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Dehara M, Kullberg S, Bixo M, Sachs MC, Grunewald J, Arkema EV. Menopausal hormone therapy and risk of sarcoidosis: a population-based nested case-control study in Sweden. Eur J Epidemiol 2024; 39:313-322. [PMID: 38212490 PMCID: PMC10994872 DOI: 10.1007/s10654-023-01084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024]
Abstract
Sarcoidosis incidence peaks in women between 50 and 60 years old, which coincides with menopause, suggesting that certain sex hormones, mainly estrogen, may play a role in disease development. We investigated whether menopausal hormone therapy (MHT) was associated with sarcoidosis risk in women and whether the risk varied by treatment type. We performed a nested case-control study (2007-2020) including incident sarcoidosis cases from the Swedish National Patient Register (n = 2593) and matched (1:10) to general population controls (n = 20,003) on birth year, county, and living in Sweden at the time of sarcoidosis diagnosis. Dispensations of MHT were obtained from the Swedish Prescribed Drug Register before sarcoidosis diagnosis/matching. Adjusted odds ratios (aOR) of sarcoidosis were estimated using conditional logistic regression. Ever MHT use was associated with a 25% higher risk of sarcoidosis compared with never use (aOR 1.25, 95% CI 1.13-1.38). When MHT type and route of administration were considered together, systemic estrogen was associated with the highest risk of sarcoidosis (aOR 1.51, 95% CI 1.23-1.85), followed by local estrogen (aOR 1.25, 95% CI 1.11-1.42), while systemic estrogen-progestogen combined was associated with the lowest risk compared to never users (aOR 1.12, 95% CI 0.96-1.31). The aOR of sarcoidosis did not differ greatly by duration of MHT use. Our findings suggest that a history of MHT use is associated with increased risk of sarcoidosis, with women receiving estrogen administered systemically having the highest risk.
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Affiliation(s)
- Marina Dehara
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital T2, 171 76, Stockholm, Sweden.
| | - Susanna Kullberg
- Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Bixo
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Michael C Sachs
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Johan Grunewald
- Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth V Arkema
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital T2, 171 76, Stockholm, Sweden
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2
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Valeyre D, Bernaudin JF, Brauner M, Nunes H, Jeny F. Infectious Complications of Pulmonary Sarcoidosis. J Clin Med 2024; 13:342. [PMID: 38256476 PMCID: PMC10816300 DOI: 10.3390/jcm13020342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
In this review, the infectious complications observed in sarcoidosis are considered from a practical point of view to help the clinician not to overlook them in a difficult context, as pulmonary sarcoidosis makes the recognition of superinfections more difficult. An increased incidence of community-acquired pneumonia and of opportunistic pneumonia has been reported, especially in immunosuppressed patients. Pulmonary destructive lesions of advanced sarcoidosis increase the incidence of chronic pulmonary aspergillosis and infection by other agents. Screening and treatment of latent tuberculosis infection are crucial to prevent severe tuberculosis. Severity in COVID-19 appears to be increased by comorbidities rather than by sarcoidosis per se. The diagnosis of infectious complications can be challenging and should be considered as a potential differential diagnosis when the exacerbation of sarcoidosis is suspected. These complications not only increase the need for hospitalizations, but also increase the risk of death. This aspect must be carefully considered when assessing the overall health burden associated with sarcoidosis. The impact of immune dysregulation on infectious risk is unclear except in exceptional cases. In the absence of evidence-based studies on immunosuppressants in the specific context of pulmonary sarcoidosis, it is recommended to apply guidelines used in areas outside sarcoidosis. Preventive measures are essential, beginning with an appropriate use of immunosuppressants and the avoidance of unjustified treatments and doses. This approach should take into account the risk of tuberculosis, especially in highly endemic countries. Additionally, parallel emphasis should be placed on vaccinations, especially against COVID-19.
