Multidisciplinary approach and long-term follow-up in a series of 640 consecutive patients with sarcoidosis: Cohort study of a 40-year clinical experience at a tertiary referral center in Barcelona, Spain

Incidence, prevalence, and mortality of sarcoidosis in England: a population-based study

Background

The epidemiology of sarcoidosis in England is largely uncharted, with no population-level prevalence data and outdated incidence and mortality estimates. Our objective was to investigate contemporary trends in incidence, prevalence, and mortality.

Methods

This cohort study used primary care data from the UK Clinical Practice Research Datalink (CPRD), linked to secondary-care and national death registration. Patients aged ≥18 with sarcoidosis were identified using primary care codes. Age-and-sex standardised incidence and prevalence were calculated. Standardised mortality ratios (SMRs) compared mortality with the general population. A matched non-sarcoidosis cohort was constructed within CPRD, and Poisson regression compared all-cause mortality between incident cases and controls.

Findings

Between 2003 and 2023, 18,554 incident sarcoidosis patients were identified. The age- and sex-standardised incidence per 100,000 person-years increased from 6.65 in 2003 to 7.73 in 2023, with the most pronounced rise occurring between 2010 and 2016. Incidence rose notably among males and those over 60-year-olds. Sarcoidosis prevalence increased from 167 to 230 per 100,000 individuals. The age-and-sex standardised all-cause mortality rate was 12.2 per 1000 patients in 2023. Elevated mortality was observed in males [SMR: 1.8 (1.7-1.8)] and females [SMR: 2.1(2.0-2.2)], particularly in those aged 30-70 years old. Regression models indicated higher all-cause mortality in the incident sarcoidosis cohort compared to controls [adjusted mortality rate ratio 1.36 (95% CI 1.27-1.44)].

Interpretation

Sarcoidosis incidence has increased during the study period, with shifts in age-and-sex distribution and excess mortality risk. Recognising this burden is key to refining healthcare policies, optimising resources and improving patient outcomes.

Funding

None.

Sarcoidosis Treatment Patterns in the United States: 2016-2022

BACKGROUND

There are limited US Food and Drug Administration-approved medications and real-world data on sarcoidosis treatment in the United States. Concordance of practice patterns with guideline recommendations have not been well characterized.

RESEARCH QUESTION

What are the practice patterns and factors associated with treatment for patients with sarcoidosis in the year following diagnosis?

STUDY DESIGN AND METHODS

A retrospective analysis was conducted of patients with sarcoidosis from 2016 to 2022 using a multicenter, all-payer claims database (TriNetX). Treatments with corticosteroids and/or nonsteroidal immunosuppressive medications (methotrexate, mycophenolate, leflunomide, hydroxychloroquine, cyclophosphamide, infliximab, adalimumab, azathioprine, rituximab, and Janus kinase inhibitors) within 1 year of diagnosis were ascertained. We summarized treatment rates and sequence of prescribed medications by mean rank, and used multivariable logistic regression analyses to identify factors associated with treatment.

RESULTS

Of 13,330 patients with sarcoidosis meeting inclusion, 5,671 (42.5%) received treatment within 1 year of diagnosis. Of those treated, 60% received steroids alone, 13% received nonsteroidal immunosuppressives alone, and 27% received both. Furthermore, 25% of treated patients received a nonsteroidal immunosuppressive as their first medication. Corticosteroids had the lowest mean rank order, indicating they were, on average, the first medication initiated. Among those with pulmonary or cutaneous involvement, the second medication initiated, on average, was hydroxychloroquine; in those with cardiac or neurologic involvement, it was adalimumab and mycophenolate, respectively. Factors associated with higher odds of treatment were Black race, organ involvement at baseline (pulmonary, cardiac, and neurologic), and comorbid diagnoses (fatigue, hypercalcemia, and interstitial lung disease).

INTERPRETATION

Within the first year of diagnosis, 43% of patients with sarcoidosis were started on treatment. Nonsteroidal immunosuppressives were used in 40% of treated patients. Although factors associated with treatment initiation aligned with guideline recommendations, practice patterns of treatment were variable, particularly in choice and sequence of nonsteroidal immunosuppressive therapy, underscoring the need for future trials and comparative effectiveness studies.

Seasonal variation in Swedish sarcoidosis patients with severe hypercalcemia

Sarcoidosis associated hypercalcemia (SAHC) is a challenging clinical problem as it can result in severe morbidity. Sunlight exposure and conversion of vitamin D to its active form by macrophages in granulomas have been suggested as possible causes. We aimed to disentangle mechanisms behind SAHC by investigating any associations with season, granuloma burden and lung macrophages. Patients with SAHC were identified from a local cohort. The patients were divided in two groups: mild and severe SAHC. Data on when SAHC occurred, HLA-DRB1 alleles, bronchoalveolar lavage fluid (BALF) macrophages, extrapulmonary manifestations (EPM) and serum angiotensin-converting enzyme (s-ACE) as a marker for granuloma burden were retrieved from medical records. Out of 83 patients with SAHC, severe hypercalcemia was found in 36 patients, 75% of whom presented between May and October (p < 0.001). No seasonal variation was observed for patients with mild hypercalcemia. Elevated s-ACE was more common in patients with severe hypercalcemia (84% of patients), compared to 46% in the group with mild hypercalcemia (p < 0.001). HLA-DRB1*04 was more frequent in the group with severe hypercalcemia, compared to the mild group (67% vs. 32%, p < 0.01). Results support SAHC being associated with sun exposure. Risk factors to be observant of are elevated s-ACE and HLA-DRB1*04.

Beyond the Graft: Recurrence of Interstitial Lung Diseases Post Transplant

Interstitial lung diseases (ILDs) represent a heterogenous group of lung disorders marked by inflammation and/or fibrosis of the lung parenchyma, often leading to progressive shortness of breath and end-stage respiratory failure. In the U.S., ILDs affect approximately 650,000 individuals and cause approximately 25,000-30,000 deaths annually. Lung transplantation (LTx) offers definitive treatment for advanced ILD, with improved survival attributed to advancements in immunosuppression, organ preservation, surgical techniques, and postoperative care. However, disease recurrence in transplanted lungs remains a significant concern. Understanding the risk factors and mechanisms underlying recurrence is critical for refining recipient selection and improving outcomes. This review examines ILD recurrence post LTx and its implications for lung transplantation success.

Phenotypes and Endotypes in Sarcoidosis: Unraveling Prognosis and Disease Course

Sarcoidosis is a multi-system granulomatous disease of unknown etiology. In genetically susceptible individuals, the precipitating factors generate, via immunity mechanisms, a host granulomatous response. The granuloma, for unknown reasons thus far, may resolve or may persist and lead to organ damage and fibrosis. Infectious agents, occupational exposure, obesity, smoking and genetic factors are implicated in the pathogenesis of sarcoidosis. Macrophages are important in granuloma formation, and their M1/M2 phenotype is associated with the prognosis of the disease. CD4+ T helper cells play a central role in the pathogenesis of sarcoidosis. The major contributors appear to be Th1 and Th17.1 cells, whose microenvironmental behavior is dictated by the secretions of macrophages and dendritic cells. Higher levels of Th1 and Th17.1 cells are associated with chronic disease and resistance to corticosteroid treatment. In recent years, advances in the phenotyping of sarcoidosis with the help of HRCT, PET-CT and lung function tests have provided us with a better understanding of the disease. Genetic phenotyping performed by the GenPhenReSa consortium and the SAGA study has led to the recognition of new, distinct phenotypes. The reconstitution of dysregulated autophagy through persistent m-TORC-1 pathways may be a new treatment target in sarcoidosis.

