Rare organ manifestations of sarcoidosis

PURPOSE

We retrospectively analyzed the frequency and clinical characteristics of organs rarely involved with sarcoidosis in a cohort of 1158 sarcoidosis patients cared for over nearly 11 years in a university outpatient sarcoidosis clinic.

METHODS

Data were analyzed from an institution-approved sarcoidosis clinical database containing demographic and clinical characteristics of sarcoidosis outpatients cared for between May 2011 and March 2021 at a university medical center sarcoidosis clinic. The diagnosis of sarcoidosis was established by standard international criteria. Rare organ involvement was defined as an organ not individually listed in the Word Association of Sarcoidosis and Other Granulomatous Disorders Sarcoidosis Organ Assessment Instrument.

RESULTS

Twenty-six of the 1158 patients (2.2%) had 27 instances of rare organ involvement. The most common rare organ involved was the GI tract, followed by the testicle and then the female reproductive tract. Only 1 of the 26 patients with rare sarcoidosis organ involvement required therapy for that organ involvement. In comparison with sarcoidosis patients without rare organ involvement, patients with rare organ involvement were more likely to be black, have more total organs involved with sarcoidosis, and more likely require anti-sarcoidosis therapy at some point during the course of their disease. There were no differences between these groups in terms of sex, age at diagnosis, and most recent percent predicted forced vital capacity.

CONCLUSIONS

Rare sarcoidosis organ involvement occurred in 2.2 percent of this cohort. Although rare organ involvement rarely required treatment, it was associated with more extensive disease that was more likely to require therapy.

Moderate or Severe Impairment in Pulmonary Function is Associated with Mortality in Sarcoidosis Patients Infected with SARS‑CoV‑2

Purpose

To investigate whether sarcoidosis patients infected with SARS-CoV-2 are at risk for adverse disease outcomes.

Study Design and Methods

This retrospective study was conducted in five hospitals within the Mount Sinai Health System during March 1, 2020 to July 29, 2020. All patients diagnosed with COVID-19 were included in the study. We identified sarcoidosis patients who met diagnostic criteria for sarcoidosis according to accepted guidelines. An adverse disease outcome was defined as the presence of intubation and mechanical ventilation or in-hospital mortality. In sarcoidosis patients, we reported (when available) the results of pulmonary function testing measured within 3 years prior to the time of SARS‑CoV‑2 infection. A multivariable logistic regression model was used to generate an adjusted odds ratio (aOR) to evaluate sarcoidosis as a risk factor for an adverse outcome. The same model was used to analyze sarcoidosis patients with moderate and/or severe impairment in pulmonary function.

Results

The study included 7337 patients, 37 of whom (0.5%) had sarcoidosis. The crude rate of developing an adverse outcome was significantly higher in patients with moderately and/or severely impaired pulmonary function (9/14 vs. 3/23, p = 0.003). While the diagnosis of sarcoidosis was not independently associated with risk of an adverse event, (aOR 1.8, 95% CI 0.9–3.6), the diagnosis of sarcoidosis in patients with moderately and/or severely impaired pulmonary function was associated with an adverse outcome (aOR 7.8, 95% CI 2.4–25.8).

Conclusion

Moderate or severe impairment in pulmonary function is associated with mortality in sarcoidosis patients infected with SARS‑CoV‑2.

Electronic supplementary material

The online version of this article (10.1007/s00408-020-00392-9) contains supplementary material, which is available to authorized users.

GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Previous attempts to characterise the burden of chronic respiratory diseases have focused only on specific disease conditions, such as chronic obstructive pulmonary disease (COPD) or asthma. In this study, we aimed to characterise the burden of chronic respiratory diseases globally, providing a comprehensive and up-to-date analysis on geographical and time trends from 1990 to 2017.

METHODS

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, we estimated the prevalence, morbidity, and mortality attributable to chronic respiratory diseases through an analysis of deaths, disability-adjusted life-years (DALYs), and years of life lost (YLL) by GBD super-region, from 1990 to 2017, stratified by age and sex. Specific diseases analysed included asthma, COPD, interstitial lung disease and pulmonary sarcoidosis, pneumoconiosis, and other chronic respiratory diseases. We also assessed the contribution of risk factors (smoking, second-hand smoke, ambient particulate matter and ozone pollution, household air pollution from solid fuels, and occupational risks) to chronic respiratory disease-attributable DALYs.

FINDINGS

In 2017, 544·9 million people (95% uncertainty interval [UI] 506·9-584·8) worldwide had a chronic respiratory disease, representing an increase of 39·8% compared with 1990. Chronic respiratory disease prevalence showed wide variability across GBD super-regions, with the highest prevalence among both males and females in high-income regions, and the lowest prevalence in sub-Saharan Africa and south Asia. The age-sex-specific prevalence of each chronic respiratory disease in 2017 was also highly variable geographically. Chronic respiratory diseases were the third leading cause of death in 2017 (7·0% [95% UI 6·8-7·2] of all deaths), behind cardiovascular diseases and neoplasms. Deaths due to chronic respiratory diseases numbered 3 914 196 (95% UI 3 790 578-4 044 819) in 2017, an increase of 18·0% since 1990, while total DALYs increased by 13·3%. However, when accounting for ageing and population growth, declines were observed in age-standardised prevalence (14·3% decrease), age-standardised death rates (42·6%), and age-standardised DALY rates (38·2%). In males and females, most chronic respiratory disease-attributable deaths and DALYs were due to COPD. In regional analyses, mortality rates from chronic respiratory diseases were greatest in south Asia and lowest in sub-Saharan Africa, also across both sexes. Notably, although absolute prevalence was lower in south Asia than in most other super-regions, YLLs due to chronic respiratory diseases across the subcontinent were the highest in the world. Death rates due to interstitial lung disease and pulmonary sarcoidosis were greater than those due to pneumoconiosis in all super-regions. Smoking was the leading risk factor for chronic respiratory disease-related disability across all regions for men. Among women, household air pollution from solid fuels was the predominant risk factor for chronic respiratory diseases in south Asia and sub-Saharan Africa, while ambient particulate matter represented the leading risk factor in southeast Asia, east Asia, and Oceania, and in the Middle East and north Africa super-region.

INTERPRETATION

Our study shows that chronic respiratory diseases remain a leading cause of death and disability worldwide, with growth in absolute numbers but sharp declines in several age-standardised estimators since 1990. Premature mortality from chronic respiratory diseases seems to be highest in regions with less-resourced health systems on a per-capita basis.

FUNDING

Bill & Melinda Gates Foundation.

New advances in the management of pulmonary sarcoidosis

Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.

[Type and frequency of cardiac symptoms in patients with pulmonary sarcoidosis]

AIM

The aim of the study was to assess the type and frequency of prevalence of cardiac symptoms in patients with pulmonary sarcoidosis.

