINGS

Only 5-30% of patients with hepatic sarcoidosis display symptoms. Occasionally, it has a rapid progressive course with serious complications, stressing an appropriate and carefully timed therapeutic approach. Because symptomatic hepatic sarcoidosis is uncommon, therapeutic studies are scarce. Answers to the questions when to initiate which treatment are lacking. Case reports describe beneficial effects of prednisone and the augmentation of cytotoxic and anti-tumor necrotic factor-α (TNF-α) therapy. However, because of small sample sizes, no meaningful conclusions could be drawn. In symptomatic hepatic sarcoidosis patients, it is recommended to start to treat the sarcoidosis with prednisone, preceded by ursodeoxycholic acid when signs of cholestasis are present. In refractory cases or when prednisone weaning is impossible, cytotoxic drugs or anti-TNF-α therapy should be considered.

SUMMARY

This review illustrates the importance of an appropriate therapeutic approach of sarcoidosis patients with hepatic involvement. It emphasizes the need for future studies to evaluate treatment options to avoid disease progression and hepatic complications.

Effect of smoking and gender on pulmonary function and clinical features in sarcoidosis

BACKGROUND

The effect of cigarette smoking on the clinical manifestations and progression of sarcoidosis is not well characterized. We sought to determine the effects of smoking in sarcoidosis patients and to evaluate for gender-specific differences.

METHODS

We examined the effects of cigarette smoking in 518 patients seen at the Sarcoidosis and Interstitial Lung Disease Center at Wayne State University using radiographic pattern, pulmonary function testing, and clinical features of the disease. We performed a separate analysis to evaluate for gender-specific differences based on smoking history.

RESULTS

We found that smokers had significantly lower FEV(1) and FEV(1)/FVC values. Total lung capacity was not significantly different between smokers and nonsmokers, but diffusion capacity for carbon monoxide (DL(CO)) was significantly reduced in smokers. Gender-based statistical analysis showed a marked decrease in DL(CO) values among female smokers. Smokers were also found to have a higher incidence of extrapulmonary involvement as multivariate regression analysis demonstrated that both smoking and female gender are significantly associated with the development of extrapulmonary manifestations.

CONCLUSIONS

Our data indicate that both cigarette smoking and gender are important in shaping the clinical manifestations of sarcoidosis. The nature of the gender difference requires further study and may be related to differences in inflammatory response.

Sarcoidosis: a comprehensive review and update for the dermatologist: part I. Cutaneous disease

Sarcoidosis is a common systemic, noncaseating granulomatous disease of unknown etiology. The development of sarcoidosis has been associated with a number of environmental factors and genes. Cutaneous sarcoidosis, the "great imitator," can baffle clinicians because of its diverse manifestations and its ability to resemble both common and rare cutaneous diseases. Depending on the type, location, and distribution of the lesions, treatment can prevent functional impairment, symptomatic distress, scarring, and disfigurement. Numerous therapeutic options are available for the treatment of cutaneous sarcoidosis, but there are few well designed trials to guide practitioners on evidence-based, best practice management. In part I, we review the current knowledge and advances in the epidemiology, etiology, pathogenesis, and genetics of sarcoidosis, discuss the heterogeneous manifestations of cutaneous sarcoidosis, and provide a guide for treatment of cutaneous sarcoidosis.

Chronic cough: a multidisciplinary approach

BACKGROUND AND METHODS

Chronic cough is defined as a cough persisting for more than eight weeks. This condition generates significant healthcare and economic costs. It is associated with a spectrum of disorders across multiple medical specialties and can provide significant challenges for effective evaluation and management. The current literature was reviewed to gain further insight into chronic cough, including its relationship with sinonasal disease.

RESULTS

Within the reviewed literature, there was strong emphasis on post-nasal drip syndrome as a major causative factor.

CONCLUSION

Cough is the most common complaint for which adult patients seek medical consultation in primary care settings. Chronic cough is associated with a deterioration in the quality of patients' lives. Thorough assessment of a patient with a chronic cough relies on a multidisciplinary approach.

Tumor necrosis factor-alpha inhibitor treatment for sarcoidosis

Sarcoidosis is a chronic multisystem disease of unknown etiology, characterized by noncaseating granulomatous infiltration of virtually any organ system. Treatment is often undertaken in an attempt to resolve symptoms or prevent progression to organ failure. Previous studies have suggested a prominent role for tumor necrosis factor-alpha (TNF-α) in the inflammatory process seen in sarcoidosis. TNF-α and interleukin-1 are released by alveolar macrophages in patients with active lung disease. Corticosteroids have proved to be efficacious in the treatment of sarcoidosis, possibly by suppressing the production of TNF-α and other cytokines. Three agents are currently available as specific TNF antagonists: etanercept, infliximab, and adalimumab. Although data from noncomparative trials suggest that all three have comparable therapeutic effects in rheumatoid arthritis, their effects in a granulomatous disease such as sarcoidosis are less consistent. In this review, current data on the effectiveness are summarized.

