Thalidomide for chronic sarcoidosis

Hepatic, ocular, and cutaneous sarcoidosis

Sarcoid affecting the skin, eye, or liver can be symptomatic of or cause significant morbidity. When disease is sever, alternative therapies may be needed.

Sarcoidosis: clinical presentation, diagnosis, and approach to treatment

Sarcoidosis is an idiopathic granulomatous disease. It usually affects the lung but may involve any organ. The diagnosis may be problematic because known causes of granulomatous inflammation must be excluded. Sarcoidosis may remit spontaneously or remain stable. Therefore, therapy is not mandated for the disease. This report reviews the clinical presentation, diagnostic approach, and treatment of sarcoidosis.

Thalidomide for treatment of intestinal involvement of juvenile-onset Behçet disease

BACKGROUND

Thalidomide has been identified and its anti-inflammatory and immunomodulatory properties clarified. This report expands our report of 2 entero-Behçet disease children who developed significant steroid toxicity and improved dramatically with thalidomide.

METHODS

We studied the effects of thalidomide in 7 juvenile-onset patients with severe, recurrent intestinal involvement of Behçet disease. Thalidomide was given at an initial dose of 2 mg/kg per day, and the dose was increased to 3 mg/kg per day if necessary (3 of 7 patients) or decreased to 1-0.5 mg/kg per day according to the responses to the drug.

RESULTS

All 7 patients showed dramatic improvement in clinical symptoms with thalidomide therapy, and they successfully discontinued steroid therapy. Patients receiving thalidomide were monitored for prolonged neurotoxicity, and the treatment and a few side effects were well tolerated by all patients.

CONCLUSIONS

Our results indicate that thalidomide can be an efficacious medication in appropriately selected patients with some inflammatory bowel diseases with many chances of success.

Prognosis of refractory neurosarcoidosis altered by thalidomide: a case report

Introduction

Sarcoidosis is a multisystem disease characterized by noncaseating granulomas in the lungs, skin, lymph nodes, and, rarely, the nervous system. Granuloma formation in sarcoidosis is mediated by increased secretion of interferon-gamma, interleukin-2, and tumor necrosis factor-alpha. 25% of patients with neurosarcoidosis are steroid resistant and another 20–40% are resistant to any conventional immunosuppression, but the typical agents suppress the immune system in a non-specific fashion. Thalidomide has been shown to have activity specific to the inflammatory mediators of sarcoidosis, has been shown to be beneficial in cutaneous sarcoidosis, and provides an interesting observation in our patient with refractory neurosarcoidosis.

Case presentation

A 40 year old African-american female presented with refractory neurosarcoidosis. Over the course of several years, the patient was treated with high dose steroids, imuran, cytoxan, and cyclosporine without benefit. Then, the patient received thalidomide, slowly escalating to 650 mg. After 2 months radiologic improvement was noted and after 6 months clinical stabilization and improvement became apparent.

Conclusion

Our case report presents a difficult, refractory case of neurosarcoidosis that demonstrates an altered prognosis based on the addition of thalidomide.

Chronic facial sarcoidosis including lupus pernio: clinical description and proposed scoring systems

BACKGROUND

Facial lesions including lupus pernio are often a form of chronic cutaneous sarcoidosis.

OBJECTIVE

To evaluate the intra- and inter-observer consistency of objective measures of chronic facial lesions.

METHOD

This was a retrospective study of patients with chronic cutaneous facial lesions including lupus pernio. The lesions were evaluated using two methods.

RESULTS

Of the 25 patients studied, 23 were women and 24 were African American. Lungs (24 patients), sinuses (11 patients), and eyes (7 patients) were also affected. The Sarcoidosis Activity and Severity Index (SASI) characterized individual areas of the face, with 95% of the observations being less than 2 points from the median. A facial SASI total gave a score for the entire face and 93.2% of the scores were within 3 points of the median.

CONCLUSION

Patients with sarcoidosis and chronic facial lesions often have lung, sinus, and eye involvement. The SASI is a reproducible scoring system for chronic facial lesions.

