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Samalia PD, Lim LL, Niederer RL. Insights into the diagnosis and management of sarcoid uveitis: A review. Clin Exp Ophthalmol 2024; 52:294-316. [PMID: 38385625 DOI: 10.1111/ceo.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.
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Affiliation(s)
- Priya D Samalia
- Department of Opthalmology, Te Whatu Ora Southern, Dunedin, New Zealand
- Otago School of Medicine, University of Otago, Dunedin, New Zealand
| | - Lyndell L Lim
- The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
| | - Rachael L Niederer
- Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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2
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Doyle D, Browne U, Brickley A, Murphy D. Vitamin D-induced hypercalcaemia and acute kidney injury in sarcoidosis. BMJ Case Rep 2023; 16:e250580. [PMID: 36690393 PMCID: PMC9872448 DOI: 10.1136/bcr-2022-250580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Vitamin D deficiency is relatively common, and its management in patients with sarcoidosis is challenging due to the risk of hypercalcaemia. Our patient had an autologous stem cell transplant for multiple sclerosis and was given high-dose vitamin D concurrently with immunosuppressive therapy. The patient subsequently presented with symptomatic hypercalcaemia and an acute kidney injury. A clinical and biochemical recovery was reached by withdrawing vitamin D and administering intravenous fluids. Interestingly, new evidence suggests that activated vitamin D can actually dampen the inflammatory process in sarcoidosis, and this was reflected in a reduction of our patient's serological markers of sarcoidosis activity. One large study found no significant risk of hypercalcaemia when low doses of vitamin D were used in sarcoidosis. Where indicated, and until clear guidelines are established, we suggest using low doses of vitamin D with cautious monitoring of calcium and renal function.
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Affiliation(s)
- Dominic Doyle
- Respiratory, Cork University Hospital, Cork, Ireland
| | - Una Browne
- Respiratory, Cork University Hospital, Cork, Ireland
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3
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The Risk of Sarcoidosis Misdiagnosis and the Harmful Effect of Corticosteroids When the Disease Picture Is Incomplete. Biomedicines 2023; 11:biomedicines11010175. [PMID: 36672683 PMCID: PMC9855435 DOI: 10.3390/biomedicines11010175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
Sarcoidosis is a complex granulomatous disease of unknown etiology. Due to the heterogeneity of the disease, the diagnosis remains challenging in many cases, often at the physician's discretion, requiring a thorough and complex investigation. Many other granulomatous diseases have the potential to mimic sarcoidosis, whether infectious, occupational, or autoimmune diseases and starting an unnecessary corticosteroid treatment can worsen the patient's prognosis, leading to side effects that can be harder to treat than the actual disease.
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Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology. The pathogenesis rests on an aberrant T cell response to unidentified antigens in individuals predisposed by genetic and environmental factors. Increased expression of polarized macrophages and disequilibrium between effector and regulator T cells contribute to the formation of noncaseating granulomas, that are frequently found in affected organs. The main kidney abnormalities in sarcoidosis are granulomatous interstitial nephritis (GIN) and hypercalcemia-related disorders. The clinical diagnosis is difficult. The outcome is variable, ranging from spontaneous remission to end-stage kidney disease (ESKD). Early diagnosis and prompt treatment with corticosteroids can improve the prognosis. Hypercalcemia may be responsible for acute kidney injury (AKI) caused by vasoconstriction of afferent arterioles. Complications of persistent hypercalcemia include nephrocalcinosis and renal stones. In patients with ESKD, dialysis and transplantation can offer results comparable to those observed in patients with other causes of kidney failure. Based on a review of the literature, we present an overview of the etiopathogenesis, the renal manifestations of sarcoidosis and their complications, management and prognosis.
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Mogal MR, Sompa SA, Junayed A, Mahmod MR, Abedin MZ, Sikder MA. Common genetic aspects between COVID-19 and sarcoidosis: A network-based approach using gene expression data. Biochem Biophys Rep 2022; 29:101219. [PMID: 35128085 PMCID: PMC8803645 DOI: 10.1016/j.bbrep.2022.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 11/21/2022] Open
Abstract
The pandemic situation of novel coronavirus disease 2019 (COVID-19) is a global threat on our current planet, with its rapid spread and high mortality rate. Sarcoidosis patients are at high risk to COVID-19 severity for having lung injuries as well as treating with immunosuppressive agents. So, physicians are in dilemma whether they should use immunosuppressive agents or not for the patients with sarcoidosis history and COVID-19 infection. Therefore, common factors should be identified to provide effective treatment. For determining the common genes between COVID-19 and sarcoidosis, GSE164805 and GSE18781 were retrieved from the Gene Expression Omnibus (GEO) database. Common upregulated genes were identified by using R language to investigate their involved pathways and gene ontologies (GO). With the aid of the STRING Cytoscape plugin tool, protein-protein interactions (PPIs) network was constructed. From the PPIs network, Hub genes and essential modules were detected by using Cytohubba, and MCODE respectively. For hub genes, TFs, TFs-miRNA, and drug, interaction networks were built through the NetworkAnalyst web platform. A total of 34 common upregulated genes were identified and among them, five hub genes, including TET2, MUC5AC, VDR, NFE2L2, and BCL6 were determined. In addition, a cluster having VDR and NFE2L2 was detected from the PPIs network. Moreover, 32 transcription factors and 9 miRNA were recognized for hub genes. Furthermore, vitamin D and some of its analogous compounds were obtained from the drug interaction network. In conclusion, hub genes identified in this study might have potential roles in modulating COVID-19 infection and sarcoidosis. However, further studies are required to corroborate this study. Sarcoidosis patients are at high risk to COVID-19 severity. This study aimed to find out common genetic factors for COVID-19 and Sarcoidosis. 34 common upregulated genes were identified from GSE164805 and GSE18781 datasets. From common upregulated genes, five hub genes, VDR, NFE2L2, BCL6, TET2, and MUC5AC, were recognized. Hub genes associated with miRNA, TFs, and drug molecules were also identified.
