The St. George's Respiratory Questionnaire in Pulmonary Sarcoidosis

RATIONALE

The Saint George's Respiratory Questionnaire (SGRQ) is a frequently used tool to assess health status in pulmonary disease patients. However, its performance characteristics in sarcoidosis patients are not well characterized.

METHODS

Data from a clinical trial of 138 symptomatic adults with sarcoidosis were used to examine the performance characteristics of SGRQ. Data were available at both baseline and week 24. Other assessments included FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6-min walk distance (6MWD), and Short Form-36 Physical Component Summary (SF-36 PCS) score.

RESULTS

Baseline SGRQ was 46.8, indicating impaired health status. At baseline, SGRQ total score correlated significantly with % predicted FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6MWD, and SF-36 PCS (r =  - 0.37, - 0.32, 0.57, 0.40, - 0.55, and - 0.80, respectively, p < 0.001). Change from baseline in SGRQ score also statistically significantly correlated with change from baseline in these parameters at week 24: r =  - 0.25, - 0.20, 0.30, 0.22, - 0.20, - 0.45, respectively (p < 0.05).

CONCLUSIONS

The SGRQ correlated with other outcome measures in sarcoidosis initially and with treatment. Improvement in FVC % predicted correlated with improvement in SGRQ. These data suggest the SGRQ may function as a reliable endpoint in clinical sarcoidosis trials.

Sarcoidosis extent relates to molecular variability

The molecular basis of sarcoidosis phenotype heterogeneity and its relationship to effective treatment of sarcoidosis have not been elucidated. Peripheral samples from sarcoidosis subjects who participated in a Phase II study of golimumab [anti-tumour necrosis factor (TNF)-α] and ustekinumab [anti-interleukin (IL)-12p40] were used to measure the whole blood transcriptome and levels of serum proteins. Differential gene and protein expression analyses were used to explore the molecular differences between sarcoidosis phenotypes as defined by extent of organ involvement. The same data were also used in conjunction with an enrichment algorithm to identify gene expression changes associated with treatment with study drugs compared to placebo. Our analyses revealed marked heterogeneity among the three sarcoidosis phenotypes included in the study cohort, including striking differences in enrichment of the interferon pathway. Conversely, enrichments of multiple pathways, including T cell receptor signalling, were similar among phenotypes. We also identify differences between treatment with golimumab and ustekinumab that may explain the differences in trends for clinical efficacy observed in the trial. We find that molecular heterogeneity is associated with sarcoidosis in a manner that may be related to the extent of organ involvement. These findings may help to explain the difficulty in identifying clinically efficacious sarcoidosis treatments and suggest hypotheses for improved therapeutic strategies.

Detection of sarcoidosis associated fasciitis by uptake on a FDG PET scan: a novel finding

We report a case of a sarcoidosis patient with bilateral calf and thigh stiffness who was noted to ha ve intense linear FDG uptake on a PET scan that localized to the fascia of his calves and theighs. His serum creatine kinase level was normal. Fasciitis has rarely been reported to be detected on FDG PET scans, and, to our knowledge, never in a sarcoidosis patient. FDG PET may have a role in identifying fasciitis or myositis when a patient has muscular complaints and no clinical or laboratory evidence of muscle injury.

The internal consistency of PRO fatigue instruments in sarcoidosis: superiority of the PFI over the FAS

INTRODUCTION

The Fatigue Assessment Scale (FAS) is a 10-item patient reported outcome (PRO) questionnaire that is used to measure fatigue in sarcoidosis. After several months of use, we began to question the reliability of the FAS in our clinic population. Therefore, we administered an additional fatigue PRO, the Patient Reported Outcomes Measurement Information Systems (PROMIS) Fatigue Instrument (PFI). Our hypothesis was that the internal consistency/reliability (Cronbach's alpha) of the PFI would be superior to the FAS in sarcoidosis patients because two of the ten FAS items (items #4 and #10) required reverse scoring (these items were scaled in the opposite direction to the other 8 items).

METHODS

The FAS and PFI were administered during the same clinic visit to consecutive patients in our sarcoidosis clinic. We calculated a) the Cronbach's alpha for a) the FAS; b) the FAS without items #4 and #10; and c) the PFI.

RESULTS

107 consecutive sarcoidosis patients underwent FAS and PFI testing. The Cronbach's alpha was 0.740, 0.911, and 0.963 for the FAS, FAS with items #4 and #10 removed, and the PFI respectively. In female patients, the Cronbach's alpha of the FAS was 0.663, which is considered as "questionable" in terms of internal consistency.

CONCLUSION

We found that the PFI had "excellent" consistency in our sarcoidosis clinic. The FAS did not demonstrate the same degree of internal consistency. The Cronbach's estimate of the FAS with items #4 and #10 removed was vastly superior to the FAS. These data support our contention that FAS items #4 and #10 detract from the internal consistency of this PRO. They also suggest that the PFI is superior to the FAS in terms of reliability.

The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States

BACKGROUND

Although numerous reports have described the clinical features of sarcoidosis in various ethnic and racial groups, many have been limited by small size, homogenous populations, and relatively short follow-up periods. We report the clinical characteristics of a large, race-sex-age diverse cohort of sarcoidosis clinic patients followed in a large university medical center for an extended period of time.

METHODS

This study included clinical data for sarcoidosis patients followed over a 12-year period at a sarcoidosis clinic at the Medical University of South Carolina.

RESULTS

1774 sarcoidosis patients were identified. Black females were more common (44%) than other race/gender combinations (p = 0.01). The diagnosis of sarcoidosis occurred > 3 months after the onset of symptoms in 48% of the cohort and > 1 year after the onset of symptoms in 25%. Anti-sarcoidosis treatment was required in 61% of the patients. Pulmonary function improved over time and the median corticosteroid requirement lessened. Compared to whites, blacks had more advanced radiographic stages of sarcoidosis (p < 0.0001), more organ involvement (p < 0.0001), and more frequently required anti-sarcoidosis medication (p < 0.0001). Compared to women, men had more advanced radiographic stages of sarcoidosis (p < 0.0001).

