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Chen C, Luo N, Dai F, Zhou W, Wu X, Zhang J. Advance in pathogenesis of sarcoidosis: Triggers and progression. Heliyon 2024; 10:e27612. [PMID: 38486783 PMCID: PMC10938127 DOI: 10.1016/j.heliyon.2024.e27612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024] Open
Abstract
Sarcoidosis, a multisystemic immune disease, significantly impacts patients' quality of life. The complexity and diversity of its pathogenesis, coupled with limited comprehensive research, had hampered both diagnosis and treatment, resulting in an unsatisfactory prognosis for many patients. In recent years, the research had made surprising progress in the triggers of sarcoidosis (genetic inheritance, infection and environmental factors) and the abnormal regulations on immunity during the formation of granuloma. This review consolidated the latest findings on sarcoidosis research, providing a systematic exploration of advanced studies on triggers, immune-related regulatory mechanisms, and clinical applications. By synthesizing previous discoveries, we aimed to offer valuable insights for future research directions and the development of clinical diagnosis and treatment strategies.
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Affiliation(s)
- Cong Chen
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
| | - Nanzhi Luo
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
| | - Fuqiang Dai
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Wenjing Zhou
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
| | - Xiaoqing Wu
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
| | - Jian Zhang
- Department of Thoracic Surgery and Institute of Thoracic Oncology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital of Sichuan University, Chengdu, 610097, China
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2
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Rubinstein A, Kudryavtsev I, Malkova A, Mammedova J, Isakov D, Isakova-Sivak I, Kudlay D, Starshinova A. Sarcoidosis-related autoimmune inflammation in COVID-19 convalescent patients. Front Med (Lausanne) 2023; 10:1271198. [PMID: 38179278 PMCID: PMC10765615 DOI: 10.3389/fmed.2023.1271198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Currently, there are a large number of reports about the development of autoimmune conditions after COVID-19. Also, there have been cases of sarcoid-like granulomas in convalescents as a part of the post-COVID-19 syndrome. Since one of the etiological theories of sarcoidosis considers it to be an autoimmune disease, we decided to study changes in the adaptive humoral immune response in sarcoidosis and SARS-CoV-2 infection and to find out whether COVID-19 can provoke the development of sarcoidosis. This review discusses histological changes in lymphoid organs in sarcoidosis and COVID-19, changes in B cell subpopulations, T-follicular helper cells (Tfh), and T-follicular regulatory cells (Tfr), and analyzes various autoantibodies detected in these pathologies. Based on the data studied, we concluded that SARS-CoV-2 infection may cause the development of autoimmune pathologies, in particular contributing to the onset of sarcoidosis in convalescents.
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Affiliation(s)
- Artem Rubinstein
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
| | - Igor Kudryavtsev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
- Far Eastern Federal University, Vladivostok, Russia
| | - Annа Malkova
- Ariel University Faculty of Natural Sciences, Ariel, Israel
| | | | - Dmitry Isakov
- First Saint Petersburg State I. Pavlov Medical University, Saint Petersburg, Russia
| | | | - Dmitry Kudlay
- Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- NRC Institute of Immunology, Moscow, Russia
- Department of Pharmacognosy and Industrial Pharmacy, Faculty of Fundamental Medicine, Moscow, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, Saint Petersburg, Russia
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3
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Belperio JA, Fishbein MC, Abtin F, Channick J, Balasubramanian SA, Lynch Iii JP. Pulmonary sarcoidosis: A comprehensive review: Past to present. J Autoimmun 2023:103107. [PMID: 37865579 DOI: 10.1016/j.jaut.2023.103107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/23/2023]
Abstract
