The mode of presentation of sarcoidosis in Finland and Hokkaido, Japan. A comparative analysis of 571 Finnish and 686 Japanese patients

Clinical Patterns of Sarcoidosis Patients with and without Uveitis: Insights from a Dutch Sarcoidosis Centre

PURPOSE

Uveitis is a common ocular manifestation in individuals with sarcoidosis, a multisystem inflammatory disorder. This study aimed to explore clinical and genetic factors associated with the presence or absence of uveitis in sarcoidosis patients.

METHODS

Total 625 Dutch sarcoidosis patients were included. Among these, 170 underwent ophthalmic examination, and 61 were diagnosed with uveitis. Demographic and clinical data, including age, gender, race, biopsy status, chest radiography findings, TNF-α inhibitor treatment, and uveitis classification were collected retrospectively from medical records. Genetic data was available for HLA haplotypes, TNF-α G-308A, and BTNL2 G16071A polymorphisms.

RESULTS

The majority of the patients presented with bilateral uveitis (80.3%). The proportion of women was higher in the uveitis group compared to the non-uveitis group (67.2% and 47.7%; p = 0.014). Pulmonary involvement (chest radiographic stage II-III) was significantly lower in patients with uveitis (36.1% versus 64.2%; p < 0.001). Patients with uveitis were more often treated with TNF-α inhibitors (67.2% versus 29.4%; p < 0.001) and the outcome was better compared with the non-uveitis group, 92% vs 68%, responders (p < 0.012). Uveitis patients treated with TNF-α inhibitors (either adalimumab or infliximab) were more likely to suffer from intermediate or posterior uveitis than anterior uveitis. Genetic analysis identified a significant association between the BTNL2 G16071A GG genotype and uveitis (p = 0.012).

CONCLUSION

This study highlights distinctive demographic, clinical and genetic features associated with uveitis in sarcoidosis patients. Ocular sarcoidosis was more prevalent in women. Further research is warranted to explore the implications of these findings for treatment strategies and prognostic assessments.

Cough in Idiopathic Pulmonary Fibrosis

Chronic cough is experienced by most patients with idiopathic pulmonary fibrosis (IPF). It is often the first symptom and is associated with reduced quality of life, increased rates of depression and anxiety, more severe physiological impairment, and disease progression. Although not fully understood, recent gains in understanding the pathophysiology of chronic cough in IPF have been made. The pathophysiology is likely multifactorial and includes alterations in mucous production and clearance, architectural distortion, and increased cough reflex sensitivity, suggesting a role for targeted therapies and multidisciplinary treatment. Modifiable comorbidities can also induce cough in patients with IPF. There is a renewed emphasis on measuring cough in IPF, with clinical trials of novel and repurposed therapies for chronic cough emerging in this population. This review provides an update on the clinical characteristics, pathophysiology, and measurement of chronic cough in patients with IPF and summarizes recent developments in non-pharmacological and pharmacological therapies.

Clinical characteristics of sarcoidosis patients in the United States versus China

Objective: To characterize and compare the disease manifestations between patients with sarcoidosis in China versus the United States using the World Association of Sarcoidosis and Other Granulomatous disease (WASOG) instrument. Methods: Clinical data and disease manifestations were reviewed from sarcoidosis patients from the Shanghai Pulmonary Hospital (China) and University of Cincinnati Medical Center (US). Results: 481 Chinese patients and 522 US patients with sarcoidosis were studied. Extra-pulmonary sarcoidosis was observed more frequently in US patients than Chinese patients. Chinese patients were more likely to develop hypercalcemia or hypercalcuria (23%) compared to US patients (14%) (χ²=18.342, P<0.001), and US White patients were more likely to experience hypercalcemia or hypercalcuria (20%) compared to US Black patients (7.6%) (χ²=16.230, P<0.001). However, Black patients were more likely to have eye involvement (39%) than White patients (26%) (χ²=10.986, P=0.001). Additionally, US patients witnessed more advanced Stage 3 or 4 chest x-ray patterns and lower predicted FVC% and DLCO% compared to Chinese patients (both P<0.001). Conclusion: Compared to US sarcoidosis patients, Chinese patients were older at diagnosis and experienced a lower frequency of extra thoracic involvement, higher incidence of hypercalcemia or hypercalcuria, and less severe lung involvement. These differences were mostly due to the African American patients seen in the US sarcoidosis clinic. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 209-216)

