Treatment with corticosteroids

Pulmonary Cavitary Sarcoidosis: A Case Report

Sarcoidosis is a granulomatous disease characterized by a non-caseating granuloma formation in different organs of the body. However, the presence of cavitary lesions is rare. We present a case report of a 38-year-old male who presented with a three-month history of cough, dyspnea, and weight loss. Computed tomography of the chest demonstrated enlarged mediastinal and bilateral hilar lymphadenopathy with bilateral perihilar consolidation and cavitation in the upper lobes of both lungs. Later, the patient underwent bronchoscopy with bronchoalveolar lavage and endobronchial biopsy which showed well-formed and non-necrotizing granulomas which were also embedded in the dense hyaline sclerosis. This finding is consistent with sarcoidosis. Treatment with systemic corticosteroids was initiated, resulting in significant improvement in the patient's symptoms. This case report highlights the uncommon manifestation of pulmonary cavitary sarcoidosis and emphasizes the significance of accurate diagnosis and appropriate management of this complex disease.

Treat to target and tight control: Could be a new approach in the treatment of sarcoidosis?

Sarcoidosis is a chronic granulomatous disease with multisystemic involvement. Although it is accepted as a benign disease, it can sometimes cause life-threatening organ (heart, brain) involvement that determines the prognosis of the disease. There are conflicting opinions about the treatment of the disease. In the generally accepted treatment approach the "step-by-step" model has gained weight. According to this approach, corticosteroids (CS) drugs alone are preferred in the first step in patients who require treatment. In the second step, immunosuppressive drugs (IS) are used in patients who do not respond to CS and/or have contraindications to CS use, and biologics (TNF-alpha inhibitors) are used in the third step. This treatment approach may be valid in cases with mild sarcoidosis. However, although sarcoidosis is considered a benign and self-limiting disease in some major organ involvement, the "step-by-step" approach may be a treatment option that puts the patient's life in danger. In such selected patients, much more rigorous, early and combined treatment approaches that definitely include CS, IS or biologic drugs may be required. In selected sarcoidosis patients with high risk, early diagnosis, "treat-to-target" (T2T) and "tight control" follow-up of patients seems to be a rational approach. This article reviews the "step-down" treatment regimens in light of recent literature data and hypothesizes that the T2T model may be a probable new treatment approach in patients with sarcoidosis.

Cardiac sarcoidosis: case report, workup, and review of the literature

INTRODUCTION

Cardiovascular disease is the leading cause of death worldwide, with coronary heart disease being the most common manifestation disease. While deaths attributed to coronary heart disease are falling in the developed world, the number of patients with cardiomyopathy continues to increase. In this paper, the current literature on imaging modalities for infiltrative and inflammatory cardiomyopathies is reviewed, focusing on the three most common diagnoses, namely sarcoidosis, amyloidosis, and myocarditis.

CASE REPORT

A 43-year-old male presented with palpitations and left ventricular systolic dysfunction for a second opinion following an initial nondiagnostic workup. The employed clinical and radiologic approach that led to a definitive diagnosis and disease-specific treatment is presented here.

CONCLUSION

The current algorithms and the strengths and weaknesses of the various radiologic techniques in establishing a diagnosis in patients who present with new onset cardiomyopathy are reviewed. Recommendations are provided regarding the selection between echocardiography, computed tomography radionuclide imaging, and magnetic resonance imaging in diagnosing the various causes of cardiomyopathy.

Pharmacotherapy for pulmonary sarcoidosis: a Delphi consensus study

BACKGROUND

Most issues concerning pharmacotherapy of pulmonary sarcoidosis have not been resolved in clinical trials. The objective was to survey sarcoidosis experts concerning the treatment of pulmonary sarcoidosis and attempt to reach a consensus by these experts using a Delphi method.

METHODS

A 6-item questionnaire was developed. Experts were identified at the Diffuse Lung Disease Network at the annual CHEST meeting in October 2008. Three rounds of questionnaires were presented to the experts. Respondent feedback and supporting literature was incorporated into the questionnaires of subsequent rounds.

RESULTS

Experts reached a consensus concerning the following issues: (a) corticosteroids are the initial therapy of choice; (b) initial use of inhaled corticosteroids are not recommended; (c) methotrexate was the preferred second-line drug; (d) 40mg of daily prednisone equivalent was the maximum dose recommended for the treatment of acute pulmonary sarcoidosis; (e) tapering to 10mg of daily prednisone equivalent for chronic pulmonary sarcoidosis was considered a successful taper. The experts could not resolve the following issues: (a) the initial corticosteroid dose for the treatment of acute pulmonary sarcoidosis; (b) the decision and timing of corticosteroid therapy in a patient with mild, Stage 2 pulmonary sarcoidosis.

CONCLUSIONS

This Delphi study revealed that sarcoidosis experts reached a consensus concerning several aspects of the treatment of pulmonary sarcoidosis; these could be considered as appropriate approaches to therapy. Other issues concerning the therapy of pulmonary sarcoidosis remain unresolved by experts, and are areas where further clinical research could be directed.

