[Familial sarcoidosis in Poland: analysis of clinical characteristics and environmental aspects]

Sarcoidosis is a systemic disease of undetermined etiology although it can be related to genetic or environmental factors or both. We investigated 19 polish caucasian families with at least two affected relatives and healthy families members in order to evaluate the clinical aspects of familial sarcoidosis and the influence of environmental factors. We have found three types of familial sarcoidosis: 10 sib pairs, 1 sib triplet, 5 parent offspring pairs and one case of sarcoidosis in cousins. Most of sarcoidosis cases were histologically proved. A high frequency of chronic onset of the disease, chronic form with extrapulmonary sarcoidosis and fibrosis were observed. In only three families the course of the disease was similar in both affected relatives. There was no specific environmental agent found that could be related to the development of the disease. We concluded that it may be possible that familial sarcoidosis can have poorer prognosis that non-familial form, but there is no epidemiological data available about the clinical aspects of sarcoidosis in Poland. The clinical aspects of familial sarcoidosis can suggest the inherited susceptibility to the disease. The etiologic extrinsic factor has not been identified, but it doesn't exclude its role in the pathogenesis.

[Comparison of HLA class I and DR class II antigen frequency in Polish patients, in relation to different stages of the disease]

The aim of this study was to analyze the association between HLA class I and class II DR frequency in the different stages of sarcoidosis in Polish population. 88 patients and 30 healthy controls have been typed. Patients were divided into three groups depending on radiological findings. In the first group were 28 cases presenting the regression of the disease. In the second were 33 patients in stable stage II or III and in the third group 27 patients with pulmonary fibrosis (stage IV). The typing was performed by NIH method using commercial sera. There were no statistically significant differences between studied group in HLA-A class I. The frequency of HLA B-18 was statistically more frequent in patients with sarcoidosis compared to healthy controls. HLA-DR1 was not present in third group of patients and the difference was significant compared to healthy controls.

Inhaled budesonide vs prednisone in the maintenance treatment of pulmonary sarcoidosis

The aim of this investigation was to compare inhaled budesonide with oral prednisone in maintenance treatment of pulmonary sarcoidosis. A double-blind controlled study was performed in 40 patients with stage II or III pulmonary sarcoidosis. After initial systemic 6 weeks treatment with prednisone (40 reduced to 20 mg daily) patients were allocated either to the systematically (S) or topically (T) treated group. S patients continued with 10 mg prednisone daily, T patients were given inhaled budesonide 1.6 mg daily. The progress of treatment was assessed by serial radiography, spirometry, serum Angiotensin Converting Enzyme (ACE) activity and plasma cortisol levels. All patients completed the 12 months treatment. Using the numerical score to assess changes on the chest radiograms S patients improved by 1.7 +/- 0.66 points; T patients improved by 1.15 +/- 0.81 points. Spirometric changes were not statistically significant. Serum ACE fell from 107 +/- 51 U/L in the S group and 92 +/- 40 U/L in the T group to 46 +/- 11 U/L and 38 +/- 21 U/L respectively during the initial phase of treatment. In the maintenance phase ACE levels remained lower than the initial ones in both groups. Morning plasma cortisol levels studied in 10 patients (5 in each group) decreased significantly during the initial phase. Thereafter cortisol levels remained low in the S patients returning to the lower limit of normal values in the T patients. We conclude that inhaled budesonide may be a safe and effective alternative to oral steroids in the maintenance treatment of pulmonary sarcoidosis especially in the early stage of the disease.

[Comparison of the effectiveness of budesonide and prednisone in the maintenance treatment of pulmonary sarcoidosis]

The aim of this investigation was to compare inhaled budesonide vs oral prednisone in the maintenance phase treatment of pulmonary sarcoidosis. Double-blind controlled study was performed in 40 patients with stage II or III pulmonary sarcoidosis. After initial systemic 6 weeks treatment with prednisone (40 reduced to 20 mg daily) patients were allocated either to systematically (P) or topically (B) treated group. P patients continued with 10 mg prednisone daily, B patients were given inhaled budesonide 1.6 mg daily. The progress of treatment was assessed by serial radiography, spirometry, serum ACE activity and plasma cortisol levels. All patients completed the 12 months treatment. Using a numerical score to assess changes on the chest radiograms P patients improved by 1.7 +/- 0.66 points; B patients improved by 1.15 +/- 0.81 points. Spirometric changes were insignificant. Serum ACE fell from 107 +/- 51 U/L in the P group and 92 +/- 40 U/L in the B group to 46 +/- 11 U/L and 38 +/- 21 U/L respectively during the initial phase of treatment. In the maintenance phase ACE levels remained lower than initial ones in both groups. Morning cortisol plasma levels studied in 10 patients (5 in each group) decreased significantly during the initial phase. Thereafter cortisol levels remained low in the P patients returning to the lower limit of normal values in the B patients. We conclude that inhaled budesonide may be a safe and effective alternative to oral steroids in the maintenance treatment of pulmonary sarcoidosis especially in the early, stage II, disease.

