Endoluminal Stenosis of Proximal Bronchi in Sarcoidosis

Imaging of Pulmonary Sarcoidosis-A Review

Sarcoidosis is the classic multisystem granulomatous disease. First reported as a disorder of the skin, it is now clear that, in the overwhelming majority of patients with sarcoidosis, the lungs will bear the brunt of the disease. This review explores some of the key concepts in the imaging of pulmonary sarcoidosis: the wide array of typical (and some of the less common) findings on high-resolution computed tomography (HRCT) are reviewed and, with this, the concept of morphologic/HRCT phenotypes is discussed. The pathophysiologic insights provided by HRCT through studies where morphologic abnormalities and pulmonary function tests are compared are evaluated. Finally, this review outlines the important contribution of HRCT to disease monitoring and prognostication.

Pulmonary Function in Pulmonary Sarcoidosis

The pulmonary function test (PFT) has been widely used in sarcoidosis. It may vary due to the severity, extent, and the presence of complications of the disease. Although the PFT of most sarcoidosis patients is normal, there are still 10-30% of cases who may experience a decrease in the PFT, with a progressive involvement of lungs. Restrictive ventilatory impairment due to parenchymal involvement has been commonly reported, and an obstructive pattern can also be present related to airway involvement. The PFT may influence treatment decisions. A diffusing capacity for carbon monoxide (DLCO) < 60% as well as a forced vital capacity (FVC) < 70% portends clinically significant pulmonary sarcoidosis pathology and warrants treatment. During follow-up, a 5% decline in FVC from baseline or a 10% decline in DLCO has been considered significant and reflects the disease progression. FVC has been recommended as the favored objective endpoint for monitoring the response to therapy, and an improvement in predicted FVC percentage of more than 5% is considered effective.

Pulmonary sarcoidosis: A comprehensive review: Past to present

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.

Differential diagnosis of pulmonary sarcoidosis: a review

Diagnosing pulmonary sarcoidosis raises challenges due to both the absence of a specific diagnostic criterion and the varied presentations capable of mimicking many other conditions. The aim of this review is to help non-sarcoidosis experts establish optimal differential-diagnosis strategies tailored to each situation. Alternative granulomatous diseases that must be ruled out include infections (notably tuberculosis, nontuberculous mycobacterial infections, and histoplasmosis), chronic beryllium disease, hypersensitivity pneumonitis, granulomatous talcosis, drug-induced granulomatosis (notably due to TNF-a antagonists, immune checkpoint inhibitors, targeted therapies, and interferons), immune deficiencies, genetic disorders (Blau syndrome), Crohn's disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and malignancy-associated granulomatosis. Ruling out lymphoproliferative disorders may also be very challenging before obtaining typical biopsy specimen. The first step is an assessment of epidemiological factors, notably the incidence of sarcoidosis and of alternative diagnoses; exposure to risk factors (e.g., infectious, occupational, and environmental agents); and exposure to drugs taken for therapeutic or recreational purposes. The clinical history, physical examination and, above all, chest computed tomography indicate which differential diagnoses are most likely, thereby guiding the choice of subsequent investigations (e.g., microbiological investigations, lymphocyte proliferation tests with metals, autoantibody assays, and genetic tests). The goal is to rule out all diagnoses other than sarcoidosis that are consistent with the clinical situation. Chest computed tomography findings, from common to rare and from typical to atypical, are described for sarcoidosis and the alternatives. The pathology of granulomas and associated lesions is discussed and diagnostically helpful stains specified. In some patients, the definite diagnosis may require the continuous gathering of information during follow-up. Diseases that often closely mimic sarcoidosis include chronic beryllium disease and drug-induced granulomatosis. Tuberculosis rarely resembles sarcoidosis but is a leading differential diagnosis in regions of high tuberculosis endemicity.