Pulmonary asymptomatic recurrent cavitary sarcoidosis: A case report

Cavitary sarcoidosis is a rare form and represents non-caseating granulomatous diseases of the lungs exhibiting a narrow range of differential diagnoses. The peculiarity of this case lies in the difficulty of distinguishing atypical manifestations of pulmonary sarcoidosis, such as cystic lesions, from cavernous tuberculosis. Both possess similar clinical and radiological features. We report a case of a 36-year-old male, who has been under observation since 2019 without active complaints. Chest computed tomography revealed bilateral reticulo-nodular changes with the formation of extensive consolidation areas and cavities, аs well as mediastinal lymphadenopathy. This article represents clinical case of patient with recurrent cavitary sarcoidosis and underscores the necessity for monitoring and adjusting of the treatment of this complex condition because their course may be punctuated by several complications including pleural effusion, hemoptysis, aspergilloma, and pneumothorax.

Erythema Nodosum in Sarcoidosis: Relationship with Extrathoracic Involvement and Prognostic Significance

INTRODUCTION

Only a few studies analysed the prognosis significance of erythema nodosum (EN) in sarcoidosis. Our objective was to analyse the prevalence of EN in sarcoidosis, its possible association of EN with extrathoracic sarcoidosis, and its prognostic significance.

METHODS

Retrospective study included patients diagnosed with sarcoidosis at Bellvitge University Hospital, Barcelona, Spain, between 1980 and 2017. Patients were followed up prospectively at the sarcoid clinic of the hospital. Patients' medical records were reviewed to obtain the clinical data.

RESULTS

A total of 728 patients (494 women and 234 men, mean age 43.45 years, SD 13,833) were diagnosed with sarcoidosis. Radiological stages were 0 in 68 patients (9.34%), 1 in 434 (59.62%), 2 in 167 (22.94%), 3 in 45 (6.18%), and 4 in 14 (1.92%). Pulmonary fibrosis at 5 years of follow-up was documented in 44 patients. EN was diagnosed in 269 (37%). In 265 cases (98.5%), EN lesions were present at the onset of sarcoidosis and mostly corresponded to radiological stage 1 at diagnosis (82.52%). Among patients with EN, 3/269 (1.11%) had pulmonary fibrosis at 5 years of follow-up (p < 0.001), sarcoidosis activity persisted for more than 5 years in 28/269 (10.41%) (p < 0.001), and oral corticosteroids were required in 48/269 patients (17.84%) (p < 0.001). Patients with EN had a low incidence of severe extrapulmonary involvement.

CONCLUSION

EN was observed in 37% of sarcoidosis patients, usually at the onset of the disease. Patients with EN-associated sarcoidosis have mainly radiological stage 1 at diagnosis and are at lower risk of chronicity, pulmonary fibrosis, and severe forms of extrathoracic organ involvement.

Quality of life, fatigue and markers in sarcoidosis: A section from Turkey

BACKGROUND AND AIM

Sarcoidosis can affect every organ with varying frequency based on ethnicity, gender and age. We aimed to evaluate the health-related quality of life (HRQoL) and fatigue levels of our sarcoidosis patients. However, our second aim is to determine whether patient or disease markers correlate with quality of life assessment questionnaires.

MATERIALS AND METHODS

Pulmonary sarcoidosis patients who were followed up in the chest diseases outpatient clinic of our hospital were included in this prospective study. In the follow-up of 2023, routine blood tests, angiotensin-converting enzyme (ACE), posteroanterior lung (thorax computed tomography in patients with parenchymal involvement) were requested from the patients. Participants were asked to fill out the short-form 36-item questionnaire (SF-36), fatigue assessment scale (FAS) and fatigue severity scale (FSS) under the control of the outpatient clinic.

RESULTS

A total of 189 patients, 139 (73.5%) female and 50 (26.5%) male, diagnosed with Sarcoidosis were included. The mean age of our patients was 53.1±13.6. ACE (IU/L) 68.5±44.5. Of the patients we followed up for pulmonary sarcoidosis, 111 (58.7%) had single organ involvement and 78 (41.3%) had additional organ involvement. FAS; It was high in 103 (64.3%) patients and 29 (15.3%) were very tired. FSS value was 4.45±0.7 (3-5.88). All SF-36 parameters were lower than expected; MH and SF was minimally lower, PF, RP, BP, GH, RE and VT were significantly lower. SF-36 scores were found to be lower in the women and additional organ involvement participating.

CONCLUSION

We found a significant decrease in HRQoL and an increase in fatigue scores of our patients. These changes were more pronounced in women participating in the study than in men. In addition, the involvement of additional organs with the lung negatively affected the quality of life.

Kidney manifestations of sarcoidosis

Renal involvement is a clinically relevant organ manifestation of sarcoidosis, leading to increased morbidity and complications. Although the exact incidence remains unknown, renal disease is likely to occur in up to one third of all sarcoidosis patients. Every patient with newly diagnosed sarcoidosis should receive a renal work-up and screening for disrupted calcium metabolism. Amid various forms of glomerulonephritis, granulomatous interstitial nephritis is the most common one, but it rarely leads to renal impairment. Histologically, granulomas can be absent. Nephrocalcinosis and nephrolithiasis are frequent forms when hypercalcaemia or hypercalciuria occur. Drugs used for treatment of systemic sarcoidosis can also cause renal damage. Due to its high heterogeneity, renal sarcoidosis can be difficult to treat. Glucocorticoids and various immunosuppressive treatments have been proven to be effective based on case series, but clinical trials are lacking. A treatment guideline for renal sarcoidosis is urgently needed. In this review article, we present an overview of the different forms of renal sarcoidosis and the diagnostic steps to confirm renal involvement; in addition, we provide insights on the management and available treatments. A better understanding regarding the pathogenesis of sarcoidosis is the key for the development of more specific, targeted therapies.

Chronic Sarcoidosis: Diagnostic Difficulties and Search for New Criteria of Inflammatory Activity (A Case Report and Literature Review)

Sarcoidosis is a systemic inflammatory disease with an unknown etiology and a wide range of clinical manifestations. The incidence of sarcoidosis ranges from approximately 1 to 15 cases per 100,000 individuals per year worldwide. The significant variability in clinical presentations and target organs, as well as concomitant diseases, greatly complicates diagnosis. We analyzed articles in PubMed, Scopus, Cochrane Library, and Embase, where databases were searched using the keywords "chronic sarcoidosis", "diagnosis of sarcoidosis", "course of sarcoidosis", "pulmonary sarcoidosis", "cardiac sarcoidosis", "skin sarcoidosis", "neurosarcoidosis", "ocular sarcoidosis", and "autoimmune inflammation". Studies on the course and diagnosis of sarcoidosis with a deep search of ten years were included. In this review, we present an analysis of publications on the course and diagnosis of chronic sarcoidosis, as well as a clinical case. We have noted that the diagnosis of chronic sarcoidosis is particularly difficult due to the lack of specific biomarkers or their combination. The development and introduction of new diagnostic criteria for this disease will contribute to increasing the level of efficiency, not only of the diagnostic complex, but also the prognosis of the development and course of the pathological process. Conclusion: For the most accurate diagnosis and determination of prognosis, the existence of a single immunological or imaging marker with sufficient sensitivity and specificity is necessary.