Airways obstruction in patients with sarcoidosis

We present data concerning the frequency of airways obstruction among 1630 patients with pulmonary sarcoidosis diagnosed and followed up in our centre between 1960 and 1988. Airways obstruction was diagnosed when FEV1% VC was below 70%. There were 93 patients in whom ventilatory impairment of the obstructive type was found (5.7%). Further, we divided them into two groups of-pure obstruction and mixed-when obstruction was accompanied by reduced vital capacity. Possible mechanisms of the obstructive pattern in spirography are discussed.

Effects of corticosteroid treatment on pulmonary haemodynamics in patients with sarcoidosis

Effects of 12 months steroid treatment on pulmonary haemodynamics in 24 patients with pulmonary sarcoidosis, stage II and III, were investigated. All patients had a chest radiograph, lung function tests, and pulmonary haemodynamics (measured at rest and during submaximal exercise) prior to the treatment. Resting pulmonary hypertension was found in 3 patients. In 18 an abnormal increase in pulmonary arterial mean pressure (PAP) on exercise was observed. All investigations were repeated after a year of treatment. In almost all patients (22) a regression of radiological changes in the lungs and improvement of pulmonary function were observed. The changes in pulmonary circulation were less uniform. In only half of the patients studied was regression of the disease seen on chest X-ray and improvement in lung function accompanied by improvement in pulmonary haemodynamics.

Effects of corticosteroid treatment on pulmonary haemodynamics in patients with sarcoidosis

Effects of 12 months steroid treatment on pulmonary haemodynamics in 24 patients with pulmonary sarcoidosis, stage II and III, were investigated. All patients had a chest radiograph, lung function tests, and pulmonary haemodynamics (measured at rest and during submaximal exercise) prior to the treatment. Resting pulmonary hypertension was found in 3 patients. In 18 an abnormal increase in pulmonary arterial mean pressure (PAP) on exercise was observed. All investigations were repeated after a year of treatment. In almost all patients (22) a regression of radiological changes in the lungs and improvement of pulmonary function were observed. The changes in pulmonary circulation were less uniform. In only half of the patients studied was regression of the disease seen on chest X-ray and improvement in lung function accompanied by improvement in pulmonary haemodynamics.

[Value of transthoracic needle biopsy of the pleura in the diagnosis of diseases of the respiratory tract]

Pleural biopsy with Abram's needle was made in 160 consecutive patients with undiagnosed pleural effusions. The sampled fluid and pleural bioptates were examined histologically, cytologically and bacteriologically. In 40 cases malignant changes were found, out of 87 with confirmed malignancy. Neoplastic cells were found in 26 patients, ovreall the diagnosis was made in 65% of lung cancer cases. Out of 41 cases of tuberculosis, pleural biopsy provided this diagnosis in 24 patients (59%). Bacteriological examination and pathological of the biopsy specimen allowed to increase the diagnostic field to 63%. Pleural biopsy did not yield any diagnosis in 9 cases of circulatory insufficiency, nor in ten patients with the following diagnoses -- pleuropneumonia, reumathoid arthritis, pulmonary thromboembolism and thoracic trauma. In 13 cases the diagnosis was not made. The diagnostic yield of pleural biopsy was similar to that reported by others. It is most valuable in cases suspected of malignancy and tuberculosis.

[The frequency and course of fibrotic changes in patients with sarcoidosis]

Basing on observations of 960 patients with pulmonary sarcoidosis the authors found fibrotic changes of pulmonary parenchyma in only a few, the incidence being 3.2. Improvement in radiological examination following steroid therapy was seen in 50%, of respiratory function in 30%. Although both examinations do not fully correlate with each other, they are however supplementary with each other, and should be regarded as important criteria of functional involvement and therapy outcome.

[Effect of steroid therapy on pulmonary circulation in pulmonary sarcoidosis]

Effect of 12 month steroid therapy on pulmonary circulation at rest and during exercise was assessed in 24 patients with histologically confirmed stage II and III pulmonary sarcoidosis. Pulmonary hypertension was found in 3 patients before starting therapy. In the remaining 21 pulmonary artery pressure was within normal limits. In 18 of these an abnormal increase of pulmonary arterial pressure during exercise was found. After 12 months of steroid therapy in all except 2 patients radiological regression was observed. In most patients pulmonary function improved. Normal pulmonary arterial pressure was found in 22 patients. An abnormal increase of pulmonary arterial pressure during exercise was seen in 12 patients. No correlation could be demonstrated between radiological evaluation, respiratory function and effect of steroids on pulmonary circulation.