MATERIALS AND METHODS

The study group consisted of 54 patients (21 female, 33 male), with biopsy-proven pulmonary sarcoidosis. Mean age was 45.85 +/-11.77 years. According to time passed from diagnosis of sarcoidosis patients were divided into 2 subgroups. Additionally, age, sex, left ventricular ejection fraction, cigarette smoking and comorbidities were analyzed. Course and stage of sarcoidosis were also included in the analysis.

RESULTS

The frequency of cardiovascular symptoms in the study group was 87.04%. 59.26% of patients reported chest pain, the same subjects reported dyspnoea. 48.15% of respondents reported heart palpitations, 33.33% pre-syncope states, 12.96% syncope, and 37.04% edema of lower limbs. There were no statistically significant differences in the incidence of analyzed symptoms, depending on the duration of lung sarcoidosis.

CONCLUSIONS

Patients with pulmonary sarcoidosis who report cardiovascular symptoms require further diagnostics.

[socioecological features of the epidemiology of sarcoidosis in the poltava region, Ukraine]

OBJECTIVE

Introduction: Lung sarcoidosis is a systemic granulomatous disease that can affect various organs and systems of a person. Due to the lack of a uniform standardized approach to the diagnosis of sarcoidosis, the epidemiological pattern is heterogeneous and depends on many factors. The aim: To investigate the correlation between the number of patients with sarcoidosis among the population of the Poltava region (Ukraine) and the ecological characteristics of the industrial activity of the region in comparison with the data on the availability of subspecialists in respiratory diseases.

PATIENTS AND METHODS

Materials and methods: The study is based on a retrospective analysis of patients with sarcoidosis living in the Poltava region (Ukraine) for the period from 2008 to 2018.

RESULTS

Results: The analysis of the correlation between the intensity of environmental impacts on the region and the number of patients with sarcoidosis did not reveal statistically significant changes. An odds ratio (OR) of the occurrence of sarcoidosis among the urban population has not experienced significant dynamics (OR 1,337, 95% CI: 0.96-1.86) compared with those living in rural areas. The number of specialists performing the duties of a pulmonologist in the region is associated with a significantly higher number of registered patients with various forms of sarcoidosis (r=0.27, p=0.04).

CONCLUSION

Conclusions: There was no reliable relationship between the risk of sarcoidosis and habitat in areas with increased ecological and industrial load in the Poltava region. The uneven distribution of specialized medical care reduces the patient's odds of establishing a diagnosis of sarcoidosis in the countryside.

Clinical Features of Pulmonary Sarcoidosis Complicated by Lung Cancer

Objective For lung cancer complicated with sarcoidosis, there are no exact features that indicate whether lymphadenopathy is metastatic. This makes the validity of surgery uncertain for clinicians. The aim of this study was to clarify the clinical features of pulmonary sarcoidosis complicated by lung cancer, especially from the viewpoint of evaluating lymphadenopathy. Methods We retrospectively reviewed medical records from 2004 to 2013 at our institution, and 18 patients who were diagnosed with sarcoidosis and lung cancer were thus found to be eligible. We investigated the relationship between the clinical and pathological findings of their swollen lymph nodes. Results Of 18 patients, 11 conducted surgery, and the postoperative pathological evaluation of swollen lymph nodes was done in 8 of the patients. Postoperative N factor in all these patients was 0, even though lymphatic metastasis had been suspected preoperatively because of the unbalanced distribution of lymphadenopathy or the accumulation of fluorodeoxyglucose. Conclusion In patients with lung cancer complicated by sarcoidosis, the clinical assessment of the state of lymphadenopathy is difficult to make. However, as many of them tend to be benign, we suggest that surgical resection should be considered for a complete cure in the absence of any remote metastasis.

Spectrum of interstitial lung disease from a tertiary care hospital in Karachi

OBJECTIVE

To determine the clinical features and patterns of interstitial lung disease.

METHODS

This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised record of patients diagnosed with interstitial lung disease from January 2005 to December 2015. All patients aged 16 years and above diagnosed with interstitial lung disease on the basis of clinical features, radiological features on high-resolution computed tomography of the chest, and lung biopsies were included. SPSS 19 was used for data analysis.

RESULTS

Of the 537 patients, 324(60.3%) of the participants were females. The overall mean age was 60.5±14.9 years. The most common co-morbid condition was diabetes mellitus in 72(13.4%) patients, followed by hypertension in 48(8.9%) and ischaemic heart disease in 21(3.9%). The most common interstitial lung disease was idiopathic pulmonary fibrosis in 217(40.4%) patients, followed by non-specific interstitial pneumonia in 106(19.7%), sarcoidosis in 82(15.3%) and connective tissue disease-related interstitial lung disease in 56(10.4%) patients.

CONCLUSIONS

Idiopathic pulmonary fibrosis was found to be the most common interstitial lung disease subtype followed by non-specific interstitial pneumonia, sarcoidosis and connective tissue disease-related-interstitial lung disease.

Epidemiology and clinical characteristics of sarcoidosis: an update from a population-based cohort study from Olmsted County, Minnesota

Information about the epidemiology, clinical manifestations and comorbidities of sarcoidosis among Caucasians is relatively scarce. This review focuses primarily on the data from a recently published Caucasianpredominant population-based cohort from Olmsted County, Minnesota. Overall, the incidence rate was 10.0 per 100,000 population, which suggested that sarcoidosis is less common in Caucasians than in Blacks, but is more common in Caucasians than in Asians. Intrathoracic involvement was seen in the vast majority of patients, but less than half have respiratory symptoms. The most common extra-thoracic manifestations were skin rash followed by arthralgia, ophthalmologic involvement, hepatic involvement, splenomegaly, renal involvement, neurological involvement, extra-thoracic lymphadenopathy, exocrine gland involvement, upper respiratory tract involvement and cardiac involvement. Compared to sex and age-matched subjects, patients with sarcoidosis suffer from increased rates of cardiovascular disease, venous thromboembolism and hospitalized infection.

Challenges in diagnosing Sarcoidosis in tuberculosis endemic regions: Clinical scenario in India

 Sarcoidosis is a chronic, systemic disease of unknown etiology that affects multiple organs. The disease was considered rare in developing countries like India. More recently sarcoidosis is being increasingly diagnosed in countries where tuberculosis continues to be endemic. There is a general perception among physicians that the prevalence of sarcoidosis has increased over the last two decades in countries like India. This may be true but could also be related to better awareness of the condition, availability of improved diagnostic facilities and the increased ability of physicians to differentiate it from tuberculosis. In India, diagnosis of tuberculosis is entertained first in patients who may have sarcoidosis and thus, it is very likely for sarcoidosis to be misdiagnosed as tuberculosis, owing to the high prevalence of tuberculosis and clinicoradiological resemblance to the disease. This editorial highlights the challenges in diagnosing tuberculosis in countries where tuberculosis still continues to be endemic.

