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Starshinova A, Zinchenko Y, Malkova A, Kudlay D, Kudryavtsev I, Yablonskiy P. Sarcoidosis and Autoimmune Inflammatory Syndrome Induced by Adjuvants. Life (Basel) 2023; 13:life13041047. [PMID: 37109576 PMCID: PMC10145559 DOI: 10.3390/life13041047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Currently, sarcoidosis remains one of the diseases with unknown etiology, which significantly complicates its diagnosis and treatment. Various causes of sarcoidosis have been studied for many years. Both organic and inorganic trigger factors, provoking the development of granulomatous inflammation are considered. However, the most promising and evidence-based hypothesis is the development of sarcoidosis as an autoimmune disease, provoked by various adjuvants in genetic predisposed individuals. This concept fits into the structure of the autoimmune/inflammatory syndrome, induced by adjuvants (ASIA) that was proposed in 2011 by Professor Shoenfeld Y. In this paper, the authors reveal the presence of major and minor ASIA criteria for sarcoidosis, propose a new concept of the course of sarcoidosis within the framework of ASIA, and point out the difficulties in creating a model of the disease and the selection of therapy. It is obvious that the data obtained not only bring us closer to understanding the nature of sarcoidosis, but also potentiate new studies confirming this hypothesis by obtaining a model of the disease.
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Affiliation(s)
- Anna Starshinova
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia
| | - Yulia Zinchenko
- Saint-Petersburg Research Institute of Phthisiopulmonology, 194064 Saint-Petersburg, Russia
| | - Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 Saint-Petersburg, Russia
| | - Dmitriy Kudlay
- Medical Department, Sechenov First Moscow State Medical University, 119435 Moscow, Russia
- Institute of Immunology, 115478 Moscow, Russia
| | - Igor Kudryavtsev
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia
- Department of Immunology, Institution of Experimental Medicine, 197022 Saint-Petersburg, Russia
| | - Piotr Yablonskiy
- Saint-Petersburg Research Institute of Phthisiopulmonology, 194064 Saint-Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 Saint-Petersburg, Russia
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Kudryavtsev I, Zinchenko Y, Starshinova A, Serebriakova M, Malkova A, Akisheva T, Kudlay D, Glushkova A, Yablonskiy P, Shoenfeld Y. Circulating Regulatory T Cell Subsets in Patients with Sarcoidosis. Diagnostics (Basel) 2023; 13:diagnostics13081378. [PMID: 37189479 DOI: 10.3390/diagnostics13081378] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
Over recent years, many researchers have supported the autoimmune theory of sarcoidosis. The presence of uncontrolled inflammatory response on local and system levels in patients with sarcoidosis did not define that the immunoregulatory mechanisms could be affected. The aim of this study was to evaluate the distribution and the disturbance circulating Treg cell subsets in the peripheral blood in patients with sarcoidosis. MATERIALS AND METHODS A prospective comparative study was performed in 2016-2018 (34 patients with sarcoidosis (men (67.6%), women (32.3%)) were examined). Healthy subjects-the control group (n = 40). The diagnosis of pulmonary sarcoidosis was performed according to the standard criteria. We used two ten-color combinations of antibodies for Treg immunophenotyping. The first one contained CD39-FITC, CD127-PE, CCR4-PE/Dazzle™ 594, CD25-PC5.5, CD161-PC7, CD4-APC, CD8-APC-AF700, CD3-APC/Cy7, HLA-DR-PacBlue, and CD45 RA-BV 510™, while the second consisted of CXCR3-Alexa Fluor 488, CD25-РЕ, CXCR5-РЕ/Dazzle™ 594, CCR4-PerСP/Сy5.5, CCR6-РЕ/Cy7, CD4-АPC, CD8 АPC-AF700, CD3-АPC/Cy7, CCR7-BV 421, and CD45 RA-BV 510. The flow cytometry data were analyzed by using Kaluza software v2.3. A statistical analysis was performed with Statistica 7.0 and GraphPad Prism 8 software packages. RESULTS OF THE STUDY Primarily, we found that patients with sarcoidosis had decreased absolute numbers of Treg cells in circulation. We noted that the level of CCR7-expressing Tregs decreased in patients with sarcoidosis vs. the control group (65.55% (60.08; 70.60) vs. 76.93% (69.59; 79.86) with p < 0.001). We noticed that the relative numbers of CD45RA-CCR7+ Tregs decreased in patients with sarcoidosis (27.11% vs. 35.43%, p < 0.001), while the frequency of CD45 RA-CCR7- and CD45RA+ CCR7- Tregs increased compared to the control group (33.3% vs. 22.73% and 0.76% vs. 0.51% with p < 0.001 and p = 0.028, respectively). CXCR3-expressing Treg cell subsets-Th1-like CCR60078CXCR3+ Tregs and Th17.1-like CCR6+ CXCR3+ Tregs-significantly increased in patients with sarcoidosis vs. the control group (14.4% vs. 10.5% with p < 0.01 and 27.9% vs. 22.8% with p < 0.01, respectively). Furthermore, the levels of peripheral blood EM Th17-like Tregs significantly decreased in the sarcoidosis group vs. the control group (36.38% vs. 46.70% with p < 0.001). Finally, we found that CXCR5 expression was increased in CM Tregs cell subsets in patients with sarcoidosis. CONCLUSIONS Our data indicated a decrease in circulating Tregs absolute numbers and several alterations in Treg cell subsets. Moreover, our results highlight the presence of increased levels of CM CXCR5+ follicular Tregs in the periphery that could be linked with the imbalance of follicular Th cell subsets and alterations in B cell, based on the immune response. The balance between the two functionally distinct Treg cell populations-Th1-like and Th17-like Tregs-could be used in sarcoidosis diagnosis and the determination of prognosis and disease outcomes. Furthermore, we want to declare that analysis of Treg numbers of phenotypes could fully characterize their functional activity in peripherally inflamed tissues.
