Performance of Serum Angiotensin-Converting Enzyme in Diagnosing Sarcoidosis and Predicting the Active Status of Sarcoidosis: A Meta-Analysis

The usefulness of serum angiotensin-converting enzyme (sACE) for diagnosing sarcoidosis and determining the active status of sarcoidosis has been reported with varying outcomes. On the basis of the majority of published data, we conducted a meta-analysis to calculate the overall predictive accuracy of sACE in sarcoidosis disease and the active status of sarcoidosis. The inclusion of related research listed in Web of Science, PubMed, Scopus, and other literature databases was assessed. SROC curves were generated to characterize the overall test results after data on sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were combined. Publication bias was identified using Deeks’ funnel plot. Thirty-five publications with 8645 subjects met the inclusion criteria. The following are summary estimates of sACE diagnostic performance for sarcoidosis: sensitivity, 60% (95% confidence interval (CI), 52–68%); specificity, 93% (95% CI, 88–96%); PLR, 8.4 (95% CI, 5.3–13.3); NLR, 0.43 (95% CI, 0.36–0.52); and DOR, 19 (95% CI, 12–31). The area under the SROC curve (AUC) was 0.84 (95% CI, 0.80–0.87). Summary estimates for predicting the active status of sarcoidosis were as follows: sensitivity, 0.76 (95% CI, 0.61–0.87); specificity, 0.80 (95% CI, 0.64–0.90); PLR, 3.9 (95% CI, 2.1–7.3); NLR, 0.29 (95% CI, 0.17–0.49); and DOR, 13 (95% CI, 6–31). The AUC was 0.85 (95% CI, 0.82–0.88). There was no evidence of publication bias. Our meta-analysis suggests that measuring the sACE may assist in the diagnosis of sarcoidosis and predicting the active status of sarcoidosis, but the interpretation of the sACE results should be with caution. Future studies should validate our results.

Elevated Serum Amyloid a Levels Are not Specific for Sarcoidosis but Associate with a Fibrotic Pulmonary Phenotype

Elevated Serum Amyloid A (SAA) levels have been found in several inflammatory diseases, including sarcoidosis. SAA is suggested to be involved in sarcoidosis pathogenesis by involvement in granuloma formation and maintenance. We hypothesized that SAA serum levels would be higher in sarcoidosis compared to other non-infectious granulomatous and non-granulomatous diseases. SAA levels were measured in serum from sarcoidosis, Hypersensitivity pneumonitis (HP), and (eosinophilic) granulomatosis with polyangiitis ((E)GPA) patients. Idiopathic pulmonary fibrosis (IPF) patients were included as non-granulomatous disease group. SAA levels of patients with sarcoidosis (31.0 µg/mL), HP (23.4 µg/mL), (E)GPA (36.9 µg/mL), and IPF (22.1 µg/mL) were all higher than SAA levels of healthy controls (10.1 µg/mL). SAA levels did not differ between the diagnostic groups. When SAA serum levels were analyzed in sarcoidosis subgroups, fibrotic sarcoidosis patients showed higher SAA levels than sarcoidosis patients without fibrosis (47.8 µg/mL vs. 29.4 µg/mL, p = 0.005). To conclude, the observation that fibrotic sarcoidosis patients have higher SAA levels, together with our finding that SAA levels were also increased in IPF patients, suggests that SAA may next to granulomatous processes also reflect the process of fibrogenesis. Further studies should clarify the exact role of SAA in fibrosis and the underlying mechanisms involved.

Circulating exosomal microRNA expression patterns distinguish cardiac sarcoidosis from myocardial ischemia

Objective

Cardiac sarcoidosis is difficult to diagnose, often requiring expensive and inconvenient advanced imaging techniques. Circulating exosomes contain genetic material, such as microRNA (miRNA), that are derived from diseased tissues and may serve as potential disease-specific biomarkers. We thus sought to determine whether circulating exosome-derived miRNA expression patterns would distinguish cardiac sarcoidosis (CS) from acute myocardial infarction (AMI).

Methods

Plasma and serum samples conforming to CS, AMI or disease-free controls were procured from the Biologic Specimen and Data Repository Information Coordinating Center repository and National Jewish Health. Next generation sequencing (NGS) was performed on exosome-derived total RNA (n = 10 for each group), and miRNA expression levels were compared after normalization using housekeeping miRNA. Quality assurance measures excluded poor quality RNA samples. Differentially expressed (DE) miRNA patterns, based upon >2-fold change (p < 0.01), were established in CS compared to controls, and in CS compared to AMI. Relative expression of several DE-miRNA were validated by qRT-PCR.

Results

Despite the advanced age of the stored samples (~5–30 years), the quality of the exosome-derived miRNA was intact in ~88% of samples. Comparing plasma exosomal miRNA in CS versus controls, NGS yielded 18 DE transcripts (12 up-regulated, 6 down-regulated), including miRNA previously implicated in mechanisms of myocardial injury (miR-92, miR-21) and immune responses (miR-618, miR-27a). NGS further yielded 52 DE miRNA in serum exosomes from CS versus AMI: 5 up-regulated in CS; 47 up-regulated in AMI, including transcripts previously detected in AMI patients (miR-1-1, miR-133a, miR-208b, miR-423, miR-499). Five miRNAs with increased DE in CS included two isoforms of miR-624 and miR-144, previously reported as markers of cardiomyopathy.

Conclusions

MiRNA patterns of exosomes derived from CS and AMI patients are distinct, suggesting that circulating exosomal miRNA patterns could serve as disease biomarkers. Further studies are required to establish their specificity relative to other cardiac disorders.

The Association of Neutrophil/Lymphocyte and Platelet/Lymphocyte Ratios and Hematological Parameters with Diagnosis, Stages, Extrapulmonary Involvement, Pulmonary Hypertension, Response to Treatment, and Prognosis in Patients with Sarcoidosis

Sarcoidosis is a rare disease characterized by granulomatous inflammation in affected organs, primarily in lungs. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) are easy and practical methods providing valuable information in diagnosis, severity, and prognosis of various diseases. Here, we aimed to investigate the association between NLR, PLR, and hematological parameters in sarcoidosis. The study was performed with 75 sarcoidosis patients and 92 controls. Patients' NLR, PLR, and hematological parameters were compared with those of controls. Additionally, while differences between NLR and PLR were investigated in sarcoidosis patients, differences of extrapulmonary involvement, pulmonary hypertension (PH), and spontaneous remission between those with and without responses to treatment concerning stages were also assessed. NLR and PLR were significantly higher in sarcoidosis patients than controls. For NLR, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were found as 68, 61, 58, and 70% respectively, while sensitivity, specificity, PPV, and NPV for PLR were found as 72, 67, 63, and 74%, respectively. In sarcoidosis patients, NLR and PLR were significantly higher at stage-2 and -3 than at stage -1 and -4. There was a significant weak positive correlation between C-reactive protein (CRP) and NLR and PLR. Mean platelet volume (MPV), hemoglobin (Hgb), and mean corpuscular volume (MCV) were lower among patients than controls. A positive moderate correlation was detected between NLR and CD4/CD8 in blood, while there was a strong positive correlation between CD4/CD8 in bronchoalveolar lavage (BAL) and positive moderate correlation between PLR and CD4/CD8 in BAL. High NLR and PLR values were not significantly associated with pulmonary PH, spontaneous remission, response to treatment, and prognosis. The increase in PLR and NLR may be a guide for diagnoses of both sarcoidosis and lung parenchymal involvement. To use these entities as markers, our findings should be supported with prospective studies with larger samples.