Airway involvement and obstruction from granulomas in African–American patients with sarcoidosis

Sarcoidosis is a global disorder whose breadth of organ involvement can often be underappreciated. Head and neck manifestations include involvement of the skin, salivary glands, sinonasal cavity, and larynx. Of cases of upper airway sarcoidosis, laryngeal sarcoidosis and airway compromise portend a greater risk of fatal outcomes. People representing all racial groups have been diagnosed with sarcoidosis. Although many studies have evaluated incidence and manifestations of sarcoidosis in multiple ethnicities, few studies have explored racial predilection for laryngeal involvement. However, assertions that disease severity and poor outcome may be tied to the African diaspora as well as related socio-economic and cultural realities have been recognized. We present our case series of six African-American patients diagnosed with sarcoidosis and presented with complaints of voice change and increased shortness of breath. Four of them required expeditious, surgical management of the airway. Two had limited supraglottic involvement and have avoided tracheotomy with aggressive and timely pharmacotherapeutic intervention and close clinical surveillance. Early recognition of laryngeal manifestations of sarcoidosis and airway compromise is essential to provide patients with conservative management without the need for aggressive surgical intervention.

Lupus pernio in sarcoidosis: clinical features and treatment outcomes of 14 patients

Lupus pernio (LP) is the most characteristic skin lesion of sarcoidosis. In this study, we retrospectively evaluated the clinical features of sarcoidosis patients with diagnosed LP at our center. Of 516 sarcoidosis patients diagnosed within a 36-year period, 14 (2.7%) had skin lesions that were clinically and histologically diagnosed as LP. Thirteen of our LP patients were females, and one was a male (mean age: 46.3, range: 24-67). In 2 sarcoidosis patients, the initial presentation of the disease was LP. When the LP patients were compared with other sarcoidosis patients, there were more females, and the frequency of extrapulmonary involvement and the number of patients with advanced stage disease were higher (P <0.001). Oral and/or intralesional steroid therapy was the preferred treatment modality in all our patients and led to either recovery or regression in most patients with LP. As our study was an uncontrolled, retrospective one with few patients, it is difficult to say whether steroids are effective. LP runs a chronic course and spontaneous remission of lesions of more than 2 years' duration is quite rare. Because of the unwanted side effects of steroids, the efficacy of new treatment modalities should be tested especially in sarcoidosis patients with only skin involvement.

Hypersensitivity pneumonitis-like syndrome associated with the use of lenalidomide

Lenalidomide is an immunomodulatory agent approved for use in patients with myelodysplastic syndrome, and in combination with dexamethasone for refractory or relapsed multiple myeloma. Pulmonary toxicity is believed to be uncommon. In this report, we describe a patient receiving lenalidomide in whom dyspnea, fever, hypoxia, and diffuse pulmonary infiltrates developed. BAL demonstrated a significant lymphocytic alveolitis typical for hypersensitivity pneumonitis. Extensive workup for other causes, including infections, was negative. Finally, the patient had improvement in symptoms and oxygenation after withdrawing lenalidomide and recurrence of symptoms when the drug was restarted. Thus, the patient's clinical course and workup strongly support a diagnosis of lenalidomide-induced hypersensitivity pneumonitis-like syndrome. Physicians should be cognizant of this potential complication in patients receiving thalidomide or thalidomide-like drugs who present with fever and pulmonary infiltrates and fail to improve despite treatment with broad-spectrum antibiotics.

Current and emerging strategies for the management of sarcoidosis

Sarcoidosis is a systemic inflammatory disorder of unknown etiology. Although any organ may be involved, the lungs are most frequently affected. The clinical course of the disease is highly variable, with up to two-thirds of untreated patients experiencing spontaneous remission within 12-24 months of onset of symptoms. When therapy is required, corticosteroids are considered standard, but studies demonstrating their ability to modify the long-term outcome in this disease are lacking. Often, the myriad of adverse side effects of corticosteroids necessitate the addition of immunosuppressants, cytotoxic agents or biologic therapies to maintain disease remission. Unfortunately, optimal therapeutic regimens have not been described. Patients who do not respond to therapy often experience progressive fibrotic changes and end-organ damage, which ultimately may result in significant morbidity or death. Agents commonly used to treat patients with sarcoidosis and emerging therapeutic options are discussed.