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Affiliation(s)
- Igor Kudryavtsev
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Yulia Zinchenko
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, 194064 St. Petersburg, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
| | - Maria Serebriakova
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Tatiana Akisheva
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Dmitriy Kudlay
- Department of Pharmacology, Sechenov First Moscow State Medical University, 119992 Moscow, Russia
- Institute of Immunology, 115552 Moscow, Russia
| | - Anzhela Glushkova
- Bekhterev National Research Medical Center for Psychiatry and Neurology, 19201 St. Petersburg, Russia
| | - Piotr Yablonskiy
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, 194064 St. Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Yehuda Shoenfeld
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer 5265601, Israel
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Malkova A, Zinchenko Y, Starshinova A, Kudlay D, Kudryavtsev I, Glushkova A, Yablonskiy P, Shoenfeld Y. Sarcoidosis: Progression to the chronic stage and pathogenic based treatment (narrative review). Front Med (Lausanne) 2022; 9:963435. [PMID: 36148463 PMCID: PMC9486475 DOI: 10.3389/fmed.2022.963435] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
Many factors confirm the autoimmune nature of sarcoidosis and help in determining the strategy of patient management and treatment initiation. However, the causes and the mechanisms of disease progression that result in fibrosis and insufficiency of the affected organ remain unclear. This narrative review aims to analyse the mechanisms and biomarkers of sarcoidosis progression, as well as the pathogenetic basis of sarcoidosis therapy. The following characteristics of progressive chronic sarcoidosis were revealed: the disease develops in patients with a genetic predisposition (SNP in genes GREM1, CARD15, TGF-β3, HLA-DQB1*06:02, HLA-DRB1*07/14/15), which contributes either the decreased ability of antigen elimination or autoimmune inflammation. Various prognostic biomarkers of disease progression (decreased levels of neopterin, elastase, sIL-2R, chitotriosidase, glycoprotein Krebs von den Lungen, Th17 cell count, reduced quantity of TNF-α in peripheral blood or bronchoalveolar lavage fluid) have been described and can potentially be used to determine the group of patients who will benefit from the use of corticosteroids/cytostatic drugs/biologics.
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Affiliation(s)
- Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, Saint Petersburg, Russia
| | - Yulia Zinchenko
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, Saint Petersburg, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- *Correspondence: Anna Starshinova ;
| | - Dmitriy Kudlay
- Department of Pharmacology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Laboratory of Personalized Medicine and Molecular Immunology, NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | - Igor Kudryavtsev
- Department of Immunology, Institution of Experimental Medicine, Saint Petersburg, Russia
| | - Anzhela Glushkova
- V.M. Bekhterev National Research Medical Center for Psychiatry and Neurology, Saint Petersburg, Russia
| | - Piotr Yablonskiy
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, Saint Petersburg, Russia
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, Saint Petersburg, Russia
| | - Yehuda Shoenfeld
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, Saint Petersburg, Russia
- Sackler Faculty of Medicine, Ariel University, Ariel, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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4
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Hussain K, Patel P, Roberts N. The role of thalidomide in dermatology. Clin Exp Dermatol 2021; 47:667-674. [PMID: 34779533 DOI: 10.1111/ced.15019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 12/18/2022]
Abstract
Thalidomide is a medication that has been in existence for over half a century, and has proven to be useful and effective in severe dermatological conditions. For dermatologists, the ability of thalidomide to reduce the levels of the cytokine tumour necrosis factor-α, along with its immunomodulatory and anti-angiogenic properties, is of great significance, with the added advantage of being an oral medication. Its use is of course strictly monitored, owing to its potential adverse effects (AEs), particularly teratogenicity, with precautions taken to ensure its safe and correct use by both prescriber and patient. In this review, we look at the background and mechanism of action of thalidomide, provide an overview of conditions it can be used for with case examples, explain the potential AEs and monitoring requirements, and discuss future developments.
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Affiliation(s)
- K Hussain
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - P Patel
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - N Roberts
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Ulcerative cutaneous sarcoidosis successfully treated with infliximab. Clin Rheumatol 2021; 40:4349-4354. [PMID: 33728543 DOI: 10.1007/s10067-021-05689-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 12/23/2022]
Abstract
Sarcoidosis is a systemic inflammatory disorder with cutaneous involvement present in 25% of cases. We present a patient with ulcerative sarcoidosis to highlight this unusual presentation of a relatively rare cutaneous condition that was treated successfully using infliximab. The drug is effective in cutaneous sarcoidosis, but relapses can occur after discontinuation. In this article, we reviewed the clinical features and therapeutic modalities for ulcerative cutaneous sarcoidosis.
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Fludarabine and rituximab with escalating doses of lenalidomide followed by lenalidomide/rituximab maintenance in previously untreated chronic lymphocytic leukaemia (CLL): the REVLIRIT CLL-5 AGMT phase I/II study. Ann Hematol 2018; 97:1825-1839. [PMID: 29862437 PMCID: PMC6097797 DOI: 10.1007/s00277-018-3380-z] [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: 03/19/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022]
Abstract
Despite recent advances, chemoimmunotherapy remains a standard for fit previously untreated chronic lymphocytic leukaemia patients. Lenalidomide had activity in early monotherapy trials, but tumour lysis and flare proved major obstacles in its development. We combined lenalidomide in increasing doses with six cycles of fludarabine and rituximab (FR), followed by lenalidomide/rituximab maintenance. In 45 chemo-naive patients, included in this trial, individual tolerability of the combination was highly divergent and no systematic toxicity determining a maximum tolerated dose was found. Grade 3/4 neutropenia (71%) was high, but only 7% experienced grade 3 infections. No tumour lysis or flare > grade 2 was observed, but skin toxicity proved dose-limiting in nine patients (20%). Overall and complete response rates after induction were 89 and 44% by intention-to-treat, respectively. At a median follow-up of 78.7 months, median progression-free survival (PFS) was 60.3 months. Minimal residual disease and immunoglobulin variable region heavy chain mutation state predicted PFS and TP53 mutation most strongly predicted OS. Baseline clinical factors did not predict tolerance to the immunomodulatory drug lenalidomide, but pretreatment immunophenotypes of T cells showed exhausted memory CD4 cells to predict early dose-limiting non-haematologic events. Overall, combining lenalidomide with FR was feasible and effective, but individual changes in the immune system seemed associated with limiting side effects. clinicaltrials.gov (NCT00738829) and EU Clinical Trials Register (www.clinicaltrialsregister.eu, 2008-001430-27)
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Abstract
The use of thalidomide in relation to dermatology is well- known and enough data is available in the literature about various aspects of thalidomide. Despite being an interesting and useful drug for many dermatoses, it is associated with many health hazards including the birth defects, phocomelia. We hereby present a comprehensive review about thalidomide and its application in dermatology.