Local and Systemic Concentrations of Pattern Recognition Receptors of the Lectin Pathway of Complement in a Cohort of Patients With Interstitial Lung Diseases

Background

The role of the lectin pathway of complement in the pathogenesis of interstitial lung diseases (ILDs) is largely unknown. Pattern recognition receptors (PRR) of the lectin pathway are involved in the clearance of apoptotic cells either via activation of the complement system or as direct opsonins. As recent findings suggest a role of apoptosis in the development of pulmonary fibrosis, the influence of plasma lectins has lately been considered in various ILDs, but data on local concentrations in the lungs are lacking. This study investigated the role of mannose-binding lectin (MBL), ficolin-2 and ficolin-3 in ILD patients with a focus on idiopathic pulmonary fibrosis (IPF) and sarcoidosis.

Methods

A case control study was conducted involving 80 patients with different forms of ILD as well as 40 control patients undergoing routine flexible bronchoscopy with bronchoalveolar lavage (BAL). Plasma and BAL fluid (BALF) levels of MBL, ficolin-2 and ficolin-3 as well as complement split products C4d and C5a (only in BALF) were measured by enzyme-linked immunosorbent assays. Eight single-nucleotide polymorphisms (SNPs) of MBL and ficolin-2 were determined by genotyping and tested for their association with ILDs.

Results

We included 35, 35, 10, and 40 patients with sarcoidosis, idiopathic pulmonary fibrosis (IPF), other ILD, and a control group, respectively. BALF but not plasma levels of the three PRR were significantly elevated in sarcoidosis patients compared to a control group without ILD (MBL: median 66.8 vs. 24.6 ng/ml, p = 0.02, ficolin-2: 140 vs. 58.8 ng/ml, p = 0.01, ficolin-3: 2523 vs. 1180 ng/ml, p = 0.02), whereas the frequency of the investigated SNPs was similar. In line, complement split products were markedly elevated in BALF of sarcoidosis patients (C4d, median 97.4 vs. 0 ng/ml, p = 0.10; C5a, 23.9 vs. 9.1 ng/ml, p = 0.01). There was a weak positive correlation of BALF ficolin-3 with serum neopterin, a marker of sarcoidosis activity. In IPF patients, we observed numerically higher MBL plasma and BALF levels (plasma, median 1511 vs. 879 ng/ml, p = 0.44; BALF, 37.5 vs. 24.6 ng/ml, p = 0.7) as well as lower ficolin-2 plasma levels (plasma 1111 vs. 1647 ng/ml, p = 0.11). Ficolin-2 plasma levels were inversely correlated with the forced vital capacity (r = 0.55, p = 0.1).

Conclusion

This is the first study to simultaneously assess systemic and local lectin pathway protein levels in ILD patients. Our data suggest an involvement of PRR of the lectin pathway in the pathogenesis of sarcoidosis given the significantly higher BALF levels compared to a control group. Additional analyses in a larger patient cohort are required to confirm or refute a potential effect of local and/or systemic ficolin-2 levels in IPF patients.

Oxaliplatin-associated sarcoid-like reaction masquerading as recurrent colon cancer

A 54-year-old man with stage IV B metastatic colorectal cancer with liver and peritoneal metastasis was treated with cytoreductive surgery (extended left colectomy, right partial hepatectomy, resection of right diaphragm nodule) and perioperative oxaliplatin-based chemotherapy. The patient was cancer-free for 6 months, at which point a surveillance positron emission tomography-CT scan showed metabolically active hepatosplenic lesions and mediastinal and bilateral hilar lymph nodes. An endobronchial ultrasound bronchoscopy-guided fine needle aspiration of the mediastinal and hilar lymph nodes revealed non-necrotising granulomas. The workup was negative for bacterial, fungal or mycobacterial infection, cancer or autoimmune disease. Carcinoembryonic antigen and COLVERA (a circulating tumour DNA liquid biopsy test for the detection of recurrent colon cancer) tests were negative. Subsequently the rare diagnosis of a sarcoidosis-like reaction from oxaliplatin-based chemotherapy was made. Repeat imaging after 3 months showed resolution of the hepatosplenic lesions and lymphadenopathy, alike.

Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline

Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure.

Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability.

Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality.

Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.

SpotLight Proteomics-A IgG-Enrichment Phenotype Profiling Approach with Clinical Implications

Sarcoidosis is a systemic interstitial lung disease of unknown aetiology. Less invasive diagnostics are needed to decipher disease pathology and to distinguish sub-phenotypes. Here we test if SpotLight proteomics, which combines de novo MS/MS sequencing of enriched IgG and co-extracted proteins with subsequent label-free quantification of new and known peptides, can differentiate controls and sarcoidosis phenotypes (Löfgrens and non-Löfgrens syndrome, LS and nonLS). Intra-individually matched IgG enriched from serum and bronchial lavage fluid (BALF) from controls (n = 12), LS (n = 11) and nonLS (n = 12) were investigated. High-resolution mass-spectrometry SpotLight proteomics and uni- and multivariate-statistical analyses were used for data processing. Major differences were particularly observed in control-BALF versus sarcoidosis-BALF. However, interestingly, information obtained from BALF profiles was still present (but less prominent) in matched serum profiles. By using information from orthogonal partial least squares discriminant analysis (OPLS-DA) differentiating 1) sarcoidosis-BALF and control-BALF and 2) LS-BALF vs. nonLS-BALF, control-serum and sarcoidosis-serum (p = 0.0007) as well as LS-serum and nonLS-serum (p = 0.006) could be distinguished. Noteworthy, many factors prominent in identifying controls and patients were those associated with Fc-regulation, but also features from the IgG-Fab region and novel peptide variants. Differences between phenotypes were mostly IgG-specificity related. The results support the analytical utility of SpotLight proteomics which prospectively have potential to differentiate closely related phenotypes from a simple blood test.

Systemic Sarcoidosis Presenting with Renal Involvement Caused by Various Sarcoidosis-associated Pathophysiological Conditions

A 61-year-old man was diagnosed with sarcoidosis involving the lungs, eyes, parotid gland and extrathoracic lymph nodes complicated by chronic kidney injury and hypercalcemia. Kidney biopsy showed non-specific interstitial nephritis and nephrosclerosis. However, immunohistochemical staining of cell surface markers revealed a multinucleated giant macrophage surrounded by T-cells, suggesting granulomatous interstitial nephritis. Corticosteroid improved the kidney function, and reduced the serum levels of calcium and angiotensin-converting enzyme. Sarcoid nephropathy may be caused by the combination of several sarcoidosis-associated pathophysiological conditions and a comprehensive kidney examination should be performed to assess the type of injury when determining a treatment strategy.

TARC expression in the circulation and cutaneous granulomas correlates with disease severity and indicates Th2-mediated progression in patients with sarcoidosis

BACKGROUND

Sarcoidosis is a systemic disorder characterized by the accumulation of lymphocytes and monocyte/macrophage lineage cells that results in the formation of non-caseating granulomas. Thymus- and activation-regulated chemokine (TARC)/CCL17 is an important chemokine in the amplification of Th2 responses, which are achieved by recruiting CCR4-expressing CD4⁺ T lymphocytes. TARC concentrations are known to increase in the serum of sarcoidosis patients; however, its role in the assessment of severity and prognosis of sarcoidosis remains unknown. The objective of this study is to elucidate the role of TARC in sarcoidosis by investigating its expression in peripheral blood and at inflammatory sites. We also examined its relationship with clinical features.

METHODS

Serum levels of TARC, soluble interleukin 2 receptor, angiotensin-converting enzyme, and lysozyme were measured in 82 sarcoidosis patients. The Th1 and Th2 balance in circulating CD4⁺ T cells was evaluated by flow cytometry. The immunohistochemical staining of TARC and CCR4 was performed in order to identify the source of TARC in affected skin tissues.

RESULTS

TARC serum levels were elevated in 78% of patients and correlated with disease severity. The percentage of CCR4⁺ cells and the CCR4⁺/CXCR3⁺ cell ratios were significantly higher in sarcoidosis patients than in normal subjects (P = 0.002 and P = 0.015, respectively). Moreover, TARC was expressed by monocyte/macrophage lineage cells within granulomas. The abundancy as well as distribution of TARC staining correlated with its serum levels.