Sarcoidosis versus Granulomatous and Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency: A Comparative Review

Sarcoidosis and Granulomatous and Lymphocytic Interstitial Lung Diseases (GLILD) are two rare entities primarily characterised by the development of Interstitial Lung Disease (ILD) in the context of systemic immune dysregulation. These two conditions partially share the immunological background and pathologic findings, with granuloma as the main common feature. In this narrative review, we performed a careful comparison between sarcoidosis and GLILD, with an overview of their main similarities and differences, starting from a clinical perspective and ending with a deeper look at the immunopathogenesis and possible target therapies. Sarcoidosis occurs in immunocompetent individuals, whereas GLILD occurs in patients affected by common variable immunodeficiency (CVID). Moreover, peculiar extrapulmonary manifestations and radiological and histological features may help distinguish the two diseases. Despite that, common pathogenetic pathways have been suggested and both these disorders can cause progressive impairment of lung function and variable systemic granulomatous and non-granulomatous complications, leading to significant morbidity, reduced quality of life, and survival. Due to the rarity of these conditions and the extreme clinical variability, there are still many open questions concerning their pathogenesis, natural history, and optimal management. However, if studied in parallel, these two entities might benefit from each other, leading to a better understanding of their pathogenesis and to more tailored treatment approaches.

Longitudinally extensive transverse myelitis as an initial manifestation of sarcoidosis: A rare case and its management

Key Clinical Message

Sarcoidosis-induced LETM represents a rare but life-threatening neurological manifestation of sarcoidosis, characterized by spinal cord inflammation, and associated neurological deficits. Sarcoidosis should be included in the differential diagnosis of LETM, particularly in patients with no lung involvement. Prompt recognition and management are obligatory to optimize outcomes and prevent long-term disability.

Abstract

Sarcoidosis is a multisystem inflammatory granulomatous disorder characterized by the formation of noncaseating granulomas. Although sarcoidosis commonly affects the skin, lymph nodes, and lungs, neurological involvement of sarcoidosis has also been reported. Longitudinally extensive transverse myelitis (LETM) is a rare but well-documented serious manifestation of neuroscoidosis. We report a case of LETM caused by sarcoidosis in a 53-year-old male who presented with progressive bilateral lower extremity weakness, urinary retention, and paresthesia. Laboratory evaluations revealed elevated inflammatory markers. Magnetic resonance imaging of the spine showed hyperintense signals consistent with transverse myelitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis and elevated protein levels. Chest computed tomography showed hilar lymphadenopathy. A biopsy of the intrathoracic lymph node showed noncaseating granulomas consistent with sarcoidosis. A diagnosis of sarcoidosis-induced LETM was made after ruling out all other possible etiologies. His condition improved gradually after starting high-dose prednisone, mycophenolate, and rehabilitation strategies. Our case underscores the importance of prompt diagnosis and management of sarcoidosis-induced LETM and highlights that sarcoidosis must be included among differential diagnoses of LETM, especially in cases with no lung involvement.

Neurosarcoidosis with enlargement of the dorsal root ganglia: A case report

We report the case of a woman in her 40s who presented with sensory disturbances in all 4 limbs and left facial palsy. MRI revealed asymmetric enlargement of the dorsal root ganglia, which was enhanced by gadolinium-a chest CT scan identified enlarged supraclavicular, mediastinal, and hilar lymph nodes. A biopsy of a hilar lymph node showed noncaseating epithelioid granulomas, confirming a sarcoidosis diagnosis. Prednisolone treatment led to symptomatic improvements. In sarcoidosis of the peripheral nervous system, there might be observable enlargement of the dorsal root ganglion alongside enhanced gadolinium contrast. Obtaining a biopsy from the dorsal root ganglion poses challenges, and radiologists should be mindful of this specific imaging characteristic.

Organ involvement in newly diagnosed sarcoidosis patients in the Netherlands: The first large European multicentre prospective study

BACKGROUND

Clinical presentation and prevalence of organ involvement is highly variable in sarcoidosis and depends on ethnic, genetic and geographical factors. These data are not extensively studied in a Dutch population.

AIM

To determine the prevalence of organ involvement and the indication for systemic immunosuppressive therapy in newly diagnosed sarcoidosis patients in the Netherlands.

METHODS

Two large Dutch teaching hospitals participated in this prospective cohort study. All adult patients with newly diagnosed sarcoidosis were prospectively included and a standardized work-up was performed. Organ involvement was defined using the WASOG instrument.

RESULTS

Between 2015 and 2020, a total of 330 patients were included, 55% were male, mean age was 46 (SD 14) years. Most of them were white (76%). Pulmonary involvement including thoracic lymph node enlargement was present in 316 patients (96%). Pulmonary parenchymal disease was present in 156 patients (47%). Ten patients (3%) had radiological signs of pulmonary fibrosis. Cutaneous sarcoidosis was present in 74 patients (23%). Routine ophthalmological screening revealed uveitis in 29 patients (12%, n = 256)). Cardiac and neurosarcoidosis were diagnosed in respectively five (2%) and six patients (2%). Renal involvement was observed in 11 (3%) patients. Hypercalcaemia and hypercalciuria were observed in 29 (10%) and 48 (26%, n = 182) patients, respectively. Hepatic involvement was found in 6 patients (2%). In 30% of the patients, systemic immunosuppressive treatment was started at diagnosis.

CONCLUSIONS

High-risk organ involvement in sarcoidosis is uncommon at diagnosis. Indication for systemic immunosuppressive therapy was present in a minority of patients.

Granulomatous liver diseases

A granuloma is a discrete collection of activated macrophages and other inflammatory cells. Hepatic granulomas can be a manifestation of localized liver disease or be a part of a systemic process, usually infectious or autoimmune. A liver biopsy is required for the detection and evaluation of granulomatous liver diseases. The prevalence of granulomas on liver biopsy varies from 1% to 15%. They may be an incidental finding in an asymptomatic individual, or they may represent granulomatous hepatitis with potential to progress to liver failure, or in chronic disease, to cirrhosis. This review focuses on pathogenesis, histological features of granulomatous liver diseases, and most common etiologies, knowledge that is essential for timely diagnosis and intervention.

A Retrospective Analysis of 2-Year Follow-Up of Patients with Incidental Findings of Sarcoidosis

INTRODUCTION

Sarcoidosis is a multi-system granulomatous disease most commonly involving the lungs. It may be incidentally diagnosed during imaging studies for other conditions or non-specific symptoms. The appropriate follow-up of incidentally diagnosed asymptomatic stage 1 disease has not been well defined.

OBJECTIVE

To define the clinical course of incidentally diagnosed asymptomatic stage 1 sarcoidosis and propose an algorithm for the follow-up of these patients.

METHODOLOGY

A retrospective case note analysis was performed of all EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration)-confirmed cases of stage 1 sarcoidosis presenting incidentally to Bristol and Liverpool Interstitial Lung Disease services. Clinical history, serology results, imaging scans, and lung function parameters were examined at baseline, 12, and 24 months. A cost analysis was performed comparing the cost of the current 2-year follow-up guidance to a 1 year follow-up period.

RESULTS

Sixty-seven patients were identified as the final cohort. There was no significant change in the pulmonary function tests over the two-year follow-up period. Radiological disease stability was observed in the majority of patients (58%, n = 29), and disease regression was evidenced in 40% (n = 20) at 1 year. Where imaging was performed at 2 years, the majority (69.8%, n = 37) had radiological evidence of disease regression, and 30.2% (n = 16) showed radiological evidence of stability. All patients remained asymptomatic and did not require therapeutic intervention over the study period.

CONCLUSIONS

Our results show that asymptomatic patients with incidental findings of thoracic lymph nodal non-caseating granulomas do not progress over a 2-year period. Our results suggest that the prolonged secondary-care follow-up of such patients may not be necessary. We propose that these patients are followed up for 1 year with a further year of patient-initiated follow-up (PIFU) prior to discharge.