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Affiliation(s)
- Dominique Valeyre
- INSERM-UMR 1272, SMBH Université Sorbonne Paris-Nord, 93009 Bobigny, France; (D.V.); (J.-F.B.); (H.N.)
- Service de Pneumologie, Groupe Hospitalier Paris Saint Joseph, 75014 Paris, France
| | - Jean-François Bernaudin
- INSERM-UMR 1272, SMBH Université Sorbonne Paris-Nord, 93009 Bobigny, France; (D.V.); (J.-F.B.); (H.N.)
- Faculty of Medicine, Sorbonne University, 75013 Paris, France
| | - Michel Brauner
- Service de Radiologie, Hôpital Avicenne, 93009 Bobigny, France;
| | - Hilario Nunes
- INSERM-UMR 1272, SMBH Université Sorbonne Paris-Nord, 93009 Bobigny, France; (D.V.); (J.-F.B.); (H.N.)
- Service de Pneumologie, Hôpital Avicenne, 93009 Bobigny, France
| | - Florence Jeny
- INSERM-UMR 1272, SMBH Université Sorbonne Paris-Nord, 93009 Bobigny, France; (D.V.); (J.-F.B.); (H.N.)
- Service de Pneumologie, Hôpital Avicenne, 93009 Bobigny, France
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3
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Belperio JA, Fishbein MC, Abtin F, Channick J, Balasubramanian SA, Lynch Iii JP. Pulmonary sarcoidosis: A comprehensive review: Past to present. J Autoimmun 2023:103107. [PMID: 37865579 DOI: 10.1016/j.jaut.2023.103107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/23/2023]
Abstract
Sarcoidosis is a sterile non-necrotizing granulomatous disease without known causes that can involve multiple organs with a predilection for the lung and thoracic lymph nodes. Worldwide it is estimated to affect 2-160/100,000 people and has a mortality rate over 5 years of approximately 7%. For sarcoidosis patients, the cause of death is due to sarcoid in 60% of the cases, of which up to 80% are from advanced cardiopulmonary failure (pulmonary hypertension and respiratory microbial infections) in all races except in Japan were greater than 70% of the sarcoidosis deaths are due to cardiac sarcoidosis. Scadding stages for pulmonary sarcoidosis associates with clinical outcomes. Stages I and II have radiographic remission in approximately 30%-80% of cases. Stage III only has a 10%-40% chance of resolution, while stage IV has no change of resolution. Up to 40% of pulmonary sarcoidosis patients progress to stage IV disease with lung parenchyma fibroplasia, bronchiectasis with hilar retraction and fibrocystic disease. These patients are at highest risk for the development of precapillary pulmonary hypertension, which may occur in up to 70% of these patients. Sarcoid patients with pre-capillary pulmonary hypertension can respond to targeted pulmonary arterial hypertension medications. Stage IV fibrocytic sarcoidosis with significant pulmonary physiologic impairment, >20% fibrosis on HRCT or pre-capillary pulmonary hypertension have the highest risk of mortality, which can be >40% at 5-years. First line treatment for patients who are symptomatic (cough and dyspnea) with parenchymal infiltrates and abnormal pulmonary function testing (PFT) is oral glucocorticoids, such as prednisone with a typical starting dose of 20-40 mg daily for 2 weeks to 2 months. Prednisone can be tapered over 6-18 months if symptoms, spirometry, PFTs, and radiographs improve. Prolonged prednisone may be required to stabilize disease. Patients requiring prolonged prednisone ≥10 mg/day or those with adverse effects due to glucocorticoids may be prescribed second and third line treatements. Second and third line treatments include immunosuppressive agents (e.g., methotrexate and azathioprine) and anti-tumor necrosis factor (TNF) medication; respectively. Effective treatments for advanced fibrocystic pulmonary disease are being explored. Despite different treatments, relapse rates range from 13% to 75% depending on the stage of sarcoid, number of organs involved, socioeconomic status, and geography. CONCLUSION: The mortality rate for sarcoidosis over a 5 year follow up is approximately 7%. Unfortunately, 10%-40% of patients with sarcoidosis develop progressive pulmonary disease, and >60% of deaths resulting from sarcoidosis are due to advance cardiopulmonary disease. Oral glucocorticoids are the first line treatment, while methotrexate and azathioprine are considered second and anti-TNF agents are third line treatments that are used solely or as glucocorticoid sparing agents for symptomatic extrapulmonary or pulmonary sarcoidosis with infiltrates on chest radiographs and abnormal PFT. Relapse rates have ranged from 13% to 75% depending on the population studied.
