Assessment of mycobacterial DNA in cells and tissues of mycobacterial and sarcoid lesions

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.

The Use of Urine Mycobacterium tuberculosis Complex Polymerase Chain Reaction as a Predictive Factor for Recurrence and Progression After Intravesical Bacillus Calmette-Guérin Therapy in Patients with Non-muscle‑invasive Bladder Cancer

Background

Intravesical bacillus Calmette-Guérin (BCG) instillation is a standard treatment for non–muscle-invasive bladder cancer (NMIBC); however, not all patients benefit from BCG therapy. Currently, no surrogate marker exists to predict BCG efficacy, and thereby, identify patients who will benefit from this treatment.

Objective

To evaluate the utility of urine Mycobacterium tuberculosis complex polymerase chain reaction (MTC-PCR) assay as a predictive marker for recurrence and progression following BCG therapy.

Design, setting, and participants

A prospective analysis was carried out for of intermediate- or high-risk NMIBC patients who received BCG instillation for the first time. Urine samples, for MTC-PCR assay, were collected at baseline and annually for up to 10 yr after the last BCG instillation, including induction and maintenance therapy. The first postoperative sample for MTC-PCR was taken at 1 yr from the last instillation.

Outcome measurements and statistical analysis

A survival analysis was performed using the Kaplan-Meier method, and risk factors for recurrence and progression after BCG treatment were assessed using Cox regression analysis.

Results and limitations

During follow-up (median: 57 mo), 468/521 samples (89.8%) were MTC-PCR positive, and 108/123 patients (87.8%) exhibited MTC-PCR positivity at least once. Five-year recurrence- and progression-free survival in patients who were not MTC-PCR positive was significantly lower than in patients who were MTC-PCR positive at least once (p <  0.001). Using multivariable Cox regression analysis, MTC-PCR positivity at least once was a significant prognostic factor for recurrence (hazard ratio [HR]: 36.782, p <  0.001) and progression (HR: 47.209, p <  0.001).

Conclusions

Patients who were not MTC-PCR positive, even once after BCG therapy, were extremely likely to exhibit recurrence and progression. Urine MTC-PCR may be an extremely useful, noninvasive surrogate marker to predict recurrence and progression following BCG therapy.

Patient summary

Urine Mycobacterium tuberculosis complex polymerase chain reaction may be a novel biomarker capable of identifying patients at risk of recurrence and progression after bacillus Calmette-Guérin (BCG) immunotherapy.

Prosthetic Rehabilitation of a Patient Diagnosed With Sarcoidosis Using Dental Implants: A Clinical Case Report

No previously published studies have reported on the placement and restoration of dental implants in a patient diagnosed with sarcoidosis. Patients with sarcoidosis may develop periodontitis as a manifestation of systemic disease and are therefore at increased risk of tooth loss. These patients are likely to want fixed dental prostheses, which may need to be supported by dental implants. The case presented is that of a 31-year-old female patient presenting with a missing maxillary central incisor and a sarcoidal process affecting the anterior maxilla, which had severely compromised the periodontium of the adjacent lateral incisor. The patient was successfully rehabilitated with an implant-retained prosthesis following a staged horizontal and vertical bone augmentation procedure. At the 4-year review, the implant restoration performed well with stable peri-implant bone levels. We conclude that dental implant rehabilitation in patients with sarcoidosis may be a predictable treatment option, depending on disease stability and concurrent systemic therapy, but these patients will require additional maintenance because of the possibility of an increased risk of peri-implantitis. The effects of sarcoidosis and its management on the success of dental implants are discussed to aid treatment planning for such patients.

The presence of mycobacterial antigens in sarcoidosis associated granulomas

Background: Sarcoidosis is a multi-organ disorder with unknown etiology. The role of bacteria in pathogenesis of sarcoidosis is still controversial. This study analyses new aspects of Mycobacterium Tuberculosis (MTB) presence in sarcoidosis diseases. Objectives: To find MTB in paraffin embedded tissues of sarcoidosis patients, samples of 10 sarcoidosis, 12 confirmed pulmonary tuberculosis (PTB) and 5 controls associated with granulomatous tissues were analysed. Methods: The paraffin embedded tissue specimens of the selected patients from the pathology archive of a subspecialty pulmonary hospital in IRAN were evaluated by Real Time PCR for MTB DNA using IS6110. Immunohistochemistry (IHC) method using MTB purified protein derivative (PPD) antibody was used to detect mycobacterial antigens. Results: All sarcoidosis patients had negative MTB DNA results in Real time PCR analysis. This analysis resulted in 10 (83.3%) positive cases for TB patients. The IHC analysis for MTB anti-PPD antibody showed positive diffused cytoplasmic staining for all TB patients whereas this staining was positive for 3 sarcoidosis patients (30%). Conclusion: Amplification of the IS6110 DNA sequence that is the most common target used for MTB diagnosis is not sensitive method to detect MTB in sarcoidosis granuloma. However, tissue IHC for anti-PPD antibody shows higher performance to detect MTB in sarcoidal granulomas reveals a mycobacterial signature in sarcoidosis tissue with negative IS6110 assay. This finding supports Mycobacterium tuberculosis may have an etiologic role in sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 236-241)

Microbial Lineages in Sarcoidosis. A Metagenomic Analysis Tailored for Low-Microbial Content Samples

RATIONALE

The etiology of sarcoidosis is unknown, but microbial agents are suspected as triggers.

OBJECTIVES

We sought to identify bacterial, fungal, or viral lineages in specimens from patients with sarcoidosis enriched relative to control subjects using metagenomic DNA sequencing. Because DNA from environmental contamination contributes disproportionately to samples with low authentic microbial content, we developed improved methods for filtering environmental contamination.