Exome Sequencing Identifies Susceptibility Loci for Sarcoidosis Prognosis

Many sarcoidosis-associating immunological genes have been shown to be shared between other immune-mediated diseases. In Finnish sarcoidosis patients, good prognosis subjects more commonly have HLA-DRB1*03:01 and/or HLA-DRB1*04:01-DPB1*04:01 haplotype, but no marker for persistent disease have been found. The objective was to further pinpoint genetic differences between prognosis subgroups in relation to the HLA markers. Whole-exome sequencing was conducted for 72 patients selected based on disease activity (resolved disease, n = 36; persistent disease, n = 36). Both groups were further divided by the HLA markers (one/both markers, n = 18; neither of the markers, n = 18). The Finnish exome data from the Genome Aggregation Database was used as a control population in the WES sample. Statistical analyses included single-variant analysis for common variants and gene level analysis for rare variants. We attempted to replicate associated variants in 181 Finnish sarcoidosis patients and 150 controls. An association was found in chromosome 1p36.21 (AADACL3 and C1orf158), which has recently been associated with sarcoidosis in another WES study. In our study, variations in these genes were associated with resolved disease (AADACL3, p = 0.0001 and p = 0.0003; C1orf158, p = 7.03E-05). Another interesting chromosomal region also peaked, Leucocyte Receptor Complex in 19q13.42, but the association diminished in the replication sample. In conclusion, this WES study supports the previously found association in the region 1p36.21. Furthermore, a novel to sarcoidosis region was found, but additional studies are warranted to verify this association.

Management of neurosarcoidosis: a clinical challenge

PURPOSE OF REVIEW

Sarcoidosis is a complex disease with many faces, and the clinical manifestation and course of neurosarcoidosis are particularly variable. Although neurosarcoidosis occurs in up to 10% of sarcoidosis patients, it can lead to significant morbidity and some mortality.

RECENT FINDINGS

Three criteria are usually required for a diagnosis of (neuro)sarcoidosis: clinical and radiologic manifestations, noncaseating granulomas, and no evidence of alternative disease. Recent guidelines have helped to clarify criteria for diagnosing neurosarcoidosis. No firm guidelines exist on whether, when, and how treatment should be started. Treatment depends on the presentation and distribution, extensiveness, and severity of neurosarcoidosis. As regards evidence-based treatment, only a few randomized controlled trials have been done. Hence, several aspects of (neuro)sarcoidosis management are not fully addressed by the current literature.

SUMMARY

Significant advances have been made in the potential and accuracy of diagnostics for neurosarcoidosis. Treatment should be approached within the context of the patient's anticipated clinical course, avoidance of adverse drug effects, and, if necessary, from the perspective of the comprehensive management of a chronic disease. A multidisciplinary approach to the management of sarcoidosis is strongly recommended.

Sarcoidosis in the Middle East

Sarcoidosis, a systemic granulomatous disease of unknown cause, has been described worldwide and in all populations with notable differences in clinical characteristics, organ involvement, disease severity, and prognosis among different ethnic and racial groups. While the exact prevalence of sarcoidosis in the Middle East is unknown, studies from various countries in the region have reported the clinical characteristics of affected patients, along with a few anecdotal reports. A search of the MEDLINE and Google Scholar databases was conducted for relevant English-language articles using the terms “sarcoidosis” and “Middle East” or “sarcoidosis” and “Arabs.” Subsequently, the names of individual countries were used as search terms, replacing “Middle East.” Overall, the clinical picture of patients with sarcoidosis in the Middle East is similar to that reported elsewhere; for example, the disease was more frequent among females and respiratory complaints were the predominant symptoms. Within the region, most patients from Oman were older and female, with arthralgia, hypercalcemia, and eye involvement being more common. Constitutional symptoms were frequent, especially among patients from Iran. Cough was more common among patients from Kuwait and Iran, while dyspnea was the predominant symptom for Saudi patients. Erythema nodosum was more common in the Turkish population. Clustering was seen in patients with Stage I and II of the disease in all countries except Oman. Apart from those in Iran, the prognosis of most patients from the Middle East was excellent.

Sarcoidosis Diagnostic Score: A Systematic Evaluation to Enhance the Diagnosis of Sarcoidosis

BACKGROUND

The diagnosis of sarcoidosis is made by the combination of clinical features and biopsy results. The clinical features of sarcoidosis can be quite variable. We developed a Sarcoidosis Diagnostic Score (SDS) to summarize the clinical features of patients with possible sarcoidosis.