Diffuse Tracheobronchial Tuberculosis With Left Pulmonary Tuberculosis Displayed on 18F-FDG PET/CT

ABSTRACT

A 57-year-old woman was admitted to the hospital with persisting cough and sputum for 2 months. Chest CT revealed multiple nodules in the left lung. 18F-FDG PET/CT scan was carried out to further evaluate these pulmonary lesions. In addition to multiple hypermetabolic nodules in the upper lobe of left lung, diffuse thickening of the trachea and left bronchial wall with increased FDG uptake was also found. Inflammatory granulation tissue with Mycobacterium tuberculosis was confirmed through the pathological examination of bronchoscopy.

Multi-disciplinary management of patients with benign airway strictures: A review

Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.

Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis

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

Critical Care of Patients With Cardiopulmonary Complications of Sarcoidosis

Sarcoidosis is a systemic inflammatory disease defined by the presence of aberrant granulomas affecting various organs. Due to its multisystem involvement, care of patients with established sarcoidosis becomes challenging, especially in the intensive care setting. While the lungs are typically involved, extrapulmonary manifestations also occur either concurrently or exclusively within a significant proportion of patients, complicating diagnostic and management decisions. The scope of this review is to focus on what considerations are necessary in the evaluation and management of patients with known sarcoidosis and their associated complications within a cardiopulmonary and critical care perspective.

Advanced Pulmonary Sarcoidosis

At least 5% of sarcoidosis patients die from their disease, usually from advanced pulmonary sarcoidosis. The three major problems encountered in advanced pulmonary sarcoidosis are pulmonary fibrosis, pulmonary hypertension, and respiratory infections. Pulmonary fibrosis is the result of chronic inflammation, but other factors including abnormal wound healing may be important. Sarcoidosis-associated pulmonary hypertension (SAPH) is multifactorial including parenchymal fibrosis, vascular granulomas, and hypoxia. Respiratory infections can be cause by structural changes in the lung and impaired immunity due to sarcoidosis or therapy. Anti-inflammatory therapy alone is not effective in most forms of advanced pulmonary sarcoidosis. New techniques, including high-resolution computer tomography and 18F-fluorodeoxyglucose positron emission tomography (PET) have proved helpful in identifying the cause of advanced disease and directing specific therapy.

Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display

Sarcoidosis is a multisystemic granulomatous disorder that can affect virtually any organ. However, pulmonary and thoracic lymph node involvement predominates; abnormalities on chest radiographs are present in 80 to 90% of patients with sarcoidosis. High-resolution computed tomographic (HRCT) scans are superior to chest X-rays in assessing extent of disease, and some CT features may discriminate an active inflammatory component (which may be amenable to therapy) from fibrosis (for which therapy is not indicated). Typical findings on HRCT include micronodules, perilymphatic and bronchocentric distribution, perihilar opacities, and varying degrees of fibrosis. Less common findings on CT include mass-like or alveolar opacities, miliary opacities, mosaic attenuation, honeycomb cysts, and cavitation. With progressive disease, fibrosis, architectural distortion, upper lobe volume loss with hilar retraction, coarse linear bands, cysts, and bullae may be observed. We discuss the salient CT findings in patients with sarcoidosis (with a major focus on pulmonary features) and present classical radiographic and histopathological images of a few extrapulmonary sites.

Indications for treatment of sarcoidosis

PURPOSE OF REVIEW

To describe the current knowledge on indications for sarcoidosis treatment.

RECENT FINDINGS

Despite the lack of evidence-based recommendations, the sarcoidosis community has adopted the concept of starting systemic anti-inflammatory treatment because of potential danger (risk of severe dysfunction on major organs or death) or unacceptable impaired quality of life (QoL). On the contrary, while QoL and functionality are patients' priorities, few studies have evaluated treatment effect on patient-reported outcomes. The awareness of long-term corticosteroids toxicities and consequences on QoL and the emergence of novel drugs have changed therapeutic management. Second-line therapy, mainly methotrexate and azathioprine, are indicated for corticosteroids sparing or corticosteroids-resistant sarcoidosis. TNF-α inhibitors are a useful third-line therapy in chronic refractory disease. In addition to organ-targeted treatment, efforts should also be taken for treating nonorgan-specific symptoms, such as physical training for fatigue, and various disease complications.