CONCLUSIONS

The present results suggest that elevations in TARC drive an imbalanced Th2- weighted immune reaction and might facilitate prolonged inflammatory reactions in sarcoidosis.

Role of serum immunoglobulins for predicting sarcoidosis outcome: A cohort study

Background

Sarcoidosis is a systemic granulomatous disease which carries variable outcomes. Serum protein electrophoresis is an easily accessible and routinely performed examination at diagnosis, in order to search for hypergammaglobulinemia, which is frequently found, and to rule out other granulomatous diseases such as common variable immunodeficiency. We aimed to assess the impact of baseline immunoglobulin level on the outcome of sarcoidosis.

Methods

We conducted a retrospective cohort-study, at Rennes University Hospital, in which all newly diagnosed patients for whom a serum protein electrophoresis had been performed at baseline were enrolled, from 2006 to 2014. The main outcome was the need for corticosteroid treatment within 2 years from diagnosis, the secondary outcome was the occurrence of relapse among treated patients.

Results

Eighty patients were included in the study, and 41.25% of them exhibited an elevated globulins rate. In univariate analysis, an elevated ACE level >70 U/l, Afro-Caribbean origin, and extra-pulmonary involvement, were associated with the need for corticosteroid treatment. In multivariate analysis, only ACE elevation (OR = 1.03, IC95% 1.01–1.05, p = 0.009) and extra-pulmonary involvement (OR = 5.8, IC95% 1.4–24, p = 0.015) were significant. Immunoglobulin level was not associated with the main outcome. Regarding the secondary outcome, none of the studied features were predictive of relapse among the 34 treated patients followed for two years.

Conclusions

There was no relation between the immunoglobulin level at diagnosis and the evolution of sarcoidosis. An elevated ACE level and the presence of initial extra-pulmonary involvement were both associated with a more severe course of the disease necessitating a corticosteroid treatment.

Clinical Significance of Tumor Necrosis Factor in Patients with Bronchogenic Carcinoma and Benign Lung Diseases: A Comparative Study

Tumor Necrosis Factor (TNF) was determined in the serum of 72 lung carcinoma patients. Twenty-four healthy subjects younger than 50 years and 10 healthy subjects older than 70 years were considered as control group. TNF was also measured in 20 patients with stage I sarcoidosis and in 15 patients with pulmonary fibrosis. The marker was detected in 32% of cases in the neoplastic group, in 37.5% of disease confined to the chest and in 25% of advanced disease cases. A large proportion of TNF-positive samples was found in sarcoidosis (30%), and even larger in pulmonary fibrosis (66.6%).

TNF was also present in healthy subjects older than 70 (40%). We conclude that TNF is not specific of malignancy, being demonstrable in other benign pulmonary diseases and even in the course of physiological aging.

Soluble Interleukin-2 Receptor: A Potential Marker for Monitoring Disease Activity in IgG4-Related Disease

BACKGROUND

IgG4-related disease (IgG4-RD) is a fibroinflammatory condition. T-cells play a crucial role in the pathogenesis, and therefore, serum soluble interleukin-2 receptor (sIL-2R) may be a potential biomarker.

METHOD

We studied the levels of sIL-2R in 26 histologically proven IgG4-RD patients with available serum sIL-2R and compared them to those in newly diagnosed and untreated sarcoidosis patients (n = 78) and controls (n = 101) and the serum sIL-2R levels in patients after treatment of IgG4-RD (n = 15). The disease activity was measured using the IgG4-Related Disease Responder Index (IgG4-RD RI).

RESULTS

Median serum sIL-2R in IgG4-RD patients was 4667 pg/ml compared to 1515 pg/ml in controls (P < 0.001) and 6050 pg/ml in sarcoidosis patients (P = 0.004 compared to IgG4-RD). All IgG4-RD patients had elevated serum sIL-2R levels compared to the reference value of <2500 pg/ml in controls and 85% elevated serum IgG4; however, these did not correlate with each other. Both serum sIL-2R and IgG4 levels declined significantly after treatment (P = 0.001 and P = 0.01, resp.). Before treatment, serum sIL-2R level and IgG4-RD RI did not correlate with each other. However, the decrease in serum sIL-2R upon treatment did correlate significantly (P = 0.04) with the decrease in disease activity assessed by IgG-RD RI.

CONCLUSION

Serum sIL-2R is elevated in IgG4-RD reflecting the inflammatory process with enhanced T-cell activation. Furthermore, serum sIL-2R might serve as a potential marker of response to treatment in IgG4-RD.

Identification of Jak-STAT signaling involvement in sarcoidosis severity via a novel microRNA-regulated peripheral blood mononuclear cell gene signature

Sarcoidosis is a granulomatous lung disorder of unknown cause. The majority of individuals with sarcoidosis spontaneously achieve full remission (uncomplicated sarcoidosis), however, ~20% of sarcoidosis-affected individuals experience progressive lung disease or cardiac and nervous system involvement (complicated sarcoidosis). We investigated peripheral blood mononuclear cell (PBMC) microRNA and protein-coding gene expression data from healthy controls and patients with uncomplicated or complicated sarcoidosis. We identified 46 microRNAs and 1,559 genes that were differentially expressed across a continuum of sarcoidosis severity (healthy control → uncomplicated sarcoidosis → complicated sarcoidosis). A total of 19 microRNA-mRNA regulatory pairs were identified within these deregulated microRNAs and mRNAs, which consisted of 17 unique protein-coding genes yielding a 17-gene signature. Pathway analysis of the 17-gene signature revealed Jak-STAT signaling pathway as the most significantly represented pathway. A severity score was assigned to each patient based on the expression of the 17-gene signature and a significant increasing trend in the severity score was observed from healthy control, to uncomplicated sarcoidosis, and finally to complicated sarcoidosis. In addition, this microRNA-regulated gene signature differentiates sarcoidosis patients from healthy controls in independent validation cohorts. Our study suggests that PBMC gene expression is useful in diagnosis of sarcoidosis.

Sarcoidosis-associated small fiber neuropathy in a large cohort: Clinical aspects and response to IVIG and anti-TNF alpha treatment

OBJECTIVE

Small fiber neuropathy commonly affects patients with sarcoidosis and is often refractory to standard immunosuppressive therapies used for systemic disease. The clinical features of sarcoidosis-associated small fiber neuropathy (SSFN) and its response to medical therapy have not been described in a large population.

METHODS

We performed a retrospective review of patients with SSFN seen at the Cleveland Clinic over a 4-year period.

RESULTS

SSFN was identified in 143 individuals although other causes of neuropathy were found in 28 cases. Of the remaining 115 patients, 100 (87%) were Caucasian and 72 (63%) were female. Median age at reported neuropathy onset was 46 years (range 19-77 years), while median age of systemic diagnosis was 41 years. Pain and paresthesias were the most common symptoms, of which 54% were nonlength-dependent. Dysautonomia was seen in 61 patients with cardiac symptoms (orthostasis, palpitations) as the most common presentation followed by gastrointestinal and sweating dysfunction. Symptomatic improvement with treatment was seen in 47 of 62 patients that received IVIG, 8 of 12 patients that received anti-TNF and 10 of 14 patients who received combination therapy. Of 27 patients who were untreated, 4 improved.

CONCLUSIONS

The most common presentation of SSFN in our series was a painful non-length dependent polyneuropathy with the highest overall incidence in Caucasian females. In most patients, neuropathy symptoms developed within 3 years of systemic sarcoidosis diagnosis. IVIG appeared beneficial in treating SSFN symptoms while nearly 2/3 of subjects also responded favorably to anti-TNF with or without IVIG. Further prospective studies are needed.

The association between osteopontin gene polymorphisms, osteopontin expression and sarcoidosis

Background

Sarcoidosis is a systemic inflammatory disease of unknown etiology. Osteopontin (SPP1, OPN) is an extra cellular matrix glycoprotein and cytokine with a known role in granuloma formation and in autoimmune and inflammatory diseases.

