Löfgren's syndrome revisited: a study of 186 patients

Association between ACE gene I/D polymorphism and clinical presentation and prognosis of sarcoidosis

Serum angiotensin converting enzyme (SACE) concentration is considered a marker of sarcoidosis activity. This concentration is influenced by an insertion/deletion (I/D) polymorphism of the ACE gene, such that SACE levels follow the pattern DD>ID>II. The aim of our work was to study the relationship between I/D polymorphism and susceptibility to sarcoidosis, as well as the relation between this polymorphism and the clinical presentation and evolution of the disease in 177 sarcoidosis patients. A group of 104 individuals without sarcoidosis was included as control. Genotyping was done by a polymerase chain reaction (PCR) method, and SACE concentration at diagnosis was determined by a kinetic method. No differences were observed in genotype or allele distributions between patients and controls, nor between patients considering the type of presentation (Löfgren versus non-Löfgren) and evolution of the disease (acute versus chronic). As reported for healthy populations, SACE concentrations followed the pattern DD>ID>II in sarcoidosis patients, but significant differences between genotypes existed only in the Löfgren group (p = 0.003) and in acute patients (p = 0.02). SACE concentrations at diagnosis were lower in acute patients (p = 0.05) and in Löfgren's syndrome (p = 0.04), but this seemed to occur only in ID individuals (p = 0.02 and p = 0.01, respectively). No relation was thus found between I/D polymorphism and susceptibility to sarcoidosis, but ACE I/D genotyping may improve the assessment of disease activity, both at diagnosis and during the follow-up of treated and untreated patients.

Löfgren's syndrome: human leukocyte antigen strongly influences the disease course

RATIONALE

Sarcoidosis may consist of a number of distinct disease entities, one of which could be Löfgren's syndrome. Patients with Löfgren's syndrome have an acute onset of erythema nodosum (EN) and/or periarticular inflammation or arthritis of the ankles, with bilateral hilar lymphadenopathy (and in some cases parenchymal infiltrates) and usually fever. There is a known association between HLA-DRB1*03 and Löfgren's syndrome.

OBJECTIVES

To investigate whether human leukocyte antigen type influences clinical manifestations, including the disease course in Löfgren's syndrome.

METHODS

We clinically characterized and HLA-DRB1 typed 301 patients with Löfgren's syndrome. A total of 275 of the patients were followed for more than 2 years and classified as having a nonresolving or a resolving disease.

MEASUREMENTS AND MAIN RESULTS

Almost every DRB1*03-positive patient had a resolving disease within 2 years, and 49% of the DRB1*03-negative patients developed a nonresolving disease. Mucosal granulomas were identified significantly more often in DRB1*03-negative patients. Among DRB1*03-negative patients who were treated with oral steroids at disease onset, 80% developed a nonresolving disease.

CONCLUSIONS

Patients with Löfgren's syndrome have a different disease course depending on whether they are DRB1*03 positive or not. This observation has clinical implications, and by comparing DRB1*03-positive and DRB1*03-negative patients with Löfgren's syndrome, we can search for additional markers of importance for developing a resolving or a nonresolving disease, respectively.

A common haplotype of the C-C chemokine receptor 2 gene and HLA-DRB1*0301 are independent genetic risk factors for Löfgren's syndrome

AIM

Sarcoidosis is a heterogeneous disorder with a strong genetic influence. Genetic factors are also thought to influence disease severity and outcome. We sought to determine whether polymorphisms within CCR2 gene predispose to Löfgren's syndrome--a clinically and genetically distinct sarcoidosis phenotype--and, importantly, whether this association is independent of the known association with the HLA-DRB1*0301 allele.

METHODS

We investigated 5 CCR2 variants and HLA-DRB1*0301 by sequence-specific primer (SSP) polymerase chain reaction (PCR) in 176 Spanish (76 Löfgren's syndrome, 100 controls) and 387 Swedish subjects (126 Löfgren's syndrome, 77 non-Löfgren sarcoidosis, 184 controls).