METHODS

Biopsy-confirmed patients with sarcoidosis seen during a 7-month period at the University of Cincinnati sarcoidosis clinic were prospectively identified. Patients with nonsarcoidosis seen at the same clinic were used as control patients. Using a modified World Association of Sarcoidosis and Other Granulomatous Disorders organ assessment instrument, we scored all patients for presence of biopsy, ≥1 highly probable symptom, and ≥1 at least probable symptom for each area. Two sarcoidosis scores were generated: SDS biopsy (with biopsy) and SDS clinical (without biopsy).

RESULTS

The 980 evaluable patients were divided into two cohorts: an initial 600 patients (450 with biopsy-confirmed sarcoidosis, 150 control patients) to establish cutoff values for SDS biopsy and an SDS clinical and a validation cohort of 380 patients (103 biopsy-confirmed patients with sarcoidosis and 277 control patients). The best cutoff value for SDS biopsy was ≥ 6 (sensitivity, 99.3%; specificity, 100%). For the total the 980 patients, an SDS clinical ≥ 3 had a sensitivity of 90.6%, specificity of 88.5%, and a likelihood ratio of 7.9. An SDS clinical score ≥ 4 had a lower sensitivity of (76.9%) but higher specificity (98.6%).

CONCLUSIONS

For sarcoidosis, the presence of specific clinical features, especially multiorgan involvement, can enhance the diagnostic certainty. The SDS scoring system quantitated the clinical features consistent with sarcoidosis.

Cough, sarcoidosis and idiopathic pulmonary fibrosis: raw nerves and bad vibrations

Cough is a common symptom in people who develop interstitial lung diseases (ILD). The pathological features of the ILDs are many and varied suggesting that the cause of cough may also vary with each disease. This article reviews what is currently known about cough in sarcoidosis and idiopathic pulmonary fibrosis; two of the commonest ILDs. It also outlines some of the theories which have been proposed to explain why cough develops in these conditions and describes what little is known about how to treat it.

Genetic testing in diffuse parenchymal lung disease

Diffuse parenchymal lung diseases (DPLD) represent a diverse group of disorders affecting the distal lung parenchyma, specifically the tissue and spaces surrounding the alveoli, which may be filled with inflammatory cells, proliferating fibroblasts or established fibrosis, often leading to architectural distortion and impaired gas exchange. While the underlying pathogenetic mechanisms are known or inferred for some DPLD (such as sarcoidosis, silicosis, drug reactions and collagen vascular diseases), the pathogenesis of the majority of these entities - particularly those characterized by progressive fibrosis - is poorly understood.

Several lines of evidence indicate that the development of pulmonary fibrosis is genetically determined. They include: 1. familial clustering; 2. the occurrence of pulmonary fibrosis in the context of rare inherited disorders; 3. substantial variability in the development of pulmonary fibrosis amongst individuals exposed to organic or inorganic dusts; 4. difference in susceptibility to fibrogenic stimuli amongst inbred strains of mice.

This review focuses on idiopathic pulmonary fibrosis (IPF) and sarcoidosis, the two most common DPLD and the two entities for which there is stronger evidence of a genetic predisposition, although how aberrant genes interact with each other and with environmental factors, such as smoking in IPF and infectious agents in sarcoidosis, in determining disease susceptibility and clinical phenotypes is largely unknown. Finally, we discuss practical issues and implications for both patients and physicians of recent advances in the genetics of sarcoidosis and IPF.

Genetic interstitial lung disease

The interstitial lung diseases (ILDs), or diffuse parenchymal lung diseases, are a heterogeneous collection of more than 100 different pulmonary disorders that affect the tissue and spaces surrounding the alveoli. Patients affected by ILD usually present with shortness of breath or cough; for many, there is evidence of pulmonary restriction, decreased diffusion capacity, and radiographic appearance of alveolar and/or reticulonodular infiltrates. This article reviews the inherited ILDs, with a focus on the diseases that may be seen by pulmonologists caring for adult patients. The authors conclude by briefly discussing the utility of genetic testing in this population.

The six-minute walk test in patients with pulmonary sarcoidosis

BACKGROUND:

The 6-min walk test (6MWT) is a useful tool to assess prognosis and functional impairment in various pulmonary diseases.

AIMS:

To evaluate functional capacity during various stages of pulmonary sarcoidosis and develop a scoring system clinical radiological physiological score (CRP) that can potentially be used to assess the functional status among patients with sarcoidosis.

MATERIALS AND METHODS:

We performed a retrospective study on 26 patients diagnosed with pulmonary sarcoidosis from 2001 to 2007. All patients completed the 6MWT. The parameters assessed during the test included spirometry, arterial blood gas, 6-min walk distance (6MWD), Borg dyspnea score, and initial and end oxygen saturation.