Neurosarcoïdose et mycophénolate mofétil

INTRODUCTION

Neurosarcoidosis is a rare (5 cases for one million) immune-mediated disease generally observed in young adults. Neurological symptoms are present in the half of patients, and symptoms remain limited to neurological system in 10p.cent. Histological criteria are mandatory to prove the diagnosis. The sensitivity and complications of biopsy are variable. The best sensitivity appears to be achieved with muscle biopsies which in addition have a lower risk of complications. Neurosarcoidosis is usually treated with corticosteroid therapy and immunosuppressive drugs (cyclophosphamide, cyclosporine, aziathoprine, methotrexate), but frequently resists standard schedules. In addition the many contraindications, side effects and cumulated toxicities of immunosuppressive drugs compromises their use. Knowledge of the effectiveness of other treatments would therefore be useful. Mycophenolate mofetil (MMF) has been used for treatment of many immune-mediated neurological diseases, like polymyositis, multifocal motor neuropathy, myasthenia or chronic inflammatory demyelinating polyradiculoneuropathy. MMF is efficient and well tolerated, but there is no case-report about neurosarcoidosis.

CASE REPORT

We report two observations of young patients (14 and 27 years) with a diagnosis of resistant neurosarcoidosis treated with MMF (2 g/j) and corticosteroids. A significant and rapid effectiveness was clinically and radiologically observed, with good clinical and hematologic tolerance.

CONCLUSION

The MMF seems to be an interesting rescue treatment for neurosarcoidosis. Further evaluation is needed.

Steroid-resistant sarcoidosis: is antagonism of TNF-alpha the answer?

Steroid-resistant sarcoidosis has conventionally been treated with various drugs, including methotrexate, azathioprine, cyclophosphamide, cyclosporine, antimalarial drugs and thalidomide, with variable success. There is a compelling need for more efficient and safer alternatives to these agents. Several lines of evidence suggest a critical role of TNF-alpha (tumour necrosis factor-alpha) in the initiation and organization of sarcoid granulomas. Inhibition of TNF-alpha with monoclonal antibodies has therefore received attention as a potential treatment option in therapy-resistant sarcoidosis. A number of case reports and small case series describe successful treatment of refractory disease with infliximab. Preliminary evidence from an RCT (randomized controlled trial) with infliximab in pulmonary sarcoidosis suggests a modest improvement in functional and radiological parameters. In contrast, the results with etanercept have been disappointing, perhaps related to differences in the mechanism of TNF-alpha blockade. The experience with adalimumab in sarcoidosis is too limited to draw conclusions. An open-label study and an RCT evaluating the efficacy of adalimumab in sarcoidosis with pulmonary and cutaneous involvement respectively, have been initiated. Although TNF-alpha antagonists appear relatively safe, especially when compared with conventional agents, caution is warranted in view of the increased incidence of tuberculosis, which may be a particular diagnostic challenge in patients with sarcoidosis. Pending publication of the RCTs, the use of TNF-alpha blockade in sarcoidosis should remain in the realm of experimental treatment.

Cutaneous sarcoidosis therapy updated

The widely accepted standard therapy for cutaneous sarcoidosis includes corticosteroids, antimalarials, and methotrexate. However, a better understanding of the basic immunopathogenic properties of sarcoidosis has elucidated a number of steps critical to the persistence and progression of disease that may be vulnerable to treatment by targeted therapy. This article reviews both standard and newer therapeutic options for cutaneous sarcoidosis.

A New Tool To Assess Sarcoidosis Severity

STUDY OBJECTIVES

Sarcoidosis is a granulomatous disorder primarily affecting the lung, but with frequent extrapulmonary organ involvement. There are no comprehensive scoring systems for sarcoidosis disease severity. Our goal was to develop and validate an objective and comprehensive sarcoidosis disease severity scoring system.

DESIGN

Three sarcoidosis experts reviewed clinical data on 104 patients with biopsy-confirmed sarcoidosis. Each expert independently scored disease severity using a visual analog scale. Interrater agreement was assessed. Univariate analysis was performed, and those variables with p values < or = 0.25 were used in backward regression multivariable analysis. A model was obtained including variables with a p value of < or = 0.15 to predict severity scores. This model was subsequently validated using an independent panel of three additional international experts.

SETTING

Granuloma clinic at National Jewish Medical and Research Center.

