1
|
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.
Collapse
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
| |
Collapse
|
2
|
Masumoto N, Watanabe K, Horita N, Hara Y, Kobayashi N, Kaneko T. Elderly sarcoidosis in Japan. J Int Med Res 2022; 50:3000605221142705. [PMID: 36562117 PMCID: PMC9793039 DOI: 10.1177/03000605221142705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The manifestations of sarcoidosis differ by ethnicity and region. However, the few studies that have focused on elderly sarcoidosis are only from Western countries. Therefore, we investigated elderly sarcoidosis in Japan. METHODS We retrospectively reviewed the records of adult patients (≥18 years old) who were diagnosed with sarcoidosis from 1 April 2006 to 31 March 2020. The diagnosis was pathologically confirmed in all patients. We compared the clinical features of elderly (diagnosed at ≥65 years old) and non-elderly (diagnosed at <65 years old) patients. RESULTS Thirty-five (33%) of 106 patients were elderly. The elderly group had significantly more comorbidities than the non-elderly group (median [range], 1 [0-4] vs. 0 [0-5]). The biopsy site at diagnosis included significantly more extrathoracic sites in the elderly than non-elderly group (57.1% vs. 33.8%). The elderly group had significantly more muscle lesions than the non-elderly group at the time of diagnosis (11.4% vs. 1.4%) and at any time during follow-up (17.1% vs. 1.4%). CONCLUSION In Japan, elderly patients with sarcoidosis might have more muscle involvement and comorbidities than younger patients. Because comorbidities might affect the prognosis of elderly sarcoidosis, further study is needed to clarify the effect of comorbidities on elderly sarcoidosis.
Collapse
Affiliation(s)
| | - Keisuke Watanabe
- Keisuke Watanabe, Department of
Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan.
,
| | | | | | | | | |
Collapse
|
3
|
Smedslund G, Kotar AM, Uhlig T. Sarcoidosis with musculoskeletal manifestations: systematic review of non-pharmacological and pharmacological treatments. Rheumatol Int 2022; 42:2109-2124. [PMID: 35943526 PMCID: PMC9548475 DOI: 10.1007/s00296-022-05171-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022]
Abstract
We aimed to summarise effects and use of non-pharmacological and pharmacological treatments for sarcoidosis with musculoskeletal manifestations. We systematically searched the Cochrane Library, Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, clinical.trials.gov, PROSPERO and PEDro for systematic reviews from 2014 to 2022 and for primary studies from date of inception to March 29, 2022, and studies with patients diagnosed with sarcoidosis with musculoskeletal manifestations. Inclusion criteria required that studies reported effects of non-pharmacological and/or pharmacological treatments or number of patients receiving these treatments. Results were reported narratively and in forest plots. Eleven studies were included. No systematic reviews fulfilled our inclusion criteria. None of the included studies had a control group. We found that between 23 and 100% received corticosteroids, 0-100% received NSAIDs, 5-100% received hydroxychloroquine, 12-100% received methotrexate, 0-100% received TNF inhibitors, and 3-4% received azathioprine. Only ten patients in one study had used non-pharmacological treatments, including occupational therapy, chiropractic and acupuncture. There are no controlled studies on treatment effects for patients with sarcoidosis with musculoskeletal manifestations. We found 11 studies reporting use of pharmacological treatments and only one study reporting use of non-pharmacological treatments. Our study identified major research gaps for pharmacological and non-pharmacological treatment in musculoskeletal sarcoidosis and warrant randomised clinical trials for both.
Collapse
Affiliation(s)
- Geir Smedslund
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Norwegian National Advisory Unit On Rehabilitation in Rheumatology, Oslo, Norway.