RESULTS

One of the deduced haplotypes (CCR2 haplotype 2) was associated with Löfgren's syndrome in both Spanish (OR: 2.03, uncorrected P = 0.02; permuted P = 0.041 vs. controls) and Swedish patients (OR: 3.02, uncorrected P = 0.0007; permuted P = 0.0027 vs. non-Löfgren sarcoidosis; OR: 2.46, uncorrected P = 0.0005; permuted P = 0.0031 vs. controls). HLA-DRB1*0301 allele frequency was also increased in Spanish (OR: 3.52, P = 0.0004 vs. controls) and Swedish patients with Löfgren's syndrome (OR: 10.98, P < 0.0001 vs. non-Löfgren sarcoidosis, OR: 7.71, P < 0.0001 vs. controls). Finally, multivariate analysis revealed that the CCR2 association was independent of HLA-DRB1*0301 in both Spanish (P = 0.02 vs. controls) and Swedish cohorts (P = 0.002 vs. non-Löfgren sarcoidosis, P = 0.001 vs. controls).

CONCLUSIONS

This study confirms that CCR2 haplotype 2 and HLA-DRB1*0301 are independent genetic risk factors for Löfgren's syndrome.

Outcome of sarcoidosis

Sarcoidosis is a chronic granulomatous inflammatory disease of unknown etiology with heterogeneous outcome. Based on the natural history or clinical treatment course, the outcomes of cases can be divided into two wings: spontaneous regression (self-limited disease) or progression of extensive fibrotic lesions as a postgranulomatous fibrosis. In addition to examining these outcomes, this article focuses on several related concepts, including chronicity (persistence of the lesions), relapse/recurrence, deterioration, and mortality. It also reviews the outcomes from the point of view of relevant clinical phenotypes, the natural disease course, the effects of treatment, and the effects of lung transplantation. Finally, it considers the effects of pulmonary hypertension, various genetic factors on the outcomes, and the efficacy of several novel therapeutic drugs in treating sarcoidosis.

Pulmonary sarcoidosis

Sarcoidosis is an inflammatory granulomatous disease that is characterized by diverse organ system manifestations, a variable clinical course, and a predilection for affecting relatively young adults worldwide. Abnormalities on chest radiographs are detected in 85% to 95% of patients who have sarcoidosis. Approximately 20% to 50% of patients who have sarcoidosis present with respiratory symptoms, including dyspnea, cough, chest pain, and tightness of the chest. The clinical course and manifestations of pulmonary sarcoidosis are protean: spontaneous remission occurs in approximately two thirds of patients; up to 30% of patients have chronic course of the lung disease, resulting in progressive, (sometimes life-threatening) loss of lung function. Morbidity that correlates to sarcoidosis occurs in 1% to 4% of patients.

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.

Granulomas não-infecciosos: sarcoidose

A sarcoidose é doença granulomatosa não infecciosa de etiologia desconhecida, de cuja patogênese parecem participar os fatores genéticos, imunológicos, ambientais e infecciosos. Vários órgãos podem ser afetados, causando amplo espectro de manifestações clínicas. A pele é acometida em cerca de 20 a 35% dos casos, proporcionando ao dermatologista importante papel no diagnóstico da doença. Epidemiologia, imunologia e tratamento também são discutidos para prover melhor entendimento dessa enfermidade.

Diagnostic value of peripheral lymph node biopsy in sarcoidosis: a report of 67 cases

A peripheral lymph node (PLN) 1 cm or greater was found in 79 of 546 sarcoidosis patients (14.5%) between 1972 and 2005. Seventy-two of the 79 sarcoidosis patients had a lymph node biopsy performed. Sixty-seven of these biopsy specimens were histologically diagnosed as sarcoidosis, whereas five patients had a reactive adenopathy. For patients with histological diagnosis of sarcoidosis, localizations of the biopsies were as follows: cervical (n=21), supraclavicular (n=20), inguinal (n=11), axillary (n=8), epitrochlear (n=5) and submandibular (n=2). At the time of biopsy, 12 patients had stage 0 disease, 37 patients had stage I disease, 14 patients had stage II disease and four patients had stage III disease. Skin involvement (16.4%) was the most frequently observed type of organ involvement in patients who had enlarged PLNs due to sarcoidosis. In the presence of an enlarged PLN in sarcoidosis, biopsy had a greater diagnostic value compared with other methods, as well as having a relatively low cost (approximately US$120) in Turkey. No procedure-related complications were observed. In conclusion, it is recommended that PLNs be thoroughly examined when sarcoidosis is suspected. If an enlarged PLN is found, biopsy should be routinely performed because it is an easy, convenient and practical method, with a low complication risk and a high sensitivity.

Löfgren Syndrome and Peritoneal Involvement by Sarcoidosis

OBJECTIVE

An unusual case of a patient with Löfgren syndrome peritoneal involvement by sarcoidosis.