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Affiliation(s)
- John A Belperio
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fereidoun Abtin
- Department of Thoracic Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jessica Channick
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shailesh A Balasubramanian
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph P Lynch Iii
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Arkema EV, Rossides M, Cozier YC. Sarcoidosis and its relation to other immune-mediated diseases: Epidemiological insights. J Autoimmun 2023:103127. [PMID: 37816661 DOI: 10.1016/j.jaut.2023.103127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023]
Abstract
Several epidemiological studies show a co-occurrence of sarcoidosis with other immune-mediated diseases (IMD). There are many similarities between sarcoidosis and IMDs in their geographical distribution and risk factors. Understanding these similarities and identifying the differences can help us to better understand sarcoidosis and put it into context with other IMDs. In this review, we present the current knowledge about the overlap between sarcoidosis and other IMDs derived from epidemiological studies. Epidemiologic methods utilize study design and statistical analysis to describe the patterns in data and, ideally, identify causal relationships between an exposure and a health outcome. We discuss how study design and analysis may affect the interpretation of epidemiological studies on this topic and highlight some theories that attempt to explain the relation between sarcoidosis and other IMDs.
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Affiliation(s)
- Elizabeth V Arkema
- Karolinska Institutet, Department of Medicine Solna, Clinical Epidemiology Division, Stockholm, Sweden.
| | - Marios Rossides
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden; Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yvette C Cozier
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA; Slone Epidemiology Center, Boston University School of Medicine, Boston, MA, USA
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Abstract
Sarcoidosis is characterized by noncaseating granulomas which form in almost any part of the body, primarily in the lungs and/or thoracic lymph nodes. Environmental exposures in genetically susceptible individuals are believed to cause sarcoidosis. There is variation in incidence and prevalence by region and race. Males and females are almost equally affected, although disease peaks at a later age in females than in males. The heterogeneity of presentation and disease course can make diagnosis and treatment challenging. Diagnosis is suggestive in a patient if one or more of the following is present: radiologic signs of sarcoidosis, evidence of systemic involvement, histologically confirmed noncaseating granulomas, sarcoidosis signs in bronchoalveolar lavage fluid (BALF), and low probability or exclusion of other causes of granulomatous inflammation. No sensitive or specific biomarkers for diagnosis and prognosis exist, but there are several that can be used to support clinical decisions, such as serum angiotensin-converting enzyme levels, human leukocyte antigen types, and CD4 Vα2.3+ T cells in BALF. Corticosteroids remain the mainstay of treatment for symptomatic patients with severely affected or declining organ function. Sarcoidosis is associated with a range of adverse long-term outcomes and complications, and with great variation in prognosis between populations. New data and technologies have moved sarcoidosis research forward, increasing our understanding of the disease. However, there is still much left to be discovered. The pervading challenge is how to account for patient variability. Future studies should focus on how to optimize current tools and develop new approaches so that treatment and follow-up can be targeted to individuals with more precision.
