Pharmacotherapeutic management of pulmonary sarcoidosis

Utilizing Melatonin to Alleviate Side Effects of Chemotherapy: A Potentially Good Partner for Treating Cancer with Ageing

Persistent senescence seems to exert detrimental effects fostering ageing and age-related disorders, such as cancer. Chemotherapy is one of the most valuable treatments for cancer, but its clinical application is limited due to adverse side effects. Melatonin is a potent antioxidant and antiageing molecule, is nontoxic, and enhances the efficacy and reduces the side effects of chemotherapy. In this review, we first summarize the mitochondrial protective role of melatonin in the context of chemotherapeutic drug-induced toxicity. Thereafter, we tabulate the protective actions of melatonin against ageing and the harmful roles induced by chemotherapy and chemotherapeutic agents, including anthracyclines, alkylating agents, platinum, antimetabolites, mitotic inhibitors, and molecular-targeted agents. Finally, we discuss several novel directions for future research in this area. The information compiled in this review will provide a comprehensive reference for the protective activities of melatonin in the context of chemotherapy drug-induced toxicity and will contribute to the design of future studies and increase the potential of melatonin as a therapeutic agent.

Novel pharmacotherapy of sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that most commonly affects the lungs. Treatment of sarcoidosis can be challenging as it is often difficult to measure disease activity and distinguish active inflammation from fibrosis. Identifying the inflammatory mediators in sarcoidosis has led to the development and use of novel therapeutic agents. The goal of pharmacotherapy is to decrease granuloma accumulation, ameliorate symptoms and improve organ function. Systemic corticosteroids remain the first line treatment. Other immunosuppressive agents may be considered for the patients who respond poorly to corticosteroids or who experience significant adverse effects. An overview of pharmacotherapy of sarcoidosis is provided here.

Targeting CD4(+) T cells for the treatment of sarcoidosis: a promising strategy?

Sarcoidois is an inflammatory disease of unknown origin characterized by the abnormal accumulation of noncaseating granulomas at sites of disease activity in multiple organs throughout the body with a predilection for the lungs. Because the exact trigger that leads to disease activity is still under investigation, current treatment options are contingent on the organ or organs affected. Corticosteroids are the therapy of choice, but antimalarials and TNF-α antagonists are also commonly prescribed. Recent findings provide evidence for the use of CD20 B-cell-depleting therapy as an alternative method of choice. However, because sarcoidosis is predominantly a T-helper cell-driven disorder, an overwhelming amount of compelling evidence exists for the use of CD4(+) T-cell targeted therapy.

Cervical lymph node diseases in children

The lymph nodes are an essential part of the body’s immune system and as such are affected in many infectious, autoimmune, metabolic and malignant diseases. The cervical lymph nodes are particularly important because they are the first drainage stations for key points of contact with the outside world (mouth/throat/nose/eyes/ears/respiratory system) – a critical aspect especially among children – and can represent an early clinical sign in their exposed position on a child’s slim neck.

Involvement of the lymph nodes in multiple conditions is accompanied by a correspondingly large number of available diagnostic procedures. In the interests of time, patient wellbeing and cost, a careful choice of these must be made to permit appropriate treatment. The basis of diagnostic decisions is a detailed anamnesis and clinical examination. Sonography also plays an important role in differential diagnosis of lymph node swelling in children and is useful in answering one of the critical diagnostic questions: is there a suspicion of malignancy? If so, full dissection of the most conspicuous lymph node may be necessary to obtain histological confirmation.

Diagnosis and treatment of childhood cervical lymph node disorders present the attending pediatric and ENT physicians with some particular challenges. The spectrum of differential diagnoses and the varying degrees of clinical relevance – from banal infections to malignant diseases – demand a clear and considered approach to the child’s individual clinical presentation. Such an approach is described in the following paper.

A review on guidelines for management and treatment of common variable immunodeficiency

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. As symptoms of CVID are usually heterogeneous and unspecific, diagnosis and follow-up of CVID can be challenging. In light of this, a broad review of advances in management and treatment of CVID is performed here in order to reach a distinct protocol. However, it should be noted that owing to the nature of the disease, it can only be treated symptomatically but not cured. There is little evidence to guide appropriate or universal guidelines to improve the current status of management of the disease. The most satisfactory treatments of CVID could be achieved by the use of immunoglobulin replacement, antibiotics, immunosuppressants and hematopoietic stem cell transplantation. This review is written based on the importance of clinical surveillance of asymptomatic CVID cases and early recognition of different clinical complications. Moreover, for each complication, appropriate interventions for improving outcomes are mentioned.

Typical and atypical pattern of pulmonary sarcoidosis at high-resolution CT: relation to clinical evolution and therapeutic procedures

AIM

This study was done to evaluate the importance of high-resolution CT (HRCT) in defining pattern and extent of disease and establishing the clinical and therapeutic pathway in sarcoidosis.