| | - Annie Martina Kotar
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Norwegian National Advisory Unit On Rehabilitation in Rheumatology, Oslo, Norway
| | - Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Norwegian National Advisory Unit On Rehabilitation in Rheumatology, Oslo, Norway
- University of Oslo, Oslo, Norway
| |
Collapse
|
4
|
Brennan M, Breen D. Sarcoidosis in the older person: diagnostic challenges and treatment consideration. Age Ageing 2022; 51:6695454. [PMID: 36088599 DOI: 10.1093/ageing/afac203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/20/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Sarcoidosis is a multi-system disorder with an increasing propensity to present in older patients. Diagnostic uncertainty is common and understandable given the higher prevalence of co-morbidities in older patients and broad differential for multi-system clinical presentations. Excluding malignancy and infection with a high degree of certainty is challenging and may require repeated confirmatory investigation where the diagnosis remains in doubt. SUMMARY OF MAIN FINDINGS There are a paucity of studies examining late-onset sarcoidosis. Female predominance, pulmonary, ocular, skin and systemic symptoms are common, while more classical presentations such as Lofgren's syndrome are uncommon. Positivity rates of biopsies vary between studies; however, targeted biopsies of accessible sites with organ involvement are the most successful. Therapeutic management is directed at reducing inflammation, and thereby reducing symptom burden, improving quality of life and avoiding progression of organ damage. While most older patients will require corticosteroid therapy, they are also more prone to developing adverse effects. Most older patients will experience a clinical remission; however, the risk of developing chronic sarcoidosis and organ damage is higher compared with younger counterparts. Patients with evidence of pulmonary fibrosis and pulmonary hypertension are at particular risk. IMPACT ON CLINICAL PRACTICE Health care providers who care for older adults should be aware of the increasing prevalence of late-onset sarcoidosis and consider the diagnosis in those who present with otherwise unexplained systemic symptoms, thoracic abnormalities on imaging and/or evidence of other organ involvement. Earlier diagnosis and therapeutic intervention to halt the development of pulmonary fibrosis and pulmonary hypertension and monitoring for treatment-related adverse effects will confer a mortality benefit.
Collapse
Affiliation(s)
- Michelle Brennan
- Department of Geriatric Medicine, Galway University Hospital, Galway, Ireland.,Interventional Respiratory Unit, Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | - David Breen
- Interventional Respiratory Unit, Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW This review aims to describe how the clinical manifestations of sarcoidosis may be shaped by the effects of sex hormones and by age dependent changes in immune functions and physiology This review is intended to highlight the need to consider the effects of sex and sex in future studies of sarcoidosis. RECENT FINDINGS The clinical manifestations of sarcoidosis differ based on sex and gender There is emerging evidence that female and male hormones and X-linked genes are important determinants of immune responses to environmental antigens, which has important implications for granuloma formation in the context of sarcoidosis Furthermore, sex hormone levels predictably change throughout adolescence and adulthood, and this occurs in parallel with the onset immune senescence and changes in physiology with advanced age. SUMMARY Recent studies indicate that sex and age are important variables shaping the immune response of humans to environmental antigens We posit herein that sex and age are important determinants of sarcoidosis clinical phenotypes Many gaps in our understanding of the roles played by sex and gender in sarcoidosis, and these need to be considered in future studies.
Collapse
Affiliation(s)
- Arindam Singha
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, Ohio
| | - Marina Kirkland
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wonder Drake
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, Ohio
| |
Collapse
|
6
|
Bindra J, Chopra I, Hayes K, Niewoehner J, Panaccio MP, Wan GJ. Understanding Predictors of Response to Repository Corticotropin Injection Treatment Among Patients With Advanced Symptomatic Sarcoidosis. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:90-100. [PMID: 35529249 PMCID: PMC9021499 DOI: 10.36469/jheor.2022.33295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