SUMMARY

Clinicians should offer a tailored treatment for each patient and ensure a holistic multidisciplinary approach, including pharmacological and nonpharmacological interventions. Patient-centered communication is critical to drive shared decisions, in particular for the tricky situation of isolated impaired QoL as the unique therapeutic indication. Once treatment is decided, clinicians should define a clear therapeutic plan, including goals and instruments to assess response.

Lung transplantation for pulmonary sarcoidosis

Although relatively few patients with pulmonary sarcoidosis develop advanced disease that progresses to respiratory insufficiency despite receiving best practice pharmacologic interventions, lung transplantation may be the only therapeutic option for such patients to both prolong survival and provide improved quality of life. Lung transplant can be successfully performed for patients with end-stage pulmonary sarcoidosis, and post-transplant survival is similar to that for other transplant indications such as idiopathic pulmonary fibrosis. However, appropriate timing of referral, comprehensive assessment of potential candidates for lung transplant, placement of patients on the lung transplant waiting list when within the transplant window as appropriate, choosing the best procedure (bilateral versus single lung transplant), and optimal peri-operative and post-transplant management are key to successful lung transplant outcomes for patients with sarcoidosis.

Pulmonary Sarcoidosis

Sarcoidosis is a systemic disease, with lung involvement in almost all cases. Abnormal chest radiography is usually a key step for considering diagnosis. Lung impact is investigated through imaging; pulmonary function; and, when required, 6-minute walk test, cardiopulmonary exercise testing, or right heart catheterization. There is usually a reduction of lung volumes, and forced vital capacity is the most accurate parameter to reflect the impact of pulmonary sarcoidosis with or without pulmonary infiltration at imaging. Various evolution patterns have been described. Increased risk of death is associated with advanced pulmonary fibrosis or cor pulmonale, particularly in African American patients.

Biomarkers in sarcoidosis

INTRODUCTION

Numerous biomarkers have been evaluated for the diagnosis, assessment of disease activity, prognosis, and response to treatment in sarcoidosis. In this report, we discuss the clinical and research utility of several biomarkers used to evaluate sarcoidosis. Areas covered: The sarcoidosis biomarkers discussed include serologic tests, imaging studies, identification of inflammatory cells and genetic analyses. Literature was obtained from medical databases including PubMed and Web of Science. Expert commentary: Most of the biomarkers examined in sarcoidosis are not adequately specific or sensitive to be used in isolation to make clinical decisions. However, several sarcoidosis biomarkers have an important role in the clinical management of sarcoidosis when they are coupled with clinical data including the results of other biomarkers.

Refractory pulmonary sarcoidosis - proposal of a definition and recommendations for the diagnostic and therapeutic approach

Patients with sarcoidosis undergo spontaneous remission or may be effectively controlled with glucocorticoids alone in many cases. Progressive and refractory pulmonary sarcoidoisis constitute more than 10% of patients seen at specialized centers. Pulmonary fibrosis and associated complications, such as infections and pulmonary hypertension are leading causes of mortality. No universal definition of refractoriness exists, we therefore propose classifying patients as having refractory disease when the following criteria are fulfilled: (1) progressive disease despite at least 10 mg of prednisolone or equivalent for at least three months and need for additional disease-modifying anti-sarcoid drugs due to lack of efficacy, drug toxicity or intolerability and (2) treatment started for significant impairment of life due to progressive pulmonary symptoms. Both criteria should be fulfilled. Treatment options in addition to or instead of glucocorticoids for these patients include second- (methotrexate, azathioprine, leflunomide) and third-line agents (infliximab, adalimumab). Other immunmodulating agents can be used, but the evidence is very limited. Newer agents with anti-fibrotic properties, such as pirfenidone or nintedanib, might hold promise also for the pulmonary fibrosis seen in sarcoidosis. Treating physicians have to actively look for potentially treatable complications, such as pulmonary hypertension, cardiac disease or infections before patients should be classified as treatment-refractory. Ultimately, lung transplantation has to be considered as treatment option for patients not responding to medical therapy. In this review, we aim to propose a new definition of refractoriness, describe the associated clinical features and suggest the therapeutic approach.