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6
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Lupsa BC, Insogna KL, Micheletti RG, Caplan A. Corticosteroid use in chronic dermatologic disorders and osteoporosis. Int J Womens Dermatol 2022; 7:545-551. [PMID: 35024411 PMCID: PMC8721058 DOI: 10.1016/j.ijwd.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/27/2021] [Accepted: 07/31/2021] [Indexed: 12/03/2022] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) is a frequently encountered and serious side effect of glucocorticoid use. Bone loss leading to an increased risk for fracture occurs early in the use of glucocorticoids, yet patients at risk for this complication are often undertreated. All physicians prescribing glucocorticoids should therefore be familiar with a basic approach to anticipating and preventing GIOP when starting patients on glucocorticoid therapy. This manuscript and its case vignettes are designed to help dermatologists assess and manage bone health to prevent GIOP in patients receiving glucocorticoid therapy.
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Affiliation(s)
- Beatrice C Lupsa
- Yale School of Medicine, Department of Medicine (Endocrinology), New Haven, Connecticut
| | - Karl L Insogna
- Yale School of Medicine, Department of Medicine (Endocrinology), New Haven, Connecticut
| | - Robert G Micheletti
- Department of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Avrom Caplan
- NYU Grossman School of Medicine, The Ronald O. Perelman Department of Dermatology, New York, New York
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Asymptomatic, reddish-brown papules and plaques in an elderly Japanese woman. JAAD Case Rep 2022; 21:179-181. [PMID: 35242974 PMCID: PMC8881601 DOI: 10.1016/j.jdcr.2021.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Chandran R, Nagendra L, Acharya S, Hosmane GB, Shetty V, Kellarai A, KR B. Vitamin D Supplementation in Sarcoidosis: A Double-Edged Sword. JOURNAL OF HEALTH AND ALLIED SCIENCES NU 2021. [DOI: 10.1055/s-0041-1736280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractSarcoidosis is complicated by disordered vitamin D and calcium metabolism, which has important implications on disease activity and bone health. Although the majority of the patients with sarcoidosis are typically deficient in 25-hydroxyvitamin D, repletion of vitamin D is controversial in light of the hypercalcemia risk. Presently, there are no clear guidelines regarding vitamin D supplementation as a part of osteoporosis prevention in patients with vitamin D deficiency and sarcoidosis. We report a patient with sarcoidosis who presented with severe hypercalcemia following vitamin D supplementation and review the debated role of vitamin D supplementation in vitamin D-deficient sarcoid patients.
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Affiliation(s)
- Rishikesh Chandran
- Department of General Medicine, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Lakshmi Nagendra
- Department of Endocrinology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Shrikrishna Acharya
- Department of Endocrinology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | | | - Vijith Shetty
- Department of Oncology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Adithi Kellarai
- Department of General Medicine, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Bhagavan KR
- Department of General Surgery, K.S Hegde Medical Academy, Mangalore, Karnataka, India
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Werner J, Rivera N, Grunewald J, Eklund A, Iseda T, Darlington P, Kullberg S. HLA-DRB1 alleles associate with hypercalcemia in sarcoidosis. Respir Med 2021; 187:106537. [PMID: 34325227 DOI: 10.1016/j.rmed.2021.106537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/19/2021] [Accepted: 07/03/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The mechanisms behind and which patients are at risk of developing sarcoidosis associated hypercalcemia (SAHC) have not been addressed. Different human leukocyte antigen (HLA) alleles associate with disease phenotypes in sarcoidosis. Insights into associations between HLA alleles, clinical phenotype and calcium levels may provide clues to mechanisms behind SAHC and help monitoring patients at risk for SAHC. AIMS AND OBJECTIVES To identify any HLA-association with SAHC, and to phenotypically characterize this patient group. METHODS 66 patients with SAHC (s-Ca2+>1.33 mmol/L) and 150 normocalcemic patients as controls were identified in a cohort of sarcoidosis patients. Data on HLA-DRB1 alleles, sex, angiotensin-converting enzyme (ACE), creatinine, extrapulmonary manifestations (EPM), age at sarcoidosis diagnosis, and how long after diagnosis SAHC emerged, were retrieved. RESULTS HLA-DRB1*04 was more common in patients with SAHC and the proportion of patients with HLA-DRB1*04 increased the more pronounced hypercalcemia. In patients with s-Ca2+>1.4 mmol/L, 20 out of 30 carried the HLA-DRB1*04 allele (67%, p < 0.01). Patients with SAHC more often disclosed renal insufficiency, elevated ACE, EPM, and a non-resolving disease than controls. The mean duration between sarcoidosis diagnosis and detection of SAHC was 1.39 years. CONCLUSIONS SAHC is associated with a more severe disease phenotype, particularly patients carrying the HLA-DRB1*04 allele are at higher risk for SAHC. HLA-assessment in the clinic can be a way to identify these patients. The results provide a basis for future studies on the connection between HLA-DRB1*04 and SAHC mechanisms.
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Affiliation(s)
- Joanna Werner
- Department of Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, 171 76, Stockholm, Sweden; Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Natalia Rivera
- Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Johan Grunewald
- Department of Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, 171 76, Stockholm, Sweden; Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Anders Eklund
- Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Tomoko Iseda
- Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Pernilla Darlington
- Department of Internal Medicine, Sjukhusbacken 10, Södersjukhuset, 118 83, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset and Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Susanna Kullberg
- Department of Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, 171 76, Stockholm, Sweden; Department of Medicine Solna, Respiratory Medicine Division, Karolinska Institutet, 171 77, Stockholm, Sweden.