MATERIALS AND METHODS

A retrospective analysis of 56 patients with pulmonary involvement of sarcoidosis was performed. Two groups were identified: 39 patients exhibiting a typical HRCT pattern and 17 patients with an atypical pattern. Inclusion criteria were the presence of radiological documentation (HRCT) of disease, clinical and radiological follow-up of 1 year and the beginning of any therapy within 1 month from the diagnosis.

RESULTS

Among subjects not receiving therapy, the comparison between the two groups showed that the radiological findings remained stable in subjects with a typical pattern, while they worsened in more than 70% of cases with atypical appearance. Therapy was more effective in patients with a typical pattern. Recurrences occurred in both groups, but more often in patients with a typical pattern. One patient not receiving treatment experienced clinical worsening. Re-evaluation of HRCT within 1 year revealed no correlation between clinical deterioration and radiological changes.

CONCLUSIONS

The findings of this study suggest that persistence of the inflammatory process rather than the radiological pattern at onset is a prognostic factor for recurrence.

Sarcoidosis and pain caused by small-fiber neuropathy

Sarcoidosis is a chronic inflammatory illness and small-fiber neuropathy (SFN) is one of the disabling and often chronic manifestations of the disease. SFN presents with peripheral pain and symptoms of autonomic dysfunction. The character of the pain can be burning or shooting. Besides, allodynia and hyperesthesia can exist. Diagnosis is usually made on the basis of clinical features, in combination with abnormal specialized tests. The aim of treatment is often to reduce pain; however, total pain relieve is seldom achieved. The role of TNF-α in the pathogenesis of SFN in sarcoidosis appears interesting to explore. Novel therapeutic agents such as ARA 290, a nonhematopoietic erythropoietin analogue with potent anti-inflammatory and tissue protective properties, are interesting to explore in the treatment of SFN in sarcoidosis.

Tumor necrosis factor-alpha inhibitor treatment for sarcoidosis

Sarcoidosis is a chronic multisystem disease of unknown etiology, characterized by noncaseating granulomatous infiltration of virtually any organ system. Treatment is often undertaken in an attempt to resolve symptoms or prevent progression to organ failure. Previous studies have suggested a prominent role for tumor necrosis factor-alpha (TNF-α) in the inflammatory process seen in sarcoidosis. TNF-α and interleukin-1 are released by alveolar macrophages in patients with active lung disease. Corticosteroids have proved to be efficacious in the treatment of sarcoidosis, possibly by suppressing the production of TNF-α and other cytokines. Three agents are currently available as specific TNF antagonists: etanercept, infliximab, and adalimumab. Although data from noncomparative trials suggest that all three have comparable therapeutic effects in rheumatoid arthritis, their effects in a granulomatous disease such as sarcoidosis are less consistent. In this review, current data on the effectiveness are summarized.

How I treat common variable immune deficiency

Common variable immunodeficiency is a rare immune deficiency, characterized by low levels of serum immunoglobulin G, A, and/or M with loss of antibody production. The diagnosis is most commonly made in adults between the ages of 20 and 40 years, but both children and older adults can be found to have this immune defect. The range of clinical manifestations is broad, including acute and chronic infections, inflammatory and autoimmune disease, and an increased incidence of cancer and lymphoma. For all these reasons, the disease phenotype is both heterogeneous and complex. Contributing to the complexity is that patient cohorts are generally small, criteria used for diagnosis vary, and the doses of replacement immune globulin differ. In addition, routines for monitoring patients over the years and protocols for the use of other biologic agents for complications have not been clarified or standardized. In the past few years, data from large patient registries have revealed that both selected laboratory markers and clinical phenotyping may aid in dissecting groups of subjects into biologically relevant categories. This review presents my approach to the diagnosis and treatment of patients with common variable immunodeficiency, with suggestions for the use of laboratory biomarkers and means of monitoring patients.

[Parotid gland sarcoidosis]

INTRODUCTION

Sarcoidosis is a granulomatous multisystemic disease of unknown origin that can occur in any organ of the body and commonly affects young adults. Pulmonary sarcoidosis is by far the most common manifestation of the disease but occasionally it presents with involvement of the lymph nodes, skin, eyes, liver, spleen, heart, bones, joints, nervous system and the oral organs. The diagnosis of sarcoidosis is complex and includes the presence of noncaseating granuloma in involved tissues, changes in chest x-ray and many other tests.

AIM

The aim of the study was to present the rare case of parotid sarcoidosis which was the origin of discussion of diagnostics and treatment of sarcoidosis in ENT field.

MATERIAL AND METHODS

The authors present a review of updated opinions on pathogenesis, diagnostics and treatment of sarcoidosis, completed with own experience concerning a case of extrapulmonary sarcoidosis that manifested with isolated parotid gland enlargement.

CONCLUSIONS

1. The incidence of head and neck sarcoidosis is rare, although this etiology should be taken into account in ENT diagnostics. 2. The lesions can occur in many organs, most common manifestation is: lungs, peripherial lymph nodes, skin, eyes, articulations, liver and spleen. 3. Course of sarcoidosis is not characteristic, chest x-ray, biopsy and the analysis of clinical signs are required to settle the diagnosis. 4. In cases of isolated salivary gland sarcoidosis the preoperative diagnosis is difficult, fine-needle biopsy and Doppler ultrasonography can be helpful. 5. The possibility of exacerbations and recidivations makes the long follow-up necessary.