METHODS

We analyzed specimens from subjects with sarcoidosis (n = 93), control subjects without sarcoidosis (n = 72), and various environmental controls (n = 150). Sarcoidosis specimens consisted of two independent sets of formalin-fixed, paraffin-embedded lymph node biopsies, BAL, Kveim reagent, and fresh granulomatous spleen from a patient with sarcoidosis. All specimens were analyzed by bacterial 16S and fungal internal transcribed spacer ribosomal RNA gene sequencing. In addition, BAL was analyzed by shotgun sequencing of fractions enriched for viral particles, and Kveim and spleen were subjected to whole-genome shotgun sequencing.

MEASUREMENTS AND MAIN RESULTS

In one tissue set, fungi in the Cladosporiaceae family were enriched in sarcoidosis compared with nonsarcoidosis tissues; in the other tissue set, we detected enrichment of several bacterial lineages in sarcoidosis but not Cladosporiaceae. BAL showed limited enrichment of Aspergillus fungi. Several microbial lineages were detected in Kveim and spleen, including Cladosporium. No microbial lineage was enriched in more than one sample type after correction for multiple comparisons.

CONCLUSIONS

Metagenomic sequencing revealed enrichment of microbes in single types of sarcoidosis samples but limited concordance across sample types. Statistical analysis accounting for environmental contamination was essential to avoiding false positives.

Is there any association between Sarcoidosis and infectious agents?: a systematic review and meta-analysis

Background

During the last few years, investigators have debated the role that infectious agents may have in sarcoidosis pathogenesis. With the emergence of new molecular biology techniques, several studies have been conducted; therefore, we performed a meta-analysis in order to better explain this possible association.

Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement from the Cochrane collaboration guidelines. Four different databases (Medline, Scopus, Web of Science, and Cochrane Collaboration) were searched for all original articles published from 1980 to 2015. The present meta-analysis included case–control studies that reported the presence of microorganisms in samples of patients with sarcoidosis using culture methods or molecular biology techniques. We used a random effects or a fixed-effect model to calculate the odds ratio (OR) and 95% confidence intervals (CI). Sensitivity and subgroup analyses were performed in order to explore the heterogeneity among studies.

Results

Fifty-eight studies qualified for the purpose of this analysis. The present meta-analysis, the first, to our knowledge, in evaluation of all infectious agents proposed to be associated with sarcoidosis and involving more than 6000 patients in several countries, suggests an etiological link between Propionibacterium acnes and sarcoidosis, with an OR of 18.80 (95% CI 12.62, 28.01). We also found a significant association between sarcoidosis and mycobacteria, with an OR of 6.8 (95% CI 3.73, 12.39). Borrelia (OR 4.82; 95% CI 0.98, 23.81), HHV-8 (OR 1.47; 95% CI 0.02, 110.06) as well as Rickettsia helvetica, Chlamydia pneumoniae, Epstein-barr virus and Retrovirus, although suggested by previous investigations, were not associated with sarcoidosis.

Conclusion

This meta-analysis suggests that some infectious agents can be associated with sarcoidosis. What seems clear is that more than one infectious agent might be implicated in the pathogenesis of sarcoidosis; probably the patient’s geographical location might dictate which microorganisms are more involved. Future investigations and more clinical trials are need to bring these evidences to a more global level.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0332-z) contains supplementary material, which is available to authorized users.

Mycobacterium avium Subsp. avium infection in four veal calves: differentiation from intestinal tuberculosis

Mycobacterium avium subsp. avium (Maa) is an intracellular pathogen belonging to the Mycobacterium avium-intracellulare complex (MAC). Reservoirs of MAC are the natural environment, wildlife and domestic animals. In adult bovine, MAC infections are typically caused by Mycobacterium avium subsp. paratuberculosis (Map). Maa infections in bovine are rarely reported but may cause clinical disease and pathological lesions similar to those observed in paratuberculosis or those induced by members of the Mycobacterium tuberculosis complex (MTBC). Therefore, differentiation of MAC from MTBC infection should be attempted, especially if unusual mycobacterial lesions are encountered. Four veal calves from a fattening farm dying with clinical signs of otitis media, fever, and weight loss were submitted for necropsy. Samples from affected organs were taken for histologic investigation, bacteriologic culture, and bacterial specification using PCR. Macroscopic thickening of the intestinal mucosa was induced by granulomatous enteritis and colitis. Intracytoplasmic acid-fast bacteria were detected by Ziehl-Neelsen stains and PCR revealed positive results for Mycobacterium avium subsp. avium. Clinical and pathological changes of Maa infection in veal calves had features of Mycobacterium avium subsp. paratuberculosis and the MTBC. Therefore, Mycobacterium tuberculosis complex infection should be considered in cases of granulomatous enteritis in calves.

Etiologic aspect of sarcoidosis as an allergic endogenous infection caused by Propionibacterium acnes

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Propionibacterium acnes is the only microorganism that has been isolated from sarcoid lesions. Many P. acnes have been detected in sarcoid lymph nodes using quantitative PCR and in sarcoid granulomas by in situ hybridization. P. acnes trigger factor protein causes a cellular immune response only in sarcoid patients and induces pulmonary granulomas in mice sensitized with the protein and adjuvant, but only those with latent P. acnes infection in their lungs. Eradication of P. acnes by antibiotics prevents the development of granulomas in this experimental model. Although P. acnes is the most common commensal bacterium in the lungs and lymph nodes, P. acnes-specific antibody detected the bacterium within sarcoid granulomas of these organs. P. acnes can cause latent infection in the lung and lymph node and persist in a cell-wall-deficient form. The dormant form is activated endogenously under certain conditions and proliferates at the site of latent infection. In patients with P. acnes hypersensitivity, granulomatous inflammation is triggered by intracellular proliferation of the bacterium. Proliferating bacteria may escape granulomatous isolation, spreading to other organs. Latent P. acnes infection in systemic organs can be reactivated by another triggering event, leading to systemic sarcoidosis.