Background: Sarcoidosis, an inflammatory systemic granulomatous disease, affects multiple organs and has a diverse clinical course. Repository corticotropin injection (RCI) is an effective treatment for advanced symptomatic sarcoidosis. Since sarcoidosis affects patients differently, treatment response may vary by patient demographic, clinical, and treatment-related characteristics and physician specialty. However, there is a paucity of literature regarding predictors of sarcoidosis treatment response. Objectives: This study investigated predictors of response to RCI treatment. Methods: Post-hoc analysis was conducted using data from a previously published retrospective cross-sectional chart review study among symptomatic sarcoidosis patients ≥18 years of age previously treated with RCI. Outcome improvement 3 months post-RCI treatment was based on the clinician's subjective evaluation and analyzed using adjusted logistic regression. The most influential predictors for each outcome were based on statistical significance (P<.05) and the strength of the relationship assessed by the standardized β coefficients. Results: The top predictors of outcome improvements were as follows. Global health assessment: (1) improvement in current health status influenced by complete RCI compliance, moderate overall symptom severity, and presence of extrapulmonary sites; and (2) improvement in overall symptoms influenced by age, shorter duration since sarcoidosis diagnosis, and complete RCI compliance. Clinical outcomes: (1) lung function improvement influenced by mild weight loss, mild wheezing/coughing, and non-African American race; (2) reduction in pulmonary fibrosis influenced by moderate overall symptom severity, mild wheezing/coughing, and mild weight loss; and (3) reduction in inflammation influenced by physician specialty, completing a course of RCI treatment, and moderate-to-severe night sweats. Patient-related outcomes: (1) reduction in fatigue influenced by physician specialty and moderate-to-severe fatigue; and (2) improvement in quality-of-life influenced by shorter duration since sarcoidosis diagnosis, moderate-to-severe wheezing/coughing, and complete RCI compliance. Corticosteroid discontinuation/reduction was influenced by physician specialty, moderate-to-severe shortness of breath, and comedication use before RCI. Conclusions: RCI may be a better treatment option for patients with more severe disease, primarily those presenting with symptoms. Complete compliance with RCI treatment may improve patients' health and quality of life. Understanding factors that influence RCI effectiveness across different treatment outcomes in real-world clinical practice is important for designing optimal sarcoidosis treatment strategies.
Collapse
Affiliation(s)
- Jas Bindra
- Falcon Research Group, North Potomac, MD
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals, Hampton, NJ
| | | | | | | |
Collapse
|
7
|
Ramachandran L, Pamulapati S, Barlas A, Aqeel A. Elderly Onset Sarcoidosis: A Case Report. Cureus 2021; 13:e20443. [PMID: 35047280 PMCID: PMC8759762 DOI: 10.7759/cureus.20443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 01/13/2023] Open
Abstract
Sarcoidosis is a multi-organ autoimmune disease that affects females more than males. While primarily considered as a disease of the young, very few cases of sarcoidosis have been reported in patients over 65 years old. We report the case of sarcoidosis in an 80-year-old female and ultimately died from sarcoidosis-related complications. We review the literature and highlight key differences in elderly onset sarcoidosis when compared to the general population. We also advise physicians to have a high index of suspicion for sarcoidosis in the elderly who present with hypercalcemia and abnormal findings on chest imaging.
Collapse
Affiliation(s)
| | | | - Aisha Barlas
- Internal Medicine, Javon Bea Hospital, Rockford, USA
| | - Ammar Aqeel
- Internal Medicine, Javon Bea Hospital, Rockford, USA
| |
Collapse
|
8
|
Bert A, Gilbert T, Cottin V, Mercier J, Gerfaud-Valentin M, Durieu I, Hot A, Hicks J, Varron L, Seve P, Jamilloux Y. Sarcoidosis diagnosed in the elderly: a case-control study. QJM 2021; 114:238-245. [PMID: 32569362 DOI: 10.1093/qjmed/hcaa171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 04/18/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Studies on sarcoidosis in elderly patients are scarce and none have specifically evaluated patients aged ≥75 at onset. AIM We aimed to analyse the characteristics of patients with sarcoidosis diagnosed after 75 and to compare them with those of younger patients. DESIGN Multicenter case-control study comparing elderly-onset sarcoidosis (EOS) with young-onset sarcoidosis (YOS) seen at Lyon University Hospitals between 2006 and 2018. METHODS Using our institutional database, we included 34 patients in the EOS group and compared them with 102 controls from the YOS group in a 1:3 ratio. Demographic characteristics, medical history, clinical presentation, laboratory and imaging findings, sites of biopsies, histological analyses, treatments and outcomes were recorded using a comprehensive questionnaire. RESULTS There were more Caucasians in the EOS group (94.1% vs. 59.8%; P < 0.001), who had significantly more comorbidities (mean, 3.1 ± 2 vs. 1.1 ± 1.6; P < 0.001). In the EOS group, there was less pulmonary involvement (26.5% vs. 49%; P = 0.022), less lymphadenopathy (2.9% vs. 16.7%; P = 0.041), no erythema nodosum (0% vs. 12.8%; P = 0.029) and no arthralgia (0% vs. 25.5%; P = 0.001). Conversely, uveitis was more common in the EOS group (55.9% vs. 20.6%; P < 0.001). Pathological confirmation was obtained significantly less frequently in the EOS group (67.7% vs. 85.3%; P = 0.023). Corticosteroid-related side effects were significantly more common in the EOS group (100% vs. 75.9%; P = 0.030). CONCLUSION Epidemiology and clinical presentation of EOS differs from YOS, including more comorbidities and more uveitis. Elderly patients are more prone to corticosteroid side effects.