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Affiliation(s)
- Iffat Hassan
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Konchok Dorjay
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Parvaiz Anwar
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
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Droitcourt C, Rybojad M, Porcher R, Juillard C, Cosnes A, Joly P, Lacour JP, D'Incan M, Dupin N, Sassolas B, Misery L, Chevrant-Breton J, Lebrun-Vignes B, Desseaux K, Valeyre D, Revuz J, Tazi A, Chosidow O, Dupuy A. A randomized, investigator-masked, double-blind, placebo-controlled trial on thalidomide in severe cutaneous sarcoidosis. Chest 2014; 146:1046-1054. [PMID: 24945194 DOI: 10.1378/chest.14-0015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Thalidomide use in cutaneous sarcoidosis is based on data from small case series or case reports. The objective of this study was to evaluate the efficacy and safety of thalidomide in severe cutaneous sarcoidosis. METHODS This study consisted of a randomized, double-bind, parallel, placebo-controlled, investigator-masked, multicenter trial lasting 3 months and an open-label study from month 3 to month 6. Adults with a clinical and histologic diagnosis of cutaneous sarcoidosis were included in nine hospital centers in France. Patients were randomized 1:1 to oral thalidomide (100 mg once daily) or to a matching oral placebo for 3 months. In the course of an open-label follow-up from month 3 to month 6, all patients received thalidomide, 100 mg to 200 mg daily. The proportions of patients with a partial or complete cutaneous response at month 3, based on at least a 50% improvement in three target lesions scored for area and infiltration, were compared across randomization groups. RESULTS The intent-to-treat population included 39 patients. None of them had a complete cutaneous response. Four out of 20 patients in the thalidomide group (20%) vs four out of 19 patients in the placebo group (21%) had a partial cutaneous response at month 3 (difference in proportion of -1% [95% CI, -26% to +24%] for thalidomide vs placebo, P = 1.0). Eight patients with side effects were recorded in the thalidomide group vs three in the placebo group. We observed a large number of adverse event-related discontinuations in patients taking thalidomide in the first 3 months (four patients with thalidomide, zero with placebo) and in the 3 following months (five patients). CONCLUSIONS At a dose of 100 mg daily for 3 months, our results do not encourage thalidomide use in cutaneous sarcoidosis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT0030552; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Catherine Droitcourt
- Université de Rennes 1, Inserm CIC 1414, Rennes; Pharmacoepidemiology Unit, Inserm CIC 1414, Rennes
| | - Michel Rybojad
- The Department of Dermatology, Hôpital Saint-Louis, AP-HP, Paris
| | - Raphaël Porcher
- The Department of Biostatistics and Medical Informatics, Hôpital Saint-Louis, AP-HP, Paris; Université de Paris Diderot-Sorbonne Paris Cité, Paris; Inserm U717, Paris
| | | | | | - Pascal Joly
- 11 chaussée de la Muette, Paris; Clinique Dermatologique
| | - Jean-Philippe Lacour
- Inserm U905, Institute for Research and Innovation in Biomedicine (IRIB), Université de Rouen, Rouen; The Department of Dermatology, Hôpital Archet-2, CHU Nice, Nice
| | - Michel D'Incan
- Université de Nice, Sophia Antipolis, Nice; The Department of Dermatology, Clermont-Ferrand
| | - Nicolas Dupin
- The Department of Dermatology, Hôpital Cochin, AP-HP, Paris; Université René Descartes, Paris
| | | | - Laurent Misery
- CHU Estaing, and Université d'Auvergne Clermont-Ferrand; The Department of Dermatology, CHRU Brest, Brest
| | | | | | - Kristell Desseaux
- The Department of Biostatistics and Medical Informatics, Hôpital Saint-Louis, AP-HP, Paris; Université de Paris Diderot-Sorbonne Paris Cité, Paris; Inserm U717, Paris
| | | | | | - Abdellatif Tazi
- The Department of Pneumology, Hôpital Saint-Louis, AP-HP, Paris; Université de Paris Diderot-Sorbonne Paris Cité, Paris
| | - Olivier Chosidow
- UFR Medicine, Université de Brest, Brest; The Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil; UPEC Université de Paris Est-Créteil Val-de-Marne, Créteil; French satellite of the Cochrane Skin Group and Centre d'Investigation Clinique 006-Inserm, Créteil, France
| | - Alain Dupuy
- The Department of Dermatology, CHU Rennes; Université de Rennes 1, Inserm CIC 1414, Rennes; Pharmacoepidemiology Unit, Inserm CIC 1414, Rennes.
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Abstract
Sarcoidosis is a chronic inflammatory disorder that has the potential to affect multiple organs, including the skin. Its cutaneous manifestations are varied and can provide clues to underlying systemic manifestations. Unfortunately, they also can be disfiguring. Therapy is usually directed at the organ system most severely affected, which often may help cutaneous disease. However, cutaneous disease may be recalcitrant to treatment directed at extracutaneous disease, or it may be severe enough to require targeted therapy. This article focuses on the dermatologist's role in recognizing and diagnosing cutaneous sarcoidosis, evaluating patients for systemic disease involvement, and treating the skin manifestations of sarcoidosis.
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Affiliation(s)
- Karolyn A Wanat
- Department of Dermatology, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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Sehgal VN, Riyaz N, Chatterjee K, Venkatash P, Sharma S. Sarcoidosis as a systemic disease. Clin Dermatol 2014; 32:351-63. [DOI: 10.1016/j.clindermatol.2013.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kosjerina Z, Zaric B, Vuckovic D, Lalosevic D, Djenadic G, Murer B. The sarcoid granuloma: 'epithelioid' or 'lymphocytic-epithelioid' granuloma? Multidiscip Respir Med 2012; 7:11. [PMID: 22958359 PMCID: PMC3436643 DOI: 10.1186/2049-6958-7-11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 06/20/2012] [Indexed: 11/16/2022] Open
Abstract
Background This study aims to analyze the structure and quantities of cellular elements in sarcoid granulomas. Methods We investigated 34 transbronchial lung biopsy samples obtained from 34 sarcoid patients. The quantity and composition of the cellular elements inside a granuloma were determined by the quantitative stereometry method, employing the numerical density as a stereological method. Results A total of 102 sarcoid granulomas were analyzed. The central part of all granulomas was occupied by epithelioid cells. Besides these, giant cells, lymphocytes, macrophages and plasma cells were also seen. The mean numerical density of all the cells in the central part of a sarcoid granuloma was 111,751 mm-3. Lymphocytes prevailed in number, exceeding the total count of all other cells. With a mean numerical density of 74,321 mm-3, lymphocytes were twice as numerous as both epithelioid cells and macrophages with a mean numerical density of 37,193 mm-3. Conclusions Lymphocytes are the predominant cell type in the central part of a sarcoid granuloma, significantly exceeding both epithelioid cells and macrophages in number, raising the question if the term “epithelioid granuloma”, routinely used to designate sarcoid granulomas, is correct, or if it would be more logical to call them “lymphocytic-epithelioid granulomas” instead. Trial registration This study was supported by the Serbian Ministry of Science and Environmental Protection Grant Number 175006/2011.