Objective

To determine whether plasma OPN levels are elevated in patients with sarcoidosis and compare the frequency of four single nucleotide polymorphism (SNPs) variants in the OPN gene in sarcoidosis patients compared to healthy controls.

Methods

Demographic and clinical information, radiological studies and pulmonary function tests were evaluated in 113 patients with sarcoidosis and in 79 healthy controls. Blood samples were analyzed for SNPs of the OPN gene and for plasma OPN and CRP levels. Association between clinical features of disease and OPN levels as well as SNP frequencies was determined.

Results

Plasma OPN levels were higher in sarcoidosis patients than in healthy subjects, (median: 217 vs 122ng/ml, p<0.001). Area under the curve for receiver operator curves (ROC) was 0.798 (0.686–0.909 95% CI.) No differences were observed between sarcoidosis patients and controls in the frequency of any of the SNPs evaluated. Presence of lung parenchymal involvement was associated with SNP distribution at rs1126772 (p = 0.02). We found no correlation between SNPs distribution and plasma OPN levels.

Conclusions

Osteopontin protein levels are elevated in sarcoidosis. We found no evidence for an association between SNPs on the osteopontin gene and plasma OPN levels or the presence of sarcoidosis, however, an association between genotype and several phenotypic clinical parameters of disease was observed.

Reticuloendothelial system involvement in untreated sarcoidosis patients as assessed by 18F-FDG PET scanning

Not available.

Transcriptional blood signatures of sarcoidosis, sarcoid-like reactions and tubercolosis and their diagnostic implications

N/A.

Serum fibroblastic growth factor 23 in acute Sarcoidosis and normal kidney function

BACKGROUND

Serum fibroblastic growth factor (FGF) 23 has recently been established as a major physiological regulator of phosphate homeostasis and may have a causal role in adverse cardiovascular and bone outcomes. However its role in states of disordered phosphate homeostasis and normal kidney function is as yet under characterised.

AIMS

To investigate whether this biomarker of vascular calcification and adverse bone outcomes is detectable in patients with sarcoidosis.

DESIGN

We conducted a cross sectional study on a convenience sample of patients presenting with acute sarcoidosis to a respiratory tertiary referral unit.

METHODS

We set out to systematically examine the characteristics and determinants of serum FGF-23 in patients presenting with acute sarcoidosis.

RESULTS

We studied 39 patients, 26 were male. Mean (SD) age was 33 (9.6) years. 15.4% of patients had a serum level of FGF-23 ≥ 9.9 pg/mL. The remaining 84.6% of patients had a serum FGF-23 < 9.9 pg/mL. Those with a detectable serum FGF-23 had a significantly higher serum calcium (P = 0.007), and lower serum iPTH (P<0.001). Serum phosphate and 25-hydroxyvitamin D were not statistically significantly different between groups (P=0.25 and P=0.83). The proportion of patients with stage II disease on CXR was higher in those with a detectable FGF-23 (P<0.001).

CONCLUSIONS

Serum FGF-23 was below the level of detection in the majority of this cohort of patients presenting with acute sarcoidosis. A detectable serum FGF-23 was associated with a higher serum calcium and lower serum iPTH.

What is the neutrophil/lymphocyte ratio in sarcoidosis?

AIM

Information regarding the Neutrophil/Lymphocyte ratio (NLR) in sarcoidosis and the data from studies recommending its use as an indicator of inflammation and in the differential diagnosis and prognosis, are limited. With this study, it was aimed to obtain data regarding the NLR level in the patients at the time of presentation to the hospital and to determine the characteristics of patients in whom the NLR value was > 2.

RESULTS

During the study period, of the 3434 patients with the sub-diagnosis of D86, 1300 cases whose complete blood count values had been recorded at the time of presentation were included in the study. Of the cases, 40 % were pulmonary sarcoidosis, 7 % were pulmonary sarcoidosis with sarcoidosis of the lymph nodes, 8 % were lymph node sarcoidosis, 1 % were sarcoidosis, of other combined areas, and 40 % of the cases were sarcoidosis that were unspecified. The F/M of the cases were 947/353, and the average age of the cases was 44. When the sarcoidosis groups were grouped into NLR < 2 (Group 1) and NLR ≥ 2 (Gorup 2), 27 % were Group 1, 73 % were Group 2, and a significant correlation was found between the two groups. When the inflammatory indicators were compared with NLR, the PLT/MPV was found to be statistically insignificant, and the ACE, ESR and CRP were found to be statistically significant.

CONCLUSION

The Neutrophil/Lymphocyte ratio in the complete blood count, which is an easy and cheap test, can be used as an indicator of inflammation in Sarcoidosis. In clinical practice, wide-based studies comprising the activity and the staging in the prognosis of sarcoidosis are required (Tab. 2, Fig. 2, Ref. 26).

Epidemiologic patterns of disease expression in sarcoidosis: age, gender and ethnicity-related differences

OBJECTIVES

To evaluate the influence of age, gender and ethnicity in the clinical presentation of sarcoidosis in a cohort of Spanish patients.

METHODS

We analysed 175 consecutive patients diagnosed with sarcoidosis between 1990 and 2014 in the Hospital Clinic of Barcelona, Spain. Sarcoidosis was diagnosed according to the 1999 WASOG criteria. Organ involvement was defined using the 2014 WASOG organ assessment instrument.

RESULTS

There were 110 women and 65 men, with a mean age at diagnosis of 47.31 ± 15.46 years (range, 16-92); 23% of patients were born outside Spain. Women had a higher mean age (p=0.027), a higher frequency of cutaneous (OR=2.28) and musculoskeletal (OR=2.73) symptoms at diagnosis, and a lower frequency of cumulated WASOG involvements including renal involvement (OR=0.17), hypercalcaemia (OR=0.20) and raised ACE levels (OR=0.30). Patients aged ≥65 years had a lower frequency of cutaneous (OR=0.23) and musculoskeletal (OR=0.13) symptomatology at diagnosis and a higher frequency of cumulated WASOG involvements including renal involvement (OR=18.70) and calcium/vitamin D abnormalities (OR=5.31). According to ethnicity, non-Spanish-born patients had a lower mean age (40 vs. 49 years, p=0.001), a higher predominance of females (68% vs. 54%, p=0.036) and a higher frequency of radiographic stages I/II at diagnosis (97% vs. 78%, p=0.041) in comparison with Spanish-born patients.

CONCLUSIONS

Using the new 2014 WASOG organ assessment instrument, we found that epidemiological features (age at diagnosis, gender and ethnicity) play a significant role in the presentation of sarcoidosis. Variations in these epidemiological features may aid early diagnostic suspicion, the search for histopathological confirmation and the prompt introduction of the appropriate therapy.

Differential Expression of Cardiac Troponin T and I in a Patient with Isolated Skeletal Muscular Sarcoidosis

A 49-year-old female was referred to our hospital due to high serum creatine kinase (CK) (2,605 IU/L) and serum cardiac troponin T (cTnT) (0.342 ng/mL) levels. She had no other complaints and further examinations suggested no signs of cardiac disease. Additionally, the serum cardiac troponin I (cTnI) levels were normal. She reported having gradually felt difficulty in walking upstairs. A biopsy indicated skeletal muscle sarcoidosis with positive staining for cTnT. Steroid therapy immediately resolved her muscular symptoms with a normalization of the serum CK levels. Since the serum levels of cTnI were normal, the concomitant measurement of cTnT/cTnI might be useful to diagnose skeletal muscular disease biochemically in such cases.

Sarcoid Myositis with Anti-Ku Antibody Consistent with both Sarcoidosis and Polymyositis

We herein describe a case of sarcoid myositis with anti-Ku antibody positivity. Pathological findings of the muscle were compatible with sarcoidosis, but could not be completely distinguished from myositis diseases that arise from other causes. According to a physical examination, pathological findings, the detection of anti-Ku antibody and the human leukocyte antigen (HLA)-DPB1 allele, we strongly suspected that the patient developed both sarcoidosis and polymyositis. Sarcoidosis is often complicated by autoimmune diseases. This case suggests the possibility that sarcoidosis and other autoimmune diseases may have common causal genetic factors.