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Affiliation(s)
- Marios Rossides
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Darlington
- Department of Clinical Science and Education, Södersjukhuset and Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Kullberg
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Respiratory Medicine Division & Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth V Arkema
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
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Belperio JA, Shaikh F, Abtin FG, Fishbein MC, Weigt SS, Saggar R, Lynch JP. Diagnosis and Treatment of Pulmonary Sarcoidosis: A Review. JAMA 2022; 327:856-867. [PMID: 35230389 DOI: 10.1001/jama.2022.1570] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sarcoidosis is an inflammatory granulomatous disease of unknown cause that affects an estimated 2 to 160 people per 100 000 worldwide and can involve virtually any organ. Approximately 10% to 30% of patients with sarcoidosis develop progressive pulmonary disease. OBSERVATION Among patients with pulmonary sarcoidosis, the rate of spontaneous remission without serious sequelae ranges from 10% to 82%. However, lung disease progression occurs in more than 10% of patients and can result in fibrocystic architectural distortion of the lung, which is associated with a mortality rate of 12% to 18% within 5 years. Overall, the mortality rate for sarcoidosis is approximately 7% within a 5-year follow-up period. Worldwide, more than 60% of deaths from sarcoidosis are due to pulmonary involvement; however, more than 70% of deaths from sarcoidosis are due to cardiac involvement in Japan. Up to 70% of patients with advanced pulmonary sarcoidosis develop precapillary pulmonary hypertension, which is associated with a 5-year mortality rate of approximately 40%. Patients with sarcoidosis and precapillary pulmonary hypertension should be treated with therapies such as phosphodiesterase inhibitors and prostacyclin analogues. Although optimal doses of oral glucocorticoids for pulmonary sarcoidosis are unknown, oral prednisone typically starting at a dose of 20 mg/d to 40 mg/d for 2 to 6 weeks is recommended for patients who are symptomatic (cough, dyspnea, and chest pain) and have parenchymal infiltrates and abnormal pulmonary function test results. Oral glucocorticoids can be tapered over 6 to 18 months if symptoms, pulmonary function test results, and radiographs improve. Prolonged use of oral glucocorticoids may be required to control symptoms and stabilize disease. Patients without adequate improvement while receiving a dose of prednisone of 10 mg/d or greater or those with adverse effects due to glucocorticoids may be prescribed immunosuppressive agents, such as methotrexate, azathioprine, or an anti-tumor necrosis factor medication, either alone or with glucocorticoids combined with appropriate microbial prophylaxis for Pneumocystis jiroveci and herpes zoster. Effective treatments are not available for advanced fibrocystic pulmonary disease. CONCLUSIONS AND RELEVANCE Sarcoidosis has a mortality rate of approximately 7% within a 5-year follow-up period. More than 10% of patients with pulmonary sarcoidosis develop progressive disease and more than 60% of deaths are due to advanced pulmonary sarcoidosis. Oral glucocorticoids with or without another immunosuppressive agent are the first-line therapy for symptomatic patients with abnormal pulmonary function test results and lung infiltrates. Patients with sarcoidosis and precapillary pulmonary hypertension should be treated with therapies such as phosphodiesterase inhibitors and prostacyclin analogues.
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Affiliation(s)
- John A Belperio
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Faisal Shaikh
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Fereidoun G Abtin
- Thoracic and Interventional Section, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - S Samuel Weigt
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
| | - Joseph P Lynch
- Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles
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Hilker C, Tizek L, Rüth M, Schielein M, Biedermann T, Zink A. Leveraging internet search data to assess prevalence, interest, and unmet needs of sarcoidosis in Germany. Sci Rep 2021; 11:20841. [PMID: 34675234 PMCID: PMC8531327 DOI: 10.1038/s41598-021-00131-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 09/30/2021] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis is a multisystemic disease of connective tissue with granuloma formation of unknown etiology and unclear prevalence. Internet search data has been shown to correlate with disease incidences and the population’s interest as well as seasonal variations. Accordingly, aim of this study was to leverage internet search data on sarcoidosis-related keywords to identify unmet needs, geographical and seasonal factors influencing sarcoidosis and estimating its prevalence. In this retrospective longitudinal study, Google Ads Keyword Planner was used to determine the internet search volume of terms related to sarcoidosis across Germany as a whole and in 17 major German cities between July 2015 and June 2019. Identified keywords were qualitatively categorized, converted into number of searches per 100,000 inhabitants and analyzed including regional and seasonal differences. With 3,068,200 queries and 425 different sarcoidosis-related search terms in the studied time period, the search volume was very high for a rare disease. Most searches (67.9%) related to general disease information with “sarcoidosis”, "Löfgren's syndrome", "sarcoidosis lung", "Morbus Boeck" and "neurosarcoidosis" as the top five keywords. Searches per 100,000 inhabitants were comparable in all 17 cities but higher than in Germany as a whole. Overall, the search volume increased from 2015 to 2019 and peaked annually in European springtime with annual lows in European autumn and winter months. The overall high search volume suggests an unmet need for sarcoidosis-related information and a diagnostic gap. Seasonal fluctuations indicate environmental as well as climatic factors that may influence sarcoidosis.