PATIENTS

A total of 104 patients with biopsy-confirmed sarcoidosis.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Pairwise assessment of interrater agreement yielded high degrees of correlation with Spearman correlation coefficients of 0.86 to 0.89 and an intraclass correlation coefficient of 0.87. Univariate analysis showed that smoking status, immunosuppressive therapy, percent predicted for diffusing capacity of the lung for carbon monoxide (Dlco), FEV1, FVC, and total lung capacity, FEV1/FVC ratio, disease duration, sites of organ involvement, and African-American race were associated with mean severity score. The multivariable model included cardiac and neurologic involvement, current therapy with noncorticosteroid immunosuppressive agents, Dlco percent predicted, FEV1/FVC ratio, African-American race, FVC percent predicted, and skin involvement. This model was validated using additional reviewer scores yielding Spearman correlation coefficients of 0.66 to 0.76 and an intraclass correlation coefficient of 0.74.

CONCLUSIONS

We derived an objective disease severity scoring system that incorporates data on demographics, pulmonary function, and organ involvement to produce a whole-body sarcoidosis assessment. This preliminary tool has potential applicability in the assessment of disease severity in sarcoidosis research.

[Methotrexate for the treatment of patients with chronic cutaneous sarcoidosis: 4 cases]

INTRODUCTION

Pathogenesis of sarcoidosis remains partially unknown. Cutaneous lesions are frequent (20 to 35% of cases). Their clinical features and follow-up data are highly variable. Numerous treatments have been proposed. The clinical features and follow up data of four patients with chronic cutaneous sarcoidosis treated with methotrexate are reported.

CASE REPORT

Mean age of patients (3 female, 1 male) was 40 years old (34-49 years). One patient presented with a lupus pernio, two patients with papules and nodules, and the last with an annular lesion of the face. All patients had been previously treated with topical corticosteroids and/or hydroxychloroquine without any success. Patients were treated with methotrexate at doses ranging from 12.5 mg to 30 mg per week for at least 6 months. Complete remission of cutaneous lesions was observed in 3 of 4 patients after a mean treatment duration of 29 months (16 to 36). Methotrexate side effects were observed in one patient (elevated liver enzymes) leading to methotrexate discontinuation.

DISCUSSION

Methotrexate seems to be an effective treatment of cutaneous sarcoidosis. It should be used namely in patients who failed to respond to previous treatments with topical corticosteroids or antimalarial drugs.

Thalidomide in the treatment of recalcitrant Sweet's syndrome associated with myelodysplasia

Sweet's syndrome is a neutrophilic dermatosis characterized by tender, erythematous, pseudovesicular plaques that can be associated with hematologic malignancy. We report a patient with recalcitrant Sweet's syndrome that preceded the development of myelodysplastic syndrome by 30 months. The delay between the onset of Sweet's syndrome and the subsequent diagnosis of myelodysplasia highlights the need for thorough and repeated evaluation for underlying malignancy in patients with such a course. Although corticosteroids are the initial treatment of choice, this patient's eruption was only partially responsive to high-dose prednisone and was refractory to metronidazole, dapsone, and methotrexate. Treatment with thalidomide resulted in complete resolution of the cutaneous lesions within one month of therapy.

Thalidomide: dermatological indications, mechanisms of action and side-effects

Thalidomide was first introduced in the 1950s as a sedative but was quickly removed from the market after it was linked to cases of severe birth defects. However, it has since made a remarkable comeback for the U.S. Food and Drug Administration-approved use in the treatment of erythema nodosum leprosum. Further, it has shown its effectiveness in unresponsive dermatological conditions such as actinic prurigo, adult Langerhans cell histiocytosis, aphthous stomatitis, Behçet's syndrome, graft-versus-host disease, cutaneous sarcoidosis, erythema multiforme, Jessner-Kanof lymphocytic infiltration of the skin, Kaposi sarcoma, lichen planus, lupus erythematosus, melanoma, prurigo nodularis, pyoderma gangrenosum and uraemic pruritus. This article reviews the history, pharmacology, mechanism of action, clinical uses and adverse effects of thalidomide.

Fungal infections as a complication of therapy for sarcoidosis

BACKGROUND

Treatment of symptomatic sarcoidosis usually includes systemic immunosuppressive agents. These agents may render the patient more susceptible to opportunistic infections. In addition, the fungal infection may be difficult to distinguish from the underlying sarcoidosis.

AIM

To examine the presentation and management of invasive fungal infections in sarcoidosis patients.

DESIGN

Retrospective record review.