Google-driven search for big data in autoimmune geoepidemiology: analysis of 394,827 patients with systemic autoimmune diseases

Systemic autoimmune diseases (SADs) are a significant cause of morbidity and mortality worldwide, although their epidemiological profile varies significantly country by country. We explored the potential of the Google search engine to collect and merge large series (>1000 patients) of SADs reported in the Pubmed library, with the aim of obtaining a high-definition geoepidemiological picture of each disease. We collected data from 394,827 patients with SADs. Analysis showed a predominance of medical vs. administrative databases (74% vs. 26%), public health system vs. health insurance resources (88% vs. 12%) and patient-based vs. population-based designs (82% vs. 18%). The most unbalanced gender ratio was found in primary Sjögren syndrome (pSS), with nearly 10 females affected per 1 male, followed by systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and antiphospholipid syndrome (APS) (ratio of nearly 5:1). Each disease predominantly affects a specific age group: children (Kawasaki disease, primary immunodeficiencies and Schonlein-Henoch disease), young people (SLE Behçet disease and sarcoidosis), middle-aged people (SSc, vasculitis and pSS) and the elderly (amyloidosis, polymyalgia rheumatica, and giant cell arteritis). We found significant differences in the geographical distribution of studies for each disease, and a higher frequency of the three SADs with available data (SLE, inflammatory myopathies and Kawasaki disease) in African-American patients. Using a "big data" approach enabled hitherto unseen connections in SADs to emerge.

Factors signifying gender differences in clinical presentation of sarcoidosis among Estonian population

INTRODUCTION

Sarcoidosis is endemically prevalent in Northern Europe, but gender differences among the sarcoidosis population have not yet been compositely addressed.

OBJECTIVES

To reveal independent factors that formulate gender differences in the presentation of sarcoidosis.

METHODS

All Caucasian patients with confirmed sarcoidosis were recruited from the outpatient department of the Lung Clinic of the Tartu University Hospital, Estonia, between February 2009 and April 2011. Data on demographics, complaints, symptoms, clinical presentation, extrapulmonary manifestations, radiographic stage, lung function parameters and sarcoidosis-related laboratory indices were all drawn from patients' clinical records at presentation. Factors characteristic of female gender were estimated using multivariate logistic regression analysis.

RESULTS

Of 230 cases included, there were significantly more females (56.5%, P = 0.005). After adjustment for age, females appeared distinguishable from males by older age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.07], less frequent smoking (OR 0.25, 95% CI 0.13-0.49), higher probability of extrapulmonary complaints (OR 2.06, 95% CI 1.16-3.65) and musculoskeletal sarcoidosis (OR 3.22, 95% CI 1.65-6.29), and after adjustment for both age and smoking status lower forced expiratory volume in 1 s and lung carbon monoxide diffusing coefficient % predicted (OR 0.89, 95% CI 0.82-0.97 and OR 0.98, 95% CI 0.96-0.995, respectively), but by higher forced vital capacity % predicted (OR 1.12, 95% CI 1.03-1.22).

CONCLUSION

Women with sarcoidosis are independently characterized by greater airflow obstruction, lower lung diffusing coefficient, older age, less smoking, and more frequent extrapulmonary complaints and musculoskeletal involvement. This may urge special attention when addressing female patients in both differential diagnostic and management settings.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

[Pseudotumor phenotype of sarcoidosis: about two cases]

INTRODUCTION

Sarcoidosis is a multisystem benign granulomatous disease of unknown etiology. It can sometimes cause diagnostic confusion by presenting in the form of a pseudotumor, thus constituting a trap for the unwary.

COMMENTS

The authors report two cases of pseudotumor sarcoidosis. In the first, the pseudotumor occurred in the context of multisystem disease in a 48-year-old man. The response to treatment with systemic corticosteroids was complicated by the development of disseminated tuberculosis, which was rapidly fatal. The second case, by contrast, was about a 58-year-old woman and the disease was self-limiting, resolving spontaneously in less than 3 months.