Influence of Gender on Epidemiology and Clinical Manifestations of Sarcoidosis: A Population-Based Retrospective Cohort Study 1976-2013

PURPOSE

The influence of ethnicity on epidemiology and clinical manifestations of sarcoidosis is well recognized. However, data on the role of sex are limited.

METHODS

The current study utilized the resource of the Rochester Epidemiology Project to identify all residents of Olmsted County, Minnesota, United States, with new diagnosis of sarcoidosis from 1976 to 2013. Diagnosis was verified by medical record and histopathological report review.

RESULTS

345 incident cases of sarcoidosis were identified: 174 (50 %) were female and 171 (50 %) were male. The age at diagnosis was significantly higher among females than males (48.3 vs. 42.8 years; p < 0.001). Intra-thoracic disease was seen in the great majority of patients (98 % among females and 96 % among males; p = 0.50). However, pulmonary symptoms were significantly more frequent among males than females (51 vs. 36 %; p = 0.006). The frequency of individual extra-thoracic organ involvement was not significantly different between females and males except for cutaneous involvement and uveitis that were significantly more common among females (6 vs. 1 % for uveitis, p = 0.012 and 25 vs. 12 % for cutaneous involvement, p = 0.002). The frequency of elevate angiotensin-converting enzyme level and hypercalcemia was not significantly different between the two sexes.

CONCLUSIONS

Females tended to be older at the age they developed sarcoidosis, and had more uveitis and cutaneous involvement than males.

Pulmonary Sarcoidosis: Diagnosis and Treatment

Sarcoidosis is a chronic granulomatous disease of unknown cause that is seen worldwide and occurs mainly in patients between the ages of 20 and 60 years. It can be difficult to diagnose because it can mimic many other diseases including lymphoproliferative disorders and granulomatous infections and because there is no specific test for diagnosis, which depends on correlation of clinicoradiologic and histopathologic features. This review will focus on recent discoveries regarding the pathogenesis of sarcoidosis, common clinical presentations, diagnostic evaluation, and indications for treatment. This review is aimed largely at general practitioners and emphasizes the importance of differentiating pulmonary sarcoidosis from its common imitators.

Epidemiology of Sarcoidosis 1946-2013: A Population-Based Study

OBJECTIVE

To characterize the epidemiology of sarcoidosis from 1946 through 2013.

PATIENTS AND METHODS

An inception cohort of patients with incident sarcoidosis from January 1, 1976, through December 31, 2013, in Olmsted County, Minnesota, was identified based on comprehensive individual medical record review. Inclusion required physician diagnosis supported by histopathologic confirmation, radiologic features of intrathoracic sarcoidosis, and a compatible clinical presentation. Data were collected on demographic characteristics, clinical presentation, laboratory investigations, and mortality. The data were augmented with a previously identified cohort of Olmsted County residents diagnosed as having sarcoidosis in 1946-1975. Incidence rates were age and sex adjusted to the 2010 US white population.

RESULTS

A total of 448 incident cases of sarcoidosis were identified (mean age, 44.2 years; 52% women). The annual incidence of sarcoidosis was 10.0 per 100,000 population. The incidence of sarcoidosis increased in women from 1950 to 1960, but otherwise there were no significant calendar year trends. However, the peak age at incidence for women shifted from 40 to 59 years in 1950 to 50 to 69 years in 2010. Similarly, the peak age at incidence for men shifted from 30 to 49 years in 1950 to 40 to 59 years in 2010. Ninety-seven percent of patients had intrathoracic involvement, but only 43% had respiratory symptoms. The overall mortality of patients with sarcoidosis was not different from that of the general population (standardized mortality ratio=0.90; 95% CI, 0.74-1.08).

CONCLUSION

Sarcoidosis occurred in approximately 10 persons per 100,000 per year. Most of the patients had intrathoracic involvement, although less than half had respiratory symptoms. Overall mortality was not different from that of the general population.

Unsuspected exposure to beryllium: potential implications for sarcoidosis diagnoses

Exposure to Beryllium (Be) can cause sensitization (BeS) and chronic beryllium disease (CBD) in some individuals.  Even relatively low exposures may be sufficient to generate an asymptomatic, or in some cases a symptomatic, immune response. Since the clinical presentation of CBD is similar to that of sarcoidosis, it is helpful to have information on exposure to beryllium in order to reduce misdiagnosis. The purpose of this pilot study is to explore the occurrence of Be surface deposits at worksites with little or no previous reported use of commercially available Be products.  The workplaces chosen for this study represent a convenience sample of businesses in eastern Iowa. One hundred thirty-six surface dust samples were collected from 27 businesses for analysis of Be. The results were then divided into categories by the amount of detected Be according to U.S. Department of Energy guidelines as described in 10 CFR 850.30 and 10 CFR 850.31. Overall, at least one of the samples at 78% of the work sites tested contained deposited Be above the analytical limit of quantitation (0.035 µg beryllium per sample).  Beryllium was detected in 46% of the samples collected. Twelve percent of the samples exceeded 0.2 µg/100 cm² and 4% of the samples exceeded a Be concentration of 3 µg/100 cm². The findings from this study suggest that there may be a wider range and greater number of work environments that have the potential for Be exposure than has been documented previously.  These findings could have implications for the accurate diagnosis of sarcoidosis.

Disseminated nocardiosis mimicking exacerbation of pulmonary sarcoidosis

Nocardiosis is a rare, mixed suppurative and granulomatous, bacterial infection that can affect various organs, but most commonly lungs. Clinical manifestation is usually uncharacteristic; can mimic fungal, parasitic and mycobacterial infections or malignancy. Presentation can be also similar to that of the other granulomatous diseases, among them sarcoidosis. We present an unusual case of disseminated nocardiosis in a patient diagnosed before with sarcoidosis and treated with glucocorticoids. Clinical symptoms initially mimicked exacerbation of pulmonary sarcoidosis. The course of disease was severe.

[Coexistence of mediastinal adenopathies of different etiologies -- case report]

The paper presents the case of a 52-year-old Caucasian female with several comorbidities (diabetes mellitus II, transitory ischemic stroke, sarcoma of uterus -operated, chemotherapy), which was addressed to the pneumology department for the diagnosis of sarcoidosis, established through mediastinoscopy followed by histopathological examination of lymph node biopsies. Further investigations performed in our department sustained the diagnosis of stage I sarcoidosis and expectative without systemic corticotherapy was the clinicians' decision. The follow-up during several months showed spontaneous remission of the mediastinal adenopathies except one, in the medium lobe, which was supposed to have other ethiology than sarcoidosis. Surgical excision of this tumor and several lymph-node biopsies was performed through right thoracotomy; the histopathological exam sustained the diagnosis of "ganglionar metastasis from endometrial sarcoma' but immunohistochemical tests showed that it was a "sclerosing hemangioma of the lung" - tumor with benign evolution. The coexistence of adenopathies of different and rare etiologies make this case interesting, the different evolution of these adenopathies suggested the different morphological pattern of them.