METHODS

We reviewed the notes of all sarcoidosis patients (n = 753) seen at our clinic over an 18-month period.

RESULTS

Seven patients (0.9%) with previously diagnosed sarcoidosis developed fungal infections: two each with Histoplasma capsulatum and Blastomyces dermatitidis and three others with Cryptococcus neoformans. No cases of invasive aspergillus or tuberculosis were identified. The diagnosis of fungal infection was made by bronchoscopy (four cases), open-lung biopsy (one case), bone-marrow aspirate (one case), and spinal fluid examination (one case). All patients were receiving corticosteroids at the time of worsening chest X-ray or clinical status. Four patients were also receiving methotrexate prior to infection. No patient with systemic fungal infection was receiving either infliximab or cyclophosphamide. All patients responded to anti-fungal therapy and a reduction in immunosuppression.

DISCUSSION

Fungal infections occur rarely in treated patients with sarcoidosis. Deterioration of chest X-ray, especially a localized infiltrate, warrants investigation.

Pulmonary sarcoidosis

Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.

Treatment of Sarcoidosis With Infliximab

BACKGROUND/OBJECTIVES

Many patients with sarcoidosis are unable to tolerate corticosteroids or alternative therapeutic agents due to side effects or have disease refractory to these agents. We report our experience using infliximab to treat such patients.

METHODS

A group of patients in whom traditional sarcoidosis therapy failed, either due to drug failure or intolerable side effects, were prescribed infliximab. Their charts were retrospectively reviewed.

RESULTS

Ten patients receiving infliximab were reviewed. Nine of the 10 patients reported a symptomatic improvement with therapy, and all 10 demonstrated objective evidence of improvement. A drug reaction developed in one patient after several months of therapy, oral candidiasis developed in one patient, and angioimmunoblastic lymphoma developed in another patient. The corticosteroid dose was reduced in five of the six patients who were receiving corticosteroids at the time of infliximab therapy.

CONCLUSION

Infliximab appears to be an effective, safe treatment for patients with refractory sarcoidosis, including such manifestations as lupus pernio, uveitis, hepatic sarcoidosis, and neurosarcoidosis. Infliximab appears to be steroid sparing. Patients receiving the drug should be screened for latent tuberculosis and lymphoproliferative disorders.

Granulomatous diseases of the oral tissues: differential diagnosis and update

Because of the relatively nonspecific clinical findings associated with a variety of granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for the clinician. The most common differential diagnosis includes foreign body reactions, infection, Crohn's disease, sarcoidosis, and orofacial granulomatosis. However, a variety of other conditions may be associated with granuloma formation. Often an extensive clinical, microscopic, and laboratory evaluation may be required to identify the source of the granulomatous inflammation. This article highlights the origin, clinical manifestations, current diagnostic modalities, and treatment of specific granulomatous diseases that may be encountered in clinical practice.

Pulmonary sarcoidosis

Pulmonary sarcoidosis is one of the most common causes of idiopathic interstitial lung disease. Clinical presentation can range from asymptomatic to respiratory failure. Although some patients never require therapy, many patients with pulmonary sarcoidosis become symptomatic enough to require therapy. Treatment options include corticosteroids.In the past few years, alternatives to corticosteroids have been developed,especially for patients with a chronic condition.

Clinical and immunologic components of sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that affects the lungs and the lymphatic system. It is seen by specialists in allergy, rheumatology, and pulmonary disease. Although there are no clues to etiology, an environmental basis has been implicated primarily on the basis of epidemiologic and anecdotal data. The majority of patients are very readily diagnosed and should not be confused with other pulmonary disorders. Sarcoidosis can become an issue if it occurs in the presence of other significant pulmonary disease, such as patients with asthma or hypersensitivity pneumonitis. Most patients remain asymptomatic and many are diagnosed when picked up on a routine screening exam. Steroids can be used to manage some patients but caution should be exercised to choose the appropriate dose and to treat patients for a limited period of time to avoid the complications of steroids. A minority of patients do progress to significant disease, including morbidity and mortality, and further research is needed to determine more appropriate and specific therapy for such situations.

Bronchoalveolar lavage in a patient with recurrence of sarcoidosis after lung transplantation

End-stage pulmonary disease due to sarcoidosis rarely leads to lung transplantation. Once a patient has undergone lung transplantation, sarcoidosis often recurs in the lung allograft. In this case report we show, for the first time, the utility of bronchoalveolar lavage fluid in diagnosing the recurrence of sarcoidosis in the transplanted allograft.