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Affiliation(s)
- Zdravko Kosjerina
- Pathology Department, Institute for Lung Diseases of Vojvodina, 21234, Sremska Kamenica, Serbia.
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Sarcoidosis: a comprehensive review and update for the dermatologist: part I. Cutaneous disease. J Am Acad Dermatol 2012; 66:699.e1-18; quiz 717-8. [PMID: 22507585 DOI: 10.1016/j.jaad.2011.11.965] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 11/14/2011] [Accepted: 11/17/2011] [Indexed: 11/23/2022]
Abstract
Sarcoidosis is a common systemic, noncaseating granulomatous disease of unknown etiology. The development of sarcoidosis has been associated with a number of environmental factors and genes. Cutaneous sarcoidosis, the "great imitator," can baffle clinicians because of its diverse manifestations and its ability to resemble both common and rare cutaneous diseases. Depending on the type, location, and distribution of the lesions, treatment can prevent functional impairment, symptomatic distress, scarring, and disfigurement. Numerous therapeutic options are available for the treatment of cutaneous sarcoidosis, but there are few well designed trials to guide practitioners on evidence-based, best practice management. In part I, we review the current knowledge and advances in the epidemiology, etiology, pathogenesis, and genetics of sarcoidosis, discuss the heterogeneous manifestations of cutaneous sarcoidosis, and provide a guide for treatment of cutaneous sarcoidosis.
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Mañá J, Marcoval J. Skin manifestations of sarcoidosis. Presse Med 2012; 41:e355-74. [DOI: 10.1016/j.lpm.2012.02.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/27/2012] [Accepted: 02/02/2012] [Indexed: 01/24/2023] Open
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Thalidomide for improving cutaneous and pulmonary sarcoidosis in patients resistant or with contraindications to corticosteroids. Biomed Pharmacother 2012; 66:300-7. [DOI: 10.1016/j.biopha.2012.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/05/2012] [Indexed: 01/17/2023] Open
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Tchernev G, Ananiev J, Cardoso JC, Wollina U, Verma SB, Patterson JW, Dourmishev LA, Tronnier M, Okamoto H, Mizuno K, Kanazawa N, Gulubova M, Manolova I, Salaro C. Sarcoidosis and molecular mimicry--important etiopathogenetic aspects: current state and future directions. Wien Klin Wochenschr 2012; 124:227-38. [PMID: 22527817 DOI: 10.1007/s00508-012-0154-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 01/21/2012] [Indexed: 01/19/2023]
Abstract
Sarcoidosis is a disease of uncertainty in terms of its cause, presentation, and clinical course. The disease has a worldwide distribution and affects all ages, races, and both sex. Sarcoidosis of the skin may have an extremely heterogeneous clinical presentation, so that the definitions of 'great imitator' and 'clinical chameleon' have long been used. The factors that influence clinical picture and severity of the disease are probably linked to the etiopathogenesis of sarcoidosis, which continues to be shrouded in mystery. The current state of the art on the pathogenesis of sarcoidosis is that it is an immunological response in a genetically susceptible individual to an as-yet undefined antigenic stimulus. How exposure occurs in genetically predisposed patients is not completely clear, but the most likely explanation is that these agents or antigens are either inhaled into the lungs or enter through contact with the skin, as these are the common target organs that are constantly in contact with the environment. An autoimmune etiology of sarcoidosis could possibly occur through a process of molecular mimicry of infectious or other environmental antigens to host antigens. This could lead to a cross-mediated immune response and induction of autoimmune disease. This molecular mimicry may probably be responsible for the heterogeneous clinical presentations of the disease. Several investigations and studies have provided valuable evidence on the etiopathogenesis of sarcoidosis, which may lead to the future development of targeted and innovative treatment strategies. Nevertheless, we are still a long way from unravelling the underlying cause of this mysterious disease.
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Affiliation(s)
- Georgi Tchernev
- Policlinic for Dermatology and Venereology, University Hospital Lozenetz, Academic Educational Hospital of The Saint Kliment Ohridski University, Koziak street 1, 1407, Sofia, Bulgaria.
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Exogenous control of the expression of Group I CD1 molecules competent for presentation of microbial nonpeptide antigens to human T lymphocytes. Clin Dev Immunol 2011; 2011:790460. [PMID: 21603161 PMCID: PMC3095450 DOI: 10.1155/2011/790460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/12/2011] [Accepted: 01/19/2011] [Indexed: 12/21/2022]
Abstract
Group I CD1 (CD1a, CD1b, and CD1c) glycoproteins expressed on immature and mature dendritic cells present nonpeptide antigens (i.e., lipid or glycolipid molecules mainly of microbial origin) to T cells. Cytotoxic CD1-restricted T lymphocytes recognizing mycobacterial lipid antigens were found in tuberculosis patients. However, thanks to a complex interplay between mycobacteria and CD1 system, M. tuberculosis possesses a successful tactic based, at least in part, on CD1 downregulation to evade CD1-dependent immunity. On the ground of these findings, it is reasonable to hypothesize that modulation of CD1 protein expression by chemical, biological, or infectious agents could influence host's immune reactivity against M. tuberculosis-associated lipids, possibly affecting antitubercular resistance. This scenario prompted us to perform a detailed analysis of the literature concerning the effect of external agents on Group I CD1 expression in order to obtain valuable information on the possible strategies to be adopted for driving properly CD1-dependent immune functions in human pathology and in particular, in human tuberculosis.