Sarcoidosis is a sterile non-necrotizing granulomatous disease without known causes that can involve multiple organs with a predilection for the lung and thoracic lymph nodes. Worldwide it is estimated to affect 2-160/100,000 people and has a mortality rate over 5 years of approximately 7%. For sarcoidosis patients, the cause of death is due to sarcoid in 60% of the cases, of which up to 80% are from advanced cardiopulmonary failure (pulmonary hypertension and respiratory microbial infections) in all races except in Japan were greater than 70% of the sarcoidosis deaths are due to cardiac sarcoidosis. Scadding stages for pulmonary sarcoidosis associates with clinical outcomes. Stages I and II have radiographic remission in approximately 30%-80% of cases. Stage III only has a 10%-40% chance of resolution, while stage IV has no change of resolution. Up to 40% of pulmonary sarcoidosis patients progress to stage IV disease with lung parenchyma fibroplasia, bronchiectasis with hilar retraction and fibrocystic disease. These patients are at highest risk for the development of precapillary pulmonary hypertension, which may occur in up to 70% of these patients. Sarcoid patients with pre-capillary pulmonary hypertension can respond to targeted pulmonary arterial hypertension medications. Stage IV fibrocytic sarcoidosis with significant pulmonary physiologic impairment, >20% fibrosis on HRCT or pre-capillary pulmonary hypertension have the highest risk of mortality, which can be >40% at 5-years. First line treatment for patients who are symptomatic (cough and dyspnea) with parenchymal infiltrates and abnormal pulmonary function testing (PFT) is oral glucocorticoids, such as prednisone with a typical starting dose of 20-40 mg daily for 2 weeks to 2 months. Prednisone can be tapered over 6-18 months if symptoms, spirometry, PFTs, and radiographs improve. Prolonged prednisone may be required to stabilize disease. Patients requiring prolonged prednisone ≥10 mg/day or those with adverse effects due to glucocorticoids may be prescribed second and third line treatements. Second and third line treatments include immunosuppressive agents (e.g., methotrexate and azathioprine) and anti-tumor necrosis factor (TNF) medication; respectively. Effective treatments for advanced fibrocystic pulmonary disease are being explored. Despite different treatments, relapse rates range from 13% to 75% depending on the stage of sarcoid, number of organs involved, socioeconomic status, and geography. CONCLUSION: The mortality rate for sarcoidosis over a 5 year follow up is approximately 7%. Unfortunately, 10%-40% of patients with sarcoidosis develop progressive pulmonary disease, and >60% of deaths resulting from sarcoidosis are due to advance cardiopulmonary disease. Oral glucocorticoids are the first line treatment, while methotrexate and azathioprine are considered second and anti-TNF agents are third line treatments that are used solely or as glucocorticoid sparing agents for symptomatic extrapulmonary or pulmonary sarcoidosis with infiltrates on chest radiographs and abnormal PFT. Relapse rates have ranged from 13% to 75% depending on the population studied.
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Affiliation(s)
- John A Belperio
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fereidoun Abtin
- Department of Thoracic Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jessica Channick
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shailesh A Balasubramanian
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph P Lynch Iii
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Danila E, Aleksonienė R, Besusparis J, Gruslys V, Jurgauskienė L, Laurinavičienė A, Laurinavičius A, Mainelis A, Zablockis R, Zeleckienė I, Žurauskas E, Malickaitė R. Lymphocyte Subsets and Pulmonary Nodules to Predict the Progression of Sarcoidosis. Biomedicines 2023; 11:biomedicines11051437. [PMID: 37239108 DOI: 10.3390/biomedicines11051437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The search for biological markers, which allow a relatively accurate assessment of the individual course of pulmonary sarcoidosis at the time of diagnosis, remains one of the research priorities in this field of pulmonary medicine. The aim of our study was to investigate possible prognostic factors for pulmonary sarcoidosis with a special focus on cellular immune inflammation markers. A 2-year follow-up of the study population after the initial prospective and simultaneous analysis of lymphocyte activation markers expression in the blood, as well as bronchoalveolar lavage fluid (BALF) and lung biopsy tissue of patients with newly diagnosed pulmonary sarcoidosis, was performed. We found that some blood and BAL fluid immunological markers and lung computed tomography (CT) patterns have been associated with a different course of sarcoidosis. We revealed five markers that had a significant negative association with the course of sarcoidosis (worsening pulmonary function tests and/or the chest CT changes)-blood CD4+CD31+ and CD4+CD44+ T lymphocytes, BALF CD8+CD31+ and CD8+CD103+ T lymphocytes and a number of lung nodules on chest CT at the time of the diagnosis. Cut-off values, sensitivity, specificity and odds ratio for predictors of sarcoidosis progression were calculated. These markers may be reasonable predictors of sarcoidosis progression.