Etiologic link between sarcoidosis and Propionibacterium acnes

Propionibacterium acnes is the only microorganism isolated from sarcoid lesions by bacterial culture. Numerous P. acnes genomes are found in lymph node samples from Japanese and European patients with sarcoidosis, whereas a few genomes are found in some non-sarcoid samples. The high frequency and specificity of detecting P. acnes within sarcoid granulomas suggests that this indigenous bacterium causes granuloma formation in many patients with sarcoidosis. P. acnes is the most common commensal bacterium in the lungs and lymph nodes. Occasional detection of P. acnes in non-granulomatous areas of these organs from non-sarcoid patients suggests that host factors are more critical than agent factors in the etiology of sarcoidosis. A particular protein, i.e., trigger factor, from P. acnes causes a cellular immune response only in sarcoid patients. The P. acnes trigger-factor protein induces pulmonary granulomas in mice sensitized with the protein and adjuvant, but only in those with latent P. acnes infection in their lungs. Eradication of P. acnes by antibiotics prevents the development of granulomas in this experimental model. P. acnes can cause latent infection in the lung and lymph nodes and persists in a cell wall-deficient form. The dormant form is endogenously activated under certain conditions and proliferates at the site of latent infection. In patients with P. acnes hypersensitivity, granulomatous inflammation is triggered by intracellular proliferation of the bacterium. Proliferating bacteria may escape granulomatous isolation, spreading to other organs. Latent P. acnes infection in systemic organs can be reactivated by another triggering event, leading to systemic sarcoidosis.

Pathogenesis of sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin. Recent research uncovered underlying immunological and genetic mechanisms, which will pave the way for more effective pharmaceutical studies. At present some of this knowledge is clinically exploited to monitor therapy and expected genetic progress will allow the development of prognostic genetic patterns or molecular signatures. Moreover, it has become obvious that several etiologic agents and cofactors will exist. These will be of animate and inanimate nature and their interplay with host mechanisms discussed in this review determines disease phenotypes.

Mycobacterium avium subspecies Paratuberculosis and Crohn's regional ileitis: how strong is association?

Mycobacterium avium subsp. paratuberculosis (MAP) is a well-established etiological agent of Johne's disease in animals. In humans, similar clinical condition, first described by Crohn as regional ileitis in 1932, now known as Crohn's diseases (CD), has also been associated with this mycobacterial species. However, there are two schools of thoughts, one favoring MAP as its etiological agent while the second considers it as an immune-inflammatory condition triggered by an external factor. Onset of CD requires a series of events including predisposition of certain inherited genetic traits, associated environmental stimuli, and immune-inflammatory response. A combination of these factors probably leads to this disease. Recently, some human genes have also been identified which regulate ability to respond appropriately to the external factors. Added to these factors are concerns about the selection of clinical specimens and poor adherence to laboratory quality controls. The literature is full of contradictory findings, but there a lack of uniformity in the materials and methods used by many of these researchers. In this review, we provide our perspective under above circumstances and give our point of view which may open a platform for debate regarding the MAP as the etiological agent of human CD.

Antimycobacterial immune responses in patients with pulmonary sarcoidosis

INTRODUCTION

Sarcoidosis is a multisystem granulomatous disease of unknown origin. Pathogenetic involvement of Mycobacterium tuberculosis has frequently been discussed in the aetiology of sarcoidosis; however, studies still remain contradictory.

OBJECTIVE

We addressed the question of mycobacterial involvement in the pathogenesis of sarcoidosis by analysing cellular immune responses to mycobacterial antigens.

METHODS

We examined the interferon (IFN)-gamma production by enzyme-linked immunospot in response to purified protein derivate (PPD) mycobacterial-specific antigen early secretory antigenic target (ESAT)-6 and culture filtrate protein (CFP)-10 by peripheral blood mononuclear cells (PBMCs) and bronchoalveolar-lavage mononuclear cells (BALMCs) of patients with pulmonary sarcoidosis, smear-negative tuberculosis and controls.

RESULTS

Release of IFN-gamma in response to ex vivo contact with PPD, ESAT-6 or CFP-10 by BALMC and PBMC were comparable among patients with sarcoidosis and controls (PBMC P = 0.2326; BALMC P = 0.1767) and were less frequently observed in both groups compared to patients with tuberculosis (BALMC P < 0.05; PBMC P < 0.0001). Within PBMC, the immunophenotype of sarcoidosis patients differed from that of patients with tuberculosis, as well as from that of controls, while within BALMC it resembled that of patients with tuberculosis.

CONCLUSION

In contrast to patients with tuberculosis, the frequency of mycobacteria-specific local and systemic immune responses is not elevated in patients with sarcoidosis when compared to controls. The immunophenotype represents the local resemblance of the granulomatous reaction underlying tuberculosis and sarcoidosis while showing systemical difference. These observations do not support a role of an infection with M. tuberculosis in the pathogenesis of sarcoidosis.

Airborne Mycobacterium avium infection in a group of red-shanked douc langurs (Pygathrix nemaeus nemaeus)

BACKGROUND

This report describes an airborne Mycobacterium avium (MA)-infection in two red-shanked douc langurs (Pygathrix nemaeus nemaeus) from Cologne zoo.

METHODS

The two individuals and their tissues were investigated clinically (including x-rays), in pathology, in pathohistology, in classical bacteriology and by polymerase chain reaction (PCR).

RESULTS

Clinically, one individual displayed emaciation and a positive reaction in an intrapalpebral testing for M. bovis/MA. The other individual was without any symptoms and did not show any reaction in the intrapalpebral test. In x-ray photos of the lungs, calcified nodules were detected. In pathology, calcified and necrotic nodules were observed within the lungs and the bronchial lymph nodes. In pathohistology, both classical tuberculous granulomas, and few acid fast rods were seen in Ziehl-Neelsen-stain. However, classical bacteriology could not demonstrate mycobacteria. In PCR, MA-infection could be confirmed in one individual using the bronchial lymph nodes.