Löfgren Syndrome: A Mosaic of Sarcoidosis Phenotypes

Sarcoidosis is an autoimmune multisystemic granulomatous disease with an unknown etiology. Löfgren syndrome (LS), an infrequent initial presentation of acute sarcoidosis, is characterized by the classic triad of acute arthritis, erythema nodosum (EN), and bilateral hilar lymphadenopathy (BHL). The presence of this triad offers high diagnostic specificity for sarcoidosis, eliminating the need for a confirmatory biopsy. Typically, LS follows a predictable, self-limiting clinical course. However, atypical presentations require early suspicion and closer monitoring. This case report highlights an unusual clinical manifestation of LS, marked by an incomplete presentation with acute panniculitis and joint lesions in the absence of EN. Acute sarcoidosis should be considered among the differential diagnoses when these clinical manifestations are present, and chest radiography should be performed to rule out BHL. In atypical cases, the disease course becomes less predictable, as exemplified in our case, where recurrence of the disease may occur, necessitating consistent monitoring.

Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension-A Challenging Mystery

Sarcoidosis has been a well-recognised risk factor for pulmonary hypertension (PH) for a long time, but still, the knowledge about this concatenation is incomplete. Sarcoidosis-associated PH (SAPH) is an uncommon but serious complication associated with increased morbidity and mortality among sarcoidosis patients. The real epidemiology of SAPH remains unknown, and its pathomechanisms are not fully explained. Sarcoidosis is a heterogeneous and dynamic condition, and SAPH pathogenesis is believed to be multifactorial. The main roles in SAPH development play: parenchymal lung disease with the destruction of pulmonary vessels, the extrinsic compression of pulmonary vessels by conglomerate masses, lymphadenopathy or fibrosing mediastinitis, pulmonary vasculopathy, LV dysfunction, and portal hypertension. Recently, it has been recommended to individually tailor SAPH management according to the predominant pathomechanism, i.e., SAPH phenotype. Unfortunately, SAPH phenotyping is not a straightforward process. First, there are gaps in our understanding of undergoing processes. Second, the assessment of such a pivotal element as pulmonary vasculature on a microscopic level is non-feasible in SAPH patients antemortem. Finally, SAPH is a dynamic condition, multiple phenotypes usually coexist, and patients can switch between phenotypes during the course of sarcoidosis. In this article, we summarise the basic knowledge of SAPH, describe SAPH phenotypes, and highlight some practical problems related to SAPH phenotyping.

MuSiC-ViT: A multi-task Siamese convolutional vision transformer for differentiating change from no-change in follow-up chest radiographs

A major responsibility of radiologists in routine clinical practice is to read follow-up chest radiographs (CXRs) to identify changes in a patient's condition. Diagnosing meaningful changes in follow-up CXRs is challenging because radiologists must differentiate disease changes from natural or benign variations. Here, we suggest using a multi-task Siamese convolutional vision transformer (MuSiC-ViT) with an anatomy-matching module (AMM) to mimic the radiologist's cognitive process for differentiating baseline change from no-change. MuSiC-ViT uses the convolutional neural networks (CNNs) meet vision transformers model that combines CNN and transformer architecture. It has three major components: a Siamese network architecture, an AMM, and multi-task learning. Because the input is a pair of CXRs, a Siamese network was adopted for the encoder. The AMM is an attention module that focuses on related regions in the CXR pairs. To mimic a radiologist's cognitive process, MuSiC-ViT was trained using multi-task learning, normal/abnormal and change/no-change classification, and anatomy-matching. Among 406 K CXRs studied, 88 K change and 115 K no-change pairs were acquired for the training dataset. The internal validation dataset consisted of 1,620 pairs. To demonstrate the robustness of MuSiC-ViT, we verified the results with two other validation datasets. MuSiC-ViT respectively achieved accuracies and area under the receiver operating characteristic curves of 0.728 and 0.797 on the internal validation dataset, 0.614 and 0.784 on the first external validation dataset, and 0.745 and 0.858 on a second temporally separated validation dataset. All code is available at https://github.com/chokyungjin/MuSiC-ViT.

Diffuse Sarcoidosis Presenting as Metastatic Malignant Disease-Like Picture: A Case Report

BACKGROUND

Sarcoidosis is a chronic inflammatory condition characterized by the formation of granulomas, which can impact various organs and tissues throughout the body. It frequently affects the lungs and mediastinal lymph nodes. The presence of multiple lytic lesions in the spine can be concerning, as it may indicate an undiagnosed or advanced metastatic malignancy. We present an unusual and interesting case of sarcoidosis in which the patient had multiple lytic lesions in the vertebrae, which resembled the presentation of metastatic malignant disease.

CASE DESCRIPTION

A 46-year-old woman with no known medical history presented to our cancer center complaining of neck pain and bilateral shoulder pain. After conducting extensive investigations, an atypical manifestation of sarcoidosis was identified. The patient was administered corticosteroids, which effectively managed the disease and resulted in a substantial improvement in her symptoms.

CONCLUSIONS

Before considering surgical intervention or radiotherapy for cases involving multiple lytic lesions in the spine with an unknown primary cause, it is essential to conduct a comprehensive diagnostic evaluation. This thorough work-up is necessary to establish a clear diagnosis. If the patient's neurological condition permits, a complete assessment can help prevent substantial morbidity. In certain cases, a patient's condition may involve an atypical manifestation of pathologies that are not related to metastatic diseases, suggesting that simpler treatment approaches might be adequate.

The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies

Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.

The Symptoms of Pulmonary Sarcoidosis

The aim of this manuscript is to provide a comprehensive review of the etiology, measurement, and treatment of common pulmonary symptoms associated with sarcoidosis. The assessment of symptoms associated with pulmonary sarcoidosis is an important component of disease management. Some symptoms of pulmonary sarcoidosis are sensitive but nonspecific markers of disease activity, and the absence of such symptoms provides evidence that the disease is quiescent. Although quantifiable objective measurements of pulmonary physiology and chest imaging are important in the assessment of pulmonary sarcoidosis, they correlate poorly with the patient's quality of life. Because the symptoms of pulmonary sarcoidosis directly relate to how the patient feels, they are reasonable endpoints in terms of clinical research and individual patient care. Recently, the symptoms of pulmonary sarcoidosis are capable of being quantified via patient-reported outcome measures and electronic devices. We conclude that a thorough assessment of the symptoms associated with pulmonary sarcoidosis improves patient care because it is a useful screen for manifestations of the disease, provides insight into the pathophysiology of manifestations of sarcoidosis, and may assist in optimizing treatment.

"The chameleon among diseases" - an explorative view of sarcoidosis and identification of the consequences for affected patients and relatives using qualitative interviews

INTRODUCTION

Sarcoidosis is a multisystemic disease, with the lungs being the main site of manifestation. Although the exact etiology remains unclear, both genetic and environmental factors are being discussed. Diagnostic evaluation is challenging, and the management of chronic patients and assessment of their needs proves difficult, especially in the absence of targeted therapy. Studies on sarcoidosis patients have shown that quality of life is limited even after clinically measurable parameters have resolved. The question remains how patients and their relatives perceive medical care and the diagnostic process and how these affect their well-being.

METHODS

Qualitative, semi-structured interviews were conducted with patients and their relatives between September 2019 and February 2020. Interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Deductive hypotheses were then formed based on categories according to personal aspects, symptoms, diagnostic, daily life activity, therapy, psychological aspects and wishes.

RESULTS

Fourteen patients and five relatives were included. Most patients reported subacute symptoms before the first organ-related episode. A high degree of personal initiative was required from the majority of respondents in both the diagnostic and subsequent therapeutic processes. In addition, respondents reported so-called "doctor-hopping", a lack of specialists or contacts, and a lack of medical support. The Internet and self-help groups played a fundamental role for patients and relatives in exchanging information with other affected persons and to compensate for an existing information deficit.