Musculoskeletal and other extrapulmonary disorders in sarcoidosis

Sarcoidosis is a multisystemic inflammatory disease, still of unknown origin, characterized by epithelioid non-caseating granuloma in all affected organs. Granuloma formation is lead by a Th1-type response. The exact mechanism that leads to either progression or spontaneous resolution of the disease is not known. Familial aggregation, and the variations in presentation and severity of sarcoidosis according to ethnic background, are suggestive of a polygenic origin that is still to be determined. The contribution of environmental factors, as well as their interactions with genetic factors, remains to be demonstrated. The clinical presentation, musculoskeletal and other extrapulmonary disorders, as well as patients work-up, are reviewed. Sarcoidosis is often a benign disease. Corticosteroids, either alone or in association with other drugs, are still the mainstay of treatment. Defining clearly who will need treatment and what treatment to be used in a particular patient remains controversial.

Tumour necrosis factor in sarcoidosis and its potential for targeted therapy

Tumour necrosis factor (TNF)-alpha is a potent cytokine involved in the inflammatory reactions of many acute and chronic diseases. Recently, agents that block TNFalpha either directly or indirectly have been successful in the treatment of a variety of immune-mediated inflammatory disorders including rheumatoid arthritis and Crohn's disease. Sarcoidosis is an immune-mediated inflammatory disorder characterised by the formation of granulomas. TNFalpha is important in the initiation and perpetuation of inflammation in sarcoidosis, contributing to the initiation of granulomas and the progression of fibrosis, as well as to nongranulomatous inflammation. Various agents used to treat sarcoidosis affect TNF, including the most widely used drug class, corticosteroids, which are usually effective in blocking TNFalpha release from cells. Other agents that nonspecifically inhibit TNFalpha release include methotrexate, azathioprine and pentoxifylline. Specific TNF-antagonising biological agents such as infliximab and etanercept are being tested in patients with sarcoidosis, with mixed success. Infliximab has been shown to produce clinical improvement and reduce the requirement for corticosteroids in a small number of patients with sarcoidosis. However, as infliximab can be associated with reactivation of tuberculosis, which could be mistaken as worsening sarcoidosis, it should be used with caution in this patient group.

Neurological complications of sarcoidosis

PURPOSE OF REVIEW

The neurological manifestations of sarcoidosis, which occur in 5% of patients with the condition, present in a variety of ways that can be assigned to several broad categories. A comprehensive approach to the diagnosis and management of neurosarcoidosis involves an appreciation of the strategies to confirm a diagnosis of sarcoidosis and neurosarcoidosis and the available therapeutic options.

RECENT FINDINGS

In addition to traditional approaches to the diagnosis of sarcoidosis, positron emission tomography can be used to identify otherwise occult sites of systemic inflammation which can be targeted for biopsy. Although corticosteroids remain the mainstay of treatment, other immunosuppressive and immunomodulatory agents can be used in the multi-modality therapy of sarcoidosis.

SUMMARY

Neurosarcoidosis can be 'staged' with the use of neurodiagnostic testing and diagnosed with varying degrees of certainty. Treatment should be approached within the context of the anticipated clinical course of the patient, avoidance of adverse drug effects, and, as necessary, from the perspective of the comprehensive management of a chronic disease.

Thalidomide

Despite its history as a human teratogen, thalidomide is emerging as a treatment for cancer and inflammatory diseases. Although the evolution of its clinical application could not have been predicted from the tragedy associated with its misuse in the past, its history serves as a lesson in drug development that underscores the need to understand the molecular pharmacology of a compound's activity, including associated toxicities. Here, we summarise the applications for thalidomide with an emphasis on clinical trials published over the past 10 years, and consider our knowledge of the molecular pharmacology of the drug in the context of clinical trial data, attempting to provide a mechanism-guided understanding of its activity.