[Change in the blood cytokine spectrum in patients with pulmonary sarcoidosis]

AIM

To assess cytokine spectrum changes in different types of pulmonary sarcoidosis (PS).

SUBJECTS AND METHODS

Twenty-seven PS patients without signs of pulmonary fibrosis and 14 patients with sarcoidosis complicated by pulmonary fibrosis were examined. Baseline serum Th1 and Th2 cytokine concentrations were studied. A control group comprised 30 healthy donors.

RESULTS

A higher interleukin (IL)-4/IL-2 ratio was found in the peripheral blood of the patients with pulmonary fibrosis-complicated sarcoidosis than in the other patients (326.4 +/- 122.6 and 88.2 +/- 28.6%, respectively; p = 0.002). The sarcoidosis patients with signs of pulmonary fibrosis and no symptoms of disease inflammatory activity had elevated blood IL-1 levels whereas an IL-1 receptor antagonist was decreased.

CONCLUSION

In the patients with PS, the development and progression of pulmonary fibrosis occur with a shift in the Th1/Th2 balance towards Th2, which manifests itself as a higher IL-4/IL-2 ratio in the peripheral blood. At the same time, the signs of systemic inflammatory activity remain.

Anxiety and depression in sarcoidosis: the influence of age, gender, affected organs, concomitant diseases and dyspnea

BACKGROUND

Heightened degrees of anxiety and depression are often found in patients suffering from sarcoidosis, but the reasons for that are unclear. Furthermore, age and gender differences of anxiety and depression in sarcoidosis have not been reported with reference to normative data.

OBJECTIVES

The aim was to test age and gender differences of anxiety and depression in a large sample, and to examine the influence of affected organs, concomitant diseases and dyspnea.

METHODS

1197 German patients diagnosed with sarcoidosis were examined, using the Hospital Anxiety and Depression Scale (HADS) and the MRC dyspnea scale.

RESULTS

Patients suffering from sarcoidosis were significantly more anxious and depressed than the general population. This effect was especially strong in young age groups. The number of affected organs, the number of concomitant diseases and the degree of dyspnea significantly predicted anxiety and depression scores in univariate analyses. Among the affected organs, muscles, nerves, and bones most significantly contributed to depression. Sleep apnea, restless legs syndrome, and arterial hypertension were associated with anxiety as well as depression. In multivariate analyses including age and gender, however, only dyspnea and the number of concomitant diseases remained predictors of anxiety and depression scores.

CONCLUSIONS

The analysis of mental distress should take into account comparisons with normative values. Young patients deserve special social support. Dyspnea proved to be an important symptom in the prediction of anxiety and depression.

[Sarcoidosis and tobacco smoking--clinical picture, diagnostic tests results and bronchoalveolar lavage fluid composition]

Sarcoidosis is a multiorgan granulomatous disease of unknown aetiology. Bronchoalveolar lavage (BAL) is approved in diagnostics of sarcoidosis. The aim of the study was to assess epidemiological data, demographic status, clinical picture of sarcoidosis patients and to correlate above-mentioned findings with smoking status.

MATERIAL AND METHODS

The study included 101 patients hospitalized due to suspicion of pulmonary sarcoidosis. The results of clinical assessment and smoking status data were obtained by retrospective analysis of 78 confirmed sarcoidosis case records.

RESULTS

Investigated group comprised 54 non-smokers (NS) and 24 smokers (S), including 9 (11.5%) active smokers (AS). Smokers were significantly younger than nonsmokers. Most of the smokers were males. The mean number of pack-years was 8.2. Respiratory symptoms occurred with similar frequency among non-smokers and smokers. The incidence of the Loefgren's syndrome was similar in S and NS . The pulmonary function tests results were comparable in both groups, however, the obstruction was more frequent among smokers. Composition of BAL fluid (BALf) differed significantly between S and NS. The total cell count was significantly higher among active smokers than among nonsmokers (29.3 +/- 19.2 x 10(6) vs 13.7 +/- 6.3 x 10(6)). Compared to non-smokers, smokers had higher number of macrophages and lower percentage of lymphocytes (11.3 +/- 11 x 10(6) vs 6.5 +/- 3.9 x 10(6), 29 +/- 19 vs 41 +/- 17%, respectively).

CONCLUSIONS

A significantly lower proportion of smokers is observed among sarcoidosis patients than in general population. The influence of smoking on clinical picture and results of pulmonary function tests is not evident in sarcoidosis. However, tobacco smoking causes significant alteration in the composition of BALf, which should be taken into account in diagnostics of sarcoidosis.

[A comparative clinical analysis of thoracic sarcoidosis and multi-organ sarcoidosis]

OBJECTIVE

To investigate the clinical characteristics of thoracic sarcoidosis compared with multi-organ sarcoidosis.

METHODS

The clinical data of 24 patients with thoracic sarcoidosis and 29 patients with multi-organ sarcoidosis histologically diagnosed at Beijing Tongren Hospital from 1995 to 2010 were retrospectively analyzed. The demographic data, clinical manifestations, diagnostic procedures, involved organs, serum angiotensin converting enzyme (ACE) levels, lung functions, and cellular characteristics of bronchoalveolar lavage fluid (BALF) were compared.

RESULTS

No difference was found in the age of onset between the 2 groups [(49 ± 12), (48 ± 11) years old; t = 0.114, P > 0.05]. Multi-organ sarcoidosis was more frequent in females compared with thoracic sarcoidosis (13/24, 24/29; χ² = 5.094, P < 0.05), and 72.41% of the patients with multi-organ disease were females above 40 years old. The patients with thoracic sarcoidosis mostly presented first to respiratory physicians or chest surgeons, often with the symptoms of lung involvement. The manifestations of multi-organ sarcoidosis varied considerably and the patients might present to any clinical departments. Sarcoidosis with rare involvement of organs as the presenting symptoms was easy to be misdiagnosed. A higher incidence of systemic constitutional symptoms (25.0%, 58.6%; χ² = 6.043, P < 0.05) and a longer duration for definite diagnosis [1.75 (0.625 - 3.000), 6 (0 - 40) months; Z = -3.377, P < 0.01] were found in patients with multi-organ sarcoidosis compared with thoracic sarcoidosis. There was no difference in the serum ACE level between the 2 groups [(72 ± 33), (75 ± 59) U/L; t = -0.193, P > 0.05]. Although forced expiratory volume in one second (FEV(1))/forced vital capacity (FVC), FEV₁ %predicted (pred), FVC%pred and total lung capacity (TLC)%pred showed no difference (t = 0.134 - 0.683, P > 0.05), the diffusing capacity of the lung of carbon monoxide (D(LCO))%pred decreased more remarkably in multi-organ sarcoidosis [(84 ± 8), (69 ± 21); t = 2.674, P < 0.05]. The total cell count, alveolar lymphocyte percentage and CD₄/CD₈ ratio of BALF demonstrated no significant difference between the 2 groups (t = -0.628 - -0.367, P > 0.05), but the neutrophil percentage was significantly higher in multi-organ sarcoidosis compared with thoracic sarcoidosis [(10.9 ± 4.9)%, (5.1 ± 2.1)%; t = -4.187, P < 0.01].