PATIENT AND METHODS

A 36-year-old woman presented with Löfgren syndrome and an increase in liver enzyme levels. An abdominal CT scan showed multiple nodules on the peritoneum mimicking peritoneal carcinomatosis. Laparoscopy was conducted with biopsy of the peritoneal nodules.

RESULTS

Biopsy specimens from the peritoneum, liver, and bronchi showed noncaseating granulomas, and the search for tuberculosis was negative. Clinical and biological features resolved within 6 months, without therapy with steroids, while a thoracic CT scan as well as an abdominal CT scan showed no change.

CONCLUSION

To our knowledge, this is the first reported case of peritoneal sarcoidosis associated with Löfgren syndrome. A longer follow-up will, however, be required to assess the chronicity of the disease.

Analysis of 275 patients with sarcoidosis over a 38 year period; a single-institution experience

BACKGROUND

Sarcoidosis is a systemic granulomatous disease with unknown etiology.

OBJECTIVES

We evaluated seasonal variation, demographic, clinical and diagnostic features of sarcoidosis in recently diagnosed symptomatic patients in the whole cohort (275 patients) and in the subgroups according to the estimated disease course (subacute course group vs. chronic course group). We also developed a prediction model to predict the course of sarcoidosis using simple clinical and demographic variables.

MATERIAL AND METHODS

Two hundred and seventy-five patients with sarcoidosis. MEASUREMENTS AND STATISTICS: Roger's test, chi-square, t-test and multiple logistic regression were used.

RESULTS

The distribution of cumulative monthly diagnosis was the lowest in November (fall) (p<0.01). Seasonal pattern was influenced by age and gender. Constitutional symptoms, stages 2 and 3 diseases and the absence of erythema nodosum were highly significant parameters for chronic course. Using these variables, the developed model had a specificity of 93.1% and its positive predictive value was 89.5%. Progression of the disease was documented 6.4% in subacute group vs. 32.1% in chronic group (p=0.00001). Preventive effect of smoking was more pronounced in females than in males in our cohort.

CONCLUSIONS

Further well-designed and large prospective studies are required to better understand the importance of these findings, and to validate the prediction model presented here.

Sarcoidosis acutely involving the musculoskeletal system

A 69-year-old man complained of knee pain, subsequent polyarthralgia, and pains of the muscles of the pelvic girdle and thighs. At the same time, erythema of the face and hands appeared. Biopsy of the skin and muscle revealed non-caseating granuloma of epithelioid cells. The level of serum angiotensin-converting enzyme was normal, but that of lysozyme was elevated. Chest X-ray and CT did not show bilateral hilar lymphadenopathy (BHL) but revealed infiltrative ground glass appearance-like shadows of both lungs, and a Ga scintigram disclosed accumulation in the right hilar region, but not in the muscles. These complaints were quickly ameliorated by the administration of prednisolone. The present patient represented a rare case of acute musculoskeletal system involvement in sarcoidosis not typical of Löfgren's syndrome.

Genetics of sarcoidosis: candidate genes and genome scans

Human leukocyte antigen class II allele associations and T-cell receptor beta chain bias in sarcoidosis suggest a specific disease-triggering antigen exposure in a genetically susceptible host. The cause of sarcoidosis has been elusive, but genetics provides one of the few promising avenues to further our understanding. We review the association studies and genome scans used to identify the genes involved in sarcoidosis.

Sex-specific manifestations of Löfgren's syndrome

MOTIVATION

It has been debated whether patients need to have erythema nodosum to be classified as having Löfgren's syndrome. In this study, we have therefore in detail evaluated and compared a large number of patients with an acute onset of sarcoidosis and bilateral hilar lymphadenopathy (BHL), with or without erythema nodosum (EN). This study is important because it may lead to a more accurate definition of Löfgren's syndrome, and an exact phenotype of patients is crucial in modern medical research.

BACKGROUND

Löfgren's syndrome is commonly regarded as a distinct clinical entity.

METHODS

We have in detail evaluated a large group of patients (n = 150) with an acute onset of sarcoidosis with BHL, in most cases with fever, EN, and/or bilateral ankle arthritis or periarticular inflammation. Within this group, 87 patients had EN (EN positive), whereas 63 were without EN (EN negative), though with distinct symmetric ankle inflammation.

