Löfgren's syndrome revisited: a study of 186 patients

Corticosteroids in Sarcoidosis

Corticosteroids are the drug of choice for the treatment of sarcoidosis. Because the natural course of sarcoidosis may be self-limiting and/or cause no long-term harm, treatment is not mandatory. Corticosteroids are usually effective for all forms of sarcoidosis, and they work quickly. However, because of the potential toxicities of corticosteroids, alternative medications often need to be considered. Efforts should be made to minimize the corticosteroid dose while keeping the risk of toxicity as low as possible. This article outlines the indications for corticosteroid therapy for sarcoidosis, discusses various dosing regimens, and suggests when alternative corticosteroid agents should be considered.

Severe Sarcoidosis

In sarcoidosis, reduction in mortality and the prevention of disability due to major organ involvement are treatment goals. Thus, it is important to recognize severe disease and identify patients at higher risk of progression to severe disease. In this article, fibrotic lung disease and cardiac sarcoidosis are reviewed as the major contributors to sarcoidosis mortality and morbidity. In the absence of a standardized definition of severe pulmonary disease, a multidisciplinary approach to clinical staging is suggested, based on symptoms, pulmonary function tests, and imaging findings at presentation, integrated with the duration of disease and longitudinal disease behavior during early follow-up.

Acute sarcoidosis: Löfgren's syndrome

Sarcoidosis is a chronic multisystem granulomatous inflammatory disorder. It can present acutely which is known as Löfgren's syndrome. The diagnosis may be missed if clinicians are not aware of its classic presenting features and the appropriate diagnostic investigations.

[Sarcoidosis : Organ involvement, diagnosis, current treatment]

Sarcoidosis is characterized by the appearance of noncausating, epitheloid cell granulomas, primarily in skin and lung. Hereditary disposition is well known; additional infection-associated triggers play a role for the development of inflammation mediated by T helper (Th)1 cells. Clinically, various disease courses can be observed that are characterized by the formation of skin papules at typical sites of the body which differ in their tendency to be associated with systemic organ involvement. Systemic disease without skin affections is also possible. The diagnosis is based on the typical clinical appearance, biopsy of affected tissue (e.g. skin, lung) and laboratory investigations. Additional systemic involvement needs to be excluded. In most cases, the disease is self-limited, but can also be life threatening due to organ fibrosis. The degree of (extra-)cutaneous involvement and level of discomfort are used to select the type of treatment, which ranges from topical immune suppressive agents to systemic therapy with corticosteroids. In nonresponders, additional modern immunosuppressive/immunomodulating therapeutic options are available.

Musculoskeletal involvement in sarcoidosis

Sarcoidosis is a multisystem inflammatory disorder of unknown cause. It most commonly affects the pulmonary system but can also affect the musculoskeletal system, albeit less frequently. In patients with sarcoidosis, rheumatic involvement is polymorphic. It can be the presenting symptom of the disease or can appear during its progression. Articular involvement is dominated by nonspecific arthralgia, polyarthritis, and Löfgren's syndrome, which is defined as the presence of lung adenopathy, arthralgia (or arthritis), and erythema nodosum. Skeletal manifestations, especially dactylitis, appear mainly as complications of chronic, multiorgan sarcoidosis. Muscle involvement in sarcoidosis is rare and usually asymptomatic. The diagnosis of rheumatic sarcoidosis is based on X-ray findings and magnetic resonance imaging findings, although the definitive diagnosis is made by anatomopathological study of biopsy samples. Musculoskeletal involvement in sarcoidosis is generally relieved with nonsteroidal anti-inflammatory drugs or corticosteroids. In corticosteroid-resistant or -dependent forms of the disease, immunosuppressive therapy, such as treatment with methotrexate or anti-TNF-α, is employed. The aim of this review was to present an overview of the various types of osteoarticular and muscle involvement in sarcoidosis, focusing on their diagnosis and management.