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Affiliation(s)
- Edvardas Danila
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Regina Aleksonienė
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Justinas Besusparis
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Vygantas Gruslys
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Laimutė Jurgauskienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Aida Laurinavičienė
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Arvydas Laurinavičius
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Antanas Mainelis
- Faculty of Mathematics and Informatics, Vilnius University, 03225 Vilnius, Lithuania
| | - Rolandas Zablockis
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Ingrida Zeleckienė
- Center of Radiology and Nuclear Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Edvardas Žurauskas
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
| | - Radvilė Malickaitė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
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Starshinova A, Zinchenko Y, Malkova A, Kudlay D, Kudryavtsev I, Yablonskiy P. Sarcoidosis and Autoimmune Inflammatory Syndrome Induced by Adjuvants. Life (Basel) 2023; 13:life13041047. [PMID: 37109576 PMCID: PMC10145559 DOI: 10.3390/life13041047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Currently, sarcoidosis remains one of the diseases with unknown etiology, which significantly complicates its diagnosis and treatment. Various causes of sarcoidosis have been studied for many years. Both organic and inorganic trigger factors, provoking the development of granulomatous inflammation are considered. However, the most promising and evidence-based hypothesis is the development of sarcoidosis as an autoimmune disease, provoked by various adjuvants in genetic predisposed individuals. This concept fits into the structure of the autoimmune/inflammatory syndrome, induced by adjuvants (ASIA) that was proposed in 2011 by Professor Shoenfeld Y. In this paper, the authors reveal the presence of major and minor ASIA criteria for sarcoidosis, propose a new concept of the course of sarcoidosis within the framework of ASIA, and point out the difficulties in creating a model of the disease and the selection of therapy. It is obvious that the data obtained not only bring us closer to understanding the nature of sarcoidosis, but also potentiate new studies confirming this hypothesis by obtaining a model of the disease.
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Affiliation(s)
- Anna Starshinova
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia
| | - Yulia Zinchenko
- Saint-Petersburg Research Institute of Phthisiopulmonology, 194064 Saint-Petersburg, Russia
| | - Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 Saint-Petersburg, Russia
| | - Dmitriy Kudlay
- Medical Department, Sechenov First Moscow State Medical University, 119435 Moscow, Russia
- Institute of Immunology, 115478 Moscow, Russia
| | - Igor Kudryavtsev
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia
- Department of Immunology, Institution of Experimental Medicine, 197022 Saint-Petersburg, Russia
| | - Piotr Yablonskiy
- Saint-Petersburg Research Institute of Phthisiopulmonology, 194064 Saint-Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 Saint-Petersburg, Russia
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6
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Sahin Ozdemirel T, Akıncı Özyürek B, Tatci E, Ertan O, Akkurt ES, Senturk A, Ozmen O. Relationships Between Systemic Inflammatory Markers and 18F-FDG PET/CT Imaging and Clinical Findings in Pulmonary Sarcoidosis. Cureus 2023; 15:e36521. [PMID: 37090303 PMCID: PMC10120846 DOI: 10.7759/cureus.36521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Background and aim Sarcoidosis is a multisystem inflammatory disease of unknown aetiology. This study aimed to evaluate the relationship between systemic inflammatory parameters, the systemic immune-inflammation index (SII) and the lymphocyte-to-monocyte ratio (LMR), and disease stage, clinical findings, and 18F-fluoro-2-deoxy-D-glucose (18F-FDG) tomography/computed tomography (PET/CT) uptake. Materials and methods Our study included 73 patients. The general characteristics, radiological features, spirometric tests, PET/CT findings, and laboratory parameters of the patients were recorded. Results Relapse and parenchymal fibrosis were not associated with metabolic parameters, such as LMR and SII. Serum angiotensin-converting enzyme (ACE) levels were lower in the relapsed group than in the non-relapse group. However, the patients' PET/CT images indicated that 18F-FDG parenchym maximum standard uptake value (SUV max), lymph node SUV max, lymph node short axis dimension, SII, and LMR were similar between all patients, relapsed or not. Conclusion Although found to be significant in other inflammatory diseases, we found that SII and LMR alone did not indicate disease prognosis in sarcoidosis due to the small number of patients and the lack of homogeneity between the groups in our study. The usefulness of these markers for clinical use should be investigated by studies that include those with extrapulmonary sarcoidosis, and that calculate these markers at the time of disease diagnosis and during the post-treatment period.