CONCLUSIONS

The analysis indicates that sarcoidosis tends to improve over time in terms of pulmonary function and medication requirements. The disease was found to be more severe in blacks than whites. Treatment was not necessarily required. These results provide a comprehensive model of the course and treatment of sarcoidosis in the clinical setting.

Endpoints for clinical trials of sarcoidosis

Over the past few years an increasing number of prospective controlled sarcoidosis treatment trials have been completed. Unfortunately, these studies utilize different endpoints making comparisons between studies difficult. At the recent World Association of Sarcoidosis and other Granulomatous disease (WASOG) meeting, a session was dedicated to the evaluation of clinical endpoints for various disease manifestations. These included pulmonary, pulmonary hypertension, fatigue, cutaneous, and a classification of clinical disease phenotypes. Based on the available literature and our current understanding of the disease, recommendations for clinical evaluation were proposed for each disease category. For example, it was recommended that pulmonary studies should include changes in the forced vital capacity. Additionally, it was recommended that all trials should incorporate measurement of quality of life.

Ambrisentan for sarcoidosis associated pulmonary hypertension

BACKGROUND

Sarcoidosis associated pulmonary hypertension (SAPH) is associated with significant morbidity and mortality. There is a paucity of information concerning therapy for this condition.

METHODS

We performed a prospective, open-label, proof of concept trial of ambrisentan for SAPH. 21 subjects with SAPH received 5 mg/day of ambrisentan for 4 weeks and then 10/mg day for 20 subsequent weeks.

RESULTS

No significant change was noted in the 6-minute walk distance over the course of the study (mean change between week 0 and 24: 9.8 +/- 54.6 meters, p: NS). There were also no significant differences between weeks 0 and 24 in terms of dyspnea as measured by the modified Borg scale, serum brain naturetic peptide, diffusing capacity, and quality of life as measured by the Short Form-36. There was a high dropout rate: overall: 11/21, 52%; social reasons: 3/21, 14%; medical reasons: 8/21, 38% because of dyspnea: 6/21, 29% and/or edema: 4/21, 19%. Of those who completed the 24 week study (10/21, 48%), there was an improvement in their WHO functional class and a marked improvement in their health related quality of life as measured by the St. George Respiratory questionnaire (-15.3 +/- 25.0). However both these improvments did not reach statistical significance possibly because of the small sample size.

CONCLUSION

Although ambrisentan was not well tolerated by many of these subjects with SAPH, in those who remained in this 24-week trial, improvements in WHO functional class and in health related quality of life suggested a possible benefit of this drug in selected patients.

Defining the clinical outcome status (COS) in sarcoidosis: results of WASOG Task Force

The clinical outcome of sarcoidosis is quite variable. Several scoring systems have been used to assess the level of disease and clinical outcome. The definition of clinical phenotypes has become an important goal as genetic studies have identified distinct genotypes associated with different clinical phenotypes. In addition, treatment strategies have been developed for patients with resolving versus non resolving disease. A task force was established by the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) to define clinical phenotypes of the disease based on the clinical outcome status (COS). The committee chose to examine patients five years after diagnosis to determine the COS. Several features of the disease were incorporated into the final nine categories of the disease. These included the current or past need for systemic therapy, the resolution of the disease, and current status of the condition. Sarcoidosis patients who were African American or older were likely to have a higher COS, indicating more chronic disease. The COS may be useful in future studies of sarcoidosis.

C-reactive protein predicts response to infliximab in patients with chronic sarcoidosis

BACKGROUND

This study assessed the value of C-reactive protein as a predictor of disease severity and response to infliximab therapy in patients with chronic pulmonary sarcoidosis.

DESIGN

Sera were collected through week 52 from 138 patients with chronic pulmonary sarcoidosis who received placebo or infliximab in a randomized, double-blind, placebo-controlled study. We evaluated the response to therapy by baseline CRP using a dichotomous cutpoint (0.8 mg/dL) for the change from baseline in percent-predicted forced vital capacity (FVC), Saint George's Respiratory Questionnaire (SGRQ), 6-minute walk distance (6MWD), Borg's CR10 dyspnea score, and Physician Organ Assessment (POA).

RESULTS

CRP was elevated in 36% of patients at baseline, and was significantly reduced by infliximab by week 2. Among patients with elevated baseline CRP, infliximab-treated patients improved significantly compared with placebo-treated patients in percent-predicted FVC (+2.5 versus -2.6%), 6MWD (+8.0 versus -34.1), Borg's CR10 dyspnea score (pre-6MWD -0.8 versus +0.9, post-6MWD -1.1 versus +0.8), and POA (-3.1 versus -0.3). Patients with lower CRP levels at baseline did not show significant differences between the placebo and infliximab groups in most endpoints evaluated.

CONCLUSIONS

In chronic sarcoidosis patients, elevated CRP appears to identify a subset with more severe disease who may respond better to treatment with infliximab.

Inhaled iloprost for sarcoidosis associated pulmonary hypertension

RATIONALE

Patients with sarcoidosis associated pulmonary hypertension (SAPH) have responded to systemic prostacyclin therapy.

OBJECTIVES

To determine the rate of response to inhaled prostacyclin, iloprost, in SAPH.

METHODS

Sarcoidosis patients with pulmonary hypertension and no evidence for left ventricular dysfunction were enrolled in an open label, prospective study. Patients underwent right heart catheterization and six minute walk (6MW) test. Quality of life was evaluated using several instruments, including the Saint George Respiratory Questionnaire (SGRQ). Patients received 5 mcg of inhaled iloprost every 2-3 hours while awake. After four months of therapy, patients underwent repeat cardiac catheterization, 6 MW test, and completed quality of life questionnaires.

MEASUREMENTS AND MAIN RESULTS

Of the 22 patients enrolled, 15 completed all 16 weeks of therapy. The most common reasons for study discontinuation included drug associated cough (3 patients) and compliance with the prescribed number of treatments per day (2 patients). Six patients experienced a 20% or greater decrease in pulmonary vascular resistance (PVR) from baseline with five of these six patients also showing > or = 5 mm Hg reduction in PA mean. Although three patients improved the 6MW distance by at least 30 meters, only one had a decrease in PVR. At 16 weeks a significant decrease was reported in the SGRQ activity score (p = 0.0273), with seven patients having a 4 point or greater decrease.