RESULTS

EN-positive and EN-negative patients were identical in every aspect except that there were significantly more women in the EN-positive group: 58 women (67%) in the EN-positive group compared with only 17 (27%) women in the EN-negative group (p < 0.0001). In all other aspects, such as age, smoking habits, seasonal clustering of disease onset, rate of positive biopsies, chest radiography, pulmonary function, bronchoalveolar lavage cell distributions including the typically increased CD4/CD8 ratio, and clinical development of the disease, the EN-positive and EN-negative groups were close to identical. The two groups were also identically strongly associated with HLA-DRB1*0301/DQB1*0201, with 60 (69.0%) and 44 (69.8%) patients having this particular HLA type in the EN-positive and EN-negative groups, respectively. Such patients recovered to the same degree-that is, at almost 100%.

CONCLUSIONS

We conclude that manifestations of Löfgren's syndrome differ between men and women, with EN found predominantly in women, whereas a marked periarticular inflammation of the ankles or ankle arthritis without EN is seen preferentially in men.

Magnetic resonance imaging in Löfgren's syndrome: demonstration of periarthritis

In Löfgren's syndrome, pain and swelling commonly involves the ankle joints. In this prospective case series, the magnetic resonance imaging findings of ankle joint involvement are described. Extensive subcutaneous and soft tissue oedema was commonly seen around the ankles. Bone, cartilage, ligaments and tendons were typically uninvolved. Small amounts of joint and tenosynovial fluid were present without evidence of synovial thickening or synovitis. The fluid is probably reactive to adjacent inflammation in the para-articular soft tissues and probably not representing a primary site of involvement. These findings demonstrate that the arthritis in Löfgren's syndrome stems primarily from periarthritis. This is consistent with prior descriptions using ultrasonography.

Analysis of 87 patients with Lofgren's syndrome and the pattern of seasonality of subacute sarcoidosis

BACKGROUND AND OBJECTIVE

Sarcoidosis is a multisystem disease of unknown aetiology. The seasonality of sarcoidosis in symptomatic, recently diagnosed patients with Löfgren's syndrome was evaluated to help better understand the possible causative factor(s) in the pathogenesis of sarcoidosis.

METHODS

Four hundred and ninety-two consecutive patients with sarcoidosis were investigated. The demographic and clinical features, course of the disease, initial diagnostic methods and both the month and age at initial diagnosis for each patient were analysed. Roger's test for cyclic variation was used to determine the significance of any seasonal variation of incidence.

RESULTS

Löfgren's syndrome was diagnosed in 87 patients (18%). The diagnosis of sarcoidosis was delayed in 45% of subjects (mean: 11.2 weeks). The distribution of cumulative monthly presentations peaked in May (spring) and was the lowest in January (winter) and November (autumn) (P < 0.001). The seasonal pattern was also influenced by age and gender (P < 0.05). At the onset, arthralgia was present in 46%, cough or dyspnoea in 37%, constitutional symptoms in 32% and skin lesions in 30% of the patients.

CONCLUSIONS

In this study, there were differences in the amplitude of the seasonal variation by age and by gender. Well-designed prospective studies are required to better understand the importance of the findings we respect to the pathogenesis of the disease.

Sarcoidosis with acute recurrent polyarthritis and hypercalcemia

A 45-year-old woman had bleary eyes and recurrent episodes of fever and arthritis in the knees and ankles. The patient had anterior uveitis, negative findings of the tuberculin test, and an increased serum lysozyme level, but bilateral hilar lymphadenopathy (BHL) was absent. During the course of her disease, the serum calcium and angiotensin-converting enzyme levels gradually increased to above the normal level, and the patient was clinically diagnosed as having sarcoidosis. The clinical features of arthritis were typical of those of Löfgrens syndrome although BHL and erythema nodosum were absent. The patient was successfully treated with 15 mg/day of prednisolone.

Acute-onset sarcoidosis with erythema nodosum and polyarthralgia (Löfgren's syndrome) in Japan: a case report and a review of the literature

Löfgren's syndrome is an acute form of sarcoidosis that is characterized by erythema nodosum (EN), bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. This syndrome is common among white people, but is considered rare among Japanese people. We present the case of a 26-year-old Japanese woman with Löfgren's syndrome. The patient complained of polyarthritis and EN of the lower extremities that lasted for 3 months. A chest radiograph revealed BHL and nodular shadows. The angiotensin-converting enzyme (ACE) level was within the normal range. Transbronchial lung biopsy revealed a noncaseating granuloma with giant cells. Six Japanese cases of Löfgren's syndrome have been reported previously. Five of the seven Japanese patients with Löfgren's syndrome had normal ACE levels; all of them exhibited BHL. Löfgren's syndrome should be considered as a possibility when examining a patient with EN and articular symptoms, even if the patient is Japanese.