CONCLUSION

Through these two cases, the authors focus on the particularities of the pseudotumor manifestation of pulmonary sarcoidosis. The diagnosis is often difficult. The mismatch between the clinical picture and the extent of radiological lesions should, however, suggest the diagnosis. Histological evidence is needed to eliminate other etiologies including malignant tumors. The condition usually resolves either spontaneously or after treatment with systemic corticosteroids. However, relapses are possible, including on discontinuation of corticosteroid therapy.

Sarcoidosis with major airway, vascular and nerve compromise

The present report describes a 60-year-old Caucasian woman who presented with progressive dyspnea, cough and wheeze. A computed tomography scan of the chest showed innumerable bilateral inflammatory pulmonary nodules with bronchovascular distribution and a mediastinal and hilar infiltrative process with calcified lymphadenopathy leading to narrowing of lobar bronchi and pulmonary arteries. An echocardiogram revealed pulmonary hypertension. Bronchoscopy showed left vocal cord paralysis and significant narrowing of the bilateral bronchi with mucosal thickening and multiple nodules. Transbronchial biopsy was compatible with sarcoidosis. Despite balloon angioplasty of the left lower lobe and pulmonary artery, and medical therapy with oral corticosteroids, her symptoms did not significantly improve. To the authors' knowledge, the present report describes the first case of pulmonary sarcoidosis resulting in major airway, vascular and nerve compromise due to compressive lymphadenopathy and suspected concurrent granulomatous infiltration. Its presentation mimicked idiopathic mediastinal fibrosis.

Distinguishing asthma from sarcoidosis: an approach to a problem that is not always solvable

BACKGROUND

Because pulmonary sarcoidosis often affects the airway, it is commonly confused with asthma.

METHODS

This article reviews the mechanisms of airflow obstruction in sarcoidosis, the symptoms associated with this phenomenon, and the approach to distinguish sarcoidosis from asthma.

DISCUSSION

Because asthma is highly likely in a patient with wheeze, cough, and chest tightness, sarcoidosis is usually not considered unless the patient has extrapulmonary manifestations of sarcoidosis or a family history of the disease. When pulmonary sarcoidosis is a consideration, a chest radiograph should be performed. A chest radiograph should also be performed in an asthmatic patient when the presentation is atypical, or fails to respond to standard asthma treatment; chest radiography should be performed in this situation to consider not only pulmonary sarcoidosis but also other possible cardiopulmonary disorders. In a patient with confirmed pulmonary sarcoidosis, the diagnosis of concomitant asthma is problematic. The symptoms associated with the two disorders are often identical. Airflow obstruction is common in sarcoidosis so that pulmonary function testing is unlikely to differentiate these two diseases. Demonstration of airway hyperreactivity may fail to distinguish these disorders as this is common in sarcoidosis. Serum IgE, serum angiotensin-converting enzyme levels, sputum eosinophilia, and exhaled nitric oxide measurements show promise as distinguishing tests, although they have not been studied specifically. Pulmonary imaging is probably of limited value unless baseline studies are available for comparison. We suspect that historical information will be more useful in distinguishing these two diseases. Not infrequently, it may be impossible to exclude or confirm an asthmatic component in a confirmed pulmonary sarcoidosis patient. Fortunately, exacerbations of both these diseases are often treated with systemic corticosteroids initially. Significant variability in pulmonary symptoms and airflow obstruction suggest that an asthma component is present, and inhaled corticosteroids and bronchodilators should be considered in these cases,

CONCLUSIONS

Asthma and sarcoidosis share many of the same symptoms, as sarcoidosis commonly affects the airways. Therefore, it is problematic to distinguish these two diseases. In this article, we have outlined an approach to assess the presence of each of these diseases and an approach to therapy.

Therapy for sarcoidosis: evidence-based recommendations

The options for treatment of sarcoidosis have expanded. In this article, we outline a stepwise approach to treatment. Recommendations for treatment are based on available evidence. While corticosteroids remain the treatment of choice for initial systemic therapy, other agents have been shown to be steroid sparing, and therefore useful for long-term management. In addition, new agents have proved to be useful for patients with refractory disease.