Granulomatous inflammation: The overlap of immune deficiency and inflammation

Pediatric granulomatous diseases constitute a heterogenous group of conditions in terms of clinical phenotypes, pathogenic mechanisms, and outcomes. The common link is the presence of multinucleated giant cells in the inflammatory infiltrate. The clinical scenario in which a tissue biopsy shows granulomatous inflammation is not an uncommon one for practicing adult and pediatric rheumatologists. Our role as rheumatologists is to develop a diagnostic plan based on a rational differential diagnostic exercise tailored to the individual patient and based mainly on a detailed clinical assessment. This chapter presents a comprehensive differential diagnosis associated with a classification developed by the authors. We describe with some detail extrapulmonary sarcoidosis, Blau syndrome, and immunodeficiency associated granulomatous inflammation, which in our view are the paradigmatic primary forms of granulomatous diseases in childhood. The other entities are presented only as differential diagnoses listing their most relevant clinical features. This chapter shows that almost all granulomatous diseases seen in adults can be found in children and that there are some entities that are essentially pediatric at onset, namely Blau syndrome and most forms of immunodeficiency associated granulomatous diseases.

Osseous sarcoidosis: clinical characteristics, treatment, and outcomes--experience from a large, academic hospital

OBJECTIVE

Osseous sarcoidosis has been infrequently reported. We aimed to characterize the distribution of lesions, clinical presentation, treatment, and outcomes for osseous sarcoidosis.

METHODS

Cases of osseous sarcoidosis were identified by directed inquiry to clinicians and electronic query. Cases were defined as having pathologic evidence of non-caseating granulomas on bone biopsy or evidence of osseous lesions on imaging attributable to sarcoidosis in patients with known sarcoidosis. Detailed characteristics were obtained by medical record review.

RESULTS

We identified a total of 20 cases of osseous sarcoidosis. Osseous lesions were detected by imaging during the initial sarcoidosis presentation in 60% of cases. In those who had a prior diagnosis of sarcoidosis, the median duration of sarcoidosis before detection of osseous involvement was 4.3 years. Symptoms were present in 50% of cases. All cases had more than one bone involved. The axial skeleton was involved in the majority of cases (90%), primarily the pelvis and the lumbar spine. Most cases required no treatment (55%); a minority of cases (45%) were treated, most often with prednisone, methotrexate, or hydroxychloroquine. Two cases required multiple immunosuppressants, including tumor necrosis factor inhibitors, for refractory symptomatic osseous sarcoidosis. Treated cases were younger than those who were untreated. At last follow-up, most cases (85%) were asymptomatic from osseous lesions.

CONCLUSIONS

In this case series of osseous sarcoidosis from a single center, most patients had multiple bones affected and had other systemic manifestations of sarcoidosis. A minority required treatment for relief of symptoms, and most cases were asymptomatic at last follow-up.

Sarcoidosis: sex-dependent variations in presentation and management

Sarcoidosis is an inflammatory disease with a wide range of clinical presentations. The manifestations and prognosis in sarcoidosis are dependent upon not only organ involvement but also age and sex. The purpose of this review is to describe the systemic and ocular manifestations of sarcoidosis with a specific focus on sex-dependent difference in presentation and management. Sarcoidosis is more common in women, particularly in patients who present after age of 50 years. Women with sarcoidosis are more likely to develop cystoid macular edema and the mortality rate is higher than that of men.

[Löfgren syndrome: a study of 80 cases]

BACKGROUND AND OBJECTIVE

Löfgren's syndrome is characterized by hiliar adenopathies, erythema nodosum and arthritis. It is a benign variant of sarcoidosis, common in the Mediterranean area. To describe the clinical characteristics, treatment and outcome of a series of patients diagnosed with Löfgren's syndrome.

PATIENTS AND METHODS

Retrospective design (1984-2013).

SETTING

Two university hospitals with a reference population of 1,015,000 inhabitants.

RESULTS

Eighty patients were diagnosed: 29 men and 51 women (mean age 42.3 years). Forty eight patients (60%) presented with the classical triad: hiliar adenopathies, erythema nodosum and arthritis; 18 (22%) with hiliar adenopathy and arthritis; 13 (16%) hiliar adenopathies and erythema nodosum. All showed abnormalities in the chest study. According to the radiological pattern, patients were classified in stage i-ii. Biopsy was performed in 39 patients and was diagnostic in 28. Treatment was based on non-steroidal anti-inflammatory drugs (54 patients, 67%) and corticosteroids (33 patients, 41%). Fourteen patients (17%) suffered a recurrence of the disease.

CONCLUSIONS

Löfgren's syndrome is a benign form of sarcoidosis with a well defined clinical pattern. Biopsy is usually not required. Recurrence is scarce. The disease has a good prognosis.