Clinical outcomes in sarcoidosis after cessation of infliximab treatment

BACKGROUND AND OBJECTIVE

Infliximab appears to be efficacious for the treatment of recalcitrant forms of sarcoidosis. However, there are minimal data concerning the course of sarcoidosis once infliximab is discontinued.

METHODS

Clinical outcomes in patients who had received infliximab and had discontinued it for at least 2 months were analysed retrospectively. The severity of involvement of the index organ from the time of discontinuation of infliximab was compared with that at the end of the follow-up period.

RESULTS

Fourteen patients with sarcoidosis who had been treated with infliximab and had discontinued this therapy were identified. Before discontinuation of infliximab, 9 of the 14 patients (64%) responded to infliximab treatment and only one (7%) deteriorated. Patients who discontinued infliximab were followed for a mean of 12 months. At the end of the follow-up period, 12 of the 14 patients (86%) had deteriorated as compared with their status at the time of discontinuation of infliximab and two (14%) had remained stable. Kaplan-Meier analysis of time to clinical deterioration showed that half the patients deteriorated within 3 months of discontinuing infliximab. Patients who had discontinued infliximab appeared to be more likely to have their dose of prednisone increased.

CONCLUSION

Patients with recalcitrant sarcoidosis who receive infliximab appear likely to deteriorate after discontinuation of this medication.

[Extra-thoracic sarcoidosis]

Sarcoidosis is a multisystemic granulomatous disease of unknown aetiology, characterized by the presence of non-caseating epithelioid cell granulomas on tissue biopsy of affected organs. It may involve any organ, presenting in multiple forms to clinicians of different specialties. In its extra-thoracic form it may involve the liver (50-80%), spleen (40-80%), eye (20-50%), extrathoracic lymph nodes (30%), skin (25%), nervous system (10%), heart (5%), kidney, muscle and bone, sometimes without symptoms. The presence of extrathoracic disease may affect the prognosis and treatment options for sarcoidosis. The authors present a review of the major extra-thoracic manifestations of sarcoidosis regarding its clinical presentation, diagnosis, treatment, follow-up and prognosis.

Treatment of Sarcoidosis With Infliximab

BACKGROUND/OBJECTIVES

Many patients with sarcoidosis are unable to tolerate corticosteroids or alternative therapeutic agents due to side effects or have disease refractory to these agents. We report our experience using infliximab to treat such patients.

METHODS

A group of patients in whom traditional sarcoidosis therapy failed, either due to drug failure or intolerable side effects, were prescribed infliximab. Their charts were retrospectively reviewed.

RESULTS

Ten patients receiving infliximab were reviewed. Nine of the 10 patients reported a symptomatic improvement with therapy, and all 10 demonstrated objective evidence of improvement. A drug reaction developed in one patient after several months of therapy, oral candidiasis developed in one patient, and angioimmunoblastic lymphoma developed in another patient. The corticosteroid dose was reduced in five of the six patients who were receiving corticosteroids at the time of infliximab therapy.

CONCLUSION

Infliximab appears to be an effective, safe treatment for patients with refractory sarcoidosis, including such manifestations as lupus pernio, uveitis, hepatic sarcoidosis, and neurosarcoidosis. Infliximab appears to be steroid sparing. Patients receiving the drug should be screened for latent tuberculosis and lymphoproliferative disorders.

Prevention of left ventricular remodeling by long-term corticosteroid therapy in patients with cardiac sarcoidosis

Forty-three patients with cardiac sarcoidosis were studied echocardiographically before and after (mean follow-up 88 months) steroid therapy to determine the effectiveness of corticosteroids to prevent left ventricular (LV) remodeling and improve LV contractility. In patients with initial LV ejection fractions (LVEFs) >or=55%, long-term steroid therapy showed preventive effects for LV remodeling and LV function. Patients with LVEF <54% showed significant reductions of LV volumes and LVEF improvement. However, in patients with LVEFs <30%, steroid therapy resulted in neither LV volume reductions nor improved LVEFs. In the early or middle stage of the disease, steroid therapy may be protective or therapeutic in preventing LV remodeling and preserving LV function. However, it may not be as effective in the late stage.

Sarcoid and erythema nodosum arthropathies

Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized in affected organs by an accumulation of activated T lymphocytes and macrophages. Musculoskeletal manifestations of sarcoidosis include acute and chronic arthritis and muscular and osseous sarcoidosis. In certain populations, acute sarcoidosis often presents with constitutional symptoms, polyarthritis and erythema nodosum (Löfgren's syndrome). Erythema nodosum, often with joint symptoms, also occurs in association with several other conditions including infections, medications and other underlying diseases. The diagnosis of sarcoidosis should be based on a tissue biopsy, but a patient with typical Löfgren's syndrome may not require biopsy proof. Among the long list of biochemical markers that have been suggested as aids for diagnosis and monitoring of sarcoidosis, calcium in serum and urine and angiotensin-converting enzyme in serum are well-established clinical tools. Serum angiotensin-converting enzyme can be used for monitoring disease activity in the individual patient, but because of lack of sensitivity and specificity its diagnostic value is rather low. Non-steroidal anti-inflammatory agents usually effectively alleviate acute sarcoid arthritis and joint symptoms associated with erythema nodosum. In severe acute arthritis and in chronic arthritis, corticosteroids may be required to control the symptoms. In patients requiring persistent corticosteroid therapy, antimalarial agents and methotrexate constitute therapeutic alternatives.