CONCLUSION

Inhaled iloprost as monotherapy was associated with an improvement in pulmonary hemodynamics and quality of life as assessed by the SGRQ activity score in some sarcoidosis patients with SAPH.

Presenting characteristics as predictors of duration of treatment in sarcoidosis

BACKGROUND

Some sarcoidosis patients never need therapy, but many still require therapy more than 2 years after initial diagnosis.

AIM

To determine what features at initial presentation are associated with treatment 2 years later.

METHODS

Patients with biopsy-confirmed sarcoidosis enrolled in the ACCESS (A Case Control Etiologic Study of Sarcoidosis) study were initially evaluated within 6 months of diagnosis. Pulmonary function, chest X-ray and dyspnoea score were measured, and systemic therapy for the sarcoidosis recorded. Organ involvement was assessed using a standardized instrument. A subset (n = 215) were seen 18-24 months later for follow-up, and these patients constitute our study group.

RESULTS

Ten patients had only received therapy before the first visit, with no further therapy, and were excluded from analysis. Of the remaining 205, 95 were not on therapy at the initial visit and 75 (79%) of these were never treated during follow-up. Of the 110 initially on therapy, 52 (47%) remained on therapy at follow-up. Other initial features associated with continued therapy were the level of dyspnoea and predicted vital capacity. On logistic regression, only dyspnoea and therapy at initial visit remained significant. Patients on systemic therapy at initial evaluation were more likely to be on therapy at follow-up (OR 3.6, p = 0.003). Neither ethnicity nor gender independently predicted therapy at follow-up.

DISCUSSION

This study group represents a sample of newly diagnosed sarcoidosis patients. However, this is a referral population, and there was no set protocol for treatment. Use of systemic therapy within the first 6 months after diagnosis appears to be strongly associated with continued use of therapy 2 years later.

Genome-wide search for sarcoidosis susceptibility genes in African Americans

Sarcoidosis, a systemic granulomatous disease of unknown etiology, likely results from an environmental insult in a genetically susceptible host. In the US, African Americans are more commonly affected with sarcoidosis and suffer greater morbidity than Caucasians. We searched for sarcoidosis susceptibility loci by conducting a genome-wide, sib pair multipoint linkage analysis in 229 African-American families ascertained through two or more sibs with a history of sarcoidosis. Using the Haseman-Elston regression technique, linkage peaks with P-values less than 0.05 were identified on chromosomes 1p22, 2p25, 5p15-13, 5q11, 5q35, 9q34, 11p15 and 20q13 with the most prominent peak at D5S2500 on chromosome 5q11 (P=0.0005). We found agreement for linkage with the previously reported genome scan of a German population at chromosomes 1p and 9q. Based on the multiple suggestive regions for linkage found in our study population, it is likely that more than one gene influences sarcoidosis susceptibility in African Americans. Fine mapping of the linked regions, particularly on chromosome 5q, should help to refine linkage signals and guide further sarcoidosis candidate gene investigation.

Sarcoidosis: social predictors of severity at presentation

To determine relationships among social predictors and sarcoidosis severity at presentation, demographic characteristics, socioeconomic status, and barriers to care, A Case-Control Etiologic Study of Sarcoidosis (ACCESS) was set up. Patients self-reported themselves to be Black or White and were tissue-confirmed incident cases aged > or =l8-yrs-old (n=696) who had received uniform assessment procedures within one of 10 medical centres and were studied using standardised questionnaires and physical, radiographical, and pulmonary function tests. Severity was measured by objective disease indicators, subjective measures of dyspnoea and short form-36 subindices. The results of the study showed that lower income, the absence of private or Medicare health insurance, and other barriers to care were associated with sarcoidosis severity at presentation, as were race, sex, and age. Blacks were more likely to have severe disease by objective measures, while women were more likely than males to report subjective measures of severity. Older individuals were more likely to have severe disease by both measures. In conclusion, it was found that low income and other financial barriers to care are significantly associated with sarcoidosis severity at presentation even after adjusting for demographic characteristics of race, sex, and age.

Is endosonography guided fine needle aspiration (EUS-FNA) for sarcoidosis as good as we think?

BACKGROUND

Preliminary data show that endosonography guided fine needle aspiration (EUS-FNA) may be an accurate method for diagnosing sarcoidosis. However, these data were obtained in a small selected group of patients with a very high pretest probability of sarcoidosis. This retrospective study reports on the use of EUS-FNA in an unselected group of patients with mediastinal lymphadenopathy of unknown origin.

METHODS

The EUS database of a single tertiary referral centre was reviewed for patients who underwent EUS-FNA for mediastinal lymphadenopathy of unknown origin. Clinical presentation and imaging studies of each case were carefully reviewed and the diagnosis "sarcoidosis" or "no sarcoidosis" attributed if possible. The diagnoses were compared with the result of EUS-FNA.

RESULTS

One hundred and twenty four patients were investigated. In 35 cases EUS-FNA identified granulomas (group 1); in the other 89 cases (group 2) no granulomas were detected. The definite diagnoses in group 1 were sarcoidosis (n = 25), indefinite (n = 7), no sarcoidosis (n = 3). The definite diagnoses in group 2 were sarcoidosis (n = 3), indefinite (n = 9), no sarcoidosis (n = 77). Of the 77 cases with no sarcoidosis, 44 were diagnosed with other diseases. The other 33 showed non-specific changes in the FNA and sarcoidosis was excluded by negative non-EUS pathology (n = 17) and clinical presentation. The sensitivity and specificity for EUS-FNA were 89% (95% CI 82 to 94) and 96% (95% CI 91 to 98), respectively, after exclusion of the indefinite cases in both groups.

CONCLUSIONS

EUS-FNA is an accurate method for diagnosing sarcoidosis in an unselected group of patients with mediastinal lymphadenopathy. The reported sensitivity and specificity must be appreciated in the context of the difficult and often incomplete clinical diagnosis of sarcoidosis.

Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS)

Despite reports of familial clustering of sarcoidosis, little empirical evidence exists that disease risk in family members of sarcoidosis cases is greater than that in the general population. To address this question, we estimated sarcoidosis familial relative risk using data on disease occurrence in 10,862 first- and 17,047 second-degree relatives of 706 age, sex, race, and geographically matched cases and controls who participated in the multicenter ACCESS (A Case-Control Etiology Study of Sarcoidosis) study from 1996 to 1999. Familial relative risk estimates were calculated using a logistic regression technique that accounted for the dependence between relatives. Sibs had the highest relative risk (odds ratio [OR] = 5.8; 95% confidence interval [CI] = 2.1-15.9), followed by avuncular relationships (OR = 5.7; 95% CI = 1.6-20.7), grandparents (OR = 5.2; 95% CI = 1.5-18.0), and then parents (OR = 3.8; 95% CI = 1.2-11.3). In a multivariate model fit to the parents and sibs data, the familial relative risk adjusted for age, sex, relative class, and shared environment was 4.7 (95% CI = 2.3-9.7). White cases had a markedly higher familial relative risk compared with African-American cases (18.0 versus 2.8; p = 0.098). In summary, a significant elevated risk of sarcoidosis was observed among first- and second-degree relatives of sarcoidosis cases compared with relatives of matched control subjects.

Clinical characteristics of patients in a case control study of sarcoidosis

Sarcoidosis may be affected by sex, race, and age. A Case Control Etiologic Study of Sarcoidosis (ACCESS) enrolled 736 patients with sarcoidosis within 6 mo of diagnosis from 10 clinical centers in the United States. Using the ACCESS sarcoidosis assessment system, we determined organ involvement for the whole group and for subgroups differentiated by sex, race, and age (less than 40 yr or 40 yr and older). The study population was heterogeneous in terms of race (53% white, 44% black), sex (64% female, 36% male), and age (46% < 40 yr old, 54% > or = 40 yr old). Women were more likely to have eye and neurologic involvement (chi(2) = 4.74, p < 0.05 and chi(2) = 4.60, p < 0.05 respectively), have erythema nodosum (chi(2) = 7.28, p < 0.01), and to be age 40 yr or over (chi(2) = 6.07, p < 0.02) whereas men were more likely to be hypercalcemic (chi(2) = 7.38, p < 0.01). Black subjects were more likely to have skin involvement other than erythema nodosum (chi(2) = 5.47, p < 0.05), and eye (chi(2) = 13.8, p < 0.0001), liver (chi(2) = 23.3, p < 0.0001), bone marrow (chi(2) = 18.8, p < 0.001), and extrathoracic lymph node involvement (chi(2) = 7.21, p < 0.01). We conclude that the initial presentation of sarcoidosis is related to sex, race, and age.

Carpal tunnel syndrome in sarcoidosis

Sarcoidosis is a systemic disease that may affect the musculoskeletal system. An association between carpal tunnel syndrome (CTS) and sarcoidosis has not been demonstrated. Consecutive patients from the sarcoidosis clinic at our institution were questioned about history and symptoms of carpal tunnel syndrome: hand numbness and nocturnal paresthesias with relief of symptoms by shaking of the hands (flick sign). A physical exam was performed to evaluate for Tinel's and Phalen's signs. A comparison of the presence of arthritis, prednisone treatment, spirometry, and number of organs involved with sarcoidosis was made in patients with a history or clinical findings of CTS versus those without. Eighty-nine patients were evaluated. Thirty-five patients (39%) had nocturnal paresthesias with a positive flick sign. Fourteen patients (16%) had physical findings of CTS. A history of CTS was present in 14 (16%) of the patients, four of which were documented by EMG. There was no significant difference between the frequency of prednisone treatment in patients with or without CTS history, nocturnal paresthesias, or Phalen's sign. There were significantly fewer patients with a positive Tinel's sign who were receiving prednisone. There was a trend toward an increased frequency of wrist arthritis in patients with a history or clinical findings of CTS. There was no significant difference in disease severity, assessed by spirometry or organ involvement, when comparing sarcoidosis patients with or without a history or clinical findings of CTS. Thirty-nine (44%) had symptoms and/or signs of CTS. Even when we adjusted our sarcoidosis population for other factors associated with CTS, the prevalence of symptoms and signs of CTS was much higher in our patient population than in studies of the general population. Our findings suggest that CTS is common in sarcoidosis.

The treatment of pulmonary aspergilloma

Aspergillomas are fungal balls within lung cavities. The natural history of patients affected is variable. Hemoptysis is a dangerous sequela. Factors associated with a poor prognosis have been defined and therapy is difficult because of the lack of a blood supply. Randomized trials are lacking. Surgical treatment is definitive but many patients are ineligible. Percutaneous therapy and bronchial artery embolization is appropriate for some patients and itraconazole has produced favorable results in several studies.

Current pharmacotherapy of allergic bronchopulmonary aspergillosis

Although no well-designed studies have been carried out, the available data support the use of corticosteroids for acute exacerbations of allergic bronchopulmonary aspergillosis (ABPA). Neither the optimal steroid dose nor the duration of therapy has been standardised but limited data suggest the starting dose should be prednisone (approximately 0.5 mg/kg/day). The decision to taper steroids should be made on an individual basis, depending on clinical course. The available data suggest that clinical symptoms alone are inadequate to make such decisions, since significant lung damage may occur in asymptomatic patients. Increasing serum IgE levels, new or worsening infiltrate on chest radiograph and worsening spirometry suggest that steroids should be used. Multiple asthmatic exacerbations in a patient with ABPA suggest that chronic steroid therapy should be used. Itraconazole appears useful as a steroid sparing agent.

Treatment of a solitary pulmonary sarcoidosis mass by CT-guided direct intralesional injection of corticosteroid

A case is reported of 38-year-old woman with chest pain attributed to a left lung sarcoidosis mass. The mass failed to diminish and symptoms failed to resolve with systemic corticosteroid therapy. CT-guided direct intralesional transthoracic injection of dexamethasone resulted in resolution of the patient's symptoms and a dramatic reduction in the size of the mass within 2 months.