CONCLUSIONS

It was an airborne infection; however, the definite source of infection in these cases remained unclear. Animals in contact to the langurs (house sparrows and mice) as well as water used in the building are the most promising candidates. The risk for a zoonotic transmission in these cases has been calculated to be low.

A rare case of pulmonary tuberculosis with simultaneous pulmonary and skin sarcoidosis: a case report

Background

Tuberculosis and sarcoidosis are chronic diseases that rarely occur concomitantly. Sarcoidosis is a multisystem granulomatous disorder characterized pathologically by the presence of non-caseating granulomas in involved tissues. Tuberculosis is infectious disease caused by Mycobacterium tuberculosis characterized by granulomas with caseous necrosis.

Case presentation

We present a case of 43-year-old female refugee from Kosovo with microbiological confirmation of pulmonary tuberculosis and pulmonary and skin sarcoidosis at the same time. Three weeks after corticosteroid therapy for pulmonary sarcoidosis was introduced, positive finding of mycobacterium culture of bronchial aspirate was observed. Based on these results, corticosteroid therapy was excluded and antituberculous therapy was introduced for six months. In the meantime, new nodes on face and nose appeared and skin sarcoidosis was diagnosed. The patient was given corticosteroids and colchicine according to the skin and pulmonary sarcoidosis therapy recommendation.

Conclusion

The authors of this study suggest that in cases when there is a dilemma in diagnosis between tuberculosis and sarcoidosis we should advance with corticosteroid therapy until we have microbiological confirmation of mycobacterium culture. This case is remarkable because this is a third described case of sarcoidosis and tuberculosis together (the first reported in Asia, the second in South Africa), and to authors knowledge, this is a first case report in Europe.

Cutaneous sarcoidosis: updates in the pathogenesis

Sarcoidosis is a multiorgan granulomatous disease in which the skin is one of the frequently involved target organs. Cutaneous involvement occurs in a third of patients with sarcoidosis and has protean manifestations. More than a century has passed since the initial description of sarcoidosis, but its cause continues to be an enigma. Recent studies have introduced several new insights into the pathogenesis of this disease. The aim of this literature review was to provide a comprehensive overview on the current updates in the pathogenesis of sarcoidosis. This review has revealed that several genetic polymorphisms are associated with an increased risk of developing sarcoidosis, suggesting that genetic susceptibility to sarcoidosis is probably polygenic. Environmental factors may also modify the susceptibility to sarcoidosis. Evidence favouring an infectious aetiology has been accumulating, but the results of studies are conflicting. The current concept is that the pathogenesis of sarcoidosis involves a T-helper-1-mediated immune response to environmental antigens in a genetically susceptible host. The studies carried out on sarcoidosis have largely focused on the pulmonary aspects and have been mainly conducted by respiratory physicians. In contrast, research conducted on the cutaneous aspects of sarcoidosis is comparatively limited. Although tremendous advances have been made, there is a significant gap between the vast knowledge accumulated on sarcoidosis in recent years and the understanding of this disease.

Considering an infectious etiology of sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause. An infectious etiology of sarcoidosis has long been suspected, but only recently has scientific evidence provided a strong link between infectious agents and sarcoidosis. Moreover, recent advances in our understanding of the relationships between sarcoidosis phenotype and host genetic factors may further illuminate the mechanisms linking infection and sarcoidosis.

Lung protective ventilatory strategies in acute lung injury and acute respiratory distress syndrome: from experimental findings to clinical application

This review addresses the physiological background and the current status of evidence regarding ventilator-induced lung injury and lung protective strategies. Lung protective ventilatory strategies have been shown to reduce mortality from adult respiratory distress syndrome (ARDS). We review the latest knowledge on the progression of lung injury by mechanical ventilation and correlate the findings of experimental work with results from clinical studies. We describe the experimental and clinical evidence of the effect of lung protective ventilatory strategies and open lung strategies on the progression of lung injury and current controversies surrounding these subjects. We describe a rational strategy, the open lung strategy, to accomplish an open lung, which may further prevent injury caused by mechanical ventilation. Finally, the clinician is offered directions on lung protective ventilation in the early phase of ARDS which can be applied on the intensive care unit.

Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome

RATIONALE

The hypothesis that lung collapse is detrimental during the acute respiratory distress syndrome is still debatable. One of the difficulties is the lack of an efficient maneuver to minimize it.

OBJECTIVES

To test if a bedside recruitment strategy, capable of reversing hypoxemia and collapse in > 95% of lung units, is clinically applicable in early acute respiratory distress syndrome.

METHODS

Prospective assessment of a stepwise maximum-recruitment strategy using multislice computed tomography and continuous blood-gas hemodynamic monitoring.

MEASUREMENTS AND MAIN RESULTS

Twenty-six patients received sequential increments in inspiratory airway pressures, in 5 cm H(2)O steps, until the detection of Pa(O(2)) + Pa(CO(2)) >or= 400 mm Hg. Whenever this primary target was not met, despite inspiratory pressures reaching 60 cm H(2)O, the maneuver was considered incomplete. If there was hemodynamic deterioration or barotrauma, the maneuver was to be interrupted. Late assessment of recruitment efficacy was performed by computed tomography (9 patients) or by online continuous monitoring in the intensive care unit (15 patients) up to 6 h. It was possible to open the lung and to keep the lung open in the majority (24/26) of patients, at the expense of transient hemodynamic effects and hypercapnia but without major clinical consequences. No barotrauma directly associated with the maneuver was detected. There was a strong and inverse relationship between arterial oxygenation and percentage of collapsed lung mass (R = - 0.91; p < 0.0001).