Associations between tumor necrosis factor alpha gene polymorphism and sarcoidosis: a meta-analysis

Published studies regarding the association between tumor necrosis factor alpha (TNF-α) gene polymorphism and sarcoidosis risk are inconsistent. In order to clarify this association, we performed a meta-analysis of case-control studies with available data. PubMed, EMBASE and BIOSIS Previews were comprehensively searched to identify relevant studies. Twelve case-control studies in 11 articles involving 3,218 participants were included in the meta-analysis to assess the association between TNF-α gene polymorphism and susceptibility to sarcoidosis. We estimated the pooled odds ratio (OR) with its 95% confidence intervals (95% CI) to explore the potential association. Our meta-analysis results suggested that TNF-α-308G/A AA/AG genotype increased sarcoidosis risk, in Asian and Caucasian ethnicity, and in sarcoidosis with Löfgren syndrome. No association was found between TNF-α-238G/A, TNF-α-857C/T polymorphism and sarcoidosis risk. In conclusion, our meta-analysis indicated that AG/GG genotype of TNF-α-308G/A are associated with increased sarcoidosis risk.

Sarcoidosis Presenting as Löfgren's Syndrome with Myopathy

A 34-year-old female patient, who had proximal muscle weakness for 8 months, presented with erythema nodosum lesions on the pretibial region in addition to pain, swelling, and movement restriction in both ankles for the last one month. Thoracic CT demonstrated hilar and mediastinal lymphadenopathy. She underwent mediastinoscopic lymph node biopsy; biopsy result was consistent with noncaseating granuloma. Serum angiotensin converting enzyme level and muscle enzymes have been elevated. Muscular MRI and EMG findings were consistent with myositis. Muscle biopsy was done, and myopathy was found. The patient was diagnosed with sarcoidosis, Löfgren's syndrome, and sarcoid myopathy. The patient displayed remarkable clinical and radiological regression after 6-month corticosteroid and MTX therapy.

Lofgren's Syndrome-Acute Onset Sarcoidosis and Polyarthralgia: A Case Report

Lofgren's syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. This syndrome is common among Caucasians but rare in the Korean population. A 44-year-old woman was admitted to our hospital complaining of polyarthralgia. A chest radiograph revealed BHL and nodular shadows. Angiotensin-converting enzyme levels were within the normal range. Tissue biopsy from a mediastinum lymph node showed noncaseating granulomas. We diagnosed her with Lofgren's syndrome, an acute form of sarcoidosis.

Pathogenesis of sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin. Recent research uncovered underlying immunological and genetic mechanisms, which will pave the way for more effective pharmaceutical studies. At present some of this knowledge is clinically exploited to monitor therapy and expected genetic progress will allow the development of prognostic genetic patterns or molecular signatures. Moreover, it has become obvious that several etiologic agents and cofactors will exist. These will be of animate and inanimate nature and their interplay with host mechanisms discussed in this review determines disease phenotypes.

HLA associations and Löfgren's syndrome

Patients with sarcoidosis can be subgrouped according to organ engagement and clinical manifestations. One such subgroup is Löfgren's syndrome (LS), constituting a distinct group of sarcoidosis patients with typical clinical manifestations, separate genetic associations and an immune response that seems to differ from that of non-LS patients. In particular, LS patients have strong associations with HLA-DRB1 alleles, and the well-known association with HLA-DRB1*03 is particularly striking. This particular HLA-DRB1 allele is also a very strong marker within that particular group of patients for a prognostically favorable disease course. This article will mainly discuss genetic associations with LS, and the possible implications of such associations.

Sarcoidosis: challenging diagnostic aspects of an old disease

Over the past few years, there have been substantial advances in our understanding of sarcoidosis immunopathogenesis. Conversely, the etiology of the disease remains obscure for a number of reasons, including heterogeneity of clinical manifestations, often overlapping with other disorders, and insensitive and nonspecific diagnostic tests. While no cause has been definitely confirmed, there is increasing evidence that one or more infectious agents may cause the disease, although the organism may no longer be viable. Here we present 2 cases, in which sarcoidosis preceded tuberculosis and non-Hodgkin lymphoma. Development of new lesions in a patient with chronic/remitting sarcoidosis should be looked at with suspicion and promptly investigated in order to rule out an alternative/concomitant diagnosis. In such cases, tissue confirmation from the most accessible site, and bone marrow biopsy-if lymphoma is in the differential diagnosis-should be performed. In conclusion, we strongly advise that physicians be ready to reconsider the diagnosis of sarcoidosis in the presence of atypical manifestations or persistent/progressive disease despite conventional therapy.