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Affiliation(s)
- Charlotte Hilker
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Linda Tizek
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Melvin Rüth
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Maximilian Schielein
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany.,Unit of Dermatology and Venerology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tilo Biedermann
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Alexander Zink
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany. .,Unit of Dermatology and Venerology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. .,Division of Dermatology and Venereology, Department of Medicine Solna, Karolinska Institutet, K2 Medicin, Solna, K2, 171 77, Stockholm, Sweden.
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Sarcoidosis epidemiology: recent estimates of incidence, prevalence and risk factors. Curr Opin Pulm Med 2021; 26:527-534. [PMID: 32701677 DOI: 10.1097/mcp.0000000000000715] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the latest studies on sarcoidosis incidence, prevalence and risk factors with a special focus on reports in the last 2 years. The potential biases affecting these studies are discussed. RECENT FINDINGS The prevalence and incidence of sarcoidosis vary greatly depending on region of the world. Variations in data sources and settings can affect estimates of the burden of sarcoidosis, sometimes making them difficult to compare across countries. It is not well understood how the distribution of sarcoidosis phenotypes differs across populations. Age, sex and race are the most important sources of variation in incidence and prevalence. Recent epidemiological studies provide new insights on the role of genetic and nongenetic risk factors for sarcoidosis. SUMMARY High-quality and systematically collected data, with depth (detailed information per individual) and breadth (many individuals), is needed to further understand the complexity and heterogeneity of sarcoidosis.
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Ceder S, Rossides M, Kullberg S, Eklund A, Grunewald J, Arkema EV. Positive Predictive Value of Sarcoidosis Identified in an Administrative Healthcare Registry: A Validation Study. Epidemiology 2021; 32:444-447. [PMID: 33625159 DOI: 10.1097/ede.0000000000001323] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND International classification of disease (ICD) codes used to study sarcoidosis has previously been validated in only 1 study. We aimed to determine the accuracy of ICD codes to identify true sarcoidosis diagnoses in Sweden. METHODS We identified adults with at least 2 ICD codes for sarcoidosis (ICD-10 D86) at Karolinska University Hospital 2010-2013 from the National Patient Register. Of these, we randomly sampled 100 patients for validation. We collected clinical data and categorized the diagnosis of sarcoidosis as definite, probable, or unlikely. We estimated the positive predictive value for definite and probable sarcoidosis-identified with at least 2 ICD codes-with 95% confidence intervals. RESULTS We deemed 77% of the cases to be definite and 17% to be probable. The positive predictive value was 0.94 (95% confidence intervals = 0.87 to 0.98). CONCLUSIONS Using at least 2 visits listing an ICD-10 code for sarcoidosis accurately identified patients with sarcoidosis from administrative health data in Sweden.