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Tateyama M, Fujihara K, Itoyama Y. Dendritic cells in muscle lesions of sarcoidosis. Hum Pathol 2010; 42:340-6. [PMID: 21111453 DOI: 10.1016/j.humpath.2010.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 07/03/2010] [Accepted: 07/08/2010] [Indexed: 10/18/2022]
Abstract
Sarcoidosis is a chronic systemic granulomatous disorder of unknown etiology. The precise mechanism by which granulomatous lesions form is still obscure. Dendritic cells (DCs) are the most efficient antigen presenting cells; however, pathologic investigations of dendritic cells in the affected lesions of sarcoidosis are quite limited. We immunohistochemically examined the localization and phenotypes of dendritic cells and the expressions of CD40 and CD40L (CD154), which are key molecules in dendritic cell activation, in the muscles of 5 patients with muscular sarcoidosis, 8 patients with muscular disorders without inflammation, and 4 patients with histologically normal muscles as controls. In muscular sarcoidosis, CD1c-positive myeloid dendritic cells were scattered mainly in the lymphocyte layers of granulomas and the endomysium around the granulomas. Double immunostaining revealed that some CD1c-positive cells expressed the mature dendritic cell marker CD83, but immature dendritic cell marker CD1a-positive cells were not found. Smaller numbers of Blood dendritic cell antigen (BDCA)-2-positive plasmacytoid dendritic cells were found in the lymphocyte layers of granulomas. In the controls, small numbers of CD1c-positive cells were seen in the endomysium, whereas BDCA-2-positive cells were not observed except in 1 case. In muscular sarcoidosis, CD40 was expressed on mononuclear cells, on the interstitium around the muscle fibers and granulomas, and on the endothelium of vessels. CD40L was positive on mononuclear cells scattered within and around granulomas in 3 of 5 patients. In the controls, CD40 was expressed on the endothelium of the vessels and sparse mononuclear cells in the lesions of muscle fiber necrosis, whereas CD40L was not seen in any. In muscular sarcoidosis, recruitment of myeloid dendritic cells and less plasmacytoid dendritic cells and up-regulation of the CD40/CD40L system in affected muscles suggest that myeloid dendritic cells may be mainly involved in granulomatous inflammation through antigen presentation in a Th1 immune milieu.
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Affiliation(s)
- Maki Tateyama
- Department of Neurology, Tohoku University School of Medicine, Sendai 980-8574, Japan.
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Reich JM. Con: the treatment of the granulomatous response is beneficial in acute sarcoidosis. Respir Med 2010; 104:1778-81; discussion 1782-5. [PMID: 20943361 DOI: 10.1016/j.rmed.2010.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Jerome M Reich
- Earl A Chiles Research Institute, Portland Providence Medical Center, Bldg A, Portland, OR 97213, USA.
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Abstract
Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.
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Affiliation(s)
- Meng Chen
- Department of Dermatology, Baylor College of Medicine, BCM Debakey Building M220, One Baylor Plaza, Mail Stop BCM368, Houston, TX 77030, USA
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Chan ASY, Sharma OP, Rao NA. Review for Disease of the Year: Immunopathogenesis of Ocular Sarcoidosis. Ocul Immunol Inflamm 2010; 18:143-51. [DOI: 10.3109/09273948.2010.481772] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yasui K, Yashiro M, Tsuge M, Manki A, Takemoto K, Yamamoto M, Morishima T. Thalidomide dramatically improves the symptoms of early-onset Sarcoidosis/Blau syndrome: Its possible action and mechanism. ACTA ACUST UNITED AC 2010; 62:250-7. [DOI: 10.1002/art.25035] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Yasui K, Yashiro M, Nagaoka Y, Manki A, Wada T, Tsuge M, Kondo Y, Morishima T. Thalidomide prevents formation of multinucleated giant cells (Langhans-type cells) from cultured monocytes: possible pharmaceutical applications for granulomatous disorders. Int J Immunopathol Pharmacol 2009; 22:707-14. [PMID: 19822087 DOI: 10.1177/039463200902200316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thalidomide is an effective drug for chronic inflammatory diseases, but the mechanism underlying its immunomodulatory action remains uncertain. Thalidomide has been reported to clinically improve chronic inflammatory granulomatous disorders. In such disorders, the granulomas consist of epithelioid cells, scattered lymphocytes and multinucleated giant cells (MNGC; Langhans-type cells). The present experimental approach permitted the reproduction of MNGC formation from peripheral blood monocytes and examination of thalidomides effect on it. MNGC can be effectively generated from monocytes cultured in the presence of interleukin-4 (IL-4) and macrophage colony-stimulating factor(M-CSF) for 14 days. Thalidomide can inhibit the formation of MNGC in a dose-dependent manner. MNGC formation was partly inhibited by the presence of neutralizing TNF-alpha antibody in the responses induced by IL-4 and M-CSF. Autocrinal TNF-alpha production and modulation of cadhelin expression to regulate cell adhesion might be involved in this inhibitory action of thalidomide. Our results support thalidomides clinical efficacy in the treatment of chronic granulomatous disorders (granulomatosis).
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Affiliation(s)
- K Yasui
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Zaba LC, Smith GP, Sanchez M, Prystowsky SD. Dendritic cells in the pathogenesis of sarcoidosis. Am J Respir Cell Mol Biol 2009; 42:32-9. [PMID: 19372243 DOI: 10.1165/rcmb.2009-0033tr] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Sarcoidosis is a noncaseating granulomatous disease, likely of autoimmune etiology, that causes inflammation and tissue damage in multiple organs, most commonly the lung, but also skin, and lymph nodes. Reduced dendritic cell (DC) function in sarcoidosis peripheral blood compared with peripheral blood from control subjects suggests that blunted end organ cellular immunity may contribute to sarcoidosis pathogenesis. Successful treatment of sarcoidosis with tumor necrosis factor (TNF) inhibitors, which modulate DC maturation and migration, has also been reported. Together, these observations suggest that DCs may be important mediators of sarcoidosis immunology. This review focuses on the phenotype and function of DCs in the lung, skin, blood, and lymph node of patients with sarcoidosis. We conclude that DCs in end organs are phenotypically and functionally immature (anergic), while DCs in the lymph node are mature and polarize pathogenic Th1 T cells. The success of TNF inhibitors is thus likely secondary to inhibition of DC-mediated Th1 polarization in the lymph node.
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Affiliation(s)
- Lisa C Zaba
- Laboratory for Investigative Dermatology, The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA.