Sarcoidosis of the lung. Natural history and effects of treatment

An analysis on the natural course of pulmonary sarcoidosis and effects of corticotherapy was carried out in 960 patients observed during 25 years (1959-1985). There were 434 males and 526 females in the studied group aged from 14 to 69 years, when entering the study. The time of follow-up ranged from 2 to 20 years. In 20% of subjects disease had an acute course, in the remaining 80% the process was symptomless, often of chronic nature. Majority of patients presented with stage I or stage II of the disease (respectively 48.2% and 48.6%). Histological confirmation was obtained in 70% of subjects. Spontaneous remission or improvement was observed in 62.2%. Remission or improvement following treatment was seen in another 18.7% (a beneficial effect being observed in 84.1% of treated patients). Altogether remission or improvement, spontaneous or after treatment, was seen in 80.9% of studied group. In the remaining 19.1%, 2.8% of whom were treated and 16.3% not treated, a progression of the pulmonary changes was observed-the disease evolved into chronic stage. In acute pulmonary sarcoidosis the evolution of the disease was more favorable. Remission or improvement, spontaneous or after treatment, was observed in 89.3% of patients, versus 76.3% of patients with symptomless course of the disease. Recurrence of the disease was observed in 21 cases. It was seen only in treated patients shortly after completion of treatment.

Pulmonary haemodynamics at rest and during exercise in patients with sarcoidosis

Pulmonary haemodynamics at rest and during exercise was studied in 30 patients with histologically confirmed sarcoidosis. All subjects were divided into three groups according to the stage of the disease assessed by radiological image of pulmonary lesions. At rest, in stage I and II patients, the mean pulmonary pressure (PAP) was normal. In stage III patients, a slight pulmonary hypertension was found. During exercise, a rise in PAP in stage I and II subjects was within the normal limits for a given workload, although in individual stage II subjects a rise in PAP was abnormally high. In all stage III patients a rise in PAP was pathologically elevated.

[Influence of corticosteroid-therapy on the course of sarcoidosis (author's transl)]

The examinations relate to 206 patients suffering from a bioptically confirmed sarcoidosis, observed during 1959-1974. The observation period amounted to 2-15 years. The indications of the corticosteroid-therapy ran as follows: 1. in cases of a lymph node sarcoidosis without respiratory disorders, after a 2 years' observation without a regression. 2. in cases with pulmonary alterations already after 3-6 months without a regression. 3. in all cases of an extended pulmonary sarcoidosis. In the first group the sarcoidosis developed spontaneously in 65.2%, after a treatment in 15.7%. In 19.1% there was an unfavourable course, even in treated cases (2.2%). In the second group there was a spontaneous regression in 35.5%, after a treatment in 57%. In 10% the sarcoidosis changed over into the chronic form. The treatment failed in about 3%. In the third group we did not observe any spontaneous regression, after the corticosteroid-therapy a regression appeared in 35.7%. The condition remained unchanged in 64.3%. Totally there was a spontaneous regressions in 44.2% of the patients. Good results after the corticosteroid-therapy were attained in 36.4%, and the rest of about 20% developed to irreversible forms of the disease.

[2nd European Symposium on Sarcoidosis. Various methods of corticosteroid therapy]

In order to achieve good results with the corticosteroid-therapy in not spontaneously regredient sarcoidoses a longterm treatment (12-24 months) by considerable corticosteroid-doses proves to be necessary; thereby the problem of side-effects by steroids will arise, especially in young women frequently developing a Cushing-syndrome. By our endeavour to prevent this unpleasant phaenomenon we carried through an alternating attempt with two variant kinds of intermittent treatment. The first method relates to 4 successive days in the week (as it is proposed by P. Krakowka) and the second procedure relates to each 2nd day. The second treatment has proved to be the better one. Side-effects appeared in 31. 9 per cent in case of a daily treatment by steroids, in 27.3 per cent after the application of the method of 4 days a week, and in no one case after an application each second day. The results of the treatment by corticosteroids are equal in all the three groups.

[Epidemiology of sarcoidosis in Poland (author's transl)]

The numbers of patients registered in chest clinics and of those treated in hospitals or sanatoria enable to calculate the index of sarcoidosis: 7.1/100000 inhabitants in 1973 and 7.7/100000 in 1974. The comparison with the data of the years 1963, 1967, 1968 and 1969 shows an increase of sarcoidosis. Highest frequency has been observed among the age group 30--40 years. Women are slightly predominating (56 p.c.).