Profile of respiratory problems in patients presenting to a referral pulmonary clinic

Analysis of OPD data of 2012 patients in a referral pulmonary clinic at Kolkata was done following a protocol-based approach. Obstructive airway diseases (COPD and asthma) were the most common (43%) problem followed by infective lung diseases (15%) including tuberculosis, bronchogenic carcinoma (8%), ILD (4%), haemopty-sis of undiagnosed etiology (4.5%), chronic cough of undiagnosed etiology (6.5%) and pleural diseases (4.6%). Other diseases like obstructive sleep apnoea, sarcoid-osis, systemic diseases with lung involvements etc., and non respiratory problems formed the rest (14.4%).

Cytological diagnosis of sarcoidosis revisited: a state of the art review

Diagnosis of sarcoidosis has never been an easy task. This is primarily because there is no single diagnostic test that can clinch the diagnosis. Demonstration of granulomas remains an essential criteria, but as granulomatous inflammation can be seen in host of conditions, it is necessary to exclude all possible causes, as well as to correlate with other findings, before arriving at the diagnosis of sarcoidosis. Cytology has been used effectively since the last few decades in demonstration of granulomas in various organs. Recent developments in various fields of cytodiagnosis of sarcoidosis including transesophageal ultrasound-guided fine-needle aspiration and endobronchial ultrasonograpy-guided transbronchial needle aspiration have revolutionized this field. These techniques are safe, minimally invasive, and give real-time information during aspiration. In comparision to the conventional methods, these allow easier sampling and have better sensitivity. In addition to these methods, a variety of ancillary techniques are also utilized and are reviewed here.

Using TNF-alpha antagonist adalimumab for treatment for multisystem sarcoidosis: a case study

We report the usage of the TNF-alpha antagonist adalimumab in patients with progressive multisystem sarcoidosis. Three patients with multisystem sarcoidosis (MSS) were treated with adalimumab for 12 months. All three patients were quickly responded to adalimumab and experienced a nearly complete regression of the symptoms that lead to an intensive immunosuppression. However, some accompanying symptoms of sarcoidosis, such as splenomegalia, did not respond. One patient suffered 18 months later a new unspecified abdominal lymphadenopathy. TNF-alpha antagonists can be helpful agents in the treatment for MSS. However, the experience with TNF-alpha antagonists in patients with sarcoidosis is still limited. Multicenter trials and a comparison of the different agents are needed to validate the safety and efficacy in these patients. Optimal dosage, duration of therapy and long-term toxicity of anti-TNF therapy in patients with refractory sarcoidosis are yet to be determined in prospective trials.

Immune response CC chemokines CCL2 and CCL5 are associated with pulmonary sarcoidosis

Background

Pulmonary sarcoidosis involves an intense leukocyte infiltration of the lung with the formation of non-necrotizing granulomas. CC chemokines (chemokine (C-C motif) ligand 2 (CCL2)-CCL5) are chemoattractants of mononuclear cells and act through seven transmembrane G-coupled receptors. Previous studies have demonstrated conflicting results with regard to the associations of these chemokines with sarcoidosis. In an effort to clarify previous discrepancies, we performed the largest observational study to date of CC chemokines in bronchoalveolar lavage fluid (BALF) from patients with pulmonary sarcoidosis.

Results

BALF chemokine levels from 72 patients affected by pulmonary sarcoidosis were analyzed by enzyme-linked immunosorbent assay (ELISA) and compared to 8 healthy volunteers. BALF CCL3 and CCL4 levels from pulmonary sarcoidosis patients were not increased compared to controls. However, CCL2 and CCL5 levels were elevated, and subgroup analysis showed higher levels of both chemokines in all stages of pulmonary sarcoidosis. CCL2, CCL5, CC chemokine receptor type 1 (CCR1), CCR2 and CCR3 were expressed from mononuclear cells forming the lung granulomas, while CCR5 was only found on mast cells.

Conclusions

These data suggest that CCL2 and CCL5 are important mediators in recruiting CCR1, CCR2, and CCR3 expressing mononuclear cells as well as CCR5-expressing mast cells during all stages of pulmonary sarcoidosis.