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10
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Gazitt T, Elias M, Feld J, Lavi I, Haddad A, Bishara-Garzuzi R, Elhija MA, Kibari A, Zisman D. Implementation of recommendations for prevention of glucocorticosteroid-induced osteoporosis in hospitalized patients. Clin Rheumatol 2021; 40:4361-4363. [PMID: 34159492 DOI: 10.1007/s10067-021-05820-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/07/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Tal Gazitt
- Rheumatology Unit, Carmel Medical Center, Michal 7 St, 3436212, Haifa, Israel.
| | - Muna Elias
- Rheumatology Unit, Carmel Medical Center, Michal 7 St, 3436212, Haifa, Israel
| | - Joy Feld
- Rheumatology Unit, Carmel Medical Center, Michal 7 St, 3436212, Haifa, Israel
| | - Idit Lavi
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Amir Haddad
- Rheumatology Unit, Carmel Medical Center, Michal 7 St, 3436212, Haifa, Israel
| | | | - Muhanad Abu Elhija
- Rheumatology Unit and Internal Medicine A Ward, Carmel Medical Center, Haifa, Israel
| | - Adi Kibari
- Rheumatology Unit and Internal Medicine B Ward, Carmel Medical Center, Haifa, Israel
| | - Devy Zisman
- Rheumatology Unit, Carmel Medical Center, Michal 7 St, 3436212, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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11
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Gerke AK. Treatment of Sarcoidosis: A Multidisciplinary Approach. Front Immunol 2020; 11:545413. [PMID: 33329511 PMCID: PMC7732561 DOI: 10.3389/fimmu.2020.545413] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
Sarcoidosis is a systemic disease of unknown etiology defined by the presence of noncaseating granulomatous inflammation that can cause organ damage and diminished quality of life. Treatment is indicated to protect organ function and decrease symptomatic burden. Current treatment options focus on interruption of granuloma formation and propagation. Clinical trials guiding evidence for treatment are lacking due to the rarity of disease, heterogeneous clinical course, and lack of prognostic biomarkers, all of which contribute to difficulty in clinical trial design and implementation. In this review, a multidisciplinary treatment approach is summarized, addressing immunuosuppressive drugs, managing complications of chronic granulomatous inflammation, and assessing treatment toxicity. Discovery of new therapies will depend on research into pathogenesis of antigen presentation and granulomatous inflammation. Future treatment approaches may also include personalized decisions based on pharmacogenomics and sarcoidosis phenotype, as well as patient-centered approaches to manage immunosuppression, symptom control, and treatment of comorbid conditions.
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Affiliation(s)
- Alicia K Gerke
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
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12
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Abstract
After the initial description of extrarenal synthesis of 1,25-dihydroxyvitamin D (1,25-(OH)2D) three decades ago, extensive progress has been made in unraveling the immunomodulatory roles of vitamin D in the pathogenesis of granulomatous disorders, including sarcoidosis. It has been shown that 1,25-(OH)2D has dual effects on the immune system, including upregulating innate immunity as well as downregulating the autoimmune response. The latter mechanism plays an important role in the pathogenesis and treatment of sarcoidosis. Vitamin D supplementation in patients with sarcoidosis has been hampered owing to concerns about the development of hypercalcemia and hypercalciuria given that extrarenal 1-α hydroxylase is substrate dependent. Recently, a few studies have cast doubt over the mechanisms underlying the development of hypercalcemia in this population. These studies demonstrated an inverse relationship between the level of vitamin D and severity of sarcoidosis. Consequently, clinical interest has been piqued in the use of vitamin D to attenuate the autoimmune response in this disorder. However, the development of hypercalcemia and the attendant detrimental effects are real possibilities. Although the average serum calcium concentration did not change following vitamin D supplementation, in two recent studies, hypercalciuria occurred in one out of 13 and two out of 16 patients. This review is a concise summary of the literature, outlining past work and newer developments in the use of vitamin D in sarcoidosis. We feel that larger-scale placebo-controlled randomized studies are needed in this population. Since the current first-line treatment of sarcoidosis is glucocorticoids, which confer many systemic adverse effects, and steroid-sparing immunosuppressant treatment options carry additional risks of adverse effects, adjunct management with vitamin D in combination with potent anti-osteoporotic medications could minimize the risk of glucocorticoid-induced osteoporosis and modulate the immune system to attenuate disease activity in sarcoidosis.
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Affiliation(s)
- Fabiola Gianella
- Pulmonary and Critical Care Medicine Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Connie CW Hsia
- Pulmonary and Critical Care Medicine Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Khashayar Sakhaee
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Zhou Y, Lower EE. Balancing Altered Calcium Metabolism with Bone Health in Sarcoidosis. Semin Respir Crit Care Med 2020; 41:618-625. [PMID: 32777848 DOI: 10.1055/s-0040-1713009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abnormal calcium metabolism in sarcoidosis patients can lead to hypercalcemia, hypercalciuria, and kidney stones. Hypercalcemia in sarcoidosis is usually due to increased activity of 1α-hydroxylase in macrophages of pulmonary granulomata, resulting in low levels of 25-hydroxyvitamin D and high levels of calcitriol. Vitamin D supplementation may be dangerous for some sarcoidosis patients and is recommended only for those with decreased 25-hydroxyvitamin D and reduced or normal calcitriol level. Diagnosis, treatment of osteoporosis, and maintenance of bone health are complex issues for sarcoidosis patients. An approach to diagnosis and treatment of bone fragility is presented.
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Affiliation(s)
- Ying Zhou
- Department of Respiratory Medicine, Clinical Research Center, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Elyse E Lower
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
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14
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Crouser ED, Maier LA, Wilson KC, Bonham CA, Morgenthau AS, Patterson KC, Abston E, Bernstein RC, Blankstein R, Chen ES, Culver DA, Drake W, Drent M, Gerke AK, Ghobrial M, Govender P, Hamzeh N, James WE, Judson MA, Kellermeyer L, Knight S, Koth LL, Poletti V, Raman SV, Tukey MH, Westney GE. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e26-e51. [PMID: 32293205 PMCID: PMC7159433 DOI: 10.1164/rccm.202002-0251st] [Citation(s) in RCA: 443] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure. Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability. Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality. Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.