Future directions in sarcoidosis research: summary of an NHLBI working group

Sarcoidosis is a systemic granulomatous disease of unknown etiology that primarily affects the lungs. The etiology remains unclear; however, environmental, genetic, ethnic, and familial factors probably modify expression of the disease. As an example, African Americans are at greater risk of mortality and morbidity than are white Americans, and more often have a family history of sarcoidosis. Most patients with sarcoidosis recover spontaneously, but some develop chronic, debilitating disease. Corticosteroids and other drugs, although effective at controlling disease activity, may not influence the overall course of disease. Because of the many uncertainties about the pathogenesis, course, and management of sarcoidosis, the National Heart, Lung, and Blood Institute convened a working group to identify future research directions and opportunities for sarcoidosis. These include developing a tissue bank, using novel methods to identify genetic factors, studying the immunopathogenesis with human tissue and animal models, exploring new approaches to diagnose and manage disease, and, finally, conducting randomized controlled trials to assess new therapies.

Sarcoidosis, Race, and Short-term Outcomes Following Lung Transplantation

BACKGROUND

Patients with sarcoidosis, many of whom are African American, may require lung transplantation (LT). Little is known about survival following LT for sarcoidosis.

OBJECTIVE

To determine short-term mortality following LT for sarcoidosis, to evaluate if survival after LT for sarcoidosis is similar to outcomes after LT for other diseases, and to investigate the impact of race on the results of LT.

DESIGN

Retrospective review.

PATIENTS

All patients who underwent LT, irrespective of diagnosis, in the United States between January 1995 and December 2000.

MEASUREMENTS

Vital status at 30 days after LT and cause of death.

RESULTS

During the study period, 4,721 LTs were performed; of these 133 LTs (2.8%) were for sarcoidosis. Approximately 83% of patients with sarcoidosis survived following LT compared to 91% of persons undergoing transplantation for other reasons (p = 0.002). In multivariate analysis controlling both for health insurance status and other factors known to affect survival after LT, patients with sarcoidosis were no more likely to die than persons undergoing transplantation for other conditions (adjusted odds ratio for death, 1.45; 95% confidence interval [CI], 0.84 to 2.48). Significant predictors of mortality included the following: undergoing combined heart-lung transplant, need for mechanical ventilation, treatment in an ICU at time of LT, pre-LT FEV(1), need for supplemental oxygen, and donor age. Both recipient race and donor race significantly affected short-term survival. African-American patients were nearly 50% more likely to die (adjusted odds ratio, 1.49; 95% CI, 1.01 to 2.20). This difference based on race persisted after excluding heart-lung recipients and after controlling for recipient-donor racial mismatch. The most frequent cause of death for patients with sarcoidosis was graft failure, while infection was the primary cause of death among other LT patients.

CONCLUSIONS

Patients with sarcoidosis do as well as patients undergoing LT for other diseases. Race is an important factor affecting survival after LT.

Treatment of cutaneous sarcoidosis with thalidomide

BACKGROUND

Although systemic corticosteroids are effective against cutaneous sarcoidosis, alternative therapies are needed.

OBJECTIVE

We sought to assess the efficacy and tolerance of thalidomide for cutaneous sarcoidosis.

METHODS

We performed a retrospective evaluation of thalidomide (100-200 mg/d) in 12 consecutive patients with cutaneous sarcoidosis treated in a university hospital between 2000 and 2002.

RESULTS

Cutaneous lesions regressed within 1 to 5 months, with an average time of 2 to 3 months for 10 patients. In all, 4 patients achieved complete responses, 6 had partial responses, and 2 had no regression. Nasopharyngeal, pulmonary neurologic, and hepatic symptoms were also attenuated. Thalidomide was well tolerated. The main adverse effect was deep vein thrombosis in 1 patient.

CONCLUSION

Thalidomide efficacy and tolerance in patients with cutaneous sarcoidosis merits further evaluation in a controlled trial.

Newer therapies for cutaneous sarcoidosis: the role of thalidomide and other agents