The role of tumor necrosis factor alpha G-308A polymorphisms in the course of pulmonary sarcoidosis

This study was designed to evaluate the relationship between the presence of tumor necrosis factor (TNF) polymorphisms, human leukocyte antigen (HLA)-DRB1*03 linkage and the prognosis of sarcoidosis. In a retrospective case-control study, TNF-alpha G-308A, TNF-alpha G-238A, lymphotoxin-alpha (LTA) and HLA-DRB1*03 were genotyped in 625 sarcoidosis patients. These patients were classified into 298 patients with persistent disease and 327 patients with non-persistent disease using chest X-ray (CXR) appearances and lung function parameters after at least 2 years of follow-up. The TNF-alpha-308A variant allele was observed in 25.5% of patients with persistent disease compared with 44.0% of patients with non-persistent disease. The corresponding odds ratio (OR) was 0.43 with a 95% confidence interval (CI) of 0.30-0.61. A strong linkage was found between TNF-alpha G-308A and HLA-DRB1*03 (OR = 0.03, 95% CI: 0.02-0.05). For TNF-alpha G-238A and LTA NcoI A252G, there were no statistically significant differences in the distribution of genotypes between the groups with and without persistent disease. The data indicate that presence of a TNF-alpha-308A variant allele and HLA-DRB1*03 were associated with a favorable prognosis. Because of the strong linkage between TNF-alpha G-308A and HLA-DRB1*03, genotyping of one simple and less expensive TNF-alpha single nucleotide polymorphism can be used to predict the prognosis of pulmonary sarcoidosis in clinical practice.

Asymptomatic stage I sarcoidosis complicated by pulmonary tuberculosis: a case report

INTRODUCTION

Sarcoidosis is a multisystem granulomatous disorder characterized pathologically by the presence of non-caseating granulomas in involved tissues. Depressed cellular immunity predisposes patients to infections with certain intracellular organisms, mostly fungi, Mycobacterium tuberculosis and Nocardia species. As these infections are mainly insidious and difficult to differentiate from the underlying disease, a possible misdiagnosis may lead to fatal complications for the patient.

CASE PRESENTATION

We present a case of a 67-year-old woman with undiagnosed asymptomatic stage I sarcoidosis for at least 8 years before her admission and a 1-month history of fever, exertional dyspnea and dry cough, in whom pulmonary tuberculosis was documented.

CONCLUSION

This case highlights the need for great vigilance among physicians in order to rule out any possible infection before establishing the diagnosis of sarcoidosis.

[Clinical utility of transbronchial needle aspiration of mediastinal lymph nodes in the diagnosis of sarcoidosis in stages I and II]

OBJECTIVE

To analyze the individual and combined diagnostic yield and clinical utility of transbronchial needle aspiration and transbronchial biopsy in the histologic diagnosis of sarcoidosis in stages I and II.

PATIENTS AND METHODS

We performed a prospective study enrolling all the patients admitted to our hospital between July 2001 and June 2006 with mediastinal lymph nodes of a diameter of over 10 mm and clinical and radiological indication of sarcoidosis. The patients underwent the following tests in the order specified: a transbronchial needle aspiration of 1 or more lymph nodes using a 19-gauge histology needle until 2 satisfactory specimens were obtained, a bronchoalveolar lavage, and 4 to 6 transbronchial biopsies.

RESULTS

A total of 32 patients were enrolled during the study period. Of these, 26 were finally diagnosed with sarcoidosis. The mean (SD) age of the patients was 38.9 (10.6) years and there were 13 women (50%). The mean (SD) lymph node diameter was 23.5 (6.5) mm. The most common lymph node aspiration sites were the subcarinal station (9 patients, 34.6%) and a combination of the subcarinal and paratracheal stations (7 patients, 26.9%). Computed tomography scans of the chest revealed parenchymal involvement in 12 (46.2%) patients. Fifteen (57.7%) patients were diagnosed by transbronchial biopsy and 16 (61.5%) by transbronchial needle aspiration. These techniques were used in isolation in 7 (26.9%) and 8 (30.8%) patients, respectively (P>.05). Diagnosis was achieved with the combined results of transbronchial biopsy and needle aspiration in 23 (88.4%) patients. Overall, the diagnostic yield of the combined techniques was significantly higher than that of either one in isolation (P=.01 vs transbronchial biopsy and P=.02 vs needle aspiration). In patients with parenchymal involvement, yield was better for the combined techniques only in comparison with transbronchial biopsy (P=.01). Only 4 (15%) patients developed complications and 20 (76.9%) tolerated the procedures well.