Extrapulmonary sarcoidosis of liver and pancreas: A case report and review of literature

Sarcoidosis is a chronic multisystemic granulomatous disease of unknown origin, which can involve nearly all organs. In the case of an infrequent gastrointestinal tract involvement in systemic sarcoidosis, granulomas of the liver are most commonly described while isolated pancreatic sarcoid lesions are rarely seen. We report a case of systemic sarcoidosis with exclusive extrapulmonal involvement of the liver and the pancreas in a 71-year-old white man. The diagnosis of liver involvement was confirmed by biopsy. Pancreatic surgery was needed because preoperative evaluation could not exclude pancreatic cancer and for biliary decompression. An extensive literature review of systemic sarcoidosis, focusing on reported cases with unusual presentation of sarcoidosis in the liver and the pancreas, its diagnosis, treatment, and prognosis was made.

Practical Issues and Challenges in the Diagnosis and Treatment of Pulmonary Sarcoidosis

Sarcoidosis is a granulomatous disease with multisystem involvement. Diagnosis is generally easy to establish from the characteristic clinical and radiographic features. In India and other developing countries, tuberculosis is the closest clinical mimic and needs to be excluded before therapy for sarcoidosis is instituted. Tuberculin anergy and histopathological demonstration of characteristic compact granulomas help in the diagnosis of sarcoidosis. Corticosteroids constitute the mainstay of therapy for symptomatic pulmonary and most other forms of extrapulmonary sarcoidosis. Asymptomatic disease does not require any treatment, but milder forms may be treated with topical corticosteroids and symptomatic therapy. Alternative drugs such as cytotoxic agents, hydroxychloroquine and other agents are used either alone or in combination for the treatment of relapses and recurrences and refractoriness or in the presence of complications of corticosteroids. Treatment is usually continued for about a year, but it may need to be prolonged in patients with disease that persists and the response to therapy is delayed.

Prevalence of hypothyroidism and Graves disease in sarcoidosis

BACKGROUND

The association of sarcoidosis (S) and thyroid autoimmunity has been reported by several studies in a wide range of variability. The aim of our study was to evaluate the prevalence of clinical and subclinical thyroid disorders in patients with S vs gender-matched and age-matched control subjects.

METHODS

Thyroid hormones and antithyroid antibodies, thyroid ultrasonography and fine-needle aspiration were performed in 111 patients with S who had been consecutively referred to the Respiratory Pathophysiology Section of the University of Pisa, and the results were compared to 333 gender-matched and age-matched control subjects from the same geographic area.

RESULTS

The odds ratio for subclinical hypothyroidism for female patients with S vs control subjects was 2.7 (95% confidence interval [CI], 1.3 to 5.9); for anti-thyroid peroxidase antibody titer (AbTPO) positivity, 2.2 (95% CI, 1.2 to 3.9); and for thyroid autoimmunity, 1.9 (95% CI, 1.1 to 3.2). The mean values of thyroid-stimulating hormone and AbTPO were higher in female S patients than in control subjects (p < 0.01). A significantly higher prevalence of clinical hypothyroidism (four patients) and Graves disease (three patients) was observed in female S patients than in control subjects (none; p = 0.005 and 0.0026, respectively). Two cases of papillary thyroid cancer were detected in S patients. No significant difference between S patients and control subjects was detected for free triiodothyronine and thyroxine, antithyroglobulin autoantibodies, thyroid volume and nodularity, and subclinical hyperthyroidism.

CONCLUSIONS

Thyroid function, AbTPO antibodies, and ultrasonography should be tested as part of the clinical profile in female S patients. Subjects who are at high risk (female subjects, those with positive AbTPOs, and those with hypoechoic and small thyroid) should have thyroid function follow-up and appropriate treatment in due course.

Sarcoidosis with upper respiratory tract involvement

The aim of the study was to investigate the upper respiratory tract as a site of extrapulmonary sarcoidosis. Diagnosis of sarcoidosis with upper respiratory tract involvement was performed on the basis of clinical, laboratory, radiographic and histological evidence and by excluding other granulomatous diseases in eight patients followed by the Sarcoidosis Regional Reference Centre pneumologists in collaboration with an experienced ENT specialist at Siena University. In five cases, sarcoidosis was localized in the parotid glands, in the other three subjects larynx, nasopharynx and nose were involved. In four patients parotid gland, nasopharynx and upper respiratory tract mucous membrane involvement was the only clinical manifestation at onset of the disease. Upper respiratory tract involvement should be suspected in all patients with systemic sarcoidosis and in patients with persistent upper respiratory tract symptoms of unknown cause. What a general practitioner should do as not to miss SURT is underlined. Interdisciplinary management and collaboration are of paramount importance for rapid diagnosis and to avoid the possible complications of this form.