CONCLUSIONS

It is often possible to reverse hypoxemia and fully recruit the lung in early acute respiratory distress syndrome. Due to transient side effects, the required maneuver still awaits further evaluation before routine clinical application.

A retrospective study of cutaneous equine sarcoidosis and its potential infectious aetiological agents

Nine horses from ages 5 to 21 years were diagnosed with cutaneous equine sarcoidosis (ES) over an 18-year period. In addition to skin, the lungs were frequently involved, with other organ systems affected less commonly. A predisposition for thoroughbreds and geldings was noted. Cutaneous lesions and signs included crusts, scales, alopecia and pruritus. These were found at various sites, particularly the legs/thighs/elbows, thorax, neck, face and ventral abdomen. Three horses were euthanized shortly after hospitalization; others survived as long as 12 years. Histopathologic stains, immunohistochemistry and polymerase chain reaction assays on paraffin-embedded cutaneous specimens from eight horses for Mycobacterium spp., Coccidioides immitis, Cryptococcus neoformans, Corynebacterium pseudotuberculosis, and Borrelia burgdorferi were all negative. The aetiology of ES is unlikely microbial and continues to be a diagnosis of exclusion. ES, when limited to the skin, is associated with a good prognosis, with either partial or complete response to glucocorticoid therapy in all the surviving horses.

Oral sarcoidosis: a review of literature

Sarcoidosis is a common systemic granulomatous disease affecting multiple organs. Oral involvement is relatively rare and, to our knowledge, there have been only 64 cases reported in the English literature. Most cases of oral sarcoidosis present with mobility of the teeth due to rapid alveolar bone loss. Other oral manifestations include asymptomatic swelling of the involved mucosa, gingivitis and ulcers. Diagnosis of sarcoidosis is by exclusion as no specific test is available. Radiographic, biochemical and histological findings are non-specific, but helpful. All cases of sarcoidosis do not require treatment. Corticosteroids are the treatment of choice in patients requiring treatment. Other drugs such as chloroquine, methotrexate, infliximab and thalidomide are also used in the treatment of sarcoidosis. In most of the oral cases reported, systemic steroids and surgery were the preferred treatment.

High prevalence of Mycobacterium tuberculosis DNA in biopsies from sarcoidosis patients from Catalonia, Spain

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology. The presence of mycobacterial nucleic acid components in patients with sarcoidosis has been demonstrated with varying degrees of success.

OBJECTIVES

The aim of this study was to estimate the presence of Mycobacterium tuberculosis DNA in tissues from sarcoidosis patients, in Catalonia, Spain, as well as to assess the long-term clinical course in these patients.

METHODS

Fifty-eight paraffin-embedded tissue biopsies corresponding to cases of sarcoidosis (n = 23), lung neoplasm (n = 23), and lung tuberculosis (n = 12) available in 1996 were analyzed in a retrospective study by means of a nested polymerase chain reaction using primers corresponding to the insertion element IS6110 of M. tuberculosis complex. For greater sensitivity, Southern blot hybridization was performed. Clinical data were recorded prior to and after PCR analysis (follow-up reported until 2002).

RESULTS

M. tuberculosis DNA was present in 9 out of 23 sarcoidosis biopsies (39%), in 1 out of 23 control patients (4%) (p < 0.01), and in all tissue samples from the 12 control patients with tuberculosis. To date, none of these sarcoidosis patients has developed tuberculosis over a mean (+/-SD) follow-up period of 11 (+/-3.4) years.

CONCLUSION

In our setting, M. tuberculosis DNA is present in tissue biopsies of significantly more sarcoidosis patients than controls. However, these results do not demonstrate causality, although they may suggest a link between M. tuberculosis infection and sarcoidosis in some cases. Follow-up of these patients suggests that M. tuberculosis-DNA-positive sarcoidosis patients are not at greater risk of developing tuberculosis than M. tuberculosis-DNA-negative patients.

The presence of Propionibacterium spp. in the vitreous fluid of uveitis patients with sarcoidosis

PURPOSE

An immunological reaction to a bacterial antigen, such as Mycobacterium tuberculosis or Propionibacterium spp., is suspected to be an initial mechanism in the disorder known as sarcoidosis. We investigated whether or not P. acnes, P. granulosum or M. tuberculosis are present in the vitreous fluid of eyes suffering from uveitis with sarcoidosis.

METHODS

Using polymerase chain reaction, we analysed the presence of P. acnes, P. granulosum and/or M. tuberculosis DNA in vitreous samples taken from six eyes with sarcoidosis and six control eyes.

RESULTS

Among the six uveitis eyes with sarcoidosis, we detected P. acnes DNA in two eyes, P. granulosum DNA in four eyes, and both P. acnes and P. granulosum DNA in one eye, but no Propionibacterium spp. in the control eyes. M. tuberculosis DNA was not present in any of the patient or control eyes.

CONCLUSIONS

This is the first report indicating the presence of Propionibacterium spp. and/or its DNA in the vitreous fluid of sarcoidic eyes with uveitis. This, therefore, supports the idea that Propionibacterium spp. are involved in the aetiology of uveitis in sarcoidosis.

Inter-laboratory validation of PCR-based detection of Mycobacterium tuberculosis in formalin-fixed, paraffin-embedded tissues

The present study is based on the initiative for quality assurance in pathology of the German Society of Pathology and the Professional Association of German Pathologists. Four panel laboratories with experience and expertise in polymerase chain reaction (PCR) detection of Mycobacterium tuberculosis were selected to establish the prerequisites for continuous external laboratory trials, in particular, by providing pre-tested specimens and evaluation criteria for participating institutes. In the first step, the four panel laboratories performed an internal trial to test their own reliability and reproducibility. Paraffin sections and DNA preparations from 34 tissues (25 clinical specimens and 9 controls) totalling to 66 samples were evaluated by each panel institute according to their own protocols. The methodologies differed and are described in detail. Despite these differences, a high degree of inter-laboratory reliability was achieved. In this report, we summarise our results including the correlation with the histology and provide recommendations for applying PCR-based methodology for the detection of mycobacterial DNA in surgical specimens. Supplementary data are available online at http://www.charite.de/ch/patho (rubric "Forschung"). Pre-tested specimens are now available for the external trial and can be ordered from the steering institute via Oligene (http://www.oligene.com/). All molecular pathology laboratories are invited to participate in this quality assurance initiative.