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Gwadera Ł, Białas AJ, Iwański MA, Górski P, Piotrowski WJ. Sarcoidosis and calcium homeostasis disturbances-Do we know where we stand? Chron Respir Dis 2020; 16:1479973119878713. [PMID: 31718265 PMCID: PMC6854763 DOI: 10.1177/1479973119878713] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The majority of cases involving hypercalcemia in the setting of sarcoidosis are explained by the overproduction of calcitriol by activated macrophages. Vitamin D takes part in the regulation of granuloma formation. However, using vitamin D metabolites to assess the activity of the disease is still problematic, and its usefulness is disputable. In some cases, though, a calcium metabolism disorder could be a valuable tool (i.e. as a marker of extrathoracic sarcoidosis). Although sarcoidosis does not cause a decrease in bone mineral density, increased incidence of vertebral deformities is noted. Despite increasing knowledge about calcium homeostasis disorders in patients with sarcoidosis, there is still a need for clear guidelines regarding calcium and vitamin D supplementation in these patients.
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Affiliation(s)
- Łukasz Gwadera
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | - Adam Jerzy Białas
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | | | - Paweł Górski
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | - Wojciech Jerzy Piotrowski
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
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Goischke HK. Vitamin D supplementation for the prevention or depletion of side effects of therapy with alemtuzumab in multiple sclerosis. Ther Clin Risk Manag 2019; 15:891-904. [PMID: 31371976 PMCID: PMC6636607 DOI: 10.2147/tcrm.s188941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/16/2019] [Indexed: 12/22/2022] Open
Abstract
PURPOSE OF REVIEW Not only the multiple sclerosis specialist but also the general neurologist and primary care practitioner are increasingly aware of possible adverse events (AEs) by treatment with alemtuzumab (over 47% risk of secondary autoimmune-mediated diseases). Vitamin D supplementation's effect (VDS) to reduce these autoimmune AEs is poorly performed in routine practice. This article seeks to justify why this simple, inexpensive, patient-friendly therapy should be seriously discussed. RECENT FINDINGS Patients who have developed autoimmunity also show a high basal level of IL-21, a cytokine which increases the growth of auto-reactive T-cells. For side effects such as thyroid dysfunction, autoimmune thrombocytopenia, autoimmune hemolytic anemia, autoimmune hepatitis, diabetes mellitus type 1, and alopecia areata/alopecia totalis, VDS may have an impact on the immunological mechanism, in particular lowering levels of IL-17 and IL-21. SUMMARY The potential role of vitamin D in influencing autoimmune diseases is evident. If a life-threatening side-effect can be prevented by high-dose VDS, it is ethical to initiate this add-on therapy despite contradictory results in studies on the effectiveness of VDS.
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Affiliation(s)
- Hans-Klaus Goischke
- Independent Research, Internal Medicine, Rehabilitation Medicine, Social Medicine, Bad Brückenau, Bavaria, Germany
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17
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Chiu ZK, Lim LL, Rogers SL, Hall AJ. Patterns of Vitamin D Levels and Exposures in Active and Inactive Noninfectious Uveitis Patients. Ophthalmology 2019; 127:230-237. [PMID: 31519386 DOI: 10.1016/j.ophtha.2019.06.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 06/20/2019] [Accepted: 06/28/2019] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To compare serum vitamin D levels and patterns of ultraviolet light and dietary exposure among patients with active and inactive noninfectious uveitis and population controls. DESIGN Prospective case-control study. All participants (n = 151) underwent serum 25-hydroxy vitamin D measurement and completed a questionnaire on vitamin D intake and ultraviolet light exposure. Serum 25-hydroxy vitamin D levels were compared between active and inactive uveitis groups and with local population estimates. PARTICIPANTS Adult patients with active and inactive noninfectious uveitis were recruited from 2 Victorian tertiary hospitals and 1 private ophthalmic practice. METHODS Serum 25-hydroxy vitamin D levels were compared between patients with active and inactive uveitis and population-based estimates of serum 25-hydroxy vitamin D levels, stratified by geographic region and season. Vitamin D intakes and exposures based on questionnaire results, including vitamin D supplementation and sunlight exposures on weekdays and weekends, were compared between active and inactive uveitis groups. MAIN OUTCOME MEASURES Serum vitamin D levels, intake of vitamin D, and exposure to sources of vitamin D. RESULTS The median level of serum vitamin D in those with active uveitis (n = 74) was 46 nmol/l (interquartile range [IQR], 29-70 nmol/l), significantly lower than in the inactive control group (n = 77) at 64 nmol/l (IQR, 52-79 nmol/l; P < 0.001). The active uveitis group also showed lower median serum vitamin D levels than the local population median of 62 nmol/l (IQR, 46-77 nmol/l). Vitamin D supplementation also was associated significantly with uveitis inactivity (P = 0.026, Kendall's τ test). In a subanalysis of vitamin D-deficient participants, sun exposure was associated significantly with uveitis inactivity (P = 0.014 for weekday and weekend analyses). CONCLUSIONS Participants with active uveitis showed significantly lower serum 25-hydroxy vitamin D levels than inactive uveitis patients and local population-based estimates. Vitamin D supplementation was found to be associated with decreased uveitis activity, as was sun exposure in those with vitamin D deficiency. These results suggest that vitamin D supplementation should be studied as an option for the prevention of uveitis relapse in at-risk patients.
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Affiliation(s)
- Zelia K Chiu
- Department of Surgery, Monash Medical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Lyndell L Lim
- Centre for Eye Research Australia, University of Melbourne, East Melbourne, Australia; Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Sophie L Rogers
- Centre for Eye Research Australia, University of Melbourne, East Melbourne, Australia; Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Anthony J Hall
- Department of Surgery, Monash Medical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia; Department of Ophthalmology, The Alfred Hospital, Melbourne, Australia.