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Affiliation(s)
- Tugce Sahin Ozdemirel
- Pulmonary Medicine, Ankara Ataturk Sanatorium Training and Research Hospital, Ankara, TUR
| | - Berna Akıncı Özyürek
- Pulmonary Medicine, Ankara Ataturk Sanatorium Training and Research Hospital, Ankara, TUR
| | - Ebru Tatci
- Nuclear Medicine, Ankara Ataturk Sanatorium Training and Research Hospital, Ankara, TUR
| | - Ozlem Ertan
- Pulmonology, Ankara Ataturk Sanatorium Training and Research Hospital, Ankara, TUR
| | - Esma Sevil Akkurt
- Pulmonology, Ataturk Sanatorium Training and Research Hospital, Ankara, TUR
| | - Aysegul Senturk
- Pulmonology, Ankara Abdurrahman Yurtaslan Oncology Hospital, Ankara, TUR
| | - Ozlem Ozmen
- Nuclear Medicine, Ankara Ataturk Sanatorium Traning and Research Hospital, Ankara, TUR
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7
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Oyama N, Baba N, Ido H, Hasegawa M. A case of widespread unilateral subcutaneous sarcoidosis with ocular and pulmonary involvements with seropositivity for anti‐double
strand‐DNA
antibody and rheumatoid factor: A revisit of gap between humoral autoimmune abnormalities and clinical findings. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2022. [DOI: 10.1002/cia2.12249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Noritaka Oyama
- Department of Dermatology, Faculty of Medical Sciences University of Fukui Fukui Japan
| | - Natsuki Baba
- Department of Dermatology, Faculty of Medical Sciences University of Fukui Fukui Japan
| | - Hideki Ido
- Department of Dermatology, Faculty of Medical Sciences University of Fukui Fukui Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences University of Fukui Fukui Japan
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8
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Belperio JA, Shaikh F, Abtin FG, Fishbein MC, Weigt SS, Saggar R, Lynch JP. Diagnosis and Treatment of Pulmonary Sarcoidosis: A Review. JAMA 2022; 327:856-867. [PMID: 35230389 DOI: 10.1001/jama.2022.1570] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- John A Belperio
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Faisal Shaikh
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Fereidoun G Abtin
- Thoracic and Interventional Section, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - S Samuel Weigt
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Joseph P Lynch
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
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9
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Cadiou S, Coiffier G, Jouneau S, Jego P, Perdriger A, Belhomme N, Guillin R, Guggenbuhl P. Sacroiliac joint in sarcoidosis on computed tomography: a monocentric retrospective study (SISTER). Rheumatol Int 2021; 42:431-440. [PMID: 34636939 DOI: 10.1007/s00296-021-05021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
Sacroiliitis and spondyloarthritis (SpA) have been associated to sarcoidosis. Sarcoidosis bone involvement of the sacral or iliac bones has been reported to mimic SpA. We aimed to evaluate the prevalence of structural sacroiliitis and structural changes of the sacroiliac joints (SIJ) in patients with sarcoidosis by abdominal-pelvic computed tomography (AP-CT). In this monocentric retrospective study, three blinded readers evaluated AP-CT that had already been performed on patients with sarcoidosis and classified them as normal, degenerative, or inflammatory. A consensus was reached for the divergent cases. Erosion, ankylosis, and sclerosis, classically associated with sacroiliitis, were noted. SpA was defined according to the ASAS 2009 classification criteria. We identified 217 patients with proven sarcoidosis who underwent AP-CT. Only three patients had sacroiliitis by CT and four had SpA, representing 1.38% and 1.85% of the patients, respectively. Degenerative SIJs represented 28.1% of patients and were significantly associated with age, at least one pregnancy, rural lifestyle, ankylosis, diffuse idiopathic skeletal hyperostosis, sclerosis, and the presence of osteophytes. Four patients had axial bone sarcoidosis. Sacroiliitis, SpA, and degenerative changes of the SIJ have been highlighted by AP-CT in patients with sarcoidosis. Osteoarthritis of the SIJ in sarcoidosis was associated with age, pregnancy, and rural lifestyle. Further studies are needed to assess the link between SpA and sarcoidosis.
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Affiliation(s)
- Simon Cadiou
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35000, Rennes, France.