[Epidemiology of sarcoidosis and its genetic and environmental risk factors]

PURPOSE

Review of the literature on epidemiologic data of sarcoidosis and risk factors.

CURRENT KNOWLEDGE AND KEY POINTS

Epidemiological data show that sarcoidosis is a world-wide disease. Frequency is influenced by multiple predisposition factors. The most important are racial factor, sex, age, familial aggregation, genetic factor and/or infective agent. One of these is insufficiency.

FUTURE PROSPECTS AND PROJECTS

Patent sarcoidosis is revealed when concomitant environmental factors (infective agent, climate, country) and predisposition ones (race, sex familial aggregation) appear together and inducing, in each patient, a particular sarcoidosis.

Obstructive sarcoidosis

Sarcoidosis is a systemic granulomatous disease that frequently involves the lung. Although classically thought of as a restrictive lung disease, airway obstruction has become a recognized feature of the disease in the past years. Sarcoidosis can affect the airway at any level and when the involvement includes small airways, it can resemble more common obstructive airway diseases, such as asthma and chronic bronchitis. Pulmonary function testing and high-resolution computerized tomography of the chest are two important tools to evaluate the presence and extent of airway obstruction in sarcoidosis. Pharmacologic options for the treatment of obstructive sarcoidosis are, in large part, not supported by large, randomized clinical trials. In severe cases of bronchostenosis owing to sarcoidosis granuloma or extrinsic compression from intrathoracic lymphadenopathy, interventional bronchoscopy has successfully been performed, although repeated procedures are usually required. Lung transplantation is an ultimate option in selected patients with late-stage fibrotic disease.

Differential gene expression pattern in alveolar macrophages of patients with sarcoidosis and tuberculosis

Sarcoidosis is a multisystem granulomatous disorder of unknown origin characterized by the presence of epithelioid granulomata in the affected organs. Histological and clinical similarities between sarcoidosis and tuberculosis caused by M. tuberculosis suggest a shared underlying pathophysiology. However, specific markers are needed. This study examined the differential gene expression pattern in alveolar macrophages of patients with granulomatous disorders. The differential mRNA regulation pattern of alveolar macrophages in the bronchoalveolar lavage of healthy controls was compared to that of patients with sarcoidosis and tuberculosis by means of differential display reverse transcription PCR. Comparative analysis of 2,498 PCR products in controls, sarcoidosis, and tuberculosis revealed a differential regulation of expressed sequence tags in only 6.5%. 1.8% showed a shared expression pattern between sarcoidosis and tuberculosis in contrast to the control. It can be assumed that these alterations are associated with common granulomatous features. In contrast, 3.0% of the amplified sequence tags showed specific up- or downregulation in sarcoidosis and 1.6% in tuberculosis. These data indicate a significant proportion of common granuloma-associated features, independent of the origin of the granulomatous disorder.

Is there a role for microorganisms in the pathogenesis of sarcoidosis?

Sarcoidosis is a granulomatous disease that has the immunopathological features of being antigen-driven. It is a complex disease that appears to arise from the interaction of one or more triggers with an immunologically predisposed host. Previous reports of familial clustering and varying prevalence of sarcoidosis in different populations could reflect differences in ethnic predisposition or differences in local environmental exposures. This review focuses specifically on these areas that have been the subjects of intensive investigation recently. Specific focus is provided on the issue of an infective trigger and highlights popular candidates. It is concluded that microbes are a likely trigger (but not as an infection) in a genetically predisposed individual and that this initial event culminates in the sarcoidosis granulomatous response.

Molecular analysis of sarcoidosis tissues for mycobacterium species DNA

We performed polymerase chain reaction analysis, for Mycobacterium species 16S rRNA, rpoB, and IS6110 sequences, on 25 tissue specimens from patients with sarcoidosis and on 25 control tissue specimens consisting of mediastinal or cervical lymph nodes and lung biopsies. Mycobacterium species 16S rRNA sequences were amplified from 12 (48%) rpoB sequences and from 6 (24%) of the sarcoidosis specimens. In total, 16S rRNA or rpoB sequences were amplified from 15 sarcoidosis specimens (60%) but were not detected in any of the control tissues (p=0.00002, chi square). In three specimens, the sequences resembled Mycobacterium species other than M. tuberculosis. All specimens with sequences consistent with M. tuberculosis were negative for IS6110. We provide evidence that one of a variety of Mycobacterium species, especially organisms resembling M. tuberculosis, is found in most patients with sarcoidosis.

What causes sarcoidosis?

Limited but encouraging progress has been made over the last several years in our understanding of the etiology of sarcoidosis as a result of recent investments in epidemiologic, immunologic, and molecular biologic studies. A recent US multicenter study of sarcoidosis found few environmental or occupational exposures associated with a two-fold or higher risk of development of sarcoidosis, suggesting noninfectious exposures play a small, if any, role in causing systemic sarcoidosis. In contrast, recent studies have linked infectious agents including mycobacterial and propionibacterial organisms with sarcoidosis. The association of sarcoidosis with the use of Th1-promoting biologic response modifiers is consistent with a central role for enhanced Th1 immune responses in the pathogenesis of sarcoidosis. Given evidence for a genetic predisposition to sarcoidosis, these findings suggest that the etiology of systemic sarcoidosis is linked to genetically determined enhanced Th1 immune responses to a limited number of microbial pathogens.