Screening for Differentially Expressed Proteins Relevant to the Differential Diagnosis of Sarcoidosis and Tuberculosis

Background

In this study, we sought to identify differentially expressed proteins in the serum of patients with sarcoidosis or tuberculosis and to evaluate these proteins as markers for the differential diagnosis of sarcoidosis and sputum-negative tuberculosis.

Methods

Using protein microarrays, we identified 3 proteins exhibiting differential expression between patients with sarcoidosis and tuberculosis. Elevated expression of these proteins was verified using the enzyme-linked immunosorbent assay (ELISA) and was further confirmed by immunohistochemistry. Receiver operating characteristic (ROC) curve, logistic regression analysis, parallel, and serial tests were used to evaluate the diagnostic efficacy of the proteins.

Results

Intercellular Adhesion Molecule 1(ICAM-1) and leptin were screened for differentially expressed proteins relevant to sarcoidosis and tuberculosis. Using ROC curves, we found that ICAM-1 (cutoff value: 57740 pg/mL) had an area under the curve (AUC), sensitivity, and specificity of 0.718, 62.3%, and 79.5% respectively, while leptin (cutoff value: 1193.186 pg/mL) had an AUC, sensitivity, and specificity of 0.763, 88.3%, and 65.8%, respectively. Logistic regression analysis revealed that the AUC, sensitivity, and specificity of combined leptin and ICAM-1 were 0.787, 89.6%, and 65.8%, respectively, while those of combined leptin, ICAM-1, and body mass index (BMI) were 0.837, 90.9%, and 64.4%, respectively, which had the greatest diagnostic value. Parallel and serial tests indicated that the BMI-leptin parallel with the ICAM-1 serial was the best diagnostic method, achieving a sensitivity and specificity of 86.5% and 73.1%, respectively. Thus, our results identified elevated expression of ICAM-1 and leptin in serum and granulomas of sarcoidosis patients.

Conclusions

ICAM-1 and leptin were found to be potential markers for the diagnosis of sarcoidosis and differential diagnosis of sarcoidosis and sputum-negative tuberculosis.

Serum levels of soluble CD163 as a specific marker of macrophage/monocyte activity in sarcoidosis patients

BACKGROUND

Monocyte-macrophage lineage cells are the main immunocompetent cells in sarcoidosis. The main cellular elements of sarcoidal granulomas are epithelioid cells and multinucleated giant cells (MGC). MGC are also produced in vitro by human blood monocytes following various stimuli. The in vitro formation of MGC is a useful tool for understanding granulomas. CD163, a scavenger receptor for the hemoglobin-haptoglobin complex, is expressed on monocytes/macrophages and shed into blood in a soluble form (sCD163) after stimulation from Toll-like receptors and oxidative stress. sCD163 serum levels have been reported to increase in inflammatory or infectious conditions.

OBJECTIVE

The aim of the present study was to examine the relationship between serum levels of sCD163 and the conventional disease markers of sarcoidosis, and also to evaluate sCD163 levels in culture supernatants following the formation of MGC by human peripheral monocytes in vitro.

PATIENTS AND METHODS

Twenty sarcoidosis patients and twenty healthy subjects were enrolled in the study. sCD163 serum levels were evaluated using sCD163 ELISA. MGC were formed from peripheral blood monocytes by treatment with supernatant of concanavalin A-stimulated peripheral blood mononuclear cells, and sCD163 levels in the culture supernatants were measured by ELISA.

RESULTS

sCD163 serum levels were significantly higher in sarcoidosis patients than in healthy controls and correlated with ACE and soluble interleukin-2 receptor serum levels. sCD163 levels in culture supernatants increased with the production of MGC.

CONCLUSIONS

sCD163 may be used as a favorable specific marker of macrophage/monocyte activity in order to more clearly understand the disease activity of sarcoidosis.

Bone density is normal and does not change over 2 years in sarcoidosis

SUMMARY

Small studies have previously suggested that sarcoidosis may be associated with low bone mineral density. In this observational study of 64 patients with sarcoidosis, bone mineral density was within the normal range at baseline, and there was no evidence of accelerated bone loss over 1-2 years.

INTRODUCTION

Several small studies have suggested that sarcoidosis may be associated with low bone mineral density (BMD).

METHODS

We undertook a cross-sectional study of BMD in 64 patients with sarcoidosis. Of these, 27 with 25-hydroxyvitamin D<50 nmol/L entered a 1-year intervention study of vitamin D supplements, and 37 entered a 2-year longitudinal study of BMD, with the primary endpoint of the change in lumbar spine BMD.

RESULTS

The mean age of participants was 58 years, 68% were female, and 8% were currently using oral glucocorticoids. At baseline, BMD for the entire cohort was greater than the expected values for the population at the lumbar spine (mean Z-score 0.7, P<0.001) and total body (0.5, P<0.001) and similar to expected values at the femoral neck (0.2, P=0.14) and total hip (0.2, P=0.14). BMD did not change at any of these four sites (P>0.19) over 2 years in the longitudinal study. In the intervention study, vitamin D supplements had no effect on BMD, and therefore we pooled the data from all participants. BMD did not change over 1 year at the spine, total hip, or femoral neck (P>0.3), but decreased by 0.7% (95% confidence interval 0.3-1.1) at the total body (P=0.019).

CONCLUSIONS

BMD was normal at baseline, and there was no consistent evidence of accelerated bone loss over 1-2 years, regardless of baseline vitamin D status. Patients with sarcoidosis not using oral glucocorticoids do not need routine monitoring of BMD.

Anti-cyclic citrullinated peptide antibodies in patients with sarcoidosis

INTRODUCTION

Anti-cyclic citrullinated peptide (anti-CCP) antibodies have a high predictive value in rheumatoid arthritis (RA) patients and are associated with disease severity. Sarcoidosis is a chronic inflammatory disease characterized by non-calcified granuloma formations.

AIM

To determining the prevalence of anti-CCP antibodies in patients with sarcoidosis, and identifying a possible correlation with clinical and laboratory findings.

MATERIALS AND METHODS

Forty-two patients presenting to the rheumatology polyclinic and diagnosed with sarcoidosis as a result of the examinations made, 45 RA patients and 45 healthy subjects were included in the study. Demographic, clinical, serological and radiological data of all patients were recorded. Anti-CCP antibodies were evaluated by using a second-generation ELISA method. Rheumatoid factor (RF) IgM was determined with the nephelometry method.

RESULTS

Forty-two patients (10 males) were included in the study. Mean patient age was 45.2 years (20-70 years) and mean duration of disease was 3.5 years. Two sarcoidosis patients (4.7%) and 38(84.4%) RA patients were found to be positive for anti-CCP antibodies while the antibody wasn't detected in any healthy subject. The two sarcoidosis patients found positive for anti-CCP were also diagnosed with rheumatoid arthritis. RF positivity was detected in 7 sarcoidosis patients (16.6%) and in only one subject in the control group.

CONCLUSION

The prevalence of anti-CCP antibodies in patients with sarcoidosis was found to be significantly lower than RA patients and similar with the healthy control group. This result shows that anti-CCP antibodies don't have an important role in the pathogenesis of sarcoidosis, but could be important in revealing the overlap syndromes of sarcoidosis-RA.

Genotyping increases the yield of angiotensin-converting enzyme in sarcoidosis--a systematic review

INTRODUCTION

The diagnosis of sarcoidosis is challenging and involves radiological, clinical and paraclinical evaluation, the latter including the measurement of serum angiotensin-converting enzyme activity (s-ACE), which is elevated in about 60% of sarcoidosis patients. The normal inter-individual biological variation of s-ACE is large. Approximately 50% of the variation is due to a genomic insertion/deletion (I/D) polymorphism in the ACE gene.