Late-onset and Rare Far-advanced Pulmonary Involvement in Patients with Sarcoidosis in Taiwan

BACKGROUND

Sarcoidosis is still considered a rare multisystem disorder in Taiwan, and data on the disease course and outcome are limited. We analyzed the clinical manifestations, disease course and complications in Taiwanese patients with sarcoidosis.

METHODS

A retrospective cohort design was used. Fifty-six patients with sarcoidosis diagnosed between 1985 and 2004 were included. Their clinical features, laboratory findings at initial presentation, disease course, and complications were analyzed.

RESULTS

Forty-three patients (76.8%) were female. The mean age at symptom onset was 47 years. The most common clinical symptoms were pulmonary (82.1%), cutaneous (23.2%), ophthalmic (19.6%), and articular (17.8%). Only two patients presented with Löfgren's syndrome. There was a seasonal variation in disease onset, with higher incidence in winter and early spring. No advanced pulmonary involvement was noted. Elevated levels of serum angiotensin converting enzyme (sACE) were found in 72.5% (29/40) of patients with active sarcoidosis, and significantly higher levels of sACE were found in patients with lung involvement (27.98+/-1.71 IU/L vs. 18.2+/-2.76 IU/L; p<0.01). In 50% (20/40) of patients, sACE levels declined significantly in parallel with clinical remission (24.75+/-1.53 IU/L vs. 16.33+/-1.21 IU/L; p<0.05). Spontaneous complete remission was found in 20.7% of patients, whereas 39.6% of patients with multiple extrapulmonary involvement responded poorly to intensive corticosteroids plus various immunosuppressants.

CONCLUSION

In this series, the mean age of disease onset was in middle age (mean, 47 years old), there was a low incidence of Löfgren's syndrome (3.6%), and no patients had advanced pulmonary syndrome. The results of this study also suggest that sACE might be a marker of pulmonary involvement that is also useful in monitoring disease activity.

Blau syndrome and related genetic disorders causing childhood arthritis

Blau Syndrome (BS) is an inheritable disorder characterized by granulomatous polyarthritis, panuveitis, and exanthema. It was described by Edward Blau in 1985, the same year in which Douglas Jabs reported a very similar family. Clinically indistinguishable from early onset sarcoidosis (EOS), both are now known to share a mutated form of caspase recruitment domain-15 (CARD 15), a protein involved in activation of nuclear factor kappa B which is in turn an up-regulator of pro-inflammatory cytokine transcription. An association between BS and EOS was suspected for years given the striking similarities of the core triad (arthritis-uveitis-dermatitis) and a common emerging pattern of systemic involvement. Hence, the familial form (BS) and the sporadic form (EOS) are almost certainly the same illness/defect, inherited in the first and acquired in the second as a result in most cases of a de novo mutation. Another form of granulomatous arthritis with uveitis, Crohn's disease, has also been associated with mutations in CARD 15 (albeit at a different domain) and despite similar phenotypes there are obvious differences including gut inflammation and pyoderma gangrenosum in Crohn's disease. This paper will review the clinical characteristics of these three disorders and their association with mutations in the CARD 15 gene.

Study of C-C Chemokine Receptor 2 Alleles in Sarcoidosis, with Emphasis on Family-based Analysis

Prevailing models of sarcoidosis pathogenesis involve the activation of alveolar macrophages, aggregation of CD4+ T lymphocytes, and their accumulation in epithelioid cell granulomas. Increasing evidence suggests that each of these steps is modified by the host genetic constitution. Consequently, candidate susceptibility genes have been selected based on their potential function under this model. The C-C chemokine receptor 2 (CCR2) is involved in Th1 immune activity by recruiting competent cells and possibly by balancing response. CCR2 gene variants have been shown to be associated with sarcoidosis or, more specifically, with Löfgren's syndrome, a distinct form of acute sarcoidosis. We have studied three CCR2 gene polymorphisms (c.190G>A, c.840C>T, and c.4385A>T) in an extended sample of 1,203 patients with sarcoidosis and their relatives. Case-control comparisons and family-based genetic analyses did not support previous findings of an association between CCR2 gene variability and the risk of sarcoidosis. However, they confirmed linkage disequilibrium and showed positive linkage results (p = 0.034) and therefore suggest a susceptibility gene in the surrounding chromosomal region.