RESULTS:

Females covered a significantly shorter distance than males (343 m (223–389) vs. 416.5 m (352–500); P < 0.0001). In addition, females had a significantly lower SpO₂ at the end of the 6MWT than males (90.5 (61–99) vs. 96 (75–98); P < 0.03). The 6MWD was inversely correlated with the final Borg score (ρ = −0.603, P = 0.004) and the CRP score (ρ = −0.364, P = 0.047) and positively correlated with forced expiratory volume in 1 s (FEV₁) % (ρ = 0.524, P = 0.006) and forced vital capacity (FVC) % (ρ = 0.407, P = 0.039).

CONCLUSIONS:

Female gender, FEV₁%, final Borg score, FVC%, CRP score, and SpO₂ at the end of the 6MWT are associated with reduced 6MWD. It appears that Saudi patients diagnosed with sarcoidosis have a markedly reduced walking distance compared with other races. The effect of race and ethnicity and the utility of the CRP score as a potential marker to assess functional status require further exploration.

A concise review of pulmonary sarcoidosis

This is an update on sarcoidosis, focusing on etiology, diagnosis, and treatment. In the area of etiopathogenesis, we now have a better understanding of the immune response that leads to the disease as well as genetic factors that modify both the risk for the disease and its clinical outcome. Several groups have also identified possible agents as a cause for sarcoidosis. Although none of these potential causes has been definitely confirmed, there is increasing evidence to support that one or more infectious agents may cause sarcoidosis, although this organism may no longer be viable in the patient. The diagnosis of sarcoidosis has been significantly aided by new technology. This includes the endobronchial ultrasound, which has been shown to increase the yield of needle aspiration of mediastinal and hilar lymph nodes. The positive emission tomography scan has proven useful for selecting possible biopsy sites by identifying organ involvement not appreciated by routine methodology. It has also helped in assessing cardiac involvement. The biologic agents, such as the anti-tumor necrosis factor antibodies, have changed the approach to refractory sarcoidosis. There is increasing evidence that the clinician can identify which patient is most likely to benefit from such therapy. As new and more potent antiinflammatory agents have been developed, it is clear that there are other factors that burden the patient with sarcoidosis, including fatigue and sarcoidosis-associated pulmonary hypertension. There have been several recent studies demonstrating treatment options for these problems.

Clinical characteristics and computed tomography findings in Arab patients diagnosed with pulmonary sarcoidosis

BACKGROUND AND OBJECTIVE

Sarcoidosis is prevalent worldwide with significant heterogeneity across different ethnic groups. We aimed To describe the clinical characteristics and computed tomography findings among Arab patients with pulmonary sarcoidosis.

METHODS

A retrospective study of patient demographics, symptoms, co-morbid illness, sarcoidosis stage, treatment, pulmonary function and CT results.

RESULTS

Of 104 patients, most (77%) were 40 years of age or older at diagnosis, and females in this category (40 years ) significantly outnumbered male patients (69/104 (66.3%) vs. 35/104 (33.7%), P=.003). The most common complaints were dyspnea (76%), cough (72.1%) and weight loss (32.7%). The majority of patients displayed impairment in lung function parameters at presentation. However, significant impairment in forced vital capacity, percentage predicted (FVC%) (

CONCLUSION

At presentation, clinical manifestations of sarcoidosis among this sample of Arab patients were similar to reports from other nations. Further studies are needed to explore the effects of race and ethnicity on disease severity in the Middle East.

Clinical and immunologic components of sarcoidosis

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

Obstructive sarcoidosis

Sarcoidosis is a systemic granulomatous disease that frequently involves the lung. Although classically thought of as a restrictive lung disease, airway obstruction has become a recognized feature of the disease in the past years. Sarcoidosis can affect the airway at any level and when the involvement includes small airways, it can resemble more common obstructive airway diseases, such as asthma and chronic bronchitis. Pulmonary function testing and high-resolution computerized tomography of the chest are two important tools to evaluate the presence and extent of airway obstruction in sarcoidosis. Pharmacologic options for the treatment of obstructive sarcoidosis are, in large part, not supported by large, randomized clinical trials. In severe cases of bronchostenosis owing to sarcoidosis granuloma or extrinsic compression from intrathoracic lymphadenopathy, interventional bronchoscopy has successfully been performed, although repeated procedures are usually required. Lung transplantation is an ultimate option in selected patients with late-stage fibrotic disease.