A current assessment of rurally linked exposures as potential risk factors for sarcoidosis

PURPOSE

To identify and quantify the risk of developing sarcoidosis associated with specific rural exposures previously recognized as potential risk factors for this disease.

METHODS

A matched case-control design was carried out with a 2-to-1 ratio of controls to cases. Case exposure histories were determine from a detailed questionnaire collecting self-reported information covering the period from birth through disease development and comparing that to exposure histories for the corresponding period in age-, race-, and gender-matched controls identified using Random Digit Dial survey methodology. Conditional logistic regression was used to analyze the matched data while controlling for several baseline variables.

RESULTS

A number of exposures were found to be univariately associated with the development of sarcoidosis including: the use of wood stoves, the use of fireplaces, the use of nonpublic water supplies, and living or working on a farm. A dose-response gradient was detected from exposure to wood stoves and fireplaces continued to be significantly associated with sarcoidosis in multivariable models.

CONCLUSIONS

The results of this study provide further support for the hypothesis that behaviors associated with rural living play some role in the development of sarcoidosis. This study further suggests that exposures involving the handling or burning of wood such as using wood stoves or fireplaces for home heating may, in part, explain this rural association.

A case report of a dactylaria fungal infection in a lung transplant patient

Dematiaceous fungi such as Dactylaria gallopava are becoming more prevalent in transplant patients, with 50% of outcomes being fatal. In this report, we describe a 32-year-old woman who presented with swelling in the right shoulder area and right lateral neck. On further investigation with a CT scan, a fluid collection in the shoulder was identified, drained, and subsequently grew D gallopava. We report the successful treatment of an invasive Dactylaria infection in a lung transplant patient predominantly by medical chemotherapy, although surgical incision and drainage was performed on one of the fungal lesions.

Depression in sarcoidosis

Sarcoidosis, a chronic, multisystem disease, impacts quality of life and may increase depression risk. No previous study has reported the depression prevalence among U.S. sarcoid patients. This cross-sectional study examined sociodemographic and disease morbidity factors associated with depression. Patients diagnosed for > or = 1 yr and treated at one of six centers were eligible (n = 176); 154 completed a questionnaire of demographics, treatment, access to medical care, and a short-form Center for Epidemiologic Studies- Depression Scale (CES-D). The primary outcome variable was a CES-D score of > or = 9, indicating clinical depression. The prevalence of depression was 60%. Gender, income, access to medical care, dyspnea on exertion, and number of systems involved were associated with depression. Female sex, decreased access to medical care, and increased dyspnea predicted depression (odds ratio [OR] = 3.33, 11.64, and 2.78, respectively) after adjusting for race, income, and steroid therapy. Despite tertiary care access, patients reported medical care limitation. Health care providers must be sensitive to multiple barriers faced by chronic sarcoid patients; acknowledging depression risk and improving access to medical care will promote better overall health among sarcoid patients. Future studies of sarcoidosis will need to address depression diagnosis and treatment.

Practice guidelines for diseases caused by Aspergillus. Infectious Diseases Society of America

Aspergillosis comprises a variety of manifestations of infection. These guidelines are directed to 3 principal entities: invasive aspergillosis, involving several organ systems (particularly pulmonary disease); pulmonary aspergilloma; and allergic bronchopulmonary aspergillosis. The recommendations are distilled in this summary, but the reader is encouraged to review the more extensive discussions in subsequent sections, which show the strength of the recommendations and the quality of the evidence, and the original publications cited in detail. Invasive aspergillosis. Because it is highly lethal in the immunocompromised host, even in the face of therapy, work-up must be prompt and aggressive, and therapy may need to be initiated upon suspicion of the diagnosis, without definitive proof (BIII). Intravenous therapy should be used initially in rapidly progressing disease (BIII). The largest therapeutic experience is with amphotericin B deoxycholate, which should be given at maximum tolerated doses (e.g., 1-1.5 mg/kg/d) and should be continued, despite modest increases in serum creatinine levels (BIII). Lipid formulations of amphotericin are indicated for the patient who has impaired renal function or who develops nephrotoxicity while receiving deoxycholate amphotericin (AII). Oral itraconazole is an alternative for patients who can take oral medication, are likely to be adherent, can be demonstrated (by serum level monitoring) to absorb the drug, and lack the potential for interaction with other drugs (BII). Oral itraconazole is attractive for continuing therapy in the patient who responds to initial iv therapy (CIII). Therapy should be prolonged beyond resolution of disease and reversible underlying predispositions (BIII). Adjunctive therapy (particularly surgery and combination chemotherapy, also immunotherapy), may be useful in certain situations (CIII). Aspergilloma. The optimal treatment strategy for aspergilloma is unknown. Therapy is predominantly directed at preventing life-threatening hemoptysis. Surgical removal of aspergilloma is definitive treatment, but because of significant morbidity and mortality it should be reserved for high-risk patients such as those with episodes of life-threatening hemoptysis, and considered for patients with underlying sarcoidosis, immunocompromised patients, and those with increasing Aspergillus-specific IgG titers (CIII). Surgical candidates would need to have adequate pulmonary function to undergo the operation. Bronchial artery embolization rarely produces a permanent success, but may be useful as a temporizing procedure in patients with life-threatening hemoptysis. Endobronchial and intracavitary instillation of antifungals or oral itraconazole may be useful for this condition. Since the majority of aspergillomas do not cause life-threatening hemoptysis, the morbidity and cost of treatment must be weighed against the clinical benefit. Allergic bronchopulmonary aspergillosis (APBA). Although no well-designed studies have been carried out, the available data support the use of corticosteroids for acute exacerbations of ABPA (AII). Neither the optimal corticosteroid dose nor the duration of therapy has been standardized, but limited data suggest the starting dose should be approximately 0.5 mg/kg/d of prednisone. The decision to taper corticosteroids should be made on an individual basis, depending on the clinical course (BIII). The available data suggest that clinical symptoms alone are inadequate to make such decisions, since significant lung damage may occur in asymptomatic patients. Increasing serum IgE levels, new or worsening infiltrate on chest radiograph, and worsening spirometry suggest that corticosteroids should be used (BII). Multiple asthmatic exacerbations in a patient with ABPA suggest that chronic corticosteroid therapy should be used (BIII). Itraconazole appears useful as a corticosteroid sparing agent (BII). (ABSTRACT TRUNCATED)

A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis

BACKGROUND

Allergic bronchopulmonary aspergillosis is a hypersensitivity disorder that can progress from an acute phase to chronic disease. The main treatment is systemic corticosteroids, but data from uncontrolled studies suggest that itraconazole, an orally administered antifungal agent, may be an effective adjunctive therapy.