| | | | - Stéphane Jouneau
- Department of Respiratory Medicine, Rennes University Hospital, Rennes, France.,University of Rennes 1, Rennes, France.,INSERM-IRSET UMR1085, Rennes, France
| | - Patrick Jego
- Internal Medicine Department, Rennes University Hospital, University of Rennes 1, 35000, Rennes, France
| | - Aleth Perdriger
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35000, Rennes, France
| | - Nicolas Belhomme
- Internal Medicine Department, Rennes University Hospital, 35000, Rennes, France
| | - Raphaël Guillin
- Department of Medical Imaging, Rennes University Hospital, 35000, Rennes, France
| | - Pascal Guggenbuhl
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, University of Rennes 1, 16 Boulevard de Bulgarie, 35000, Rennes, France.,INSERM, CHU Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), UMR 1241, Univ Rennes, 35000, Rennes, France
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ÇELİK D, BULUT S. EFFECTIVENESS OF CLINICAL PARAMETERS AND LABORATORY VALUES IN PREDICTING THE CLINICAL COURSE OF SARCOIDOSIS-SINGLE CENTER EXPERIENCE. ACTA MEDICA ALANYA 2021. [DOI: 10.30565/medalanya.948632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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11
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Shi TY, Wen XH, Shi XH, Meng J, Lu YW. Associations between sarcoidosis, autoimmune diseases, and autoantibodies: a single-center retrospective study in China. Clin Exp Med 2021; 22:277-283. [PMID: 34191227 DOI: 10.1007/s10238-021-00737-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 10/21/2022]
Abstract
To describe the clinical manifestations, immunological features, and risk factors in patients with sarcoidosis complicated with autoimmune diseases (ADs) as well as determine the frequency of autoantibodies and possible correlation between autoantibodies and laboratory data. Patients with pathologically confirmed sarcoidosis at Beijing Chaoyang Hospital (China) between January 2017 and October 2020 were included. Age- and sex-matched patients who visited the rheumatology outpatient clinic without systemic or ADs were included as controls. Demographic, clinical, serological, and radiological data of sarcoidosis patients were recorded and analyzed. To exclude ADs, autoantibodies, such as antinuclear antibody, extractable nuclear antigen antibodies, and anti-cyclic citrullinated peptide antibody were assessed in controls. A total of 154 sarcoidosis patients (111 females; 72.1%) with a mean ± standard deviation age of 50.7 ± 10.3 years were included. Nineteen patients (12.3%) had ADs; Hashimoto's thyroiditis (n = 6) and Sjogren's syndrome (n = 4) were common. Age, globulin, immunoglobulin G, erythrocyte sedimentation rate (ESR), and C-reactive protein were significantly different between sarcoidosis patients with and without ADs. The ESR level might be a risk factor for sarcoidosis complicated with ADs (RR = 1.053; P = 0.018). Autoantibodies were detected in 29 patients (18.8%), and the frequency was significantly higher than that in controls (18.8% vs. 3%; P = 0.001). Sarcoidosis patients were more likely to have autoantibodies despite the absence of ADs (10.4% vs. 3%; P = 0.031). Age may be a risk factor for sarcoidosis patients presenting with autoantibodies (RR = 1.077; P = 0.042). An association was identified between ADs and sarcoidosis. The inflammatory indexes, such as ESR, IgG, and CRP, were significantly different between sarcoidosis patients with and without ADs. ESR might be a risk factor for the coexistence of ADs and sarcoidosis. Sarcoidosis patients were prone to being autoantibody-positive despite the absence of ADs, and age might be a risk factor for sarcoidosis presenting with autoantibodies.
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Affiliation(s)
- Tian-Yan Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, No. 4 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xiao-Hong Wen
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, No. 4 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xu-Hua Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, No. 4 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Juan Meng
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, No. 4 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Yue-Wu Lu
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, No. 4 Gongti South Road, Chaoyang District, Beijing, 100020, China.
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12
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Mousapasandi A, Herbert C, Thomas P. Potential use of biomarkers for the clinical evaluation of sarcoidosis. J Investig Med 2021; 69:jim-2020-001659. [PMID: 33452128 DOI: 10.1136/jim-2020-001659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown etiology and pathogenesis with a heterogeneous clinical presentation. In the appropriate clinical and radiological context and with the exclusion of other diagnoses, the disease is characterized by the pathological presence of non-caseating epithelioid cell granulomas. Sarcoidosis is postulated to be a multifactorial disease caused by chronic antigenic stimulation. The immunopathogenesis of sarcoidosis encompasses a complex interaction between the host, genetic factors and postulated environmental and infectious triggers, which result in granuloma development.The exact pathogenesis of the disease has yet to be elucidated, but some of the inflammatory pathways that play a key role in disease progression and outcomes are becoming apparent, and these may form the logical basis for selecting potential biomarkers.Biomarkers are biological molecules that are altered pathologically. To date, there exists no single reliable biomarker for the evaluation of sarcoidosis, either diagnostically or prognostically but new candidates are emerging. A diagnosis of sarcoidosis ideally requires a biopsy confirming non-caseating granulomas, but the likelihood of progression that requires intervention remains unpredictable. These challenging aspects could be potentially resolved by incorporating biomarkers into clinical practice for both diagnosis and monitoring disease activity.This review outlines the current knowledge on sarcoidosis with an emphasis on pulmonary sarcoidosis, and delineates the understanding surrounding the implication of biomarkers for the clinical evaluation of sarcoidosis.