METHODS

We searched the MEDLINE library for articles presenting genotype-based reference intervals for s-ACE in healthy people. We summarised the results as weighted mean DD/II ratios of s-ACE. We also summarised the presented frequencies of the genotypes.

RESULTS

We identified nine studies presenting genotype-based reference intervals. All studies found a significant difference between mean s-ACE in the three genotype groups DD, ID and II. The mean DD/II ratio was 1.85 (range: 1.79-1.92) for all studies, 2.01 (1.92-2.10) for Caucasians and 1.64 (1.55-1.73) for Asians. The median frequencies of genotypes among Caucasians were 23% II, 45% ID and 30% DD, and 45% II, 49% ID and 14% DD among Asians.

CONCLUSION

Genotyping for the I/D polymorphism increases the benefit of s-ACE since all studies found significantly different levels between genotype groups in healthy subjects. Genotyping is of special value if s-ACE is between the upper 97.5 percentile for genotype II and DD since values in this interval are at risk of being misclassified. Due to assay variation, genotype-specific reference levels should be verified locally.

Calcitriol-mediated hypercalcemia: causes and course in 101 patients

CONTEXT

Hypercalcemia mediated by 1,25-dihydroxy vitamin D (calcitriol) is uncommon, with evidence on etiology limited to small case series or case reports.

OBJECTIVE

The objective of the study was to systematically identify a large series of cases of calcitriol-mediated hypercalcemia and document the presentation, demographics, and clinical course across etiologies.

DESIGN, SETTING, AND PATIENTS

The study was a hospital-based, retrospective case series, identifying subjects from 1999 through 2009 across the public hospital system in Queensland, Australia. All patients aged over 18 years were identified that had persistent hypercalcemia associated with elevated or inappropriately normal calcitriol concentration or elevated serum angiotensin-converting enzyme.

RESULTS

A total of 101 cases were identified. Sarcoidosis was the most common etiology (49%), followed by hematological malignancy (17%) and infections (8%). Etiologies not previously described include squamous cell carcinoma of the tongue, ovarian cystadenocarcinoma, and chronic lymphocytic leukemia. Median serum angiotensin-converting enzyme was higher in sarcoid patients compared with all other causes [218 U/L (176-277) vs 155 U/L (110-208), P < .001], but a level above the normal range did not discriminate well between cases of sarcoidosis and other causes (specificity at cutoff of 130 U/L was only 31%). However, a value greater than 250 U/L was highly specific (89%) for sarcoidosis but lacked sensitivity (31%). A calcitriol level greater than 300 pmol/L was not seen in sarcoidosis but was seen with other etiologies. Cases with neoplastic etiologies were older (61.4 ± 11.4 y) than all other subjects (51.7 ± 15.0 y, P = .006).

CONCLUSIONS

Hypercalcemia mediated by calcitriol remains a rare presentation. In almost half the cases, sarcoidosis was the underlying cause, whereas a third of patients had cancer or systemic infections.

Sarcoid arthropathy and the association with the human leukocyte antigen. The Icelandic Sarcoidosis Study

OBJECTIVES

The aim of the present study was to evaluate whether certain HLA antigens were risk factors for developing sarcoid arthritis and whether HLA antigens appear to account for the phenotype and the resolution of the arthritis condition in an unselected nationwide cohort.

METHODS

The Icelandic Sarcoidosis Study (ISS) contains all tissue-verified cases of sarcoidosis in Iceland since 1981. Of a total of 234 cases, 39 patients were identified with arthritis and of those 36 delivered a biosample for the study. The patient cohort has previously been described in detail. DNA was isolated from EDTA blood and HLA antigen typing was performed. A total of 544 Icelandic stem cell donors acted as controls.

RESULTS

HLA-B8 and HLA-B14 antigens were more common among those who suffered from sarcoid arthritis (24% vs. 11%, p<0.01; 6.5% vs. 2.4%, p<0.05). DRB1*03 was also found more frequently in patients with sarcoid arthritis compared to controls (28% vs. 11%, p<0.001), while DRB1*04 was less frequently reported (5.6% vs. 17%, p<0.01). No differences were found in the HLA-A distribution between the groups. A higher proportion of patients with chronic arthritis had HLA-A11 than those with resolving joint problems (60% vs. 3.8%).

CONCLUSIONS

Our nationwide study of patients with sarcoid arthritis further supports the conclusion that genetics may strongly influence the development and the clinical course of the disease. Furthermore, some HLA antigens may even be protective for the disease. Thus, classification of the major histocompatibility complex may have clinical implications.

Coexisting primary hyperparathyroidism and sarcoidosis cause increased angiotensin-converting enzyme and decreased parathyroid hormone and phosphate levels

CONTEXT

Primary hyperparathyroidism (PHPT) and sarcoidosis may separately contribute to abnormal calcium and phosphate metabolism via different mechanisms, and their coexistence is infrequently reported.

OBJECTIVE

We sought to characterize a group of 50 patients with coexisting PHPT and sarcoidosis in our institution to evaluate their clinical and laboratory characteristics.

DESIGN AND SETTING

This was a retrospective observational study of patients with both disorders at our institution between January 1980 and December 2011.

OUTCOME

A cohort of 50 patients was identified, with mean ± SD age 59.6 ± 13.9 years and 86% women. Serum calcium in the cohort was 11.1 ± 1.1 mg/dL, phosphate was 3.3 ± 0.6 mg/dL, and PTH was 76 ± 42 pg/mL. Serum 25-hydroxyvitamin D was 25 ± 9 ng/mL, and serum 1,25-dihydroxyvitamin D was 51 ± 20 pg/mL; 24-hour urine calcium was 275 ± 211 mg. In subjects with sarcoidosis, serum angiotensin-converting enzyme (ACE) was 47.2 ± 37.4 U/L. Sarcoidosis was diagnosed first in 50% of patients, PHPT was diagnosed first in 16% of patients, and sarcoidosis and PHPT were both diagnosed within 6 months of each other in 30% of patients. The interval between the 2 diagnoses when sarcoidosis was diagnosed first was 15.5 ± 12.4 years and was 5.5 ± 6.0 years when PHPT was diagnosed first. Patients with PHPT who had active sarcoidosis had higher serum ACE levels (60.9 ± 38.1 vs 20.2 ± 14.0 U/L, P <.0001), lower PTH levels (60 ± 24 vs 96 ± 41 pg/mL, P = .01), and lower phosphate levels (2.7 ± 0.6 vs 3.2 ± 0.5 mg/dL, P = .02).

CONCLUSIONS

Fifty patients with coexisting PHPT and sarcoidosis are described, with patients with PHPT coexisting with clinically active sarcoidosis having increased serum ACE levels and decreased serum PTH and phosphate levels compared with those with inactive sarcoidosis.

Comparative analysis of circulating dendritic cell subsets in patients with atopic diseases and sarcoidosis

BACKGROUND

Dendritic cells (DCs) are professional antigen-presenting cells that play a crucial role in the initiation and modulation of immune responses. Human circulating blood DCs are divided into two major subsets: myeloid DCs (mDCs); and plasmacytoid DCs (pDCs). Furthermore, mDCs are subdivided into two subsets: Th1-promoting mDCs (mDC1s); and Th2-promoting mDCs (mDC2s). Although CD1a, CD1c, and CD141 are generally used for classifying mDC subsets, their adequacy as a specific marker remains unclear. We performed this study to compare circulating mDC, pDC, mDC1, and mDC2 subsets between Th1- and Th2-mediated diseases using CD1a and CD141, and to analyze the adequacy of CD1a and CD141 as a marker for mDC1s and mDC2s, respectively.

METHODS

Thirty patients with sarcoidosis, 23 patients with atopic diseases, such as atopic bronchial asthma, and 23 healthy subjects as controls were enrolled in this study. Peripheral blood DC subsets were analyzed with flow cytometry according to expressions of CD11c, CD123, CD1a, and CD141. For functional analysis, we measured interleukin (IL) 12p40 levels produced by the sorted mDC subsets.