METHODS

We conducted a randomized, double-blind trial of treatment with either 200 mg of itraconazole twice daily or placebo for 16 weeks in patients who met immunologic and pulmonary-function criteria for corticosteroid-dependent allergic bronchopulmonary aspergillosis. A response was defined as a reduction of at least 50 percent in the corticosteroid dose, a decrease of at least 25 percent in the serum IgE concentration, and one of the following: an improvement of at least 25 percent in exercise tolerance or pulmonary-function tests or resolution or absence of pulmonary infiltrates. In a second, open-label part of the trial, all the patients received 200 mg of itraconazole per day for 16 weeks.

RESULTS

There were responses in 13 of 28 patients in the itraconazole group (46 percent), as compared with 5 of 27 patients in the placebo group (19 percent, P=0.04). The rate of adverse events was similar in the two groups. In the subsequent open-label phase, 12 of the 33 patients who had not had a response during the double-blind phase (36 percent) had responses, and none of the patients who had a response in the double-blind phase of the trial had a relapse.

CONCLUSIONS

For patients with corticosteroid-dependent allergic bronchopulmonary aspergillosis, the addition of itraconazole can lead to improvement in the condition without added toxicity.

Concomitant acute sinusitis and acute lung rejection

Two lung transplant recipients had concomitant acute sinusitis and acute lung rejection. Antibiotics and decongestants alleviated the sinusitis, but the symptoms of cough and dyspnea as well as spirometric defects necessitated treatment of acute lung rejection. In patients with clinical evidence of acute sinusitis after lung transplantation, concomitant acute lung rejection should be suspected if dyspnea or pulmonary dysfunction is also present. This appears to be the first report of concomitant acute sinusitis and acute lung rejection.

Clinical aspects of pulmonary sarcoidosis

Pulmonary sarcoidosis has a variable natural course from an asymptomatic state to a progressive life-threatening condition. Radiographic abnormalities are frequently an important clue to the diagnosis. The diagnosis usually requires a tissue biopsy that demonstrates noncaseating granulomas that cannot be ascribed to another clinical condition. The lung may be biopsied, but extrapulmonary sites may be biopsied for the diagnosis if such sites are involved with disease. When the lung is biopsied, a transbronchial lung biopsy with a flexible bronchoscope is the procedure of choice, even if the chest radiograph shows thoracic adenopathy alone without obvious parenchymal infiltration. On occasion the diagnosis can be made on clinical grounds without biopsy when the presentation is highly specific for sarcoidosis, such as Lofgren's Syndrome. Treatment for pulmonary sarcoidosis has not been standardized. Since many patients have spontaneous remissions and the benefits of therapy do not affect the long-term outcome, therapy is reserved for patients with severe or progressive pulmonary symptoms and/or pulmonary dysfunction. Corticosteroids are the primary therapy for pulmonary sarcoidosis. Corticosteroid therapy involves six phases: initial high dose, taper to a maintenance dose, a maintenance dose, taper off corticosteroids, monitor off therapy, and treatment of relapse if it occurs.

Geographic variation in sarcoidosis in South Carolina: its relation to socioeconomic status and health care indicators

Geographic patterns of sarcoidosis have been detected and studied on a global scale. However, the associations between these disease patterns and population characteristics have not been determined. The authors studied the geographic pattern of sarcoidosis in South Carolina and its relation to socioeconomic status (SES) and health status indicators. Hospitalization rates for the period 1985-1995 were used as geographic indicators of sarcoidosis. Rates were assessed for the 46 counties in South Carolina, adjusting for differences in SES, availability/accessibility of health care, diagnostic practices, and hospital utilization. Patterns in geographic variation were assessed based on physiographic characteristics and proximity to the Atlantic coastline. Significant variation was identified with an increase in sarcoidosis rates proximal to the Atlantic coastline. Population characteristics were identified that appeared to explain regional variation in sarcoidosis in Caucasians; however, regression analysis was unable to explain the regional differences in disease distribution by variation in SES, diagnostic practices, accessibility/availability, or hospital utilization in African Americans. These results suggest that the development of sarcoidosis is associated with a geographically linked risk factor in African Americans. This work supports the need for additional studies that will identify this risk factor(s).

Endoscopic ultrasonography with fine-needle aspiration: an accurate and simple diagnostic modality for sarcoidosis

BACKGROUND AND STUDY AIMS

Sarcoidosis is a chronic multisystem granulomatous disease that is often diagnosed after a finding of hilar and mediastinal lymphadenopathy on a chest radiograph. This often requires further evaluation by transbronchial biopsy or other clinical parameters. The present study is a descriptive, retrospective one using endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of mediastinal lymph nodes in seven patients with sarcoidosis.

PATIENTS AND METHODS

Among 108 consecutive patients who underwent EUS-FNA of mediastinal lymph nodes for various clinical indications between July 1994 and October 1997, seven patients were found to have sarcoidosis on EUS-FNA, and the EUS morphology was studied in these patients.

RESULTS

Sarcoidosis was diagnosed in seven patients using endosonographic characteristics and clinical follow-up. EUS with FNA showed cytological evidence of sarcoidosis in six patients. Seven patients were found to have subcarinal lymph nodes, and six patients had abnormally enlarged aortopulmonary (AP) window lymph nodes. The nodes in all patients had three endosonographic criteria for malignancy. The long axis of the largest mediastinal lymph nodes measured 3.44+/-1.42 cm (range 1.8-6.0 cm). The short axis measured 2.50+/-0.69 (range 1.0-4.0 cm). The average number of nodes seen in each patient was 2.80+/-0.75 (range 2-4). The nodes in all seven patients were discrete and well demarcated. A central hyperechoic strand was evident in these nodes in four patients (57%). There were no complications.