CONCLUSIONS

Compared with thoracic sarcoidosis, multi-organ sarcoidosis seemed to be more common in females and more serious. Increased percentage of neutrophils in BALF may be a suggestive index for multiple organ involvements.

Interferon gamma release assay (QuantiFERON-TB Gold In Tube) in patients of sarcoidosis from a population with high prevalence of tuberculosis infection

BACKGROUND AND OBJECTIVE

Detecting latent tubercular infection (LTBI) in sarcoidosis has important treatment implications. Traditionally tuberculin skin test (TST) is relied upon for this purpose. However, sarcoidosis is known to produce tuberculin anergy, which is not affected by high prevalence of tuberculosis (TB) infection. Interferon gamma release assays (IGRAs) have a higher sensitivity and specificity for detecting Mycobacterium tuberculosis (MTB) infection than the conventional TST as they utilize antigens specific for MTB complex. However, there is limited data regarding the performance of these tests in sarcoidosis, particularly in a setting of high population prevalence of LTBI. Herein, we studied the utility of IGRAs in the diagnostic work up of patients with sarcoidosis.

PATIENTS AND METHODS

Prospectively enrolled, biopsy-confirmed, glucocorticoid naive cases of pulmonary sarcoidosis; pulmonary and extrapulmonary TB; and, healthy controls underwent TST using 0.1 mL (1 tuberculin unit) of purified protein derivative RT23, and IGRA using QuantiFERON-TB-Gold In Tube assay (QFT) in blood. For TST an induration > or =10 mm was taken as positive. QFT was performed and interpreted as per the manufacturer's instructions.

RESULTS

We studied 38 patients with sarcoidosis (22 men, 16 women; mean age 42.5 years), 30 patients of TB (18 pulmonary, 12 extrapulmonary) and 30 healthy controls. Patients with sarcoidosis were more likely to have a negative TST compared to healthy controls (89.5% vs. 60%, p = 0.004) or TB (89.5% vs. 23.3%, p < 0.001). However, QFT positivity was not significantly different in sarcoidosis compared to controls (34.2% vs. 50%, p = 0.19), but was higher in TB patients as compared to sarcoidosis (60% vs. 34.2%, p = 0.03).

CONCLUSIONS

There is anergy to tuberculin in sarcoidosis. However, the results of QFT are not similarly affected. QFT continues to remain positive in many patients with sarcoidosis, and thus may be more accurate to detect LTBI in these patients.

Factor analysis of sarcoidosis phenotypes at two referral centers in Brazil

BACKGROUND

In sarcoidosis, clinical presentations and outcomes vary widely.

OBJECTIVE

To characterize the clinical phenotypes of sarcoidosis, by factor analysis, in a series of cases with long-term follow-up.

METHODS

We conducted a retrospective study involving 137 patients with biopsy-confirmed sarcoidosis, recruited from two referral centers in São Paulo, Brazil. Organ involvement was evaluated in accordance with a previously established protocol. Sarcoidosis phenotypes were characterized by factor analysis.

RESULTS

Follow-up ranged from 6 to 144 months. Four factors (phenotypes) were identified: relevant residual pulmonary fibrosis; relapse; residual airflow limitation; and acute disease. The four factors collectively accounted for 66% of the total variance. Patients with relevant residual pulmonary fibrosis were older and presented with the following: greater symptom duration; skin involvement; low forced vital capacity; low forced expiratory volume in one second/forced vital capacity ratio; and more advanced radiographic stages at baseline. The relapse phenotype was associated with chronic disease, greater dyspnea severity, neurologic involvement, and cardiac involvement. Patients with residual airflow limitation more often had airflow obstruction at baseline, chronic disease, and relevant residual pulmonary fibrosis. Acute disease was associated with being younger, weight loss, scoring lower for dyspnea, and having extensive involvement. Abnormal calcium metabolism was associated with acute disease and with relapse.

CONCLUSIONS

Sarcoidosis can be categorized into four different clinical phenotypes: three that are chronic; and one that is acute and self-limiting. In many cases, these phenotypes can be easily recognized.

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.

"Sarcoid like" granulomatous pulmonary disease in World Trade Center disaster responders

BACKGROUND

More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of "sarcoid like" granulomatous pulmonary disease in other WTC responders.

METHODS

Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only "definite" cases are reported.

RESULTS

Thirty-eight patients were classified as "definite" cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality.

CONCLUSIONS

Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected.

Sarcoidosis in Ireland: regional differences in prevalence and mortality from 1996-2005

BACKGROUND

Sarcoidosis is a common multisystem disease of unknown cause and Ireland is among the countries with the highest reported prevalence of disease worldwide. Despite this, reports on the geographical distribution of disease and differences in mortality due to sarcoidosis within Northern Ireland (NI) and the Republic of Ireland (ROI) are currently lacking.

OBJECTIVE

This study was performed to examine sarcoidosis prevalence and mortality in Ireland (NI and ROI) to specifically determine if geographical or temporal clusters of disease are present and if any differences in mortality exist between NI and ROI.

DESIGN

A retrospective study, examining hospital discharge data for NI and ROI and data on deaths due to sarcoidosis, obtained from the relevant official government agencies.

RESULTS

For 1996-2005, the prevalence of sarcoidosis was 28.13 per 100,000 for ROI compared with 11.16 per 100,000 for NI (p = 0.002). Two significant spatial clusters of disease were detected in the Northwest (Prevalence = 44.9 per 100,000) and also the Midlands region (32.1 per 100,000). Two lower-prevalence spatial clusters were also detected in the South and Southeast of ROI. Temporal clustering was also present throughout ROI and NI for the years 2000 to 2004, while space-time clustering was found in three regions, the West (ROI), the East (ROI) and Northeast (ROI and NI). The case fatality rate for ROI was 0.84%, and for NI was 1.44% (p = 0.03).

CONCLUSION

Considerable heterogeneity in disease prevalence is evident in Ireland as significant spatial, temporal and space-time clusters of sarcoidosis are demonstrated in this study. Prevalence rates are also higher than that previously reported for Ireland and are comparable to those of Scandinavian countries. Although case-fatality is low in both ROI and NI, it is significantly lower in ROI. Further study is needed to investigate these findings and the creation of an all-island sarcoidosis registry would provide a mutually beneficial means of capturing this data more effectively.