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Serum CXCL11 correlates with pulmonary outcomes and disease burden in sarcoidosis. Respir Med 2019; 152:89-96. [PMID: 31128616 DOI: 10.1016/j.rmed.2019.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Sarcoidosis is a systemic granulomatous disease of unknown etiology that affects the lungs in 90% of patients, but has a wide range of disease manifestations and outcomes including chronic and progressive courses. Noninvasive biomarkers are needed to assess these outcomes and guide decisions for long term monitoring and treatment. Interferon-gamma (IFN-γ)-inducible chemotactic cytokines (chemokines), CXCL9, CXCL10 and CXCL11, show promise in this regard because they have been implicated in the pathogenesis of and reflect the burden of granulomatous inflammation. CXCL11 has been reported to have unique functional properties in modulating adaptive immunity in model systems so our goal was to examine serum levels of CXCL11 in relation to clinical outcomes in a heterogeneous cohort of sarcoidosis subjects. METHODS CXCL19, CXCL10, and CXCL11 serum levels were measured in sarcoidosis and healthy subjects using ELISA assay. We determined relationships between CXCL11 and standard clinical inflammatory markers, expression of IFN-γ-related genes in whole blood, organ involvement, dyspnea scores, and measures of pulmonary function. RESULTS In a cross-sectional analysis of 104 sarcoidosis subjects, serum CXCL11 was significantly elevated compared to 49 healthy controls (p < 0.001). CXCL11 was positively correlated with CXCL9 and CXCL10 (p < 0.001), sedimentation rate (p < 0.01), and mean expression of three IFN-γ-related genes in whole blood (GBP1, STAT1, and STAT2) (p < 0.001). CXCL11 was inversely correlated with FVC %predicted (%pred) and FEV1 %pred and higher levels were associated with higher patient-reported dyspnea scores. We found positive correlations between CXCL11 and number of organs involved. Using survival analyses, we found that CXCL11 levels were predictive of future pulmonary function test (PFT) decline (log rank <0.001 and HR of log10(CXCL11) = 5.1, 95% CI 1.2-21, p = 0.026). CONCLUSIONS The pattern of expression of serum CXCL11 in sarcoidosis patients suggests that this blood measure could be helpful in identifying patients that need longer-term monitoring for progressive thoracic and extra-thoracic sarcoidosis.
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Serum and urinary calcium level in Latvian patients with sarcoidosis. Reumatologia 2018; 56:377-381. [PMID: 30647484 PMCID: PMC6330682 DOI: 10.5114/reum.2018.80715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/03/2018] [Indexed: 12/19/2022] Open
Abstract
Objectives Sarcoidosis is a multisystem granulomatous disease of unknown etiology that in 90% of cases affects the lungs. Calcium metabolism testing can be useful in diagnostics. The aim of the study was to assess the correlation between calcium metabolism and sarcoidosis form of manifestation/demographic indicators. Material and methods In a retrospective study medical records of all patients (n = 699) who had been hospitalized with suspected sarcoidosis in a specialized clinic of Riga Eastern Clinical University Hospital during the period from January 1st, 2013 until December 31st, 2014 were analyzed. Further analysis included only patients with histologically and/or clinically confirmed sarcoidosis (n = 281). Results Patients’ average age at the time of diagnosis was 39 ±13 years. Elevated serum calcium was observed in 9.9% of cases. A statistically significant correlation was found between serum calcium and age (p < 0.01). There was an association between serum calcium and gender (p < 0.05) – levels were higher in men (2.43 mmol/l) than in women (2.40 mmol/l). Elevated calcium in 24-hour urine was observed in 22.7% of patients. The mean value was 232.3 mg/24 h, levels were higher in men (258.7 mg/24 h) than in women (202.3 mg/24 h), and the association with gender was statistically significant (p < 0.01). Conclusions We can conclude that in Latvia sarcoidosis affects mostly young and middle-aged people. Both serum calcium and calcium in 24-hour urine are important parameters for sarcoidosis diagnostics. Hypercalcemia was found in 9.9% of patients, hypercalciuria in 22.7% of patients, and both were statistically significantly higher in men, regardless of age.
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Rohmer J, Hadjadj J, Bouzerara A, Salah S, Paule R, Groh M, Blanche P, Mouthon L, Monnet D, Le Jeunne C, Guibourdenche J, Brézin A, Terrier B. Serum 1,25(OH)2 Vitamin D and 25(OH) Vitamin D Ratio for the Diagnosis of Sarcoidosis-Related Uveitis. Ocul Immunol Inflamm 2018; 28:341-347. [DOI: 10.1080/09273948.2018.1537399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Julien Rohmer
- Department of Internal Medicine, Cochin Hospital, Paris, France
| | - Jérôme Hadjadj
- Department of Internal Medicine, Cochin Hospital, Paris, France
| | | | - Sawsen Salah
- Department of Ophthalmology, Cochin Hospital, Paris, France
| | - Romain Paule
- Department of Internal Medicine, Cochin Hospital, Paris, France
| | - Matthieu Groh
- Department of Internal Medicine, Cochin Hospital, Paris, France
- Department of Internal Medicine, Foch Hospital, Suresnes, France
| | | | - Luc Mouthon
- Department of Internal Medicine, Cochin Hospital, Paris, France
- 5 INSERM 1016, Centre de référence pour les Maladies Auto-immunes Rares, Université Paris Descartes, Paris, France
| | | | | | | | - Antoine Brézin
- Department of Ophthalmology, Cochin Hospital, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Cochin Hospital, Paris, France
- 5 INSERM 1016, Centre de référence pour les Maladies Auto-immunes Rares, Université Paris Descartes, Paris, France
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Jomphe V, Lands LC, Mailhot G. Nutritional Requirements of Lung Transplant Recipients: Challenges and Considerations. Nutrients 2018; 10:E790. [PMID: 29921799 PMCID: PMC6024852 DOI: 10.3390/nu10060790] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/15/2018] [Indexed: 12/19/2022] Open
Abstract
An optimal nutritional status is associated with better post-transplant outcomes and survival. Post-lung transplant nutrition management is however particularly challenging as lung recipients represent a very heterogeneous group of patients in terms of age, underlying diseases, weight status and presence of comorbidities. Furthermore, the post-transplant period encompasses several stages characterized by physiological and pathophysiological changes that affect nutritional status of patients and necessitate tailored nutrition management. We provide an overview of the current state of knowledge regarding nutritional requirements in the post-lung transplant period from the immediate post-operative phase to long-term follow-up. In the immediate post-transplantation phase, the high doses of immunosuppressants and corticosteroids, the goal of maintaining hemodynamic stability, the presence of a catabolic state, and the wound healing process increase nutritional demands and lead to metabolic perturbations that necessitate nutritional interventions. As time from transplantation increases, complications such as obesity, osteoporosis, cancer, diabetes, and kidney disease, may develop and require adjustments to nutrition management. Until specific nutritional guidelines for lung recipients are elaborated, recommendations regarding nutrient requirements are formulated to provide guidance for clinicians caring for these patients. Finally, the management of recipients with special considerations is also briefly addressed.