CONCLUSIONS

Mediastinal lymph nodes in patients with sarcoidosis appear to have specific echo characteristics, and EUS-FNA can be used for confirmatory tissue diagnosis.

An approach to the treatment of pulmonary sarcoidosis with corticosteroids: the six phases of treatment

Corticosteroid therapy for pulmonary sarcoidosis is not standardized. There is no consensus on which patients should receive treatment, how patients should be monitored, and the dose of corticosteroids once the decision to treat has been made. These issues are important for several reasons. First, inappropriate use of corticosteroids may result in unnecessary toxic reactions. Second, inadequate use of corticosteroids might result in permanent pulmonary and extrapulmonary organ dysfunction from sarcoidosis. Third, patients who are inappropriately labeled as "corticosteroid failures" may be subjected to other potentially toxic drugs or even lung transplantation. Corticosteroid dosing involves six phases: (1) initial high doses to control inflammation; (2) tapering to a maintenance dose that will continue to suppress the inflammation but lessen the risk of corticosteroid toxic reactions; (3) continuing to receive the maintenance dose until a decision to taper off corticosteroids is made; (4) tapering off corticosteroid therapy; (5) observation for relapse; and (6) treatment if relapse occurs. Although these phases of treatment have been alluded to in the literature, few of them have been studied rigorously. This article describes the use of corticosteroids for pulmonary sarcoidosis in terms of the above six phases. The proposed dosing schedules are based on the natural history of the disease and the results from published treatment studies.

Defining organ involvement in sarcoidosis: the ACCESS proposed instrument. ACCESS Research Group. A Case Control Etiologic Study of Sarcoidosis

BACKGROUND

Sarcoidosis is a multiorgan granulomatous disease of unknown cause. Lack of an objective system for assessment of sarcoidosis to evaluate disease course and effectiveness of therapy is a major problem.

METHODS

The sarcoidosis assessment instrument was developed by the Steering Committee of A Case Control Etiologic Study of Sarcoidosis (ACCESS) which included investigators at the ten ACCESS Clinical Centers, the Clinical Coordinating Center, and representatives of the National Heart, Blood, and Lung Institute. This system was developed to assess sarcoidosis organ involvement in ACCESS patients who would be followed over a two-year period. The system represents a consensus of opinions of members of the Steering Committee based on review of their experience and the medical literature.

RESULTS

Criteria for involvement in patients with biopsy-confirmed sarcoidosis are presented for organs and systems that are commonly involved (lung, skin, eyes, liver, calcium metabolism), unusual but clinically important (nervous system, kidney, heart) and other sites (non-thoracic lymph nodes, bone marrow, spleen, bone/joint, ear/nose/throat, parotid/salivary glands, muscles).

CONCLUSION

The proposed instrument is partially subjective in that it depends upon the clinician's diligence in pursuing evidence for sarcoidosis involvement of various organs. It is hoped that this instrument will lead to increased standardization in the definition of sarcoidosis organ involvement to help clinicians and researchers better characterize patients with sarcoidosis.

Successful treatment of widely disseminated acanthamoebiasis

Disseminated Acanthamoeba infections are almost invariably fatal, with no universally accepted standard for treatment. Reports of acanthamoebiasis in non-human-immunodeficiency-virus infected hosts are rare. We successfully treated a lung transplant patient who had disseminated acanthamoebiasis using a combination of pentamidine, 5-fluorocytosine, itraconazole, and topical chlorhexidine gluconate/ketoconazole cream.

The "fairy ring": a new radiographic finding in sarcoidosis

A patient who had the "fairy ring" finding shows another new radiographic presentation of pulmonary sarcoidosis that clinicians can add to the list of signs of the disease.

Airway obstruction arising from blood clot: three reports and a review of the literature

Airway obstruction due to presence of blood clot occurs in a variety of clinical settings; however, it is not always preceded by hemoptysis. The impact on respiratory function may be minimal or result in life-threatening ventilatory impairment. Three illustrative cases and a comprehensive literature review are presented. The presence of endobronchial blood clot is suggested by the clinical and radiographic findings of focal airway obstruction. The diagnosis is established by direct endoscopic evaluation. Initial efforts at removal of the airway clot, if warranted, involve lavage, suctioning, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, Fogarty catheter dislodgment of the clot, and topical thrombolytic agents.

Bullous sarcoidosis: a report of three cases

Three cases of pulmonary sarcoidosis presented as bullous emphysema with severe airflow obstruction, and the diagnosis of sarcoidosis was unsuspected for at least 2 years. Potential mechanisms of bullous emphysema from sarcoidosis are discussed. The physician should suspect sarcoidosis as the cause of bullous emphysema when young patients who have smoked relatively few pack-years present with emphysema or severe airflow obstruction. Additional clues are the presence of mediastinal adenopathy on a chest radiograph or a CT scan and a history consistent with extrapulmonary sarcoidosis.

Lung transplantation for pulmonary sarcoidosis

Patients with end-stage sarcoidosis have now undergone lung transplantation successfully with good short-term and intermediate-term results. Lung transplantation for sarcoidosis requires several considerations unique to this disease. Selection of pulmonary sarcoidosis patients for transplantation requires that medical therapy has been exhausted. This may involve the use of corticosteriods and alternative medications. Causes of pulmonary dysfunction other than pulmonary sarcoidosis, such as bronchiectasis and myocardial sarcoidosis, must be excluded before candidates are considered for transplantation. The extent and severity of extrapulmonary disease must also be assessed and may preclude lung transplantation. The presence of mycetomas is considered a relative contra-indication by some transplant centres and an absolute contra-indication by others. Relatively few patients with pulmonary sarcoidosis have undergone transplantation and, therefore, there are few data on outcome. Sarcoidosis frequently recurs in the allograft, but rarely causes symptoms or pulmonary dysfunction. More severe acute rejection episodes may occur in sarcoidosis transplant recipients, although at present there is no evidence of an increased risk of obliterative bronchiolitis or increased mortality.