Extra-pulmonary manifestations of sarcoidosis

Although, the diagnosis and evaluation of sarcoidosis has traditionally remained confined to the chest, its multi-system nature has been widely recognized. Radiological features of pulmonary sarcoidosis are well known but extra-pulmonary manifestations can produce a plethora of non-specific imaging findings that can affect subcutaneous tissue, and the neurological, cardiac, gastrointestinal, urological, liver, spleen, and skeletal systems. In the literature, there are various case reports and specific system reviews but there are few reviews that encompass all the extra-pulmonary manifestations. In this paper, we comprehensively review the imaging features of extra-pulmonary sarcoidosis with characteristic features as well as atypical presentations. In addition, we discuss the emerging role of nuclear medicine in sarcoidosis.

Sarcoidosis

Sarcoidosis is a multisystem, granulomatous disease. In this article, the various clinical manifestations, approach to, and management of, pulmonary and extrapulmonary sarcoidosis are reviewed.

Specific cutaneous lesions in patients with systemic sarcoidosis: relationship to severity and chronicity of disease

BACKGROUND

Specific (granulomatous) cutaneous lesions are seen in 9-37% of cases of systemic sarcoidosis, and are usually classified into maculopapules, plaques, lupus pernio (LP), scar sarcoidosis, and subcutaneous sarcoidosis. Their prognostic significance has not been fully established.

AIM

To analyse the relationship between the clinical type of granulomatous cutaneous lesions and the systemic features and prognosis of systemic sarcoidosis.

METHODS

The clinical charts of 86 patients (19 men, 67 women, mean age 46.82 years) with systemic sarcoidosis and granulomatous cutaneous involvement followed up for > 2 years at Bellvitge University Hospital were reviewed.

RESULTS

Cutaneous lesions developed before or at the time of diagnosis of systemic sarcoidosis in 80.23% of patients. The main cutaneous lesions were classified as maculopapules (28 patients), plaques (31), LP (6), scar sarcoidosis (7) and subcutaneous sarcoidosis (14). Erythema nodosum (EN) was seen in 30 patients. Radiological stage was 0 for 8 patients, I for 48, II for 24, III for 5 and IV for 1. Systemic sarcoidosis activity persisted for > 2 years in 47 patients, and 42 received systemic corticosteroid treatment for their disease. Maculopapular and subcutaneous sarcoidosis were mainly seen in patients with EN and radiological stage I. Plaques and LP were associated with chronic disease and requirement for systemic corticosteroids.

CONCLUSIONS

Cutaneous granulomatous lesions are usually present at the diagnosis of systemic sarcoidosis, and the type of cutaneous involvement may have prognostic significance.

Sarcoidosis--scientific progress and clinical challenges

Sarcoidosis is an uncommon systemic inflammatory disorder characterized by noncaseating granulomatous inflammation that most commonly affects the lungs, intrathoracic lymph nodes, eyes and skin. One-third or more of patients with sarcoidosis have chronic, unremitting inflammation with progressive organ impairment. Findings of family and genetic studies indicate a genetic susceptibility to sarcoidosis, with genes in the MHC region having a dominant role. Immunologic hallmarks of the disease include highly polarized expression of cytokines produced by type 1 T helper cells and tumor necrosis factor (TNF) at sites of inflammation. Increasing evidence obtained within the past decade suggests the etiology of sarcoidosis predominantly involves microbial triggers, with the most convincing data implicating mycobacterial or propionibacterial organisms. Innate immune mechanisms, possibly involving misfolding and aggregation of serum amyloid A, might have a critical role in the pathobiology of sarcoidosis. Despite these advances, there are no clinically useful biomarkers that can assist the clinician in diagnosis, prognosis or assessment of treatment effects. Corticosteroids remain the cornerstone of therapy when organ function is threatened or progressively impaired. The role of immunosuppressive drugs and anti-TNF agents in the treatment of sarcoidosis remains uncertain, and there are no FDA-approved therapies. Meaningful progress in developing clinically useful tools and new therapies will depend on further advances in understanding the pathogenesis of sarcoidosis and its disease-specific pathways.