CONCLUSION

The results provide new insights into patients' and relatives' perceptions of the sarcoidosis diagnosis and treatment process. Identification of barriers such as a lack of physicians and an information deficit highlights potential targets for strategies to optimize sarcoidosis management.

[Sarcoidosis]

Sarcoidosis is the most common granulomatous disease in northern Europe. A distinction is made between acute forms of sarcoidosis and chronic sarcoidosis. Chronic sarcoidosis can affect practically all organs but the lungs are affected in 90-95% of patients. The clinical appearance varies between asymptomatic and oligosymptomatic courses, which are diagnosed more by chance, to courses with acute organ failure. An extensive organ work-up is necessary at the time of the initial diagnosis in order to record the extent of organ involvement and to make appropriate treatment decisions. Asymptomatic courses with purely pulmonary sarcoidosis do not require treatment and can be observed over the course of the disease, whereas courses with extensive organ involvement or organ dysfunction require treatment. The treatment consists primarily of the administration of glucocorticoids. If the effect of the glucocorticoids is insufficient or if there are side effects, various immunosuppressive agents, including biologics can be added.

The Overlap of Kidney Failure in Extrapulmonary Sarcoidosis in Children-Case Report and Review of Literature

Sarcoidosis is a non-necrotizing granulomatous inflammatory multisystemic disorder of unknown etiology. In children, as in adults, it can involve a few or all organ systems to a varying extent and degree, entailing multisystemic manifestations. Kidney involvement in pediatric-onset adult-type sarcoidosis is rare, with a wide range of renal manifestations, most of them related to calcium metabolism. Children with renal sarcoidosis tend to be more symptomatic than adults, although male patients have a higher prevalence. We present the case of a 10-year-old boy who presented with advanced renal failure with nephrocalcinosis and important hepatosplenomegaly. The diagnosis was established by histopathological examination, with consequent cortisone therapy and hemodialysis. This review emphasizes that sarcoidosis should be considered in the differential diagnosis of pediatric patients with acute kidney insufficiency or chronic kidney disease of an unknown etiology. As far as we know, this is the first study regarding extrapulmonary sarcoidosis in children from Romania.

Renal disease in sarcoidosis patients in a German multicentric retrospective cohort study

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease potentially affecting every organ system. Renal involvement is reportedly rare, and the evidence consists of case reports and cohort studies. Systematic investigations are scarce and show a varying prevalence ranging from <1% to 30-50%.

METHODS

We retrospectively analyzed data from patients with a recent diagnosis of sarcoidosis from five tertiary care centers focusing on renal sarcoidosis.

RESULTS

We analyzed data from 327 patients with sarcoidosis between 2001 and 2021. Of 327 patients, 109 (33.3%) had probable or definite renal sarcoidosis. 90 (27.5%) had histopathologic confirmation. 57 (64%) had an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m². The most prominent associated finding was an elevated soluble interleukin-2 receptor. Patients with renal sarcoidosis more frequently received glucocorticoids than other non-renal sarcoidosis patients (92% vs. 78%, p < 0.01). Also, azathioprine (38% vs. 16%, p < 0.001) and mycophenolate mofetil (5% vs. 1%, p < 0.05) were more frequently used in renal sarcoidosis compared to non-renal sarcoidosis, whereas methotrexate was used less frequently (7% vs. 17%, p < 0.05).

CONCLUSIONS

Our data of the largest cohort with biopsy-confirmed renal sarcoidosis demonstrate a higher prevalence (27.5% of all patients) than previously published with a relevant disease burden. The urinary findings in most cases were only mildly abnormal, and some patients did not have renal biopsy despite abnormal urinary results. A renal workup should be performed in all patients with a new diagnosis of sarcoidosis.

Sarcoidosis

Sarcoidosis is a disease of unknown cause characterized by granulomatous inflammation. Although the lung is almost universally involved, any organ can be affected. Complex pathogenesis and protean clinical manifestations are additional features of the disease. The diagnosis is one of exclusion, although the presence of noncaseating granulomas at disease sites is a prerequisite in most cases. The management of sarcoidosis requires a multidisciplinary approach, particularly when the heart, the brain, or the eyes are involved. The paucity of effective therapies and the lack of reliable predictors of disease behavior greatly contribute to making sarcoidosis a challenging disease to manage.

Extrapulmonary Sarcoidosis With Multi-Organ Involvement Presenting Primarily as Hypercalcemia

Sarcoidosis is a highly variable disease. The majority of cases affect the lungs, but they can involve other organs as well. Extrapulmonary sarcoidosis is rare, and it can present in many ways. Therefore, the diagnosis can be challenging. We hereby present a case of a patient presenting with hypercalcemia and diagnosed with extrapulmonary sarcoidosis with multi-organ involvement. This article was previously presented as a meeting abstract at the MI-ACP 2022 Annual Scientific Meeting on October 14, 2022.

Hepatic sarcoidosis with symptomatic portal hypertension: A report of 12 cases with review of the literature

Introduction

Sarcoidosis is a systemic granulomatosis of unknown etiology, characterized by the presence of immune granulomas. Liver damage is a relatively common extra-pulmonary manifestation, occurring in 3.6-30% of cases. Some patients can develop symptomatic portal hypertension (PH). Few series have evaluated the prognosis of symptomatic PH as well as the efficacy and safety of specific treatment on this complication.

Methods

This is a multicenter retrospective study of cases of histologically proven hepatic sarcoidosis with symptomatic PH (ascites, digestive hemorrhage) and/or hepatic encephalopathy. Demographic characteristics, comorbidities, clinical manifestations of sarcoidosis, biological data, imaging study of the liver, treatment, and clinical outcomes were collected.

Results

Twelve patients were identified, with a mean follow-up of 140 months. The M/F ratio was 1 and Caucasian origin was the most represented (75%). Seven patients presented with hepatic comorbidities: metabolic syndrome, chronic alcoholism or chronic viral hepatitis. Apart from hepatic involvement, mediastino-pulmonary involvement was the most common followed by osteoarticular and skin. Liver damage was inaugural in two thirds of cases. Nine patients developed ascites, six presented esophageal varices complicated by gastrointestinal bleeding. Three patients presented with both ascites and variceal bleeding. One case of hepatic encephalopathy was observed. Five patients presented signs of hepatocellular insufficiency during follow-up, of whom three had hepatic comorbidities. Eight out of 12 patients required second-line treatment after failure of corticosteroids, three patients underwent ligation of esophageal varices but with recurrent digestive bleeding in all cases. Two patients benefited from a transjugular intrahepatic portosystemic shunt (TIPS), also with poor result. At the end of follow-up, five patients were alive and seven patients died. Two patients received a liver transplant, with good result and without recurrence of sarcoidosis on the transplant thereafter. Two patients had quiet sarcoidosis on low dose of corticosteroids and one patient was lost to follow-up.

Conclusion

Symptomatic PH related to hepatic sarcoidosis is a severe complication, with high morbidity and mortality, and frequent failure of specific treatments of PH. Early management of these patients, with detection of hepatic comorbidities seems important. In case of therapeutic failure, liver transplantation is an option to consider.