Effect of gender on health related quality of life in sarcoidosis

BACKGROUND

Sarcoidosis has different phenotypic manifestations which may have a diverse effect on functional status and quality of life. There are few studies in sarcoidosis addressing gender disparity and its effect on Health-Related Quality of Life (HRQL) and functional status.

OBJECTIVE

The purpose of this study was to investigate the effects of gender on HRQL and to identify associations between poor HRQL and the results of common clinical tests.

DESIGN

We assessed HRQL for 221 patients with sarcoidosis in a prospective, cross-sectional study using the Short Form-36 Health Survey and Sarcoidosis Health Questionnaire. We evaluated the association between the scores of these measures with patient characteristics, pulmonary function test (PFT) and 6-minute walk test (6MWT) data.

RESULTS

Women had lower scores than men on every measure of HRQL and weaker associations to findings from PFT and 6MWT. Multivariate linear regression analyses demonstrated that reduced 6MWT distance and DLCO were significantly associated with poor HRQL in both genders but the sensation of dyspnea played a significant role in women only.

CONCLUSIONS

Our results indicate that women with sarcoidosis have a lower HRQL score and a greater degree of functional impairment than men. The factors that are associated with poor HRQL differ by gender. Predictors of poor HRQL include reduction in DLCO and 6MWT distance and an increased sensation of dyspnea.

The role of atopy in the clinical course of pulmonary sarcoidosis in the Japanese population

Sarcoidosis is a multisystem disorder characterized by a T-helper 1 (Th1)-mediated immune response. Conversely, atopy is characterized by the presence of a specific immunoglobulin E (IgE) E response in association with a Th2-type immune response. Several epidemiological studies have shown that atopic status influences disease activity and clinical course for several Th1-mediated diseases. The aim of this study was to evaluate associations between atopic status and clinical findings of sarcoidosis. We further evaluated the impact of atopic status on the clinical course of pulmonary sarcoidosis. We defined atopy as a positive specific IgE response to at least one common inhaled allergen (multiple antigen simultaneous test scores, lumicount of >1.01). Subjects comprised 134 patients given a diagnosis of sarcoidosis between 2000 and 2006, divided into atopic and nonatopic groups. Several clinical findings were compared between the two groups. Furthermore, 100 subjects observed 2 years after diagnosis were divided into resolving and persistent clinical course groups according to chest radiography and associations with atopic status were evaluated. Atopy was more prevalent among men than women (p = 0.009) and subjects with atopy were younger (p = 0.002) and showed less frequent lung parenchymal lesions (stages II and III; p = 0.018) compared with subjects without atopy. The prevalence of atopy was higher in the resolving clinical course group than in the persistent clinical course group (p = 0.002) and this association was independent of sex, age, presence of lung parenchymal lesions, and presence of extrapulmonary lesions (p = 0.037). Classification of sarcoidosis based on atopic status might be useful for predicting the clinical course of pulmonary sarcoidosis.

[Epidemiology of interstitial lung diseases]

Diffuse interstitial lung diseases (DILD) cover more than 200 conditions classified in 4 groups: secondary DILD; sarcoidosis; particular DILDs and idiopathic interstitial pneumonias. Overall, these diseases have a prevalence of 60-80/100,000 and an incidence around 30/100,000. Sarcoidosis and idiopathic pulmonary fibrosis are the 2 most frequent diseases, accounting together for more than 50% of all cases, followed by DILD related to connective tissue disease and to immunologic lung diseases. The incidence of different causes of DILD depends on epidemiologic factors: age, sex, race, smoking habits, and history. Mortality is very elevated in idiopathic pulmonary fibrosis, linked in more than 80% of cases to the fibrosis itself, with a median survival between 24 and 36 months. The epidemiologic studies on DILD have substantial limitations, and new studies must be conducted, in particular in France where we lack epidemiologic data beyond one old study of sarcoidosis and one more recent study focused on farmer's lung in the Doubs.

Characteristics of patients presenting with erythema nodosum and sarcoidosis

We explored the relationship between erythema nodosum (EN) and sex, age, serum angiotensin converting enzyme (ACE), bronchoalveolar lavage lymphocytosis (BAL-I), interstitial granulomas and radiological stage in patients presenting with pulmonary sarcoidosis in Ireland. Sixty-nine patients diagnosed with sarcoidosis between 2003 and 2006 were studied. Forty one patients (59%) were male. Sixteen patients (23%) presented with EN. Forty one patients of 65 (63%) had transbronchial biopsies demonstrating non-caseating granulomas. Patients with sarcoidosis presenting with EN were more likely to be female (p=0.042), younger (p=0.012) and have earlier stage pulmonary disease (p=0.02). There were no correlations between serum ACE, interstitial granulomas and disease stage. BAL-I did however predict increasing disease radiological stage (p=0.042). In this study, one quarter of patients with sarcoidosis presented with EN among their presenting features. These patients were more likely to be young females with early stage radiological disease.

[Interstitial lung diseases in sarcoidosis]

Sarcoidosis is a multisystem disorder of unknown aetiology characterized by immune granuloma in involved tissue with predilection for lung and lymphoid system. The sarcoidosis aetiology remains unknown. It could result of genetic predisposition and exposure to specific enviromental factors. The chest X-ray is abnormal in 90% of cases with adenopathies and/or massive pulmonary infiltration with or without fibrosis. The different aspects are classified in 4 stages. The diagnosis is done when clinical and radiological usual signs are present with histological granuloma without caseum and in the absence of any other granulomatous disease. Most of the time, sarcoidosis spontaneously heals in 2 to 3 years. 10 to 30% of cases are chronic and often more severe. The disease could lastly generate a pulmonary fibrosis with a potential respiratory insufficiency, cor pulmonale, or aspergillus infection. Cardiac, neurologic, throat, kidney or ophthalmologic lesions or hypercalcemia may also be of bad prognosis. Sarcoidosis is lethal in 0.5 to 5% of cases. Mild disease does not need to be treated. Systemic corticosteroid for 12 months at least is the treatment for more severe diseases. Antimalarials drugs and immunomodulatory agents may be used if corticosteroids cannot be used or failed. TNFalpha recently proposed is currently evaluated.

The incidence of cancer in patients with idiopathic pulmonary fibrosis and sarcoidosis in the UK

BACKGROUND

The aim of this study was to use a longitudinal computerised health care dataset (The Health Improvement Network) to provide information on the overall incidence of cancer, and on the incidence of organ-specific cancers, in people with idiopathic pulmonary fibrosis (IPF) and sarcoidosis in comparison to the general population.

METHODS

Incident cases of IPF and sarcoidosis were identified with up to four controls matched by age, gender and general practice. Cancer incidence rates were compared between cohorts using Cox regression and adjusting for age, gender and smoking habit.