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Affiliation(s)
- Amir Mousapasandi
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Cristan Herbert
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Paul Thomas
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, Prince of Wales' Hospital and Prince of Wales' Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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13
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Abstract
PURPOSE OF REVIEW Ocular sarcoidosis is one of the most common causes of uveitis worldwide. The diagnosis and treatment of patients with ocular sarcoidosis remains challenging in some cases. It is important for clinicians to keep up to date with new diagnostic and treatment tools for this disease. RECENT FINDINGS The International Workshop on Ocular Sarcoidosis diagnostic criteria were first proposed in 2009 and revised in 2017. The new criteria contained two parts: ocular presentation and systemic investigation. The diagnostic value of liver enzymes was reduced in the new criteria, whereas the value placed of lymphopenia and the CD4/CD8 ratio in bronchoalveolar lavage fluid were increased. Despite not being included in the criteria, recent studies have also highlighted the diagnostic value of serum soluble interleukin-2 receptors. Recent ophthalmologic imaging also provides useful insights for the differential diagnosis.Many new treatments for ocular sarcoidosis have been developed in recent years. The introduction of biological immunomodulatory agents for uveitis treatment represents a big improvement. Antitumor necrosis factor-alpha antibodies, including adalimumab, have been proven to be effective for treating ocular sarcoidosis. Many studies have also suggested that other biological agents could be effective and well tolerated. Newer intravitreal dexamethasone and fluocinolone implants have been developed. Patients treated with these implants have experienced good and sustained control of their intraocular inflammation. SUMMARY Diagnosis and treatment options for ocular sarcoidosis have changed over time. However, challenges still exist in some difficult patients. Future studies should focus on finding more sensitive biomarkers and developing more effective immunomodulatory treatments with longer efficacy and less side effects.
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Affiliation(s)
- De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, and National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital
- Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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14
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Borba V, Malkova A, Basantsova N, Halpert G, Andreoli L, Tincani A, Amital H, Shoenfeld Y. Classical Examples of the Concept of the ASIA Syndrome. Biomolecules 2020; 10:biom10101436. [PMID: 33053910 PMCID: PMC7600067 DOI: 10.3390/biom10101436] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/13/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was first introduced in 2011 by Shoenfeld et al. and encompasses a cluster of related immune mediated diseases, which develop among genetically prone individuals as a result of adjuvant agent exposure. Since the recognition of ASIA syndrome, more than 4400 documented cases have been reported so far, illustrated by heterogeneous clinical manifestations and severity. In this review, five enigmatic conditions, including sarcoidosis, Sjögren's syndrome, undifferentiated connective tissue disease, silicone implant incompatibility syndrome (SIIS), and immune-related adverse events (irAEs), are defined as classical examples of ASIA. Certainly, these disorders have been described after an adjuvant stimulus (silicone implantation, drugs, infections, metals, vaccines, etc.) among genetically predisposed individuals (mainly the HLA-DRB1 and PTPN22 gene), which induce an hyperstimulation of the immune system resulting in the production of autoantibodies, eventually leading to the development of autoimmune diseases. Circulating autonomic autoantibodies in the sera of patients with silicone breast implants, as well as anatomopathological aspects of small fiber neuropathy in their skin biopsies have been recently described. To our knowledge, these novel insights serve as a common explanation to the non-specific clinical manifestations reported in patients with ASIA, leading to the redefinition of the ASIA syndrome diagnostic criteria.
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Affiliation(s)
- Vânia Borba
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5265601, Israel; (V.B.); (G.H.); (H.A.)
| | - Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, 5265601 Saint-Petersburg, Russia; (A.M.); (N.B.)
| | - Natalia Basantsova
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, 5265601 Saint-Petersburg, Russia; (A.M.); (N.B.)
| | - Gilad Halpert
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5265601, Israel; (V.B.); (G.H.); (H.A.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (L.A.); (A.T.)