Collapse
Affiliation(s)
- A Bert
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - T Gilbert
- Short Stay Geriatric Unit, Lyon Sud University Hospital, University Claude Bernard University Lyon 1, 165 Chemin du Grand Revoyet, 69310 Pierre-Bénite, France
| | - V Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel University Hospital, University Claude Bernard University Lyon 1, 59 Boulevard Pinel, 69500 Bron, France
| | - J Mercier
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - M Gerfaud-Valentin
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - I Durieu
- Department of Internal Medicine, Lyon Sud University Hospital, University Claude Bernard University Lyon 1, 165 Chemin du Grand Revoyet, 69310 Pierre-Bénite, France
| | - A Hot
- Department of Internal Medicine, Edouard Herriot University Hospital, University Claude Bernard University Lyon 1, 5 Place d'Arsonval, 69003 Lyon, France
| | - J Hicks
- Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
| | - L Varron
- Department of Internal Medicine, Montélimar Hospital, Quartier Beausseret, Route de Sauzet, 26200 Montélimar, France
| | - P Seve
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Y Jamilloux
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University Lyon 1, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| |
Collapse
|
9
|
Kirkil G, Lower E, Baughman R. Advances in predicting patient survival in pulmonary sarcoidosis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1925107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Gamze Kirkil
- Medicine Faculty, Department of Chest Disease, Firat University, Elazig, Turkey
| | - Elyse Lower
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Robert Baughman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Cincinnati, USA
| |
Collapse
|
10
|
Darlington P, Kullberg S, Eklund A, Grunewald J. Subpopulations of cells from bronchoalveolar lavage can predict prognosis in sarcoidosis. Eur Respir J 2020; 55:13993003.01450-2019. [PMID: 31439687 PMCID: PMC6991162 DOI: 10.1183/13993003.01450-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/14/2019] [Indexed: 01/13/2023]
Abstract
Sarcoidosis is characterised by an accumulation of CD4+ T-cells in the lungs and an increased bronchoalveolar lavage fluid (BALF) CD4/CD8 ratio (>3.5) [1]. In sarcoidosis, an expansion of BALF CD4+ T-cells expressing the T-cell receptor Vα2.3 has been associated with good prognosis and with specific HLA-alleles, i.e. HLA-DRB1*0301 and HLA-DRB3*0101 (which is often carried together with HLA-DRB1*13). HLA-DRB1*03 and HLA-DRB3*0101 molecules show similarities in the region important for antigen presentation and both may therefore be capable of presenting identical antigens to the lung T-cells [2]. The higher the proportion of a T-cell subset (CD4+Vα2.3+ T-cells) in bronchoalveolar lavage fluid of sarcoidosis patients, the better the prognosis and therefore it may be used as an additional prognostic toolhttp://bit.ly/2Mta0Cs
Collapse
Affiliation(s)
- Pernilla Darlington
- Respiratory Medicine Division, Dept of Clinical Science and Education, Södersjukhuset and Karolinska Institutet, Stockholm, Sweden
| | - Susanna Kullberg
- Respiratory Medicine Division, Dept of Medicine Solna and Center for Molecular Medicine (CMM), Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Anders Eklund
- Respiratory Medicine Division, Dept of Medicine Solna and Center for Molecular Medicine (CMM), Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Johan Grunewald
- Respiratory Medicine Division, Dept of Medicine Solna and Center for Molecular Medicine (CMM), Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|