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Abstract
The classification of thalidomide as an orphan drug with anti-inflammatory actions has led to its off-label use in conditions refractory to other medications. Although the observed clinical effects of thalidomide suggest it to have immunomodulatory capabilities, the mechanism of action is unclear. Here we review both the positive and negative studies of thalidomide at the bench in order to improve our understanding of the possible mechanisms of this drug in treating a variety of diseases at the bedside. Studies on the effects of thalidomide on the innate and adaptive immune system as well as tumorigenesis and angiogenesis are discussed.
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Affiliation(s)
- Taraneh Paravar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Mathew S, Bauer KL, Fischoeder A, Bhardwaj N, Oliver SJ. The anergic state in sarcoidosis is associated with diminished dendritic cell function. THE JOURNAL OF IMMUNOLOGY 2008; 181:746-55. [PMID: 18566441 DOI: 10.4049/jimmunol.181.1.746] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sarcoidosis is a chronic inflammatory disease of unknown cause, characterized by granuloma formation similar to tuberculosis, but without clear evidence of a microbial infection. Because sarcoidosis is linked with clinical anergy and other evidence of diminished cellular immunity, we hypothesized that decreased skin delayed-type hypersensitivity (DTH) responses to recall Ags in affected individuals would be associated with decreased function of their blood dendritic cells (DCs). Our study involved ex vivo isolation, phenotyping, and functional testing of myeloid DCs (mDCs), plasmacytoid DCs, and T lymphocytes from blood of normal healthy volunteers and sarcoidosis subjects with active, untreated pulmonary disease. We found mDC function in the allogeneic MLR directly corresponded to the magnitude of skin DTH reactions to recall Ags in both sarcoidosis subjects and normal volunteers. However, both of these outcomes were significantly decreased in the sarcoidosis group. Diminished mDC function occurred despite up-regulated costimulatory and maturation markers. Clinical relevance is suggested by the inverse relationship between both mDC allogeneic responses and skin DTH responses with clinical disease severity as measured by chest radiograms. Because granulomas form when cellular immunity fails to clear antigenic stimuli, attenuated mDC function in sarcoidosis may contribute to susceptibility and persistence of the chronic inflammation characteristic of this disease.
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Affiliation(s)
- Sneha Mathew
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
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Affiliation(s)
- Christy B Doherty
- Department of Dermatology, Baylor College of Medicine, Houston, Texas 77005, USA
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Abstract
The immunopathogenesis of sarcoidosis has been difficult to charaterize given the heterogeneity of disease, the elusiveness of the causative antigen, and the lack of an adequate animal model. However, by examining well-defined clinical cohorts, the interplay between genetic predisposition and immunologic response has been increasingly informative. Technological advances in cellular analysis have allowed researchers to characterize the immune responses important in the maintenance of granulomatous inflammation. Finally, "new" clinical observations such as granuloma responsiveness to targeted biological therapies, sarcoid developing during immune restoration, and the relationship between sarcoidosis and Hepatitis C will provide future insight to the immunopathogenesis of sarcoidosis.
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Affiliation(s)
- Aliya Noor
- Division of Pulmonary and Critical Care Medicine, Indiana University and the Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Badgwell C, Rosen T. Cutaneous sarcoidosis therapy updated. J Am Acad Dermatol 2007; 56:69-83. [PMID: 17190623 DOI: 10.1016/j.jaad.2006.06.019] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 04/14/2006] [Accepted: 06/19/2006] [Indexed: 11/30/2022]
Abstract
The widely accepted standard therapy for cutaneous sarcoidosis includes corticosteroids, antimalarials, and methotrexate. However, a better understanding of the basic immunopathogenic properties of sarcoidosis has elucidated a number of steps critical to the persistence and progression of disease that may be vulnerable to treatment by targeted therapy. This article reviews both standard and newer therapeutic options for cutaneous sarcoidosis.
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Affiliation(s)
- Christy Badgwell
- Dermatology Department, Baylor College of Medicine, and Houston Veterans Affairs Medical Center, Texas, USA
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Du GJ, Lin HH, Xu QT, Wang MW. Thalidomide inhibits growth of tumors through COX-2 degradation independent of antiangiogenesis. Vascul Pharmacol 2006; 43:112-9. [PMID: 15982930 DOI: 10.1016/j.vph.2005.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 03/21/2005] [Accepted: 04/15/2005] [Indexed: 11/23/2022]
Abstract
Thalidomide is an antiangiogenic drug and is clinically useful in a number of cancers. However, the molecular mechanism by which thalidomide exerts its antitumor effects is poorly understood. This study was designed to clarify the relationship between antiangiogenesis and antitumor effects of thalidomide and to explore the molecular mechanism for its antitumor activity. We evaluated the effects of thalidomide on the growth of human tumor cells expressing (MCF-7 and HL-60) or not expressing (HeLa and K562) COX-2 in vitro. We also studied the effects of thalidomide on COX-1, COX-2 or bcl-2 expression, TNFalpha, VEGF, GSH and cytochrome c in these cells. Thalidomide could inhibit tumor growth in a concentration-dependent manner in MCF-7 and HL-60; its IC50s for them were 18.36+/-2.34 and 22.14+/-2.15 microM, respectively, while this effect was not observed in HeLa and K562. Thalidomide reduced COX-2 expression accompanied by a decrease of bcl-2 protein, TNFalpha, VEGF, GSH and an increased cytochrome c, but had no effect on that of COX-1, in MCF-7 and HL-60. Moreover, cells not expressing COX-2 were insensitive to the growth-inhibitory and effects on cytokines of thalidomide. In our mouse xenograft model of OVCAR-3 and HCT-8, we found that thalidomide could decrease intratumoral microvessel density in both tumors; it exerted antitumor effects only on OVCAR-3 expressing COX-2 but did not on HCT-8 not expressing COX-2. Effect of thalidomide on COX-1 and COX-2 in vivo was consistent with that of in vitro. These results demonstrated that thalidomide might inhibit growth of tumors through COX-2 degradation independent of antiangiogenesis.
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Affiliation(s)
- Gang-Jun Du
- Department of Pharmacology, Pharmacy College of He-nan University, Kaifeng 475001, He-nan, China.