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Affiliation(s)
- Valerie Jomphe
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis Street, Montreal, QC H2X 0A9, Canada.
| | - Larry C Lands
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal, 900 Saint-Denis Street, Montreal, QC H2X 0A9, Canada.
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Centre, 1001 Décarie Boulevard, Montreal, QC H4A 3J1, Canada.
- Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, 1001 Décarie Boulevard, Montreal, QC H4A 3J1, Canada.
| | - Genevieve Mailhot
- Department of Nutrition, Faculty of Medicine, Université de Montreal, 2405 Cote Sainte-Catherine Rd., Montreal, QC H3T 1A8, Canada.
- Research Centre, CHU Sainte-Justine, 3175 Cote Sainte-Catherine Rd., Montreal, QC H3T 1C5, Canada.
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Papanikolaou IC, Tabila B, Tabila K, Borok Z, Sharma O, Gould MK. Vitamin D status in sarcoidosis: a cross-sectional study. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2018; 35:154-159. [PMID: 32476896 DOI: 10.36141/svdld.v35i2.6199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 09/25/2017] [Indexed: 11/02/2022]
Abstract
Background: Hypercalcemia, a common feature in sarcoidosis, is due to the excessive production of active Vitamin D metabolite, 1,25(OH)2D. Levels of 25(OH) Vitamin D however may not be appropriate. Objectives: To assess Vitamin D status and its clinical associations in sarcoidosis patients compared to a general respiratory diseases out-patient clinic population, serving as controls. Methods: 64 sarcoidosis cases and 53 control cases with other than sarcoidosis respiratory diseases, matched for age and sex were included in the study. Serum 25(OH)D, 1,25(OH)2D, calcium, angiotensin converting enzyme (ACE) were measured. 25(OH) Vitamin D was described as deficient when <20 ng/ml and insufficient when <30 ng/ml. Clinical parameters were recorded for sarcoidosis cases. Results: Overall 41/64 sarcoidosis cases (64%) had low 25(OH) D, 7/64 (11%) had high 1,25(OH)2D and 2/64 had hypercalcaemia (3%). Sarcoidosis subjects likely exhibited deficient (39%) or normal 25(OH)D levels (36%) in comparison to controls (p=0.018). 25(OH) Vitamin D deficiency in sarcoidosis was associated with race and radiological stage I disease, with regression analysis identifying African-American race as the only significant risk factor (p=0.03). An inverse correlation between ACE and 25(OH)D levels was found (p=0.052). 1,25(OH)2D was significantly elevated in sarcoidosis compared to controls. Among sarcoidosis patients, those with insufficient 25(OH)D levels exhibited higher calcium levels in serum. Conclusions: 25(OH) Vitamin D deficiency is prevalent in sarcoidosis, particularly in African-Americans and likely those with active disease. However, concomitant 1,25(OH)2D elevation and associated hypercalcaemia make Vitamin D supplementation dangerous in sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 154-159).
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Affiliation(s)
- Ilias C Papanikolaou
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, USA.,Department of Pulmonary Medicine, Corfu General Hospital, Greece
| | - Brian Tabila
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, USA
| | | | - Zea Borok
- Will Rogers Institute Pulmonary Research Center, Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, USA
| | - Om Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, USA
| | - Michael K Gould
- Health Services Research and Implementation Science, Kaiser Permanente Southern California
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23
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Kiani A, Abedini A, Adcock IM, Mirenayat MS, Taghavi K, Mortaz E, Kazempour-Dizaji M. Association Between Vitamin D Deficiencies in Sarcoidosis with Disease Activity, Course of Disease and Stages of Lung Involvements. J Med Biochem 2018; 37:103-109. [PMID: 30581345 PMCID: PMC6294100 DOI: 10.1515/jomb-2017-0041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/28/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite negative association between 25-hydroxy vitamin D and incidence of many chronic respiratory diseases, this feature was not well studied in sarcoidosis. Current study investigated the association between 25-hydroxy vitamin D deficiency with sarcoidosis chronicity, disease activity, extra-pulmonary skin manifestations, urine calcium level and pulmonary function status in Iranian sarcoidosis patients. Results of this study along with future studies, will supply more effective programs for sarcoidosis treatment. METHODS Eighty sarcoidosis patients in two groups of insufficient serum level and sufficient serum level of 25-hydroxy vitamin D were studied. Course of sarcoidosis was defined as acute and chronic sarcoidosis. Pulmonary function test (PFT) was assessed by spirometry. Skin involvements were defined as biopsy proven skin sarcoidosis. 24-hour urine calcium level was used to specify the disease activity. Stages of lung involvements were obtained by CT-scan and chest X-ray. The statistical analyses were evaluated using Statistical Package for the Social Sciences. RESULTS A significant negative correlation was obtained between vitamin D deficiency in sarcoidosis patients and disease chronic course and stages two to four of lung involvements. Considering other parameters of the disease and vitamin D deficiency, no significant correlation was detected. CONCLUSIONS In conclusion, results of the current study implies in the role of vitamin 25(OH)D deficiencies in predicting the course of chronic sarcoidosis. Furthermore, it was concluded that vitamin 25(OH)D deficiency can direct pulmonary sarcoidosis toward stage 2-4 of lung involvements.