Clinical courses and prognoses of pulmonary sarcoidosis

In this article, long-term prognoses and prognostic factors of patients with sarcoidosis are reviewed. In patients with intrathoracic sarcoidosis, functional impairments and parenchymal lesions at the time of initial examination strongly predicted an unfavorable prognosis. We also discussed the significance of extrathoracic lesions in terms of clinical outcomes of intrathoracic sarcoidosis. In addition, we focused on the genetic approach and the new insights being offering with respect to the disease susceptibility and the development of pulmonary lesions.

An approach to the treatment of pulmonary sarcoidosis with corticosteroids: the six phases of treatment

Corticosteroid therapy for pulmonary sarcoidosis is not standardized. There is no consensus on which patients should receive treatment, how patients should be monitored, and the dose of corticosteroids once the decision to treat has been made. These issues are important for several reasons. First, inappropriate use of corticosteroids may result in unnecessary toxic reactions. Second, inadequate use of corticosteroids might result in permanent pulmonary and extrapulmonary organ dysfunction from sarcoidosis. Third, patients who are inappropriately labeled as "corticosteroid failures" may be subjected to other potentially toxic drugs or even lung transplantation. Corticosteroid dosing involves six phases: (1) initial high doses to control inflammation; (2) tapering to a maintenance dose that will continue to suppress the inflammation but lessen the risk of corticosteroid toxic reactions; (3) continuing to receive the maintenance dose until a decision to taper off corticosteroids is made; (4) tapering off corticosteroid therapy; (5) observation for relapse; and (6) treatment if relapse occurs. Although these phases of treatment have been alluded to in the literature, few of them have been studied rigorously. This article describes the use of corticosteroids for pulmonary sarcoidosis in terms of the above six phases. The proposed dosing schedules are based on the natural history of the disease and the results from published treatment studies.

The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital

Sarcoidosis is an enigmatic disease with extremely variable manifestations in pattern, severity and course. Since Longcope and Freiman's descriptive monograph in 1952 (50) summarizing the clinical findings of the first half of this century, new dimensions of assessing the disease and treatment have been added. The impact of corticosteroids is central. The present review extends the studies to the second half of this century. Earlier diagnosis is facilitated and treatment often reverses many of the disease manifestations and improves the quality and extent of life for the patient. The management issues and guidelines outlined in this paper for both intrathoracic and extrathoracic disease are based on several longitudinal studies of the sarcoidosis patients summarized here, and 50 years of clinical experience by the senior author (CJJ) at Johns Hopkins Hospital, a tertiary referral center with an active Sarcoid Clinic. Case reports are presented in the appendix. It is clear that corticosteroids are the most effective therapeutic agent for sarcoidosis, usually with impressive and prompt response. This represents the dramatic difference in this disease after 1950. No more specific or effective immunosuppressive or antiinflammatory agents have been identified. Undesirable side effects are minimal if excessive doses are avoided. The effectiveness of "steroid-sparing agents" such as methotrexate is uncertain. Although irreversible tissue damage from the disease may limit the effectiveness of treatment, benefits of corticosteroids greatly exceed the negative side effects. Since spontaneous remissions without treatment do occur, a period of observation of 2 years are more is warranted if the patient is relatively asymptomatic. Gradual radiographic progression for 2 or more years, even without major symptoms or reduction in pulmonary function, indicates the need for a trial of corticosteroid treatment, especially in white patients where symptoms may lag behind the radiographic changes. Relapses as treatment is withdrawn are frequent, especially in African-American patients, who tend to have more severe and more prolonged disease than white patients. A minimum of 1 year of treatment is recommended unless no improvement is noted after 3 months. Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease. Periodic attempts at tapering are justified. Repeated relapses may indicate the need for life-long treatment. When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents. Many agents related to sarcoidosis require further research. The most important question facing sarcoid researchers today is etiology. It is difficult to design specific therapy when the fundamental causes and disease mechanisms are not established. Rather than being a single disease with a single cause, it is possible that a number of genetic factors and environmental or infectious agents may result in an immune response that is manifested as sarcoidosis. Understanding basic causal mechanisms may help explain the varied disease manifestations and aid in designing curative treatments. Such etiologic questions should be explored from both a basic science and an epidemiologic approach. Therapeutic trials of new drugs such as pentoxyfylline and possibly thalidomide are needed to address their potential as well as limitations of steroid therapy. Finally, for patients who have progressed to organ failure, the problems of sarcoid recurrence in transplanted tissue, increased allograft rejection, and long-term prognosis of solid organ transplants have yet to be resolved. (ABSTRACT TRUNCATED)