Manifestations ostéo-articulaires de la sarcoïdose

OBJECTIVE

Osteo-articular sarcoidosis may be evoked in the presence of peripheral articular manifestations or bone lesions that are sometimes asymptomatic. The aim of this work is to describe clinical and progressive features of sarcoidosis with osteo-articular involvement.

METHODS

Our retrospective study concerned 18 patients presenting with osteo-articular sarcoidosis from 1985 to 1999. We included patients with clinical diagnosis suggestive of sarcoidosis and with at least one positive biopsy.

RESULTS

Among 35 cases of sarcoidosis, 18 patients had an osteo-articular manifestation (51.42%), which revealed the disease in 2 patients. The female sex was predominant (sex ratio M/F of 0.12), the mean age was 47 years and the time before diagnosis was 3.6 years. Articular involvement was the most frequent. Inflammatory joint pains were present in 11 cases, a Lofgren syndrome in 2 cases, a chronic arthritis in 4 cases and acute monoarthritis of the elbow in 1 case. A female patient exhibited a probable association with a spondylarthropathy. The bone involvement, revealing the disease in 1 case, was also noted in 5 cases, located exclusively on hands; this sarcoidosal dactyly was represented in 2 cases in the form of phalangeal geodes, in wired form (2 cases) and in large bulla form (1 case). The bone biopsy when it was performed was positive in all 3 cases. The patients responded well to corticosteroids.

CONCLUSION

The osteo-articular involvement of sarcoidosis is polymorphic and can reveal the disease or may appear during the course of its progression.

Radiologic manifestations of sarcoidosis in various organs

Sarcoidosis is a systemic disorder of unknown cause with a wide variety of clinical and radiologic manifestations. The diagnosis is usually made on the basis of these manifestations supported by histologic findings. Systemic manifestations (eg, Löfgren syndrome, Heerfordt syndrome) are commonly seen at clinical examination. Bilateral hilar lymphadenopathy is the most common radiologic finding-frequently with associated pulmonary infiltrates-and typically has a characteristic perivascular distribution at high-resolution chest computed tomography. Radiologic findings in the short tubular bones of the hands and feet and magnetic resonance imaging findings of nodular involvement of muscle are often sufficient to raise suspicion for sarcoidosis. In the liver, spleen, kidneys, and scrotum, coalescing granulomas form nodules whose imaging features may occasionally be nonspecific, although familiarity with the relevant clinical settings will be helpful in recognizing the presence of sarcoidosis. Radiologic recognition of cardiac and central nervous system involvement is also important because patients may be only mildly symptomatic. The clinical course and prognosis of sarcoidosis are highly variable, often correlating with the mode of onset. Familiarity with the clinical and radiologic features of sarcoidosis in various anatomic locations plays a crucial role in diagnosis and management.

Rheumatologic manifestations of sarcoidosis

PURPOSE OF REVIEW

This review emphasizes the importance of the rheumatological signs and symptoms in the presentation of sarcoidosis. Often the presence of musculoskeletal findings may lead to the diagnosis of the disease and the institution of the appropriate treatment.

RECENT FINDINGS

There have been significant advances in the treatment of sarcoidosis with the use of biologic agents for recalcitrant and severe manifestations of the disease as well as some new data regarding pathogenetics and new applications of diagnostic imaging studies such as positron emission tomography scanning.

SUMMARY

Although pulmonary disease is the most frequent manifestation of sarcoidosis, musculoskeletal symptoms are not only common, but may be the initial presentation of this systemic inflammatory process and could mimic other arthritic and autoimmune disorders. This article focuses on the rheumatological aspects of sarcoidosis and includes a review of the most recent literature, which shows new data on the diagnosis, pathogenesis, and treatment of this condition.

Les splénomégalies sarcoïdosiques : caractéristiques cliniques et évolutives. À propos de 17 observations

PURPOSE

To describe the clinical features, biological datas and outcome of patients with systemic sarcoidosis and splenomegaly.

METHODS

A retrospective analysis of 17 patients presenting splenomegaly and sarcoidosis with histological proof.