Sarcoidosis with musculoskeletal manifestations: systematic review of non-pharmacological and pharmacological treatments

We aimed to summarise effects and use of non-pharmacological and pharmacological treatments for sarcoidosis with musculoskeletal manifestations. We systematically searched the Cochrane Library, Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, clinical.trials.gov, PROSPERO and PEDro for systematic reviews from 2014 to 2022 and for primary studies from date of inception to March 29, 2022, and studies with patients diagnosed with sarcoidosis with musculoskeletal manifestations. Inclusion criteria required that studies reported effects of non-pharmacological and/or pharmacological treatments or number of patients receiving these treatments. Results were reported narratively and in forest plots. Eleven studies were included. No systematic reviews fulfilled our inclusion criteria. None of the included studies had a control group. We found that between 23 and 100% received corticosteroids, 0-100% received NSAIDs, 5-100% received hydroxychloroquine, 12-100% received methotrexate, 0-100% received TNF inhibitors, and 3-4% received azathioprine. Only ten patients in one study had used non-pharmacological treatments, including occupational therapy, chiropractic and acupuncture. There are no controlled studies on treatment effects for patients with sarcoidosis with musculoskeletal manifestations. We found 11 studies reporting use of pharmacological treatments and only one study reporting use of non-pharmacological treatments. Our study identified major research gaps for pharmacological and non-pharmacological treatment in musculoskeletal sarcoidosis and warrant randomised clinical trials for both.

Evaluation of clinical and laboratory characteristics of patients with cutaneous sarcoidosis: A single-center retrospective cohort study

Background

Cutaneous sarcoidosis is a relatively rare disease whose clinical manifestations include red-brown macules, plaques, papules and subcutaneous nodules. The skin changes may also be restricted to pre-existing scars. Cutaneous sarcoidosis can be associated with systemic organ involvement.

Objectives

Aim of this retrospective study was to longitudinally investigate clinical and laboratory findings in patients with cutaneous sarcoidosis.

Methods

Patients (>18 years) with histologically confirmed cutaneous sarcoidosis between January 2014 and December 2020 were included. Patient demographics, clinical features, laboratory and radiological findings, management, clinical outcomes and co-morbidities associated with cutaneous sarcoidosis were analyzed.

Results

Thirty-seven patients with cutaneous sarcoidosis were identified, of whom 57% were female. The most common clinical phenotype of cutaneous sarcoidosis was papular sarcoidosis (n = 16), while plaques and nodules were present in 9 patients. In contrast, subcutaneous (n = 1) and scar-associated sarcoidosis (n = 1) were rare. Of patients with systemic disease, the cutaneous disease followed, preceded, and coincided with the development of systemic sarcoidosis in 2, 9, and 12 patients, respectively. Levels of soluble interleukin (IL)-2 receptor, angiotensin converting enzyme (ACE), and C-reactive protein (CRP) were elevated, in 76%, 21%, and 50% of the tested patients respectively and predicted systemic involvement. Hypercalcemia was present in 6% of patients. Female sex and younger age (<54 years) were significantly associated with systemic manifestations.

Conlcusions

Cutaneous sarcoidosis was frequently associated with additional systemic involvement, particularly when present in young females. 24 % of patients with cutaneous sarcoidosis developed additional organ involvement during follow-up.

Autoimmune pulmonary alveolar proteinosis and sarcoidosis in the same patient: Case report and systematic review

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by surfactant accumulation in the alveolar spaces while sarcoidosis is a multisystem granulomatous disease of unknown etiology. The occurrence of PAP and sarcoidosis in the same patient is rare. A 37-year-old woman presented with cough and breathlessness and was diagnosed to have autoimmune PAP. She responded well to subcutaneous injections of recombinant granulocyte macrophage colony stimulating factor. Three years later, she developed fever, chest pain, cough, and facial palsy. The evaluation revealed a diagnosis of sarcoidosis that responded to immunosuppressive treatment. We discuss the link between PAP and sarcoidosis and review the literature on this association.

Sarcoidosis. Disease progression based on radiological and functional course: Predictive factors

BACKGROUND

Sarcoidosis is a multiorgan granulomatous disease with a variable course.

OOBJECTIVES

The purpose of this study is to identify the patients that are more likely to experience disease progression.

METHODS

A retrospective study in patients ≥18 years. Pulmonary function and radiological stage (Scadding criteria) were assessed at diagnosis, and at 1, 3 and 5 years. Sarcoidosis progression was established based on deterioration of radiological or pulmonary function (decrease ≥10% of FVC and/or ≥15% of diffusing capacity of the lung (DLCO).

RESULTS

The sample included 277 caucasian patients [mean age, 50±13.6; 69.7% between 31-60 years; 56.3% men]. In total, 65% had stage II sarcoidosis, whereas only 8.3% had stage III/IV disease. Mean pulmonary function (FVC, FEV₁, FEV₁/FVC and DLCO) at diagnosis was 103±21.8, 96±22.2, 76.2±8 and 81.7±21.7, respectively. The percentage of patients with normal FVC and DLCO was 72.2% and 51.8%, respectively. Radiological stage did not change significantly during follow-up (5 years; p=0.080) and only progressed in 13 patients (5.7%). At 3 years, FVC improved, whereas DLCO exacerbated significantly (p<0.001 for the two). Disease progressed in 34.5% of the patients (57/165) whose pulmonary function and radiological stage were available (both baseline and at 3 years). Age was associated with disease progression [OR=1.04 (95%CI=1.01, 1.06)]. Risk increased by 4% for each year older a patient was at diagnosis.

CONCLUSIONS

At 3 years, a third of patients experienced sarcoidosis progression. Age was the only factor associated with disease prognosis.

Recurrence of primary disease following lung transplantation

Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation.

Diagnosis and Treatment of Pulmonary Sarcoidosis: A Review

IMPORTANCE

Sarcoidosis is an inflammatory granulomatous disease of unknown cause that affects an estimated 2 to 160 people per 100 000 worldwide and can involve virtually any organ. Approximately 10% to 30% of patients with sarcoidosis develop progressive pulmonary disease.

OBSERVATION

Among patients with pulmonary sarcoidosis, the rate of spontaneous remission without serious sequelae ranges from 10% to 82%. However, lung disease progression occurs in more than 10% of patients and can result in fibrocystic architectural distortion of the lung, which is associated with a mortality rate of 12% to 18% within 5 years. Overall, the mortality rate for sarcoidosis is approximately 7% within a 5-year follow-up period. Worldwide, more than 60% of deaths from sarcoidosis are due to pulmonary involvement; however, more than 70% of deaths from sarcoidosis are due to cardiac involvement in Japan. Up to 70% of patients with advanced pulmonary sarcoidosis develop precapillary pulmonary hypertension, which is associated with a 5-year mortality rate of approximately 40%. Patients with sarcoidosis and precapillary pulmonary hypertension should be treated with therapies such as phosphodiesterase inhibitors and prostacyclin analogues. Although optimal doses of oral glucocorticoids for pulmonary sarcoidosis are unknown, oral prednisone typically starting at a dose of 20 mg/d to 40 mg/d for 2 to 6 weeks is recommended for patients who are symptomatic (cough, dyspnea, and chest pain) and have parenchymal infiltrates and abnormal pulmonary function test results. Oral glucocorticoids can be tapered over 6 to 18 months if symptoms, pulmonary function test results, and radiographs improve. Prolonged use of oral glucocorticoids may be required to control symptoms and stabilize disease. Patients without adequate improvement while receiving a dose of prednisone of 10 mg/d or greater or those with adverse effects due to glucocorticoids may be prescribed immunosuppressive agents, such as methotrexate, azathioprine, or an anti-tumor necrosis factor medication, either alone or with glucocorticoids combined with appropriate microbial prophylaxis for Pneumocystis jiroveci and herpes zoster. Effective treatments are not available for advanced fibrocystic pulmonary disease.

CONCLUSIONS AND RELEVANCE

Sarcoidosis has a mortality rate of approximately 7% within a 5-year follow-up period. More than 10% of patients with pulmonary sarcoidosis develop progressive disease and more than 60% of deaths are due to advanced pulmonary sarcoidosis. Oral glucocorticoids with or without another immunosuppressive agent are the first-line therapy for symptomatic patients with abnormal pulmonary function test results and lung infiltrates. Patients with sarcoidosis and precapillary pulmonary hypertension should be treated with therapies such as phosphodiesterase inhibitors and prostacyclin analogues.