[Interferon-alfa induced reactivation of sarcoidosis in a patient with chronic hepatitis C]

The data on reactivation of sarcoidosis during treatment with interferon-alfa is unsatisfactory. We here report the case of a female patient with a history of sarcoidosis more than 20 years ago. Due to chronic hepatitis C the patient was treated with pegylated interferon-alfa and ribavirin. Beginning in the 32(nd) week, the patient developed a reactivation of sarcoidosis. The antiviral therapy was continued until week 48 without administration of systemic steroids. Six month after the end of antiviral treatment the sarcoidosis was in remission and the hepatitis C was cured.

Clinical and radiographic features of sarcoidosis in menopausal women: The impact on therapeutic approach and prognosis

Background/Aim. Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. The aim of the study was to determine are there significant differences in clinical manifestations, radiographic and lung function findings and therapeutic approach in menopausal female sarcoidosis patients compared to premenopausal ones. Methods. Seventy seven Caucasian women (average age 43.71 years, range 38- 54) with sarcoidosis diagnosed at the University Hospital from January to October 2006, were included in the study. They were divided into two groups according to their menstrual period status. The group I included 42 women with normal menstrual cycle, while the group II included 35 menopausal women (either spontaneous or after hysterectomy). The patients were not under hormonal therapy. Results. We found significantly higher proportion of the first radiographic stage (66.7% vs 34.2%, p < 0.05) and acute form of sarcoidosis (57.2% vs 17.1%; p < 0.01) in the group I in relation to the group II. Extrapulmonary sarcoidosis was more frequent in the group II than in the group I (p < 0.01). Disturbances of lung ventilation were registered in 50.8% of all the patients, and decrease of one or both of diffusion parameters was found in 63.6%, but without significant differences between the groups (p > 0.05). Hypercalciuria was found in 19.1% of the patients in the group I and 42.8% of the patient in the group II (p < 0.05). A difference in the therapy approach was also found to be significant with methotrexate more frequently applied in the group II than in the group I (p < 0.01). Conclusion. Menopausal women with sarcoidosis may represent a group of patients that requires special attention in diagnostic procedure, therapeutic approach and follow-up, to prevent unfavourable course of the disease. Attention should be particularly focused on the detection of extrapulmonary sites involvement in this group of the patients. Further prospective studies are needed to reveal the role of hormones, and especially plasma estrogen level in sarcoidosis appearance.

[Young woman with relapsing arthritis]

A 28-years old lady complains of self-limited episodes of relapsing knee arthritis of 48-72h of duration every 2 weeks. Immunological profile was all negative. At the same time, radiological images did not reveal any abnormality. She underwent to knee arthroscopy, however, a definite diagnosis was not reached. We discuss the differential diagnosis of relapsing arthritis.

Acute-onset sarcoidosis with polyarthralgia and hilar lymphadenopathy

A 33-year-old man was admitted to our hospital because of fever and arthralgia. Radiographic findings revealed bilateral hilar lymphadenopathy (BHL) and enlargement of lymph nodes of the mediastinum. Tissue from a mediastinum lymph node showed noncaseating granulomas. An acute form of sarcoidosis, Lofgren's syndrome, was diagnosed. Prednisolone was administered. Because this syndrome is rare in Japan, histopathological examination was necessary to diagnose and treat this patient.

Chronic sarcoid arthritis presenting as an intra-articular knee mass

Patients may present with a primary complaint of intra-articular knee masses causing mechanical symptoms of snapping or locking. If the history, physical examination, laboratory tests, and imaging studies point to a benign process, acceptable treatment consists of arthroscopic excision and postoperative pathology analysis. As reported in several case series, the final diagnosis can be pigmented villonodular synovitis, localized nodular synovitis, hemangioma, lipoma, or rheumatoid nodules. In this case presentation, a 39-year-old man with no previous medical conditions and a negative preoperative chest radiograph underwent arthroscopic surgery for a single intra-articular knee mass. The unexpected diagnosis, after pathology review and further medical work-up, was arthritis secondary to chronic sarcoidosis.