RESULTS

Splenomegaly was clinically perceptible in 13 patients, with a spleen size that extended 4 cm or more below the costal margin in 11 patients. It was painful in five cases. The more frequent clinical features are constitutional symptom (fever in 9 cases) and hepatomegaly (N =7). Chest X-ray showed bilateral hilar lymphadenopathy in nine patients and no abnormality in five cases. Serum angiotensin converting enzyme levels were elevated in 81% of cases. Thrombopenia (N =5) and hypersplenism (N =5) were also observed. Corticosteroid were given to 88% with a good clinical and biological response including a decrease in the spleen volume. Corticotherapy and splenectomy (performed in two patients to rule out lymphoma) didn't change outcome of disease. Sarcoidosis is often chronical (82%) and extensive.

CONCLUSION

Splenomegaly may be present in sarcoidosis. Management is not standardized. Corticosteroid is indicated for symptomatic or massive splenomegaly. Splenomegaly is frequently in chronic and extensive sarcoidosis.

Older Sarcoidosis Patients: Experience of a Medical Center in Turkey

OBJECTIVES

Although sarcoidosis is classically defined to be a disease of young adults, it might also be seen at older ages. There are very few clinical studies which focus on the features of patients diagnosed at older ages. In this study, we tried to determine the frequency of patients diagnosed at or above 50 years of age and to compare the clinical and demographic features of these subjects with other sarcoidosis patients.

METHODS

We evaluated the general clinical features of sarcoidosis patients more than 50 years of age who were diagnosed at our center within a 36-year period. We also compared the clinical features of older sarcoidosis patients with the features of other patients.

RESULTS

Of 579 sarcoidosis patients being followed up at our center, 102 (17.7%) were older than 50 years of age at the time of initial diagnosis. The female to male ratio in this group was higher than the ratio in other sarcoidosis patients (3.43 versus 1.85, P = 0.015). When the features of older patients were compared with other sarcoidosis patients, extrapulmonary involvement was observed to be more common in this group (P < 0.001). By contrast, arthritis or arthralgia (P < 0.001), clinical presentation in the form of Löfgren syndrome (P < 0.001), erythema nodosum (P < 0.001), and uveitis (P = 0.006) were less frequent.

CONCLUSIONS

Although generally presenting as a disease of the young, in many subjects sarcoidosis is diagnosed at older ages, and this study indicates that the clinical features of sarcoidosis in older subjects differ from those found among younger patients.

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.

Löfgren syndrome in Turkey

In the 36-year period between 1966 and 2002, 514 patients were diagnosed with sarcoidosis at Cerrahpaşa Medical Faculty, Istanbul, Turkey, and of these 98 (19.1%) had Löfgren syndrome. The frequency of female patients with Löfgren was higher than the frequency among other sarcoidosis patients (female:male ratio 4.8 vs. 1.64; P < 0.001). Erythema nodosum was diagnosed in 72.4% of the subjects and arthritis or arthralgia was diagnosed in 51%. Erythema nodosum and arthritis or arthralgia were more frequent in Löfgren; however, pulmonary parenchymal involvement was more frequent in other sarcoidosis patients (all P-values < 0.001).

Papular sarcoidosis of the knees: a clue for the diagnosis of erythema nodosum-associated sarcoidosis

BACKGROUND

In recent years we have systematically explored the skin whenever sarcoidosis was suggested and we have observed with increasing frequency the presence of granulomatous cutaneous lesions of sarcoidosis involving the knees.

OBJECTIVE

We sought to evaluate the specific cutaneous lesions of sarcoidosis involving the knees.

METHODS

A total of 18 patients with biopsy-proven specific cutaneous sarcoidosis predominantly involving the knees were included in the study. Biopsy specimens were evaluated under polarized light.

RESULTS

Of these cases, 4 corresponded to scar-sarcoidosis, 1 to plaque-type sarcoidosis, and 13 were an admixture of papules and minute scars frequently associated with erythema nodosum (papular sarcoidosis of the knees). Foreign particles were observed in 10 of 13 patients with papular sarcoidosis.

CONCLUSION

Papular sarcoidosis of the knees can be considered a frequent form of cutaneous sarcoidosis, mainly observed in acute forms of the disease, and frequently associated with erythema nodosum.