CONCLUSIONS

Diagnostic yield was significantly higher when transbronchial biopsy and transbronchial needle aspiration were used in combination than when used alone, particularly in patients without parenchymal involvement. There were few complications and tolerance was good.

Clinical presentation of sarcoidosis in a mixed population in the middle east

BACKGROUND

Regional and ethnic differences in the presentation and prognosis of sarcoidosis have been reported.

OBJECTIVES

To describe and compare the clinical characteristics of sarcoidosis among Arabs and South East Asians (SEA).

METHODS

Data on patients with sarcoidosis were collected retrospectively 1983-1995 and prospectively 1995-2003.

RESULTS

A total of 142 patients, 57% females and 80% Arabs, were identified. The age at onset shows the majority of cases (45%) among Arab males occur at 30-39 years, 60% of Arab females occur at 40-59 years and 61% of SEA males occur at 40-49 years. The most common symptoms were cough 77.5%, dyspnoea 54.2%, fever 31.0%, arthralgia 19%, uveitis 14.8%, erythema nodosum 14.8%, and lymphadenopathy 12%. The radiological stage at presentation was stage 0,2.1%, I,44.4%, II,42.3%, and III,11.3%. The frequency of either stage 0 or I was higher among SEA (62%) compared to Arabs 42.5%, p=0.05.

CONCLUSION

There is a peak of sarcoidosis among Arab males at 30-39 years, Arab females at 40-59 years and SEA males at 40-49 years. Arab patients presented more frequently with either stage II or III compared to SEA who usually present with stage 0 or I.

Mediastinal lymph node amyloidosis in a patient with sarcoidosis

A 27-year-old male patient presented with respiratory symptoms, bilateral enlargement of the cervical lymph nodes and enlarged liver. In the imaging studies, bilateral enlargement of the hilar nodes was observed, together with pulmonary infiltrate. The patient was submitted to lung and liver biopsies, which revealed noncaseating granulomas. The clinical, radiological and histopathological findings were consistent with sarcoidosis and lymph node amyloidosis. The combination of sarcoidosis and amyloidosis has rarely been reported.

Pattern of ocular manifestations in patients with sarcoidosis in developing countries

PURPOSE

Sarcoidosis is increasingly diagnosed in developing countries, although it was earlier thought to be uncommon. We describe the pattern of ocular manifestations in sarcoidosis in India.

METHODS

A total of 48 consecutive patients with histologically confirmed sarcoidosis, referred to a teaching university hospital, underwent a detailed ophthalmological examination, irrespective of whether they had eye symptoms or not.

RESULTS

Ocular involvement was seen in 14 (29%) patients. The mean age at presentation was 50 years, and neither two peaks of incidence nor a female preponderance could be demonstrated. The majority of patients had chronic disease. Posterior uveitis was distinctly more common (12/14) than anterior (5/14) uveitis. Conjunctival involvement was uncommon. These findings differ from those reported in the Western literature.

CONCLUSIONS

Eye involvement is common in sarcoidosis in India and may occur without ocular symptoms. Posterior segment involvement is more common than has been reported. Ophthalmologists need to be aware of ocular involvement in this disease as untreated disease can have significant visual consequences.

Steroid-resistant sarcoidosis: is antagonism of TNF-alpha the answer?

Steroid-resistant sarcoidosis has conventionally been treated with various drugs, including methotrexate, azathioprine, cyclophosphamide, cyclosporine, antimalarial drugs and thalidomide, with variable success. There is a compelling need for more efficient and safer alternatives to these agents. Several lines of evidence suggest a critical role of TNF-alpha (tumour necrosis factor-alpha) in the initiation and organization of sarcoid granulomas. Inhibition of TNF-alpha with monoclonal antibodies has therefore received attention as a potential treatment option in therapy-resistant sarcoidosis. A number of case reports and small case series describe successful treatment of refractory disease with infliximab. Preliminary evidence from an RCT (randomized controlled trial) with infliximab in pulmonary sarcoidosis suggests a modest improvement in functional and radiological parameters. In contrast, the results with etanercept have been disappointing, perhaps related to differences in the mechanism of TNF-alpha blockade. The experience with adalimumab in sarcoidosis is too limited to draw conclusions. An open-label study and an RCT evaluating the efficacy of adalimumab in sarcoidosis with pulmonary and cutaneous involvement respectively, have been initiated. Although TNF-alpha antagonists appear relatively safe, especially when compared with conventional agents, caution is warranted in view of the increased incidence of tuberculosis, which may be a particular diagnostic challenge in patients with sarcoidosis. Pending publication of the RCTs, the use of TNF-alpha blockade in sarcoidosis should remain in the realm of experimental treatment.