A case of hepatic and bone marrow sarcoidosis with progressive renal failure: diagnostic and therapeutic challenges

Sarcoidosis is a systemic granulomatous disease, sometimes characterized by an extrapulmonary localization in 30 - 50% of cases. We describe a 60-year-old Italian man with an unexplained history of fatigue, ascitis and progressive renal function impairment. Diagnosis of hepatic and bone marrow sarcoidosis was established by histology, and fast improvement of renal function was obtained after starting  corticosteroid therapy. Atypical presentation and simultaneous involvement of liver, bone marrow and kidneys make diagnosis of extrapulmonary sarcoidosis still a diagnostic challenge. Delayed diagnosis could lead to serious organ damage like a progressive severe kidney failure.

A Comprehensive Review of Sarcoidosis Diagnosis and Monitoring for the Pulmonologist

Sarcoidosis is a systemic granulomatous disease with heterogenous clinical manifestations. Here we review the diagnosis of sarcoidosis and propose a clinically feasible diagnostic work-up and monitoring protocol. As sarcoidosis is a systemic disease, a multidisciplinary approach is recommended for best outcomes. However, since the lungs are frequently involved, the pulmonologist is often the referral physician for diagnosis and management. When sarcoidosis is suspected, diagnosis needs to be confirmed and organ involvement/impairment assessed. This process is also required to establish whether the patient is likely to benefit from treatment, as many cases of sarcoidosis are self-limited and remit spontaneously. Whether or not treatment is started, effective regular follow-up is necessary to monitor changes in the disease, including extension, progression, remissions, flare-ups, and complications.

Renal involvement in sarcoidosis: histological patterns and prognosis, an Italian survey

Background

Granulomatous interstitial nephritis in sarcoidosis (sGIN) is generally clinically silent, but in <1% causes acute kidney injury (AKI).

Methods

This Italian multicentric retrospective study included 39 sarcoidosis-patients with renal involvement at renal biopsy: 31 sGIN-AKI, 5 with other patterns (No-sGIN-AKI), 3 with nephrotic proteinuria. We investigate the predictive value of clinical features, laboratory, radiological parameters and histological patterns regarding steroid response. Primary endpoint: incident chronic kidney disease (CKD) beyond the 1°follow-up (FU) year; secondary endpoint: response at 1°line steroid therapy; combined endpoint: the association of initial steroid response and outcome at the end of FU.

Results

Complete recovery in all 5 No-sGIN-AKI-patients, only in 45% (13/29) sGIN-AKI-patients (p=0.046) (one lost in follow-up, for another not available renal function after steroids). Nobody had not response. Primary endpoint of 22 sGIN-AKI subjects: 65% (13/20) starting with normal renal function developed CKD (2/22 had basal CKD; median FU 77 months, 15-300). Combined endpoint: 29% (6/21) had complete recovery and final normal renal function (one with renal relapse), 48% (10/21) had partial recovery and final CKD (3 with renal relapse, of whom one with basal CKD) (p=0.024). Acute onset and hypercalcaemia were associated to milder AKI and better recovery than subacute onset and patients without hypercalcaemia, women had better endpoints than men. Giant cells, severe interstitial infiltrate and interstitial fibrosis seemed negative predictors in terms of endpoints.

Conclusions

sGIN-AKI-patients with no complete recovery at 1°line steroid should be treated with other immunosuppressive to avoid CKD, in particular if males with subacute onset and III stage-not hypercalcaemic AKI.

How to Tackle the Diagnosis and Treatment in the Diverse Scenarios of Extrapulmonary Sarcoidosis

Extrapulmonary sarcoidosis occurs in 30–50% of cases of sarcoidosis, most often in association with pulmonary involvement, and virtually any organ can be involved. Its incidence depends according to the organs considered, clinical phenotype, and history of sarcoidosis, but also on epidemiological factors like age, sex, geographic ancestry, and socio-professional factors. The presentation, symptomatology, organ dysfunction, severity, and lethal risk vary from and to patient even at the level of the same organ. The presentation may be specific or not, and its occurrence is at variable times in the history of sarcoidosis from initial to delayed. There are schematically two types of presentation, one when pulmonary sarcoidosis is first discovered, the problem is then to detect extrapulmonary localizations and to assess their link with sarcoidosis, while the other presentation is when extrapulmonary manifestations are indicative of the disease with the need to promptly make the diagnosis of sarcoidosis. To improve diagnosis accuracy, extrapulmonary manifestations need to be known and a medical strategy is warranted to avoid both under- and over-diagnosis. An accurate estimation of impairment and risk linked to extrapulmonary sarcoidosis is essential to offer the best treatment. Most frequent extrapulmonary localizations are skin lesions, arthritis, uveitis, peripheral lymphadenopathy, and hepatic involvement. Potentially severe involvement may stem from the heart, nervous system, kidney, eye and larynx. There is a lack of randomized trials to support recommendations which are often derived from what is known for lung sarcoidosis and from the natural history of the disease at the level of the respective organ. The treatment needs to be holistic and personalized, taking into account not only extrapulmonary localizations but also lung involvement, parasarcoidosis syndrome if any, symptoms, quality of life, medical history, drugs contra-indications, and potential adverse events and patient preferences. The treatment is based on the use of anti-sarcoidosis drugs, on treatments related to organ dysfunction and supportive treatments. Multidisciplinary discussions and referral to sarcoidosis centers of excellence may be helpful for difficult diagnosis and treatment decisions.

Hypoxia Promotes a Mixed Inflammatory-Fibrotic Macrophages Phenotype in Active Sarcoidosis

Background

Macrophages are pivotal cells in sarcoidosis. Monocytes-derived (MD) macrophages have recently been demonstrated to play a major role especially in pulmonary sarcoidosis. From inflammatory tissues to granulomas, they may be exposed to low oxygen tension environments. As hypoxia impact on sarcoidosis immune cells has never been addressed, we designed the present study to investigate MD-macrophages from sarcoidosis patients in this context. We hypothesized that hypoxia may induce functional changes on MD-macrophages which could have a potential impact on the course of sarcoidosis.

Methods

We studied MD-macrophages, from high active sarcoidosis (AS) (n=26), low active or inactive sarcoidosis (IS) (n=24) and healthy controls (n=34) exposed 24 hours to normoxia (21% O2) or hypoxia (1.5% O2). Different macrophage functions were explored: hypoxia-inducible factor-1α (HIF-1α) and nuclear factor-kappa B (NF-κB) activation, cytokines secretion, phagocytosis, CD80/CD86/HLA-DR expression, profibrotic response.

Results

We observed that hypoxia, with a significantly more pronounced effect in AS compared with controls and IS, increased the HIF-1α trans-activity, promoted a proinflammatory response (TNFα, IL1ß) without activating NF-κB pathway and a profibrotic response (TGFß1, PDGF-BB) with PAI-1 secretion associated with human lung fibroblast migration inhibition. These results were confirmed by immunodetection of HIF-1α and PAI-1 in granulomas observed in pulmonary biopsies from patients with sarcoidosis. Hypoxia also decreased the expression of CD80/CD86 and HLA-DR on MD-macrophages in the three groups while it did not impair phagocytosis and the expression of CD36 expression on cells in AS and IS at variance with controls.

Conclusions

Hypoxia had a significant impact on MD-macrophages from sarcoidosis patients, with the strongest effect seen in patients with high active disease. Therefore, hypoxia could play a significant role in sarcoidosis pathogenesis by increasing the macrophage proinflammatory response, maintaining phagocytosis and reducing antigen presentation, leading to a deficient T cell response. In addition, hypoxia could favor fibrosis by promoting profibrotic cytokines response and by sequestering fibroblasts in the vicinity of granulomas.