Lung transplantation for pulmonary sarcoidosis

Patients with end-stage sarcoidosis have now undergone lung transplantation successfully with good short-term and intermediate-term results. Lung transplantation for sarcoidosis requires several considerations unique to this disease. Selection of pulmonary sarcoidosis patients for transplantation requires that medical therapy has been exhausted. This may involve the use of corticosteriods and alternative medications. Causes of pulmonary dysfunction other than pulmonary sarcoidosis, such as bronchiectasis and myocardial sarcoidosis, must be excluded before candidates are considered for transplantation. The extent and severity of extrapulmonary disease must also be assessed and may preclude lung transplantation. The presence of mycetomas is considered a relative contra-indication by some transplant centres and an absolute contra-indication by others. Relatively few patients with pulmonary sarcoidosis have undergone transplantation and, therefore, there are few data on outcome. Sarcoidosis frequently recurs in the allograft, but rarely causes symptoms or pulmonary dysfunction. More severe acute rejection episodes may occur in sarcoidosis transplant recipients, although at present there is no evidence of an increased risk of obliterative bronchiolitis or increased mortality.

Pneumoperitoneum to treat air leaks and spaces after a lung volume reduction operation

Lung volume reduction surgery is an option for the management of end-stage emphysema. The most frequent surgical complication of lung volume reduction is prolonged air leaks. We describe a patient undergoing a lung volume reduction operation complicated by persistent bilateral air spaces with large air leaks. Treatment with recurrent pneumoperitoneum via a peritoneal dialysis catheter along with chemical sclerosis successfully resolved both problems.

Primary pulmonary involvement of Fusarium solani in a lung transplant recipient

A case of cavitary lung disease caused by Fusarium solani in a lung transplant recipient is presented. A mechanism for development of this infection is proposed. Lipid complex amphotericin B (Abelcet) was effective in eradicating this infection. To our knowledge, invasive lung disease caused by the Fusarium species has not been previously reported in a solid organ transplant recipient.

Is there an anatomic explanation for chest pain in patients with pulmonary sarcoidosis?

BACKGROUND

Chest pain (CP), its cause unknown, is a common and often prominent symptom of sarcoidosis.

METHODS

We determined the frequency and character of CP in patients with pulmonary sarcoidosis and examined its relationship with (1) length of time since diagnosis, (2) roentgenograhic stage, and (3) radiographic abnormalities on spiral chest computed tomography (CT).

RESULTS

Twenty-two patients were studied: 14 of 22 patients (64%) had CP, with 4 of 14 (29%) identifying pain as their primary symptom. Eleven of 14 (79%) had pleuritic CP; 12 of 22 (54.5%) described CP as substernal; and 5 of 22 (22.7%) described CP between the scapula. There was not a significant correlation between CP and the presence or degree of lymphadenopathy. There was no significant correlation between CP and the presence or location of pleural disease. Abnormalities of other thoracic structures also had no significant correlation with the presence of CP.

CONCLUSIONS

We conclude that there is no "anatomic reason" for CP in patients with pulmonary sarcoidosis that is evident on chest CT.

Origin of pleural cells after lung transplantation: from donor or recipient?

We evaluated the change in the percentage of cells of donor origin in pleural fluid of 13 consecutive patients who underwent lung transplantation. Pleural fluid was sampled 2, 4, and 8 days after lung transplantation. DNA, which was extracted from the blood of donors and recipients and from the pleural fluid, was amplified using a polymerase chain reaction technique. The reaction products were electrophoresed, and bands indicating amplified human leukocyte antigen (HLA)-DR alleles were quantified by determining the area under the curve (AUC) by a densitometric analysis. HLA-DR alleles, which were present only in recipient cells (recipient allele), were analyzed and compared to HLA-DR alleles that were present only in donor cells (donor allele). A dilution study was first performed to provide a standard curve relating the percentage of donor and recipient cells in a mixture to their AUC. The AUC of the recipient alleles did not change significantly over the first 8 postoperative days. The AUC of the donor alleles was less on postoperative days 4 and 8 than on day 2 (p<0.05). The donor allele AUC on day 8 was <20% of the shared allele AUC, corresponding to <1% of all cells by the dilution study. We conclude that donor cells are rapidly cleared from the pleural space after lung transplantation, with <1% of cells of donor origin by postoperative day 8.

Respiratory reovirus 1/L induction of intraluminal fibrosis. A model for the study of bronchiolitis obliterans organizing pneumonia

Bronchiolitis obliterans organizing pneumonia (BOOP) is a term that was first applied in 1985 to describe a long-observed but unclassified pattern of acute lung injury. BOOP lesions are characterized by fibrous extensions into the alveolar spaces in association with a peribronchiolar organizing pneumonia. Since 1985, an increasing number of reports of BOOP have appeared in the clinical literature, and it is now accepted that BOOP is a significant pulmonary syndrome. Although BOOP can be associated with a number of documented pulmonary insults, many cases are not associated with known causes and are thus classified as idiopathic. The lack of an appropriate small animal model that closely mimics the generation of BOOP lesions has been an impediment to basic studies of the pathogenic mechanisms responsible for the generation of BOOP in humans. In this report, we describe an animal model for BOOP in which CBA/J mice infected with reovirus serotype 1/strain Lang develop BOOP lesions. These lesions closely resemble those seen in humans and occur in a well defined temporal sequence that proceeds from initial peribronchiolar inflammatory lesions to characteristic, fibrotic cellular BOOP lesions over a 3-week time course.

Pleural effusion from acute lung rejection

A single-lung transplant recipient developed an ipsilateral pleural effusion from acute lung rejection 2 weeks after transplantation. The pleural effusion was exudative and contained more than 80% lymphocytes on two separate determinations. Acute lung rejection should be added to the differential diagnosis of a lymphocyte-predominant exudative pleural effusion.