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Affiliation(s)
- Sylvia Ceder
- From the Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Marios Rossides
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Kullberg
- From the Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eklund
- From the Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Grunewald
- From the Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth V Arkema
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW Ocular sarcoidosis is one of the most common causes of uveitis worldwide. The diagnosis and treatment of patients with ocular sarcoidosis remains challenging in some cases. It is important for clinicians to keep up to date with new diagnostic and treatment tools for this disease. RECENT FINDINGS The International Workshop on Ocular Sarcoidosis diagnostic criteria were first proposed in 2009 and revised in 2017. The new criteria contained two parts: ocular presentation and systemic investigation. The diagnostic value of liver enzymes was reduced in the new criteria, whereas the value placed of lymphopenia and the CD4/CD8 ratio in bronchoalveolar lavage fluid were increased. Despite not being included in the criteria, recent studies have also highlighted the diagnostic value of serum soluble interleukin-2 receptors. Recent ophthalmologic imaging also provides useful insights for the differential diagnosis.Many new treatments for ocular sarcoidosis have been developed in recent years. The introduction of biological immunomodulatory agents for uveitis treatment represents a big improvement. Antitumor necrosis factor-alpha antibodies, including adalimumab, have been proven to be effective for treating ocular sarcoidosis. Many studies have also suggested that other biological agents could be effective and well tolerated. Newer intravitreal dexamethasone and fluocinolone implants have been developed. Patients treated with these implants have experienced good and sustained control of their intraocular inflammation. SUMMARY Diagnosis and treatment options for ocular sarcoidosis have changed over time. However, challenges still exist in some difficult patients. Future studies should focus on finding more sensitive biomarkers and developing more effective immunomodulatory treatments with longer efficacy and less side effects.
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Affiliation(s)
- De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, and National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital
- Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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11
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Rossides M, Kullberg S, Eklund A, Di Giuseppe D, Grunewald J, Askling J, Arkema EV. Risk of first and recurrent serious infection in sarcoidosis: a Swedish register-based cohort study. Eur Respir J 2020; 56:13993003.00767-2020. [PMID: 32366492 PMCID: PMC7469972 DOI: 10.1183/13993003.00767-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022]
Abstract
Serious infections impair quality of life and increase costs. Our aim was to determine if sarcoidosis is associated with a higher rate of serious infection and whether this varies by age, sex, time since diagnosis or treatment status around diagnosis. We compared individuals with sarcoidosis (at least two International Classification of Diseases codes in the Swedish National Patient Register 2003–2013; n=8737) and general population comparators matched 10:1 on age, sex and residential location (n=86 376). Patients diagnosed in 2006–2013 who were dispensed at least one immunosuppressant ±3 months from diagnosis (Swedish Prescribed Drug Register) were identified. Cases and comparators were followed in the National Patient Register for hospitalisations for infection. Using Cox and flexible parametric models, we estimated adjusted hazard ratios (aHR) and 95% confidence intervals for first and recurrent serious infections (new serious infection >30 days after previous). We identified 895 first serious infections in sarcoidosis patients and 3881 in comparators. The rate of serious infection was increased 1.8-fold in sarcoidosis compared to the general population (aHR 1.81, 95% CI 1.65–1.98). The aHR was higher in females than males and during the first 2 years of follow-up. Sarcoidosis cases treated with immunosuppressants around diagnosis had a three-fold increased risk, whereas nontreated patients had a 50% increased risk. The rate of serious infection recurrence was 2.8-fold higher in cases than in comparators. Serious infections are more common in sarcoidosis than in the general population, particularly during the first few years after diagnosis. Patients who need immunosuppressant treatment around diagnosis are twice as likely to develop a serious infection than those who do not. Sarcoidosis is associated with an increased risk of serious infections, especially during the first 2 years after diagnosis. Patients in need of immunosuppressants around diagnosis are twice as likely to develop serious infections than those who do not.https://bit.ly/2VFOvSo
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Affiliation(s)
- Marios Rossides
- Clinical Epidemiology Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Kullberg
- Respiratory Medicine Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Eklund
- Respiratory Medicine Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Daniela Di Giuseppe
- Clinical Epidemiology Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Grunewald
- Respiratory Medicine Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Respiratory Medicine, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth V Arkema
- Clinical Epidemiology Division, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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