RESULTS

The sarcoidosis group showed decreased total DC (P < 0.05) and mDC counts (P < 0.05) compared to controls. The atopy group showed decreased CD1a+mDC count (P < 0.05), and increased CD1a-mDC count (P < 0.05) compared to controls. CD141+mDC count in the atopy group was higher than controls (P < 0.05). Sorted CD1a+mDCs produced higher levels of IL-12p40 than CD1a-mDCs (P = 0.025) and CD141+mDCs (P = 0.018).

CONCLUSIONS

We conclude that decreased count of CD1a+mDC and increased count of CD141+mDC may reflect the Th2-skewed immunity in atopic diseases. The results of IL-12 levels produced by the sorted mDC subsets suggested the adequacy of CD1a and CD141 as a marker for mDC1 and mDC2, respectively, in vivo.

Inappropriately normal plasma ACTH and cortisol concentrations in the face of increased circulating interleukin-6 concentration in exercise in patients with sarcoidosis

Sarcoidosis is an autoimmune disease, and hypothalamic-pituitary-adrenal (HPA) axis activity is blunted in autoimmunity. Exercise stimulates the HPA axis, and we hypothesized that in sarcoidosis patients responses to treadmill exercise would be reduced. Hence, we studied 44 sarcoidosis patients [27 untreated (age, mean ± SD, 42 ± 2 years, 12 males, 15 females) and 17 dexamethasone treated (age, 46 ± 4 years, 7 males, 10 females)] and 20 healthy controls (40 ± 5 years old, 9 males, 11 females). Blood samples were drawn before, at peak (exhaustion), and 15 min after treadmill exercise for adrenocorticotropic hormone (ACTH), cortisol, tumor necrosis factor (TNF), interleukin-1β (IL-1β) and IL-6 measurements. At peak, plasma ACTH (pg/ml) was increased in untreated (mean ± SE, ΔACTH = 162.8 ± 29.9) and treated (ΔACTH = 123.3 ± 48.1) patients and controls (ΔACTH = 112.3 ± 41.7). Post-exercise, cortisol (ng/ml) was increased (p < 0.05) in untreated patients (Δcortisol = 48.4 ± 14.7) and controls (Δcortisol = 46.0 ± 15.9), but not significantly in treated patients (Δcortisol = 1.43 ± 2.56). At baseline, serum IL-6 (pg/ml) and TNF (pg/ml) were higher in untreated (3.02 ± 0.54 and 3.89 ± 0.72) and treated (1.75 ± 0.33 and 2.16 ± 1.00) patients, respectively, than in controls (0.80 ± 0.66 and 1.58 ± 0.32). At peak exercise, IL-6 was increased in untreated (ΔIL-6 = 0.96 ± 0.14) and treated (ΔIL-6 = 0.91 ± 0.47) patients and controls (ΔIL-6 = 0.96 ± 0.18); IL-1β was increased only in controls. Hence, the HPA axis of untreated sarcoidosis patients and controls responded similarly to treadmill exercise. In sarcoidosis patients, increased IL-6 was associated with HPA stimulation. Cortisol concentrations were similar between patients and controls, although IL-6 concentrations were higher in patients. Thus, in the face of chronically elevated IL-6 levels in sarcoidosis, there may be dysfunctional IL-6-induced HPA responses or HPA adaptation to high IL-6 concentrations.

Sarcoidosis of the liver: to treat or not to treat?

INTRODUCTION

Sarcoidosis is a non-caseating, granulomatous disease of incompletely understood aetiology that can affect nearly all organs including the liver. Hepatic involvement is thought to occur in 50-90% of patients but may remain undiagnosed in many cases. Evidence-based guidelines for the treatment of sarcoidosis of the liver are lacking. Patients usually receive no treatment or are treated pragmatically with corticosteroids. However, treatment with systemic corticosteroids has had mixed results. The use of ursodeoxycholic acid (UDCA) in the treatment of sarcoidosis-associated cholestasis has been reported by several groups, and is empirically prescribed to sarcoidosis patients with hepatic involvement.

METHODS

The effect of UDCA on symptoms and serum liver tests was investigated in a retrospective cohort study in which hepatic sarcoidosis patients had received either no treatment, prednisolone treatment or UDCA treatment. For all patients, laboratory results on ASAT, ALAT, AP and GGT were collected. Patients described the severity of their symptoms before and after treatment on a numerical scale.

RESULTS

A total of 17 patients participated in the study. Serum liver tests in the group treated with UDCA had improved as compared with the other groups. Also, symptomatic improvement of pruritus and fatigue was reported in the group treated with UDCA.

CONCLUSION

This retrospective cohort study supports the empirical first-line use of UDCA in the treatment of sarcoidosis of the liver, especially in symptomatic patients. Prospective randomised trials are needed to adequately support this concept.

Peripheral blood gene expression as a novel genomic biomarker in complicated sarcoidosis

Sarcoidosis, a systemic granulomatous syndrome invariably affecting the lung, typically spontaneously remits but in ~20% of cases progresses with severe lung dysfunction or cardiac and neurologic involvement (complicated sarcoidosis). Unfortunately, current biomarkers fail to distinguish patients with remitting (uncomplicated) sarcoidosis from other fibrotic lung disorders, and fail to identify individuals at risk for complicated sarcoidosis. We utilized genome-wide peripheral blood gene expression analysis to identify a 20-gene sarcoidosis biomarker signature distinguishing sarcoidosis (n = 39) from healthy controls (n = 35, 86% classification accuracy) and which served as a molecular signature for complicated sarcoidosis (n = 17). As aberrancies in T cell receptor (TCR) signaling, JAK-STAT (JS) signaling, and cytokine-cytokine receptor (CCR) signaling are implicated in sarcoidosis pathogenesis, a 31-gene signature comprised of T cell signaling pathway genes associated with sarcoidosis (TCR/JS/CCR) was compared to the unbiased 20-gene biomarker signature but proved inferior in prediction accuracy in distinguishing complicated from uncomplicated sarcoidosis. Additional validation strategies included significant association of single nucleotide polymorphisms (SNPs) in signature genes with sarcoidosis susceptibility and severity (unbiased signature genes - CX3CR1, FKBP1A, NOG, RBM12B, SENS3, TSHZ2; T cell/JAK-STAT pathway genes such as AKT3, CBLB, DLG1, IFNG, IL2RA, IL7R, ITK, JUN, MALT1, NFATC2, PLCG1, SPRED1). In summary, this validated peripheral blood molecular gene signature appears to be a valuable biomarker in identifying cases with sarcoidoisis and predicting risk for complicated sarcoidosis.

Approach to a patient with elevated serum alkaline phosphatase

Cholestasis develops either from a defect in bile synthesis, impairment in bile secretion, or obstruction to bile flow, and is characterized by an elevated serum alkaline phosphatase and gamma-glutamyltransferase disproportionate to elevation of aminotransferase enzymes. Key elements to the diagnostic workup include visualization of the biliary tree by cholangiography and evaluation of liver histology. The hope is that recent advances in understanding the genetic factors and immune mechanisms involved in the pathogenesis of cholestasis will lead to newer therapeutic interventions in the treatment of these diseases.

Serial measurement of high-sensitivity cardiac troponin I and N-terminal proB-type natriuretic peptide in a patient presenting with cardiac sarcoidosis

A 65-year-old woman presenting with cardiac sarcoidosis underwent serial measurement of her serum high-sensitivity cardiac troponin I (Hs-cTnI) and N-terminal proB-type natriuretic peptide (NT-proBNP) concentrations. She was treated with 1,000 mg/day methylprednisolone for 2 days, which was subsequently replaced by 30 mg/day prednisolone, and decreased to 20 mg/day at the time of discharge, 2 months later. Her echocardiogram showed improvements in the left ventricular systolic and diastolic function, along with a decrease in the concentration of Hs-cTnI and NT-proBNP. This is the first report suggesting that Hs-cTnI might be a reliable means of assessing the effects of treatment of cardiac sarcoidosis.