Assessment of mycobacterial, propionibacterial, and human herpesvirus 8 DNA in tissues of greek patients with sarcoidosis

The causes of sarcoidosis are unknown. In this study, we report the presence of Mycobacterium tuberculosis complex and Propionibacterium granulosum DNA in a significant proportion of Greek patients with sarcoidosis. Human herpesvirus 8 DNA was not detected in sarcoid tissues from Greek patients. Our findings are discussed.

Mycobacterium avium subsp. paratuberculosis infection in a patient with HIV, Germany

Mycobacterium avium subsp. paratuberculosis (MAP), the causative agent of Johne disease in ruminants, has been incriminated as the cause of Crohn disease in humans. We report the first case of human infection with MAP in a patient with HIV; infection was confirmed by obtaining isolates from several different specimen types.

Quantitative analysis of mycobacterial and propionibacterial DNA in lymph nodes of Japanese and European patients with sarcoidosis

The cause(s) of sarcoidosis is unknown. Mycobacterium spp. are suspected in Europe and Propionibacterium spp. are suspected in Japan. The present international collaboration evaluated the possible etiological links between sarcoidosis and the suspected bacterial species. Formalin-fixed and paraffin-embedded sections of biopsy samples of lymph nodes, one from each of 108 patients with sarcoidosis and 65 patients with tuberculosis, together with 86 control samples, were collected from two institutes in Japan and three institutes in Italy, Germany, and England. Genomes of Propionibacterium acnes, Propionibacterium granulosum, Mycobacterium tuberculosis, Mycobacterium avium subsp. paratuberculosis, and Escherichia coli (as the control) were counted by quantitative real-time PCR. Either P. acnes or P. granulosum was found in all but two of the sarcoid samples. M. avium subsp. paratuberculosis was found in no sarcoid sample. M. tuberculosis was found in 0 to 9% of the sarcoid samples but in 65 to 100% of the tuberculosis samples. In sarcoid lymph nodes, the total numbers of genomes of P. acnes or P. granulosum were far more than those of M. tuberculosis. P. acnes or P. granulosum was found in 0 to 60% of the tuberculosis and control samples, but the total numbers of genomes of P. acnes or P. granulosum in such samples were less than those in sarcoid samples. Propionibacterium spp. are more likely than Mycobacteria spp. to be involved in the etiology of sarcoidosis, not only in Japanese but also in European patients with sarcoidosis.

Reduced T-cell receptor CD3zeta-chain protein and sustained CD3epsilon expression at the site of mycobacterial infection

Control of mycobacterial infection by the cellular immune system relies both on antigen-presenting cells and on T lymphocytes. The quality of an effective cellular immune response is dependent on functional signal transduction residing in the cytoplasmic tails of the T-cell receptor CD3 components. In order to investigate potential effects of mycobacteria on T-cell receptor signalling, we examined the protein expression of T-cell signal transduction molecules (CD3zeta, ZAP-70, p59fyn, p56lck). In Western blots of peripheral blood mononuclear cells of Mycobacterium tuberculosis infected patients, only the CD3zeta-chain showed a marked reduction in protein expression. To investigate the situation in situ, immunoenzymatic and immunofluorescence stainings for CD3epsilon and CD3zeta expression were performed on sections of normal lymphoid tissue, M. leprae infected and sarcoid tissue. CD3epsilon and CD3zeta expression were similar with respect to intensity, localization and the number of cells stained in normal lymphoid tissue and in sarcoid granulomas. In contrast, the granulomas of M. leprae infected tissues showed a significantly reduced expression of CD3zeta compared to CD3epsilon. Using double immunofluorescence analysis, virtually no CD3zeta expression could be detected in comparison to the CD3epsilon expression in the lesions. Apparently, mycobacteria are capable of significantly reducing CD3zeta-chain expression, which may be restored by cytokines. IL-2-enhanced zeta-chain expression and T-cell effector functions, defined by interferon-gamma release, in M. tuberculosis-specific and human leucocyte antigen-DR restricted CD4+ T cells isolated from granuloma lesions from patients with pulmonary tuberculosis. Because CD3zeta is essential for CD3 signalling and for eliciting T-cell effector functions, reduced CD3zeta protein expression could result in altered signal transduction and inefficient T-cell effector functions. Alternatively, reduced CD3zeta-chain expression may protect T cells from repetitive TCR stimulation associated with anergy or apoptosis.

Differential requirement for interferon-gamma to restrict the growth of or eliminate some recently identified species of nontuberculous mycobacteria in vivo

In recent years, a number of newly identified species of the genus Mycobacterium (M.) have been isolated from tissues of both immunocompetent and immunocompromised patients, e.g. M. celatum, M. intermedium, M. interjectum, M. bohemicum, M. conspicuum, M. confluentis, M. heidelbergense, M. lentiflavum, and M. branderi. Little is known about their in vivo virulence characteristics and the host factors predisposing to infection with these strains. In an effort to elucidate the pathogenesis of these nontuberculous mycobacterial species, BALB/c and syngeneic IFNgamma-deficient (GKO) mice were intravenously infected with 106 colony forming units of each of these species, and bacterial growth in infected organs and the development of splenomegaly and granulomatous liver lesions were examined for a period of 3 months. Based on their in vivo virulence, mycobacterial strains could be divided into three major groups: (i) Most species examined either grew progressively or persisted at plateau levels in the livers and spleens of immunocompetent mice, and their growth was increased in GKO mice. (ii) M. heidelbergense, M. intermedium and another species not officially accorded separate taxonomical status were eliminated in BALB/c mice, but persisted in GKO mice. (iii) M. confluentis, M. lentiflavum and another novel species were eradicated even in the absence of IFNgamma. Nontuberculous mycobacterial species differed widely in their capacity to induce splenomegaly and lymphadenopathy in GKO mice. In conclusion, IFNgamma is a crucial determinant of infection outcome with most, but not all opportunistic mycobacterial species.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

Clinical insights and basic science correlates in sarcoidosis

More than a century has elapsed since the initial description of sarcoidosis, but critical aspects of the disorder remain poorly understood. Information obtained from epidemiologic observations and basic laboratory research suggests that the disease may represent an immunologic response to an exogenous agent in a genetically susceptible individual. However, a definitive etiologic role for any specific exogenous agent has never been proved, and a "candidate gene" underlying a predisposition to sarcoidosis has not yet been identified. This review presents an historical framework for considering available evidence regarding a transmissible agent in sarcoidosis and host susceptibility to the disease.