Severe bronchoconstriction due to sarcoid-like reaction to lung cancer

Chest radiography in a 59-year-old woman with recurrent pneumonia showed infiltrates in her left upper lung field. Fiberoptic bronchoscopy and chest computed tomography revealed severe constriction in the upper bronchus and a nodule in the left upper lobe. After lobectomy, adenocarcinoma was confirmed, with multiple non-caseating granulomas in the lung parenchyma and lymph nodes. Bronchial constriction was thought to be due to a sarcoid-like reaction secondary to lung cancer, leading to granuloma formation.

Sarcoidosis of the upper and lower airways

Sarcoidosis is a systemic granulomatous disease of undetermined etiology characterized by a variable clinical presentation and disease course. Although clinical granulomatous inflammation may occur within any organ system, more than 90% of sarcoidosis patients have lung disease. Sarcoidosis is considered an interstitial lung disease that is frequently characterized by restrictive physiologic dysfunction on pulmonary function tests. However, sarcoidosis also involves the airways (large and small), causing obstructive airways disease. It is one of a few interstitial lung diseases that affects the entire length of the respiratory tract - from the nose to the terminal bronchioles - and causes a broad spectrum of airways dysfunction. This article examines airway dysfunction in sarcoidosis. The anatomical structure of the airways is the organizational framework for our discussion. We discuss sarcoidosis involving the nose, sinuses, nasal passages, larynx, trachea, bronchi and small airways. Common complications of airways disease, such as, atelectasis, fibrosis, bullous leions, bronchiectasis, cavitary lesions and mycetomas, are also reviewed.

A concise review of pulmonary sarcoidosis

This is an update on sarcoidosis, focusing on etiology, diagnosis, and treatment. In the area of etiopathogenesis, we now have a better understanding of the immune response that leads to the disease as well as genetic factors that modify both the risk for the disease and its clinical outcome. Several groups have also identified possible agents as a cause for sarcoidosis. Although none of these potential causes has been definitely confirmed, there is increasing evidence to support that one or more infectious agents may cause sarcoidosis, although this organism may no longer be viable in the patient. The diagnosis of sarcoidosis has been significantly aided by new technology. This includes the endobronchial ultrasound, which has been shown to increase the yield of needle aspiration of mediastinal and hilar lymph nodes. The positive emission tomography scan has proven useful for selecting possible biopsy sites by identifying organ involvement not appreciated by routine methodology. It has also helped in assessing cardiac involvement. The biologic agents, such as the anti-tumor necrosis factor antibodies, have changed the approach to refractory sarcoidosis. There is increasing evidence that the clinician can identify which patient is most likely to benefit from such therapy. As new and more potent antiinflammatory agents have been developed, it is clear that there are other factors that burden the patient with sarcoidosis, including fatigue and sarcoidosis-associated pulmonary hypertension. There have been several recent studies demonstrating treatment options for these problems.

Bronchoscopic management of sarcoidosis related bronchial stenosis with adjunctive topical mitomycin C

A 58-year-old woman with multiple proximal airway stenoses due to sarcoidosis failed to improve with steroid therapy. After bronchoscopic balloon dilation with adjunctive topical mitomycin C, there was symptomatic improvement and preserved patency of the airways one month later. However, the patient's effort tolerance gradually deteriorated subsequently, and a repeat bronchoscopy one year later showed recurrence of airway stenosis.

The Histology of Pulmonary Sarcoidosis: A Review with Particular Emphasis on Unusual and Underrecognized Features

The pathologist is frequently involved in the diagnostic approach to the patient with suspected sarcoidosis. Although the histologic diagnosis is generally not difficult, atypical and underrecognized features may occasionally occur and may result in diagnostic problems. The authors review the histology of pulmonary sarcoidosis, focusing particularly on these unusual problematic findings.