An update on interstitial lung disease

Interstitial lung diseases are a complex group of conditions that cause inflammation and scarring of the lung interstitium. This article discusses the diagnosis and management of common interstitial lung diseases including idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, connective tissue disease associated-interstitial lung disease, sarcoidosis and drug-induced interstitial lung disease. A multidisciplinary approach to diagnosis of interstitial lung disease is the gold standard; key history and examination features, blood panel, pulmonary function tests, high resolution computed tomography imaging, and when required bronchoalveolar lavage and lung biopsy results are discussed to reach a multidisciplinary consensus diagnosis. Advances, including the development of the disease-modifying anti-fibrotic medications nintedanib and pirfenidone, continue to shape the future management of interstitial lung disease. A holistic approach to the care of patients with interstitial lung disease is paramount, as they often have a high symptom burden and considerable palliative care needs.

Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis

Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.

Lung transplantation for sarcoidosis: outcome and prognostic factors

Study question

In patients with sarcoidosis, past and ongoing immunosuppressive regimens, recurrent disease in the transplant and extrapulmonary involvement may affect outcomes of lung transplantation. We asked whether sarcoidosis lung phenotypes can be differentiated and, if so, how they relate to outcomes in patients with pulmonary sarcoidosis treated by lung transplantation.

Patients and methods

We retrospectively reviewed data from 112 patients who met international diagnostic criteria for sarcoidosis and underwent lung or heart–lung transplantation between 2006 and 2019 at 16 European centres.

Results

Patient survival was the main outcome measure. At transplantation, median (interaquartile range (IQR)) age was 52 (46–59) years; 71 (64%) were male. Lung phenotypes were individualised as follows: 1) extended fibrosis only; 2) airflow obstruction; 3) severe pulmonary hypertension (sPH) and airflow obstruction; 4) sPH, airflow obstruction and fibrosis; 5) sPH and fibrosis; 6) airflow obstruction and fibrosis; 7) sPH; and 8) none of these criteria, in 17%, 16%, 17%, 14%, 11%, 9%, 5% and 11% of patients, respectively. Post-transplant survival rates after 1, 3, and 5 years were 86%, 76% and 69%, respectively. During follow-up (median (IQR) 46 (16–89) months), 31% of patients developed chronic lung allograft dysfunction. Age and extended lung fibrosis were associated with increased mortality. Pulmonary fibrosis predominating peripherally was associated with short-term complications.

Answer to the study question

Post-transplant survival in patients with pulmonary sarcoidosis was similar to that in patients with other indications for lung transplantation. The main factors associated with worse survival were older age and extensive pre-operative lung fibrosis.

Comparison of typical and atypical computed tomography patterns regarding reversibility and fibrosis in pulmonary sarcoidosis

PURPOSE:

This study aims to investigate whether there is a significant difference between typical and atypical parenchymal patterns in the development of fibrosis, which is the most crucial factor affecting morbidity in pulmonary sarcoidosis.

METHODS:

In our hospital, 145 cases with Siltzbach Types 2 and 3 sarcoidoses diagnosed by clinical, radiological, and histopathologic were retrospectively investigated. Perilymphatic nodules, accompanying mosaic attenuation, and interlobular septal thickening and central peribronchovascular bunch-like thickening on high-resolution computed tomography were assessed as typical. Solid nodules, galaxy finding, consolidation, ground-glass opacity, isolated mosaic attenuation, and interlobular septal thickening, and pleural fluid were accepted as atypical findings. Findings indicating fibrosis were fine and rough reticular opacity, traction bronchiectasis, volume loss, and cystic changes. For the analysis of variables, SPSS 25.0 program was used.

RESULTS:

Ten (16%) of the 61 cases with typical findings and 16 (19%) of the 84 with atypical findings developed fibrosis (P = 0.827). The mean age of cases with fibrosis was higher. With the cut-off of 50 years, sensitivity was 61.5%, and specificity was 68.9%. The highest fibrosis rate was in cases with ground glass pattern (n = 7/17), whereas higher reversibility rates were in those with miliary pattern (n = 9/12) and galaxy sign (n = 5/6).

CONCLUSION:

The incidence of fibrosis is higher in the atypical group with no significant difference. The incidence of fibrosis differs in each atypical pattern, being highest in ground-glass opacity and lowest in the miliary pattern.

Incidence and baseline characteristics of relapse or exacerbation in patients with pulmonary sarcoidosis in Japan

BACKGROUND

To identify the incidence and baseline characteristics of relapse and exacerbation in patients with pulmonary sarcoidosis over a long-term period.

METHODS

We enrolled 103 patients. The incidence and characteristics of relapse or exacerbation were retrospectively recorded and statistically analysed.

RESULTS

Of 103 patients, 79% were women. Mean age at diagnosis was 50.1 ± 16.4 y. Mean observation period was 9.8 ± 8.6 y. Overall relapse or exacerbation was 22.3% (n = 23) and mean time from diagnosis (including diagnosis of ocular disease at another facility) to relapse or exacerbation was 8.7 ± 8.3 y. We analysed the data of 69 -patients who were observed for > 5 y and identified relapse or exacerbation within 5 y in 9 patients. -Comparison of characteristics at diagnosis between the relapse/exacerbation group and the improved/stable group showed that the relapse/exacerbation group had a significantly higher frequency of bilateral hilar lymphadenopathy, longer disease duration, ocular involvement, cardiac involvement, and oral glucocorticoid use at diagnosis (P = 0.014, 0.027, 0.019, 0.035, and 0.0043, respectively). The number of risk factors was positively and significantly associated with the cumulative rate of relapse/exacerbation (P = 0.048).

CONCLUSION

Our long-term observational cohort study newly identified the incidence and baseline risk factors for relapse or exacerbation in patients with pulmonary sarcoidosis over a long-term period. Scoring the number of factors at baseline may facilitate the prediction of relapse or exacerbation.

Defining prognosis in sarcoidosis

Sarcoidosis is a multi-systemic granulomatous disease. Affected individuals can show spontaneous healing, develop remission with drug treatment within 2 years, or become chronically ill. Our main goal was to identify features that are related to prognosis.The study consisted of 101 patients, recruited at a single center, who were already diagnosed with sarcoidosis at the start of the study or were diagnosed within 48 months. Ninety individuals were followed-up for at least 24 months and were classified according to clinical outcome status (COS 1 to 9). Those with COS 1-4 and COS 5-9 were classified as having favorable and unfavorable outcomes, respectively. Unconditional logistic regression analyses were conducted to define which variables were associated with sarcoidosis outcomes. Subsequently, we established a scoring system to help predict the likelihood of a favorable or unfavorable outcome.Of our patients, 48% developed a chronic form of the disease (COS 5-9). Three clinical features were predictive of prognosis in sarcoidosis. We built a score-based model where the absence of rheumatological markers (1 point), normal pulmonary functions (2 points), and the presence of early respiratory symptoms manifestations (2 points) were associated with a favorable prognosis. We predicted that a patient with a score of 5 had an 86% (95% confidence interval [CI] 74%-98%) probability of having a favorable prognosis, while those with scores of 4, 3, 2, 1, and 0 had probabilities of 72% (95% CI 59-85%), 52% (95% CI 40-63%), 31% (95% CI 17-44%), 15% (95% CI 2-28%), and 7% (95% CI 0-16%) of having a favorable prognosis, respectively. Thus, our easy-to-compute algorithm can help to predict prognosis of sarcoidosis patients, facilitating their management.