RESULTS

One thousand and sixty-four incident cases of IPF (mean age at diagnosis 71.5 years; 62.4% male) were identified. Overall, the incidence of cancer was increased in people with IPF compared to the general population (rate ratio 1.51; 95% CI 1.20-1.90), but this was largely due to a marked increase in the incidence of lung cancer (rate ratio 4.96; 95% CI 3.00-8.18). One thousand one hundred and fifty-three incident cases of sarcoidosis (mean age at diagnosis 47.0 years; 47.2% male) were identified. There was an overall increased incidence of cancer in sarcoidosis (rate ratio 1.65; 95% CI 1.22-2.24) and this was largely explained by an increase in the incidence of skin cancers (rate ratio 1.86; 95% CI 1.11-3.11).

CONCLUSIONS

This study provides further evidence of a marked increase in the incidence of lung cancer in people with IPF, but we found no increase in the risk of other cancers. People with sarcoidosis did have an increase risk of skin cancers, but not cancers at other sites.

Seasonality of the onset of symptoms, tuberculin test anergy and Kveim positive reaction in a large cohort of patients with sarcoidosis

BACKGROUND AND OBJECTIVES

Sarcoidosis is a systemic granulomatous disease of unknown aetiology and pathogenesis. This study evaluated the seasonal variation in the onset of symptoms, Tuberculin anergy and Kveim positive reaction in a cohort of 492 patients with sarcoidosis and in a subgroup of 248 patients with known Kveim test responses.

METHODS

The medical records of 492 patients with sarcoidosis were retrospectively reviewed. Roger's test for cyclic variation was used to assess the statistical significance of the observed seasonal variation.

RESULTS

For all sarcoidosis patients (n = 492) the onset of symptoms was most frequent in spring (61.8%) and least frequent in summer (31.7%) (P < 0.001). For patients with Tuberculin anergy (n = 364) the onset of symptoms was most frequent in spring and least frequent in autumn (P < 0.001); there was no seasonal variation among Tuberculin positive patients (n = 128). Of those patients with a Kveim test result (n = 248), the onset of symptoms was most frequent in spring and least frequent in summer (P < 0.001); there was no seasonal variation for patients with a negative Kveim results (n = 50 patients).

CONCLUSIONS

The onset of the symptoms was most frequent in spring and least frequent in the second half of the year (summer or autumn) in patients with sarcoidosis, Tuberculin anergy and a positive Kveim reaction. The significance of this finding in relation to aetiology and clinical utility needs to be further assessed.

Lesson learned from ACCESS (A Case Controlled Etiologic Study of Sarcoidosis)

ACCESS (A Case Control Etiologic Study of Sarcoidosis) was funded by the National Institutes of Health and collected data on 704 newly diagnosed, biopsy-proven cases of sarcoidosis and control subjects matched by age, sex, race, and geographic area. The goal of this study was to generate hypotheses about the etiology of sarcoidosis. The major hypothesis of the ACCESS investigators was that sarcoidosis occurs in genetically susceptible individuals through alteration in immune response after exposure to an environmental, occupational, or infectious agent. Strict criteria were used for the diagnosis of sarcoidosis and definitions of specific organ involvement were developed. The patients recruited for ACCESS represent the best clinical description of sarcoidosis at presentation in the United States. The study investigated the following: occupational/environmental triggers using a detailed questionnaire, infectious agents in the blood by polymerase chain reaction of 16s rDNA of microorganisms and cultures for cell wall-deficient mycobacteria, and genetic associations using a questionnaire to determine familial aggregation and candidate gene analysis. No single cause of sarcoidosis was identified. The results of this study are reviewed and possible lessons learned are discussed.

Sarcoidosis in Singapore: epidemiology, clinical presentation and ethnic differences

BACKGROUND AND OBJECTIVES

The aim of this study is to better understand the epidemiological and clinical features of patients with sarcoidosis in Singapore and to ascertain if ethnic differences exist.

METHODS

A review of hospital medical records from June 1998 to May 2004 to identify patients with sarcoidosis.

RESULTS

There were 59 patients with sarcoidosis identified (19 Chinese, 29 Asian Indian and 11 Malay). The estimated annual incidence of sarcoidosis in Singapore was 0.56 per 100,000. There was a significant difference between the observed and expected disease frequency in Chinese (32.2% vs 78.7%) and Indians (49.2% vs 6.0%, P < 0.005). A bimodal distribution of age at diagnosis was seen with peaks in the 30-39 years and 50-59 years age groups; 38.9% of cases were over the age of 50. Chinese patients were more likely to be asymptomatic (57.9%, P = 0.015) and less likely to have impaired spirometry (P = 0.013). Pulmonary sarcoid presented largely as stage 0 or stage 1 disease (74.4%). Overall mean spirometry was unimpaired and prognosis was good with 79.2% showing no radiological deterioration. There were no significant differences in organ involvement or treatment between ethnic groups.

CONCLUSION

Sarcoidosis in Singapore is rare and the incidence differs between ethnic groups. Chinese appear to have a lower incidence and a less symptomatic presentation; Indians have a higher incidence and poorer clinical course.

Epidemiology of sarcoidosis: recent advances and future prospects

Sarcoidosis is by definition a disease of "unknown causes," but recent epidemiologic advances suggest that the long-standing definition of sarcoidosis may soon need to be amended. The recently completed ACCESS (A Case-Control Etiologic Study of Sarcoidosis) study was not able to definitively identify the "cause" of sarcoidosis, but yielded important findings regarding familial and environmental risks that have advanced our understanding of this disease. The HLA-DRB1 associations reported in ACCESS along with the results of two recently completed genome scans of sarcoidosis in German Caucasians and African-Americans, respectively, have further defined the genetics of sarcoidosis. These studies suggest genetic heterogeneity of sarcoidosis risk between Caucasians and African-Americans and multiple susceptibility genes that interact together and with environmental factors in the disease pathogenesis. Genes that influence sarcoidosis clinical phenotypes may also be largely separate from sarcoidosis susceptibility genes. Although genetic studies of sarcoidosis in African-American populations are confounded by Caucasian admixture, this same admixture may be useful in identifying sarcoidosis genes linked with African ancestry. Case-only methods may be useful in identifying recent acute exposures linked to disease, genetic variants of risk, and gene-environment interactions. In summary, the epidemiology of sarcoidosis has a promising future that should eventually provide the answers to the etiologic origins of this complex disease.

[The incidence of sarcoidosis in the Armed Forces: diagnosis, treatment and regular medical check-up]

Sarcoidosis is a chronic multi-system granulomatous disease of unknown etiology, which is characterized by development of epitheliocellular granulomas. Its therapy is not substantiated enough. The incidence of sarcoidosis among the called up servicemen is 1,1 and among the contract servicemen--3,5. According to the structure of contingents with initial diagnosis the called up servicemen constitute 18,6%, officers and praporschiks--57,7% and the contract servicemen without commissioned ranks--23,7%. The comparative analysis has shown that among the contract servicemen suffering from sarcoidosis the number of women was 2,1 times more than among the patients with tuberculosis. The medical personnel in the sarcoidosis group is observed more often (1,5 times more) than in the tuberculosis.