Pulmonary hypertension caused by sarcoidosis

Pulmonary hypertension is an uncommon complication of sarcoidosis, but in severe pulmonary disease it occurs frequently. It is an important cause of cryptogenic dyspnea in sarcoidosis patients and can occur despite the absence of pulmonary fibrosis. The true prevalence is unknown. With the advent of specific therapies for pulmonary hypertension, there has been a resurgence of interest in the pathophysiology, diagnosis, and treatment of sarcoidosis-associated pulmonary hypertension. This article reviews the status of the current epidemiologic, pathophysiologic, and therapeutic knowledge regarding this entity.

BAL fluid cells and pulmonary function in different radiographic stages of newly diagnosed sarcoidosis

PURPOSE

Sarcoidosis affected lungs detected in more than 90% of patients. The relationship between different stages of pulmonary sarcoidosis and pulmonary function tests (PFT) as well as bronchoalveolar lavage fluid (BALF) cells can be established. Geographic and ethnic factors are known to be linked to the specific characteristics of patients with sarcoidosis. The purpose of the study was to evaluate peculiarities of BALF cells pattern and pulmonary function tests at the time of the diagnosis of different radiographic types of sarcoidosis in a large group of Lithuanian sarcoid patients.

MATERIAL AND METHODS

This is the prospective study of BALF cells and PFT of patients with newly diagnosed sarcoidosis. The study population consisted of 221 non-treated non-smoker patients. All patients underwent BAL and the majority of them underwent PFT.

RESULTS

Comparing Stage I to Stage III groups, a slight increase in the macrophage and neutrophil count and a decrease of lymphocyte count was apparent. However, the leukocyte population difference was not statistically significant. We have observed significant increase of CD8 cell count, as well as a decrease of both the CD4 cell count and the CD4/CD8 ratio from Stage I to Stage III. We have determined statistically significant differences in all PFT parameters among the patient groups with different radiographic stages of sarcoidosis. The values of FVC, VC and TLC tended to decrease with an elevation of BALF neutrophils and/or eosinophils count. However BALF cells did not correlate well with PFT indices.

CONCLUSIONS

In newly diagnosed sarcoid patients, BALF cell and PFT markers depend on the sarcoidosis stage.

[Atypical sarcoidosis]

PURPOSE

Sarcoidosis is a granulomatous disease of unknown etiology. Lung and lymphatic system are the principal localisations. Clinical presentations are various depending on involved organs. Some presentations, which are easily diagnosed, are typical and frequent. Atypical forms have unusual presentations and/or are rare. Beside, in a multisystemic sarcoidosis, the affection of only one organ can be unusual. Rigorous diagnosis procedure could avoid errors.

CURRENT KNOWLEDGE AND KEY POINTS

Twenty percent of sarcoidosis have atypical presentation. However, each of them are infrequent. Atypical features are wide and can concern pulmonary or extrapulmonary manifestations, general manifestations, blood testing or pathological pattern.

FUTURE PROSPECTS AND PROJECTS

Describing atypical forms are necessary for their diagnosis. The diagnosis of atypical sarcoidosis is found on the knowledge of atypical forms previously described, presence of granulomas on specimen biopsy and excluding other granulomatous disease.

Airway involvement in interstitial lung disease

PURPOSE OF REVIEW

After briefly discussing several ways to approach airway involvement in interstitial lung diseases - by diagnostic methodologies used to assess it, considering different topographical involvement, related to its presence in the diffuse lung diseases with higher prevalence, or from a causal point of view - the author describes in more detail, taking into account recent literature, new proposed entities combining airways (at different levels) and interstitial damage, like airway-centered interstitial fibrosis and acute fibrinous organizing pneumonia.

RECENT FINDINGS

These proposed patterns are being discussed, as possible autonomic interstitial lung disease disorders, and also from the perspective of its relationship with the main differential diagnosis, within known interstitial pictures.

SUMMARY

Thus, airway-centered interstitial fibrosis and acute fibrinous organizing pneumonia may widen the spectrum of the yet described long list of interstitial lung diseases, and its diagnosis may be considered, under specific circumstances, when there is airway involvement associated with interstitial damage.