Sarcoidosis

There have been several new insights into the cause and treatment of sarcoidosis. Studies of genetic variation have shown that specific genetic polymorphisms are associated with increased risk of disease or affect disease presentation. These polymorphisms include variation of MHC and cytokines such as tumour necrosis factor (TNF). Not all investigators have come to the same conclusion, suggesting an interaction of various factors, including the patient's ethnic origin. Treatment of sarcoidosis varies considerably. Patients with symptomatic disease for more than 2-5 years have been of particular interest. Corticosteroids remain the standard of care in such cases, but immunosuppressive drugs have proved steroid-sparing in many patients. New agents, including pentoxifylline, thalidomide, and infliximab have proved useful in selected cases. The effectiveness of these agents seems to lie in their ability to block TNF, especially in the treatment of chronic disease.

Endocrine aspects of neurosarcoidosis

The involvement of the hypothalamus and/or pituitary gland by granulomatous, infiltrative or autoimmune diseases is a rare condition of non-tumoral-non-vascular acquired hypothalamic dysfunction and hypopituitarism. In this paper, we present the case of a 26-year-old woman, who showed an amenorrhea-galactorrhea syndrome with hypogonadotropic hypogonadism due to an isolated hypothalamic-peduncular localization of neurosarcoidosis. Acquired GH deficiency was also demonstrated. This clinical case provided the opportunity for a review of the endocrine aspects linked to brain infiltrative diseases that may affect the hypothalamic-pituitary function, with a focus upon neurosarcoidosis. Sarcoidosis is a pathogen-free granulomatous disease that affects both the central and peripheral nervous system in 5-16% of patients. In most cases, such involvement by sarcoidosis occurs within a multi-systemic disease, but disease localization limited to the nervous system may also be observed. Endocrine manifestations of neurosarcoidosis disclose "chameleon-like" clinical pictures, which are usually expressed by the evidence of hypothalamic dysfunction, diabetes insipidus, adenopituitary failure, amenorrhea-galactorrhea syndrome, in isolated fashion or variedly combined. More rarely, inappropriate anti-diuretic hormone secretion, isolated secondary hypothyroidism, adrenal insufficiency or altered counter-regulation of glucose homeostasis have been reported. Neurosarcoidosis is often hard to diagnose, especially when the neurological localization of the disease is not accompanied by other systemic localizations or by specific signs of the disease, and when the lesion is too deep to obtain bioptic confirmation. The study of cerebrospinal fluid and blood lymphocyte sub-populations, integrated by MRI and nuclear scans (67GalIium uptake and 111Indium-pentetreotide, Octreoscan), may be helpful for a correct diagnosis. Therapy with corticosteroid and immunosuppressive drugs, such as cyclosporine A, and other treatment approaches to neurosarcoidosis are also accounted for.

Sarcoid arthritis: clinical characteristics, diagnostic aspects, and risk factors

OBJECTIVES

(a) To describe the clinical characteristics of acute sarcoid arthritis and the diagnostic value of its presenting clinical features; (b) to evaluate whether disease onset is seasonal; and (c) to evaluate whether smoking behaviour or the presence of HLA class II alleles is a risk factor for the disease.

METHODS

579 consecutive patients with recent onset arthritis who had been newly referred to a rheumatology outpatient clinic were included in a prospective cohort study. The presenting clinical features, the smoking behaviour, and the results of HLA-DQ and HLA-DR DNA typing of 55 patients with sarcoid arthritis, 524 patients with other arthritides of recent onset, and samples of the normal population were compared.

RESULTS

In all cases the disease showed a self limiting arthritis and overall good prognosis. The diagnostic ability of a combination of four clinical features--symmetrical ankle arthritis, symptoms of less than two months, age below 40 years, and erythema nodosum--was exceptionally high. When test positivity is defined as the presence of at least three of four criteria the set rendered a sensitivity of 93%, a specificity of 99%, a positive predictive value of 75%, and a negative predictive value of 99.7%. The disease clustered in the months March-July. The disease was negatively associated with smoking (odds ratio (OR) 0.09; 95% confidence interval (95% CI) 0.02 to 0.37) and positively associated with the presence of the DQ2 (DQB1*0201)-DR3 (DRB1*0301) haplotype (OR 12.33; 95% CI 5.97 to 25.48).

CONCLUSION

The disease entity acute sarcoid arthritis has highly diagnostic clinical features. The seasonal clustering, the protective effect of smoking, and the association with specific HLA class II antigens support the hypothesis that it results from exposure of susceptible hosts to environmental agents through the lungs.