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Wu JJ, Huang DB, Pang KR, Hsu S, Tyring SK. Thalidomide: dermatological indications, mechanisms of action and side-effects. Br J Dermatol 2005; 153:254-73. [PMID: 16086735 DOI: 10.1111/j.1365-2133.2005.06747.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thalidomide was first introduced in the 1950s as a sedative but was quickly removed from the market after it was linked to cases of severe birth defects. However, it has since made a remarkable comeback for the U.S. Food and Drug Administration-approved use in the treatment of erythema nodosum leprosum. Further, it has shown its effectiveness in unresponsive dermatological conditions such as actinic prurigo, adult Langerhans cell histiocytosis, aphthous stomatitis, Behçet's syndrome, graft-versus-host disease, cutaneous sarcoidosis, erythema multiforme, Jessner-Kanof lymphocytic infiltration of the skin, Kaposi sarcoma, lichen planus, lupus erythematosus, melanoma, prurigo nodularis, pyoderma gangrenosum and uraemic pruritus. This article reviews the history, pharmacology, mechanism of action, clinical uses and adverse effects of thalidomide.
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Affiliation(s)
- J J Wu
- Department of Dermatology, University of California, Irvine, Irvine, CA, USA
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Abstract
Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.
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Affiliation(s)
- H Nunes
- Service de Pneumologie, Hôpital Avicenne, GHU Nord, Assistance Publique Hôpitaux de Paris et Faculté de Médecine, Université Paris, Bobigny, France
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Estrada-G I, Garibay-Escobar A, Núñez-Vázquez A, Hojyo-Tomoka T, Vega-Memije E, Cortés-Franco R, Pérez-Uribe A, Flores-Romo L, Santos-Argumedo L, Estrada-Parra S, Domínguez-Soto L. Evidence that thalidomide modifies the immune response of patients suffering from actinic prurigo. Int J Dermatol 2005; 43:893-7. [PMID: 15569010 DOI: 10.1111/j.1365-4632.2004.02274.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Actinic prurigo (AP) is a photodermatosis with a restricted ethnic distribution, mainly affecting Mestizo women (mixed Indian and European). The lesions are polymorphic and include macules, papules, crusts, hyperpigmentation and lichenification. Thalidomide, an effective immunomodulatory drug, was first used successfully to treat AP in 1973. In this work we describe the effect that thalidomide had on TNF-alpha sera levels and on IL-4- and IFN gamma (IFNgamma)-producing lymphocytes of actinic prurigo (AP) patients. METHODS Actinic prurigo patients were analyzed before and after thalidomide treatment. The percentage of IL-4+ or IFNgamma+ CD3+ lymphocytes was analyzed in eight of them by flow cytometry. TNFalpha in sera was measured by ELISA in 11 patients. RESULTS A direct correlation was observed between resolution of AP lesions and an increase in IFNgamma+ CD3+ peripheral blood mononuclear cells (P < or = 0.001) and a decrease in TNFalpha serum levels (no statistical difference). No IL-4+ CD3+ cells were detected. CONCLUSIONS Our findings confirm that AP is a disease that has an immunological component and that thalidomide clinical efficacy is exerted not only through inhibition of TNFalpha synthesis, but also through modulation of INFgamma-producing CD3+ cells. These cells could be used as clinical markers for recovery.
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Affiliation(s)
- Iris Estrada-G
- Depto. de Inmunología, Escuela Nacional de Ciencias Biológicas, IPN, Centro de Investigaciones y Estudios Avanzados, IPN, México, DF.
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Lee AS, Utz JP, Specks U. Tumor necrosis factor alpha blockade as therapy for sarcoidosis: comment on the article by Ulbricht et al. ARTHRITIS AND RHEUMATISM 2004; 50:2717-8; author reply 2718-9. [PMID: 15334498 DOI: 10.1002/art.20373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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Nguyen YT, Dupuy A, Cordoliani F, Vignon-Pennamen MD, Lebbé C, Morel P, Rybojad M. Treatment of cutaneous sarcoidosis with thalidomide. J Am Acad Dermatol 2004; 50:235-41. [PMID: 14726878 DOI: 10.1016/j.jaad.2003.07.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although systemic corticosteroids are effective against cutaneous sarcoidosis, alternative therapies are needed. OBJECTIVE We sought to assess the efficacy and tolerance of thalidomide for cutaneous sarcoidosis. METHODS We performed a retrospective evaluation of thalidomide (100-200 mg/d) in 12 consecutive patients with cutaneous sarcoidosis treated in a university hospital between 2000 and 2002. RESULTS Cutaneous lesions regressed within 1 to 5 months, with an average time of 2 to 3 months for 10 patients. In all, 4 patients achieved complete responses, 6 had partial responses, and 2 had no regression. Nasopharyngeal, pulmonary neurologic, and hepatic symptoms were also attenuated. Thalidomide was well tolerated. The main adverse effect was deep vein thrombosis in 1 patient. CONCLUSION Thalidomide efficacy and tolerance in patients with cutaneous sarcoidosis merits further evaluation in a controlled trial.
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Affiliation(s)
- Yên Thi Nguyen
- Dermatology Department, Hôspital Saint-Louis, Paris, France
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Baughman RP, Lower EE. Newer therapies for cutaneous sarcoidosis: the role of thalidomide and other agents. Am J Clin Dermatol 2004; 5:385-94. [PMID: 15663335 DOI: 10.2165/00128071-200405060-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Robert P Baughman
- Department of Medicine, Interstitial Lung Disease and Sarcoidosis Clinic, University of Cincinnati, Cincinnati, Ohio, USA.
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Sato H, Lagan AL, Alexopoulou C, Vassilakis DA, Ahmad T, Pantelidis P, Veeraraghavan S, Renzoni E, Denton C, Black C, Wells AU, du Bois RM, Welsh KI. The TNF-863A allele strongly associates with anticentromere antibody positivity in scleroderma. ACTA ACUST UNITED AC 2004; 50:558-64. [PMID: 14872499 DOI: 10.1002/art.20065] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Scleroderma is characterized by the presence of 3 predominant, yet almost mutually exclusive, antibodies: anticentromere antibody (ACA), antitopoisomerase antibody, and anti-RNA polymerase antibody. The purpose of this study was to investigate tumor necrosis factor (TNF) polymorphisms in scleroderma, with the specific aim of determining whether TNF polymorphisms would prove to be stronger markers for ACA than class II major histocompatibility complex (MHC). METHODS We studied 214 UK white scleroderma patients and 354 healthy controls. All subjects were investigated for 5 TNF promoter region polymorphisms by sequence-specific polymerase chain reaction. RESULTS We showed that an NF-kappaB binding site polymorphism (known to be functionally relevant) in the TNF promoter region was present in 51.8% of patients with ACA and 16.3% of patients without ACA (chi(2) = 25.1, P = 0.000004 [corrected P = 0.00002]). Using haplotype mapping, we showed that this was a primary TNF association that could explain the previous weak links between ACA production and class II MHC alleles. In marked contrast to our ACA results, HLA class II (especially DRB1*11) appeared to be primary in that it could explain the weaker TNF association with antitopoisomerase production. Further, we observed a separate TNF haplotype to be associated with scleroderma per se, although the level of significance was much lower (chi(2) = 8.7, P = 0.003 [corrected P = 0.02]). CONCLUSION We believe these findings may have importance both for the directional pathogenesis of scleroderma progression and for the treatment of scleroderma with anti-TNF agents.