- Rheumatology and Clinical Immunology, ASST Spedali Civili, 25123 Brescia, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (L.A.); (A.T.)
- Rheumatology and Clinical Immunology, ASST Spedali Civili, 25123 Brescia, Italy
- Ministry of Health of the Russian Federation, Sechenov First Moscow State Medical University, 119146 Moscow, Russia
| | - Howard Amital
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5265601, Israel; (V.B.); (G.H.); (H.A.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5265601, Israel; (V.B.); (G.H.); (H.A.)
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, 5265601 Saint-Petersburg, Russia; (A.M.); (N.B.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Correspondence:
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15
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Current perspectives on the immunopathogenesis of sarcoidosis. Respir Med 2020; 173:106161. [PMID: 32992264 DOI: 10.1016/j.rmed.2020.106161] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/28/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022]
Abstract
Sarcoidosis is an inflammatory systemic disease that commonly affects the lungs or lymph nodes but can manifest in other organs. Herein, we review the latest evidence establishing how innate and adaptive immune responses contribute to the pathogenesis and clinical course of sarcoidosis. We discuss the possible role of microbial organisms as etiologic agents in sarcoidosis and the evidence supporting sarcoidosis as an autoimmune disease. We also discuss how animal and in vitro human models have advanced our understanding of the immunopathogenesis of sarcoidosis. Finally, we discuss therapeutics for sarcoidosis and the effects on the immune system.
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16
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Starshinova AA, Malkova AM, Basantsova NY, Zinchenko YS, Kudryavtsev IV, Ershov GA, Soprun LA, Mayevskaya VA, Churilov LP, Yablonskiy PK. Sarcoidosis as an Autoimmune Disease. Front Immunol 2020; 10:2933. [PMID: 31969879 PMCID: PMC6960207 DOI: 10.3389/fimmu.2019.02933] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/29/2019] [Indexed: 12/20/2022] Open
Abstract
Despite the large number of performed studies, the etiology and pathogenesis of sarcoidosis still remain unknown. Most researchers allude to the possible autoimmune or immune-mediated genesis of the disease. This review attempts an integral analysis of currently available information suggesting an autoimmune genesis of sarcoidosis and is divided into four categories: the evaluation of clinical signs described both in patients with sarcoidosis and “classic” autoimmune diseases, the role of triggering factors in the development of sarcoidosis, the presence of immunogenic susceptibility in the development of the disease, and the analysis of cellular and humoral immune responses in sarcoidosis. Studying the etiology and pathogenesis of sarcoidosis will improve diagnostic procedures as well as the prognosis and patients' quality of life.
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Affiliation(s)
- Anna A Starshinova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia
| | - Anna M Malkova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia
| | - Natalia Y Basantsova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia.,Phthisiopulmonology Department, St. Petersburg State Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Yulia S Zinchenko
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia.,Phthisiopulmonology Department, St. Petersburg State Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Igor V Kudryavtsev
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia.,Immunology Department, Institute of Experimental Medicine, St. Petersburg, Russia.,Immunology Department, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia
| | - Gennadiy A Ershov
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia
| | - Lidia A Soprun
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia
| | - Vera A Mayevskaya
- Foreign Languages Department, St. Petersburg University of Economics, St. Petersburg, Russia
| | - Leonid P Churilov
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia.,Phthisiopulmonology Department, St. Petersburg State Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Piotr K Yablonskiy
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, St. Petersburg, Russia.,Phthisiopulmonology Department, St. Petersburg State Research Institute of Phthisiopulmonology, St. Petersburg, Russia
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17
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Ramos-Casals M, Retamozo S, Sisó-Almirall A, Pérez-Alvarez R, Pallarés L, Brito-Zerón P. Clinically-useful serum biomarkers for diagnosis and prognosis of sarcoidosis. Expert Rev Clin Immunol 2019; 15:391-405. [DOI: 10.1080/1744666x.2019.1568240] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Rheumatology Unit, Instituto Modelo de Cardiología Privado S.R.L, Córdoba, Argentina
- Rheumatology Unit, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Antoni Sisó-Almirall
- Centre d’Assistència Primària ABS Les Corts, CAPSBE, Barcelona, Spain
- Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain
| | - Roberto Pérez-Alvarez
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Department of Internal Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Lucio Pallarés
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Systemic Autoimmune Diseases Uni, Department of Internal Medicine, Hospital de Son Espases, Palma de Mallorca, Spain
| | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA, Sanitas, Spain
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