Tuberculosis of the axis in a patient with systemic sarcoidosis: technique of posterior open biopsy of the dens: case report

OBJECTIVE AND IMPORTANCE

This case report illustrates the importance of obtaining tissue from a destructive lesion of the dens in a patient with systemic sarcoidosis. Although sarcoidosis can involve the axial skeleton, tissue obtained at the time of C1-C2 fusion demonstrated unsuspected pathological features, which dramatically altered the subsequent medical treatment. The technique of open posterior biopsy of the dens is illustrated, and the advantages of the approach are discussed.

CLINICAL PRESENTATION

A 40-year-old woman with systemic sarcoidosis developed neck pain and atlantoaxial instability. Imaging revealed multiple thoracic and cervical vertebral abnormalities, including a destructive enhancing lesion involving the base of the dens.

INTERVENTION

At the time of posterior C1-C2 fusion, we elected to perform an open biopsy of the base of the dens. A 16-gauge biopsy needle was introduced along the medial portion of the left C2 pars, aiming medially toward the base of the odontoid process. This procedure was performed under direct observation, with fluoroscopic guidance. The biopsy specimen contained caseating granulomas, and cultures were positive for Mycobacterium tuberculosis.

CONCLUSION

The unusual presentation, the technique, and the importance of obtaining tissue to confirm the diagnosis of tuberculous involvement of the dens are emphasized. The relationship between sarcoidosis and tuberculosis reported in the literature is reviewed. In the current case, cell wall-positive tuberculous bacteria were cultured, confirming the presence of two separate diseases in the same patient.

Gamma interferon is essential for clearing Mycobacterium genavense infection

Factors determining the in vivo replication of the opportunistic pathogen Mycobacterium genavense are largely unknown. Following intravenous injection of a patient isolate, M. genavense could not be recovered by culture or detected by PCR in the livers or spleens of infected BALB/c mice. In contrast, M. genavense was found to chronically persist and multiply in the livers and spleens of intravenously infected syngeneic gamma-interferon-gene-deficient (GKO) mice as evidenced by acid-fast stains of infected tissues and recovery by both PCR and liquid culture following organ homogenization. In GKO mice, M. genavense elicited a chronic inflammatory response, resulting in marked splenomegaly and extensive lymphadenopathy. Granulomatous lesions in the livers of GKO mice were diffuse, were composed of monocytes, neutrophils, and CD3(+) cells, and were histochemically negative for inducible nitric oxide synthase.

Regional pressure volume curves by electrical impedance tomography in a model of acute lung injury

OBJECTIVE

A new noninvasive method, electrical impedance tomography (EIT), was used to make pressure-impedance (PI) curves in a lung lavage model of acute lung injury in pigs. The lower inflection point (LIP) and the upper deflection point (UDP) were determined from these curves and from the traditional pressure-volume (PV) curves to determine whether the PI curves resemble the traditional PV curves. Furthermore, regional differences in the mentioned determinants were investigated.

DESIGN

Prospective, experimental study.

SETTING

Animal research laboratory.

INTERVENTIONS

In nine anesthetized pigs, repeated lung lavage was performed until a Pao2 <80 torr was reached. Thereafter, an inspiratory PV curve was made using a constant flow of oxygen. During the intervention, EIT measurements were performed.

MEASUREMENTS AND MAIN RESULTS

In this study, the LIP(EIT) was within 2 cm H2O of the LIP(PV). Furthermore, it was possible to visualize regional PI curves by EIT. No significant difference was found between the LIP(PV) (21.3+/-3.0 cm H2O) and the LIP(EIT) of the total lung (21.5+/-3.0 cm H2O) or the anterior parts of the lung (21.5+/-2.9 cm H2O). A significantly higher LIP (29.5+/-4.9 cm H2O) was found in the posterior parts of the lung. A UDP(PV) could be found in three animals only, whereas in all animals a UDP(EIT) could be determined from the anterior part of the lung.

CONCLUSIONS

Using EIT, determination of LIP and UDP from the regional PI curves is possible. The obtained information from the regional PI curves may help in understanding alveolar recruitment. The use of this new bedside technique for clinical decision making remains to be examined.

Analysis of the Kveim-Siltzbach test reagent for bacterial DNA

The sarcoid spleen-derived reagent for the Kveim-Siltzbach test (KST) elicits a sarcoid-specific, granulomatous, cutaneous response used to establish the diagnosis of sarcoidosis. In the context of the ongoing discussion of a bacterial cause of sarcoidosis we asked the question whether bacterial DNA could be found in the KST reagent. For this purpose two different KST reagents, an identical preparation from a normal spleen, and a native sarcoid spleen were analyzed by polymerase chain reaction (PCR) employing universal primers detecting conserved DNA sequences coding for bacterial ribosomal 16S RNA. Neither KST reagents, the control preparation, nor the spleen yielded a positive signal, indicating that the preparations are free of bacterial contamination. Because the KST reagent elicits granuloma, these results do not support the hypothesis of a bacterial cause of sarcoid granuloma.