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Affiliation(s)
- Hiroe Sato
- Imperial College of Science, Technology and Medicine, and the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
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Nasca MR, Micali G, Cheigh NH, West LE, West DP. Dermatologic and nondermatologic uses of thalidomide. Ann Pharmacother 2003; 37:1307-20. [PMID: 12921515 DOI: 10.1345/aph.19255] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To review published data on thalidomide, with emphasis on current knowledge about mechanism of action, new and/or potential dermatologic and nondermatologic therapeutic applications, well-known and emerging adverse effects, and current indications for its safe use. DATA SOURCES Review articles, in vitro research studies, references from retrieved articles, case reports, and clinical trials were identified from a computerized literature search using MEDLINE and OVID (1966-January 2003) and on the Cochrane Clinical Trials Register (January 2003). Information available from meetings' abstract books, Internet, or pharmaceutical companies was also considered. STUDY SELECTION AND DATA EXTRACTION All articles identified as relevant, including those from non-English literature, were considered in an attempt to provide to the reader both the theoretical basis and practical guidelines for thalidomide pharmacotherapy. DATA SYNTHESIS Thalidomide has hypnosedative, antiangiogenic, antiinflammatory, and immunomodulatory properties. Moreover, it has been shown to selectively inhibit the production of tumor necrosis factor-alpha and reduce the expression of various integrin receptors on the membrane of leukocytes and other cell types in a dose-dependent fashion. Controlled trials demonstrated the efficacy of thalidomide in a number of diseases, including erythema nodosum leprosum, lupus erythematosus, aphthosis, graft-versus-host disease, prurigo nodularis, and actinic prurigo. Single case reports or studies in small series have also suggested a possible role for thalidomide in numerous other dermatologic and nondermatologic disorders. Possibly severe and sometimes irreversible risks related to the clinical use of thalidomide include teratogenicity and neurotoxicity. CONCLUSIONS Although teratogenicity and neurotoxicity are significant adverse effects requiring cautious use, thalidomide is an effective therapeutic modality in a variety of difficult-to-treat disorders and, providing careful selection of patients, should offer an acceptable risk-to-benefit ratio.
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Affiliation(s)
- Maria R Nasca
- Department of Dermatology, University of Catania, Catania, Italy
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Abstract
BACKGROUND Thalidomide is best known as a major teratogen that caused birth defects in up to 12,000 children in the 1960s. More recently, this agent has been approved by the US Food and Drug Administration for the treatment of erythema nodosum leprosum (ENL) through a restricted-use program. Its immunomodulatory, anti-inflammatory, and antiangiogenic properties are currently under study in a number of clinical conditions. OBJECTIVE This article reviews the pharmacology of thalidomide; its approved and off-label uses in dermatologic, oncologic, and gastrointestinal conditions; and adverse events associated with its use. METHODS Relevant articles were identified through searches of MEDLINE (1966-June 2002), International Pharmaceutical Abstracts (1970-June 2002), and EMBASE (1990-June 2002). Search terms included but were not limited to thalidomide, pharmacokinetics, pharmacology, therapeutic use, and teratogenicity, as well as terms for specific disease states and adverse events. Further publications were identified from the reference lists of the reviewed articles. Abstracts of recent symposia were obtained from the American Society of Clinical Oncology Web site. RESULTS Thalidomide is thought to exert its therapeutic effect through the modulation of cytokines, particularly tumor necrosis factor-alpha. In addition to its approved indication for ENL, thalidomide has been studied in various other conditions, including graft-versus-host disease, discoid lupus erythematosus, sarcoidosis, relapsed/refractory multiple myeloma, Waldenstrom's macroglobulinemia, myelodysplastic syndromes, acute myeloid leukemia, myelofibrosis with myeloid metaplasia, renal cell carcinoma, malignant gliomas, prostate cancer, Kaposi's sarcoma, colorectal carcinoma, oral aphthous ulcers, Behçet's disease, Crohn's disease, and HIV/AIDS-associated wasting. Adverse events most frequently associated with its use include somnolence, constipation, rash, peripheral neuropathy, and thromboembolism. CONCLUSIONS Use of thalidomide is limited by toxicity, limited efficacy data, and restricted access. Evidence of its efficacy in conditions other than ENL awaits the results of controlled clinical trials.
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Affiliation(s)
- S James Matthews
- Department of Pharmacy Practice, School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts 02115, USA.
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Abstract
Progress in our understanding of the scientific basis of granulomatous inflammation in sarcoidosis provides a framework for enlightened treatment decisions. Current evidence supports the concept that the pathogenesis of sarcoidosis involves a highly polarized T-helper 1 (Th1) immune response to pathogenic tissue antigens. Conventional treatment is focused on attenuating granuloma formation with antimalarial drugs that inhibit antigen presentation or with nonspecific anti-inflammatory agents such as glucocorticosteroids, methotrexate, or azathioprine. Anti-tumour necrosis factor (TNF)-alpha agents such as pentoxifylline, thalidomide, etanercept and remicade, have recently shown some successes in sarcoidosis. Designing future therapies depends on improved knowledge of the critical immunological processes operative in different stages of disease.
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Affiliation(s)
- D R Moller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Abstract
Sarcoidosis is one in a heterogeneous family of granulomatous disorders. The clinical manifestations of sarcoidosis can vary widely, depending on the patient and the tissues involved. Recent advances in our understanding of the immunologic steps leading to granuloma formation and persistence have yet to translate into more effective care for patients with this disease. This review discusses the immunology of granuloma formation and systemic disease, the various nonpulmonary expressions of the clinical disease, and the treatment options available to the practicing physician.
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Affiliation(s)
- Stephen J Oliver
- Laboratory of Cellular Physiology & Immunology, Rockefeller University, 1230 York Avenue, New York, NY 10021, USA.
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