[Sarcoidosis: problems in classification]

In this article the authors discuss the issues related to assessment of activity and severity of sarcoidosis, course and radiographic manifestations of this disease. Problems in defining of different forms of sarcoidosis resulted in suggestion of new version of classification.

Sarcoidal tattoo granuloma

A 41-year-old man presented for evaluation of a widespread eruption. The eruption started six months beforehand as bumps within pre-existing black tattoos over his trunk and arms. One month later, the patient developed eye pain and the diagnosis of a uveitis was made. A different eruption soon followed, which the patient described as patches of rough skin. Finally, the patient developed discrete patches of hair thinning. The clinical examination, history, skin biopsy findings, and elevated angiotensin-1 converting enzyme and immunoglobulin levels supported the diagnosis of systemic sarcoidosis, which manifested as a sarcoidal tattoo granuloma, perifollicular cutaneous sarcoidosis, and uveitis.

Tumoral calcinosis associated with hypercalcemia in a patient with chronic renal failure

A 56-year-old male with chronic renal failure was admitted to the hospital because of progressive hip pain, appetite loss, general fatigue, and hypercalcemia. Slight pain had developed in the left hip 3 months before the initiation of hemodialysis, which subsequently developed into hyperalgesia. The patient was suspected to have sarcoidosis based on the elevated serum angiotensin-converting enzyme and lysozyme levels, and the ocular finding characterized by punched out chorioretinal scarring, although this could not be confirmed by histological evaluations. There was an abnormal uptake of gallium in the dependent portion of the tumoral calcinosis, which could have suggested either the presence of granulomatous sarcoid tissue within the calcified mass or active calcification associated with an inflammatory reaction. Elevated serum concentrations of 1,25-dihydroxyvitamin D3, which should be implicated in the development of hypercalcemia, promptly decreased after the administration of steroids. Steroid administration subsequently led to a decrease in the serum calcium and relief of the hip pain. This was a rare case of sarcoidosis associated with symptomatic tumoral calcinosis and hypercalcemia. The diagnostic significance of a gallium scan in this case will also be discussed.

Significance of plasma NT-proBNP levels as a biomarker in the assessment of cardiac involvement and pulmonary hypertension in patients with sarcoidosis

BACKGROUND

Cardiac involvement and pulmonary hypertension (PH) are life-threatening complications in sarcoidosis.

OBJECTIVE

This study aimed to investigate the utility of plasma NT-proBNP in the assessment of these conditions in sarcoidosis patients.

STUDY DESIGN AND METHODS

A prospective, observational study was performed on 150 consecutive Japanese sarcoidosis patients. Doppler echocardiography was performed in all subjects, and those who were successfully evaluated for PH status were included in the analysis. Cardiac sarcoidosis was diagnosed based on Japanese guidelines, and PH was defined as estimated systolic pulmonary artery pressure (sPAP) > or = 35 mmHg. The diagnostic accuracy of NT-proBNP according to the presence of cardiac sarcoidosis and PH was assessed based on receiver-operator characteristic (ROC) curves.

RESULTS

130 subjects were successfully evaluated for PH status. Of these, 29 met the diagnostic criteria of cardiac sarcoidosis, and 21 were diagnosed with PH. Plasma NT-proBNP levels were significantly higher in patients with cardiac sarcoidosis (p < 0.0001). Stepwise regression analysis showed that presence of cardiac sarcoidosis, decreased ejection fraction and increased sPAP were all independently associated with higher plasma NT-proBNP levels. Plasma NT-proBNP showed good accuracy in identifying patients with cardiac sarcoidosis (area under the ROC curve; AURC = 0.913). However, even when patients with cardiac sarcoidosis were excluded, plasma NT-proBNP levels could not be used reliably to identify patients with PH (AURC = 0.681).

CONCLUSION

In patients with sarcoidosis, plasma NT-proBNP levels are a useful biomarker to identify cardiac involvement, but not to identify PH.

Spinal cord sarcoidosis: clinical and laboratory profile and outcome of 31 patients in a case-control study

Sarcoidosis is a granulomatous disorder of unknown cause that affects the spinal cord in fewer than 1% of patients who suffer from it. We conducted a retrospective case-control study of 31 patients with spinal cord sarcoidosis and compared them to 30 patients with myelopathies of other causes to analyze their clinical, laboratory, and magnetic resonance imaging (MRI) profiles and to assess their long-term prognoses. Thirty-one patients presented with clinical signs of myelopathy and were diagnosed with sarcoidosis. Twenty-two of these patients had biopsy-proven noncaseating granulomas. In 9 patients, sarcoidosis involved only a neurologic localization. Patients in the control group were mainly diagnosed with multiple sclerosis or optic neuromyelitis. Patients with sarcoidosis were more likely to have elevated levels of C-reactive protein (CRP), elevated lactate dehydrogenase (LDH), and hypergammaglobulinemia in serum, as well as a higher protein content and white blood cell count in cerebrospinal fluid. Spinal cord MRIs performed in 26 patients with spinal cord sarcoidosis revealed T2-hyperintensities that were extensive and heterogeneous with a central distribution in axial slides. Twenty-six patients with spinal cord sarcoidosis presented neurologic sequelae after follow-up (mean, 64 +/- 8 mo), although 2 patients completely recovered. Neurologic sequelae correlated with cerebrospinal fluid white blood cell counts. One-third of the patients had a monophasic course of the disease, another third had a relapsing-remitting course, and the remaining third had a progressive course. Four patients had pulmonary embolism during follow-up. Spinal cord sarcoidosis remains a diagnostic dilemma since neurologic localization is frequently the only manifestation. Because treatment for spinal cord sarcoidosis is far different from treatment for other myelopathies, such as multiple sclerosis and optic neuromyelitis, diagnosis of sarcoidosis remains an important challenge. Here, we show that spinal cord MRI and blood and cerebrospinal markers may be useful tools in the diagnosis of spinal cord sarcoidosis. We suggest that accessory salivary gland biopsies, chest X-rays, protein electrophoresis, and blood levels of CRP and LDH should be obtained for each patient with subacute myelopathy. We also recommend paying careful attention to thromboembolism in patients with spinal cord sarcoidosis because of systemic disease and their decreased mobility.

Significant CD4, CD8, and CD19 lymphopenia in peripheral blood of sarcoidosis patients correlates with severe disease manifestations

Background

Sarcoidosis is a poorly understood chronic inflammatory condition. Infiltration of affected organs by lymphocytes is characteristic of sarcoidosis, however previous reports suggest that circulating lymphocyte counts are low in some patients with the disease. The goal of this study was to evaluate lymphocyte subsets in peripheral blood in a cohort of sarcoidosis patients to determine the prevalence, severity, and clinical features associated with lymphopenia in major lymphocyte subsets.

Methodology/Principal Findings

Lymphocyte subsets in 28 sarcoid patients were analyzed using flow cytometry to determine the percentage of CD4, CD8, and CD19 positive cells. Greater than 50% of patients had abnormally low CD4, CD8, or CD19 counts (p<4×10⁻¹⁰). Lymphopenia was profound in some cases, and five of the patients had absolute CD4 counts below 200. CD4, CD8, and CD19 lymphocyte subset counts were significantly correlated (Spearman's rho 0.57, p = 0.0017), and 10 patients had low counts in all three subsets. Patients with severe organ system involvement including neurologic, cardiac, ocular, and advanced pulmonary disease had lower lymphocyte subset counts as a group than those patients with less severe manifestations (CD4 p = 0.0043, CD8 p = 0.026, CD19 p = 0.033). No significant relationships were observed between various medical therapies and lymphocyte counts, and lymphopenia was present in patients who were not receiving any medical therapy.

Conclusions/Significance

Significant lymphopenia involving CD4, CD8, and CD19 positive cells was common in sarcoidosis patients and correlated with disease severity. Our findings suggest that lymphopenia relates more to disease pathology than medical treatment.