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Affiliation(s)
- Arda Kiani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atefeh Abedini
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ian M. Adcock
- Cell and Molecular Biology Group, Airways Disease Section, National Heart and Lung Institute, Imperial College London, Dove house Street, London, UK. 10
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Maryam Sadat Mirenayat
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kimia Taghavi
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mortaz
- Department of Immunology, Faculty of Medicine, Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Kazempour-Dizaji
- Mycobacteriology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
Musculoskeletal manifestations in the context of sarcoidosis are frequently observed. The rheumatologist regularly encounters this disease in clinical practice. In the present review, we aim to give a current overview of the manifestations and treatments relevant to the practicing rheumatologist. The most frequently encountered manifestation is Lofgren's syndrome, which is characterized by bilateral ankle periarthritis, bilateral hilar lymphadenopathy, and erythema nodosum and has an excellent prognosis. Chronic arthropathy most commonly manifests as oligoarthritis, which sometimes hampers its differentiation from spondylarthropathies, especially when sacroiliitis, enthesitis or dactylitis are simultaneously present. Isolated vertebral granulomas are rare and require infectious and malignant disorders to be excluded, since there are no specific imaging findings that are exclusively found in vertebral sarcoidosis. The presence of granulomas in skeletal muscle is common in muscle biopsies, whereas clinically overt myopathy is present in only around 1-2% of patients. Therapeutic responses vary among the different clinical phenotypes. Non-steroidal anti-inflammatory drugs and low to medium dose glucocorticoids are the first-line therapy for musculoskeletal manifestations and often lead to adequate disease control in acute sarcoidosis. When these are ineffective or not tolerated, steroid-sparing agents are increasingly used in chronic sarcoidosis. Evidence for all medications used in sarcoid-related arthritis is comparatively scant. When supplementing vitamin D, the possible development of hypercalcemia, even at standard doses, needs to be considered; the optimal therapeutic levels for the prevention of medication-induced osteoporosis in sarcoidosis have not been firmly established.
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Affiliation(s)
- P Korsten
- Klinik für Nephrologie und Rheumatologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - G Chehab
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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25
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Abstract
PURPOSE OF REVIEW Vitamin D supplementation is widespread used in the general population. In sarcoidosis, up to 50% of patients, especially postmenopausal women and those taking corticosteroids, show evidence of increased bone fragility. The purpose of this review is to provide an evidence-based rationale on how to treat sarcoidosis patients with bone health issues. RECENT FINDINGS Evidence from observational studies show that decreased 25-hydroxy vitamin D is common in sarcoidosis. However, the great majority of sarcoidosis patents have normal or often elevated levels of 1,25-dihydroxy vitamin D (calcitriol), a marker associated with disease activity. High calcitriol levels may often be associated with hypercalcemia and hypercalcuria. The few interventional randomized controlled studies in the field, suggest that vitamin D supplementation may not be well tolerated because of hypercalcemia, moreover without substantial benefit on bone health and risk for fractures in these patients. SUMMARY Vitamin D supplementation may be withheld in sarcoidosis patients with bone fragility, unless calcitriol levels are below normal limits. A treating scheme is proposed.
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Saidenberg-Kermanac’h N, Valeyre D, Boissier MC. Vitamin D supplementation in patients treated for sarcoidosis: Controversy or consensus? Joint Bone Spine 2017; 84:521-523. [DOI: 10.1016/j.jbspin.2017.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 11/24/2022]
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Robertson AP, Weinreb A, Weinreb JE. Protection of Bone Density in Sarcoidosis: Can we Give Vitamin D without Causing Hypercalcemia? AACE Clin Case Rep 2017. [DOI: 10.4158/ep161608.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Martinez-Bravo MJ, Wahlund CJE, Qazi KR, Moulder R, Lukic A, Rådmark O, Lahesmaa R, Grunewald J, Eklund A, Gabrielsson S. Pulmonary sarcoidosis is associated with exosomal vitamin D-binding protein and inflammatory molecules. J Allergy Clin Immunol 2016; 139:1186-1194. [PMID: 27566455 DOI: 10.1016/j.jaci.2016.05.051] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/18/2016] [Accepted: 05/31/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sarcoidosis is an inflammatory granulomatous disorder characterized by accumulation of TH1-type CD4+ T cells and immune effector cells within affected organs, most frequently the lungs. Exosomes are extracellular vesicles conveying intercellular communication with possible diagnostic and therapeutic applications. OBJECTIVES We aimed to provide an understanding of the proinflammatory role of bronchoalveolar lavage fluid (BALF) exosomes in patients with sarcoidosis and to find candidates for disease biomarkers. METHODS We performed a mass spectrometric proteomics characterization of BALF exosomes from 15 patients with sarcoidosis and 5 healthy control subjects and verified the most interesting results with flow cytometry, ELISA, and Western blot analyses in an additional 39 patients and 22 control subjects. RESULTS More than 690 proteins were identified in the BALF exosomes, several of which displayed significant upregulation in patients, including inflammation-associated proteins, such as leukotriene A4 hydrolase. Most of the complement-activating factors were upregulated, whereas the complement regulator CD55 was seen less in patients compared with healthy control subjects. In addition, for the first time, we detected vitamin D-binding protein in BALF exosomes, which was more abundant in patients. To evaluate exosome-associated vitamin D-binding protein as a biomarker for sarcoidosis, we investigated plasma exosomes from 23 patients and 11 healthy control subjects and found significantly higher expression in patients. CONCLUSION Together, these data contribute to understanding the role of exosomes in lung disease and provide suggestions for highly warranted sarcoidosis biomarkers. Furthermore, the validation of an exosome-associated biomarker in the blood of patients provides novel, and less invasive, opportunities for disease diagnosis.