World Trade Center "sarcoid-like" granulomatous pulmonary disease in New York City Fire Department rescue workers

BACKGROUND

Previous reports suggest that sarcoidosis occurs with abnormally high frequency in firefighters. We sought to determine whether exposure to World Trade Center (WTC) "dust" during the collapse and rescue/recovery effort increased the incidence of sarcoidosis or "sarcoid-like" granulomatous pulmonary disease (SLGPD).

METHODS

During the 5 years after the WTC disaster, enrollees in the Fire Department of New York (FDNY) WTC monitoring and treatment programs who had chest radiograph findings suggestive of sarcoidosis underwent evaluation, including the following: chest CT imaging, pulmonary function, provocative challenge, and biopsy. Annual incidence rates were compared to the 15 years before the WTC disaster.

RESULTS

After WTC dust exposure, pathologic evidence consistent with new-onset sarcoidosis was found in 26 patients: all 26 patients had intrathoracic adenopathy, and 6 patients (23%) had extrathoracic disease. Thirteen patients were identified during the first year after WTC dust exposure (incidence rate, 86/100,000), and 13 patients were identified during the next 4 years (average annual incidence rate, 22/100,000; as compared to 15/100,000 during the 15 years before the WTC disaster). Eighteen of 26 patients (69%) had findings consistent with asthma. Eight of 21 patients (38%) agreeing to challenge testing had airway hyperreactivity (AHR), findings not seen in FDNY sarcoidosis patients before the WTC disaster.

CONCLUSION

After the WTC disaster, the incidence of sarcoidosis or SLGPD was increased among FDNY rescue workers. This new information about the early onset of WTC-SLGPD and its association with asthma/AHR has important public health consequences for disease prevention, early detection, and treatment following environmental/occupational exposures.

Pneumomediastinum and right sided pneumothorax following dual chamber-ICD implantation

A 64-year-old-male with ischemic cardiomyopathy and a severely reduced left ventricular ejection fraction underwent a left sided ICD implantation for primary prophylaxis. Given a history of sarcoidosis and bifasicular block on ECG, a dual chamber device was placed in anticipation of progressive conduction disease. The patient returned 2 days after implantation with a right sided tension pneumothorax. A chest tube was immediately placed with hemodynamic and clinical improvement. CT chest revealed extrusion of the atrial lead through the right atrial appendage. The atrial lead was removed without incident.

[Epidemiology of sarcoidosis]

Sarcoidosis is a multisystemic disease in which lung involvement is common. Its incidence and prevalence have been extensively studied, but with contradictory results because of the lack of standard diagnostic criteria, variations in the methods for detecting cases, and the low sensitivity and specificity of diagnostic tests. Prognosis is generally favorable. Many of those affected remain asymptomatic and remission often occurs spontaneously, although between 10% and 30% of the patients have chronic disease and permanent deterioration in lung function. Sarcoidosis is caused by an external agent that triggers a characteristic immune response in genetically susceptible individuals. Environmental, occupational, and genetic factors have all been implicated, but research is still in the early stages. Case-control studies, as well as advances in molecular biology, will help to identify genetic susceptibility factors and to understand the different phenotypes of sarcoidosis.

[Types of skin lesions in pulmonary sarcoidosis and their prognostic value]

When sarcoidosis is suspected, a patient should be meticulously examined for dermal changes, the favorite sites of which are the skin of the face, ears, upper and lower extremities, and trunk. Elements may vary in number from solitary to multiple. When dermal changes are suspected of sarcoidosis, a dermatologist should examine the patient and, if there are some doubts about the nature of dermal elements, biopsy and histological study should be made since the morphological verification of the diagnosis primarily requires the use of extrapulmonary sites of the process, namely superficial peripheral lymph nodes, as well as the skin. The findings suggest that skin sarcoidosis characterized by the long-term chronic or progressive course is encountered at different (X-ray) stages of sarcoidosis of respiratory organs and is of poor prognostic value. The severity of dermal manifestations is no less and, in individual cases, more significant than pulmonary symptoms. Great or ugly skin lesions require prednisolone treatment. In some cases, long-term therapy cannot yield a result. Delagil treatment of dermal manifestations remains to be effective.

Pulmonary sarcoidosis associated with psoriasis vulgaris: coincidental occurrence or causal association? Case report

BACKGROUND

Sarcoidosis is rarely associated with a distinct disease. One disease infrequently associated with sarcoidosis is psoriasis.

CASE PRESENTATION

This case study describes a 38-year-old male, who presented with chest pain, high-grade fever, arthralgias and a skin rash accompanied by bilateral hilar lymphadenopathy on his chest radiograph. Extensive investigations including fiber-optic bronchoscopy with bronchoalveolar lavage and labial and skin biopsies, demonstrated that two distinct clinical entities co-existed in the same patient: pulmonary sarcoidosis and psoriasis vulgaris. Combination therapy for both diseases was applied and the patient was greatly improved.

CONCLUSION

This is the first well-documented case of sarcoidosis and psoriasis in the same patient, reported on the basis of safe and widely-used techniques that were not available until fairly recently. These disorders might share common pathogenic mechanisms that could explain their co-existence in the patient.

Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) and sarcoidosis are common diagnoses in patients attending chest clinics, but little is known about the epidemiology of these diseases. We used data from a general practice database to provide information on the current incidence of IPF and sarcoidosis in the UK.

METHODS

Data were extracted for all patients with a diagnosis of IPF or sarcoidosis between 1991 and 2003. The whole population of the database was used to calculate disease incidence stratified by age, sex, region, and time period. Poisson regression was used to compare the incidence between populations and Cox regression was used to compare survival between populations.

RESULTS

920 cases of IPF (mean age 71 years, 62% male) and 1019 cases of sarcoidosis (mean age 47 years, 47% male) were identified. The overall incidence rate per 100 000 person-years was 4.6 for IPF and 5.0 for sarcoidosis. The incidence of IPF increased progressively between 1991 and 2003 (p<0.00001), and was highest in Northern England and Scotland (p<0.0001). The survival of patients with IPF was stable over time. In contrast, the incidence of sarcoidosis was highest in London, West Midlands and Northern Ireland and remained stable over time.

CONCLUSIONS

The incidence of IPF has more than doubled between 1990 and 2003; this is not due to the ageing of the UK population or an increased ascertainment of milder cases. The incidence of sarcoidosis has not changed during this time period. Our findings suggest that more than 4000 new cases of IPF and 3000 new cases of sarcoidosis are currently diagnosed each year in the UK.