Skin involvement occurs in a third of patients with sarcoidosis. The type of lesions can range from the transient erythema nodosum to the chronic facial lesion lupus pernio. For some patients with sarcoidosis, lesions on the face or elsewhere on the body may be the major or only indication for therapy. These lesions are often chronic and the use of corticosteroids may lead to more long-term complications. Conventional alternatives to corticosteroids include antimalarial agents, methotrexate, and azathioprine. Recently, several drugs have been studied for chronic cutaneous sarcoidosis; thalidomide has been the most widely used. Thalidomide has been demonstrated to suppress tumor necrosis factor (TNF) release, which may be important at both the initial and chronic phases of the inflammation of sarcoidosis and appears to be crucial as part of the initial granulomatous response. Thalidomide has a different toxicity profile than corticosteroids or immunosuppressives. The usual dosage has recently been investigated in a dose-escalation trial, with the majority of patients responding to 100 mg/day. Drug toxicity has been reported in the sarcoidosis trials. The most serious adverse effect has been peripheral neuropathy, which often resolves by reducing the dose or discontinuing the medication. Other drugs that have been studied for sarcoidosis include infliximab and tetracyclines. Infliximab is a chimeric monoclonal antibody against TNF, and several published reports have shown it to be effective for the treatment of cutaneous sarcoidosis. The efficacy of tetracyclines for cutaneous sarcoidosis could be on the basis of their immunologic properties. In addition, these drugs have potent antimicrobial activity against Propionibacterium acnes; there is increasing evidence to suggest this may be one of the causes of sarcoidosis. However, most of the newer agents for cutaneous sarcoidosis have only been studied in small series. Over the next few years, it is hoped that there will be clinical trials to determine the role of each new therapy in the treatment of cutaneous sarcoidosis.

The TNF-863A allele strongly associates with anticentromere antibody positivity in scleroderma

OBJECTIVE

Scleroderma is characterized by the presence of 3 predominant, yet almost mutually exclusive, antibodies: anticentromere antibody (ACA), antitopoisomerase antibody, and anti-RNA polymerase antibody. The purpose of this study was to investigate tumor necrosis factor (TNF) polymorphisms in scleroderma, with the specific aim of determining whether TNF polymorphisms would prove to be stronger markers for ACA than class II major histocompatibility complex (MHC).

METHODS

We studied 214 UK white scleroderma patients and 354 healthy controls. All subjects were investigated for 5 TNF promoter region polymorphisms by sequence-specific polymerase chain reaction.

RESULTS

We showed that an NF-kappaB binding site polymorphism (known to be functionally relevant) in the TNF promoter region was present in 51.8% of patients with ACA and 16.3% of patients without ACA (chi(2) = 25.1, P = 0.000004 [corrected P = 0.00002]). Using haplotype mapping, we showed that this was a primary TNF association that could explain the previous weak links between ACA production and class II MHC alleles. In marked contrast to our ACA results, HLA class II (especially DRB1*11) appeared to be primary in that it could explain the weaker TNF association with antitopoisomerase production. Further, we observed a separate TNF haplotype to be associated with scleroderma per se, although the level of significance was much lower (chi(2) = 8.7, P = 0.003 [corrected P = 0.02]).

CONCLUSION

We believe these findings may have importance both for the directional pathogenesis of scleroderma progression and for the treatment of scleroderma with anti-TNF agents.

Refractory Sarcoidosis Responding to Infliximab *

Despite aggressive treatment with conventional therapy, sarcoidosis may be progressive and debilitating. Tumor necrosis factor (TNF)-alpha is critical in the genesis and maintenance of granulomatous inflammation. Agents developed to inhibit TNF-alpha have been approved to treat rheumatoid arthritis and inflammatory bowel disease with unprecedented success. As such, physicians are increasingly using these agents to treat patients with other inflammatory diseases, including sarcoidosis. We report a case of refractory sarcoidosis, involving the lung, eyes, skin, and heart, which flared despite aggressive therapy. Oculocutaneous sarcoid dramatically improved after treatment with the anti-TNF antibody infliximab.

Sarcoidosis: benefits of a multidisciplinary approach

It is well established that sarcoidosis is a multisystem disorder of unknown cause(s). Practically no organ is immune to sarcoidosis. It subsides in most cases, but it may worsen and become chronic in others. Pulmonary problems may persist, but also devastating extrapulmonary complications may become apparent. Appropriate management of sarcoidosis is mandatory as it predominantly affects fairly young adults. This requires the attention of pulmonologists as well as specialists from other medical disciplines. Accordingly, when treating sarcoidosis patients, a multidisciplinary approach is recommended that focuses attention on somatic as well as psychosocial aspects of this erratic disorder. Specialists from all participating medical disciplines-including respiratory diseases-may benefit from a multidisciplinary approach and be stimulated to enhance their professional interest and knowledge of sarcoidosis. The benefit of such an approach should be explored in the near future.