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Affiliation(s)
- Maria-Jose Martinez-Bravo
- Unit for Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Casper J E Wahlund
- Unit for Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Khaleda Rahman Qazi
- Unit for Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Robert Moulder
- Turku Centre for Biotechnology, University of Turku, Turku, Finland
| | - Ana Lukic
- Department of Medical Biochemistry and Biophysics, Division of Physiological Chemistry II, Karolinska Institutet, University Hospital, Solna, Stockholm, Sweden
| | - Olof Rådmark
- Department of Medical Biochemistry and Biophysics, Division of Physiological Chemistry II, Karolinska Institutet, University Hospital, Solna, Stockholm, Sweden
| | - Riitta Lahesmaa
- Turku Centre for Biotechnology, University of Turku, Turku, Finland
| | - Johan Grunewald
- Respiratory Unit, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Anders Eklund
- Respiratory Unit, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Susanne Gabrielsson
- Unit for Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Treatment of sarcoidosis is not required in all patients with the diagnosis. The decision to treat and the strategy for how to treat usually require input and shared decision making by the patient. Some common consequences of sarcoidosis are not caused by granulomatous inflammation, but may be the dominant disease manifestation and should be actively considered when formulating a treatment plan. The medication regimen should be tailored to each patient. Steroid-sparing medications should be prescribed early as part of a long-term strategy.
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Affiliation(s)
- Marlies S Wijsenbeek
- Department of Pulmonary Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Capolongo G, Xu LHR, Accardo M, Sanduzzi A, Stanziola AA, Colao A, Agostini C, Zacchia M, Capasso G, Adams-Huet B, Moe OW, Maalouf NM, Sakhaee K, Hsia CCW. Vitamin-D status and mineral metabolism in two ethnic populations with sarcoidosis. J Investig Med 2016; 64:1025-34. [PMID: 27053725 DOI: 10.1136/jim-2016-000101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2016] [Indexed: 01/23/2023]
Abstract
Vitamin-D insufficiency and sarcoidosis are more common and severe in African Americans (AA) than Caucasians. In sarcoidosis, substrate-dependent extrarenal 1,25-dihydroxyvitamin-D (1,25-(OH)2D) production is thought to contribute to hypercalciuria and hypercalcemia, and vitamin-D repletion is often avoided. However, the anti-inflammatory properties of vitamin-D may also be beneficial. We prospectively examined serum vitamin-D levels, calcium balance, and the effects of vitamin-D repletion in 86 AA and Caucasian patients with biopsy-proven active sarcoidosis from the USA (US) and Italy (IT) in university-affiliated outpatient clinics. Clinical features, pulmonary function, and calciotropic hormones were measured. 16 patients with vitamin-D deficiency and normal serum ionized calcium (Ca(2+)) were treated with oral ergocalciferol (50,000 IU/week) for 12 weeks. Baseline mineral parameters were similar in US (93% AA) and IT (95% Caucasian) patients irrespective of glucocorticoid treatment. Pulmonary dysfunction was less pronounced in IT patients. Nephrolithiasis (in 11% US, 17% IT patients) was associated with higher urinary calcium excretion. Vitamin-D deficiency was not more prevalent in patients compared to the respective general populations. As serum 25-hydroxyvitamin-D (25-OHD) rose postrepletion, serum 1,25-(OH)2D, γ-globulins, and the previously elevated angiotensin converting enzyme (ACE) levels declined. Asymptomatic reversible increases in Ca(2+) or urinary calcium/creatinine (Ca/Cr) developed in three patients during repletion. In conclusion, Caucasian and AA patients show similar calcium and vitamin D profiles. The higher prevalence of hypercalciuria and nephrolithiasis in sarcoidosis is unrelated to endogenous vitamin-D levels. Vitamin-D repletion in sarcoidosis is generally safe, although calcium balance should be monitored. A hypothesis that 25-OHD repletion suppresses granulomatous immune activity is provided.
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Affiliation(s)
- Giovanna Capolongo
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Cardio-thoracic & Respiratory Sciences, Division of Nephrology, Second University of Naples, Naples, Italy
| | - Li Hao Richie Xu
- Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mariasofia Accardo
- Department of Clinical Medicine & Surgery, Division of Respiratory disease, University Federico II of Naples, Naples, Italy
| | - Alessandro Sanduzzi
- Department of Clinical Medicine & Surgery, Division of Respiratory disease, University Federico II of Naples, Naples, Italy
| | - Anna Agnese Stanziola
- Department of Clinical Medicine & Surgery, Division of Respiratory disease, University Federico II of Naples, Naples, Italy
| | - Annamaria Colao
- Department of Clinical Medicine & Surgery, Unit of Endocrinology, University Federico II of Naples, Naples, Italy
| | - Carlo Agostini
- Department of Medicine (DIMED), Clinical Immunology Unit, Padua University, Italy
| | - Miriam Zacchia
- Department of Cardio-thoracic & Respiratory Sciences, Division of Nephrology, Second University of Naples, Naples, Italy
| | - Giovambattista Capasso
- Department of Cardio-thoracic & Respiratory Sciences, Division of Nephrology, Second University of Naples, Naples, Italy
| | - Beverley Adams-Huet
- Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orson W Moe
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Naim M Maalouf
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Khashayar Sakhaee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA Charles & Jane Pak Center for Mineral Metabolism & Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Connie C W Hsia
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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