Genetic influences on sarcoidosis

Cutaneous Granulomatosis: a Comprehensive Review

Cutaneous granulomatosis is a heterogeneous group of diseases, characterized by a skin inflammatory reaction triggered by a wide variety of stimuli, including infections, foreign bodies, malignancy, metabolites, and chemicals. From a pathogenic point of view, they are divided into non-infectious and infectious granulomas. Pathophysiological mechanisms are still poorly understood. Non-infectious granulomatous skin diseases include granuloma annulare, necrobiosis lipoidica, rheumatic nodules, foreign body granulomas, cutaneous sarcoidosis, and interstitial granulomatous dermatitis. Necrobiosis lipoidica is more frequent in diabetic patients. Infectious granulomas of the skin are caused by mycobacteria, in particular Mycobacterium tuberculosis or atypical mycobacteria; parasites, such as Leishmania; or fungi. Pathogenic mechanisms of M. tuberculosis-related granuloma are discussed. From a clinical point of view, it is useful to divide cutaneous granulomatosis into localized and more disseminated forms, although this distinction can be sometimes artificial. Three types of localized granulomatous lesions can be distinguished: palisaded granulomas (granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules), foreign body granulomas, and infectious granulomas, which are generally associated with localized infections. Disseminated cutaneous granulomas can be divided into infectious, in particular tuberculosis, and non-infectious forms, among which sarcoidosis and interstitial granulomatous dermatitis. From a histological point of view, the common denominator is the presence of a granulomatous inflammatory infiltrate in the dermis and/or hypodermis; this infiltrate is mainly composed of macrophages grouped into nodules having a nodular, palisaded or interstitial architecture. Finally, we propose which diagnostic procedure should be performed when facing a patient with a suspected cutaneous granulomatosis.

What is new in the histogenesis of granulomatous skin diseases?

A granuloma is a form of inflammation, which predominantly consists of macrophages. It typically develops when the immune system attempts to enclose substances that are usually insoluble and cannot be eliminated to prevent the spread of these substances to the other body compartments. According to the source of the substances, granulomatous diseases can be divided into two groups: infectious and non-infectious. The mechanisms of infectious granuloma formation have been widely investigated because of its easy reproducibility in experimental models, both in vivo and in vitro. On the contrary, mechanisms of non-infectious granuloma formation have not been well investigated because of the difficulty to reproduce this formation in experimental models. In this article, we review our recent understanding of the histogenesis and pathogenesis of granuloma formation, confirmed from studies of infectious granulomas, and we present potential hypotheses of the histogenesis and pathogenesis of non-infectious granulomas based on clinical investigations.

Different ophthalmologic manifestations of sarcoidosis

PURPOSE OF REVIEW

Sarcoidosis can manifest with different ocular findings. Three different cases have been presented, each of which showed different ocular problems. The literature has also been reviewed as to find out other eye signs and treatment strategies of the disease. The diagnosis may be difficult and the treatment may include combination of different immunosuppressors.

RECENT FINDINGS

Recent findings include a genetic basis, and certain human leukocyte antigens may affect the course of the disease. Sarcoidosis can influence the eye and the optic nerves in the beginning, and biopsy of the involved tissue may be necessary for the diagnosis. Laboratory investigation may be unyielding. Once the diagnosis is made, steroids are generally started. Other than the classical corticosteroid treatment, other immunosuppressive agents show promise in the atypical cases.

SUMMARY

Our cases show different manifestations of the disease like bilateral optic neuropathy, Horner's syndrome, pars planitis, and anterior and posterior uveitis. Patients recovered with steroid treatment, but especially in young patients other agents like methotrexate were needed because of the sideeffects of steroids.

Association between open-angle glaucoma and gene polymorphism for heat-shock protein 70-1

PURPOSE

Heat-shock proteins (HSPs) or antibodies against them may contribute to glaucomatous optic neuropathy. We investigated the associations of HSP70-1 polymorphisms with open-angle glaucoma (OAG) in a Japanese population.

METHODS

In 241 normal Japanese controls and 501 Japanese OAG patients, including 211 with primary open-angle glaucoma (POAG) and 290 with normal-tension glaucoma (NTG), two single-nucleotide polymorphisms, A-110C and G+190C, of HSP70-1 were identified by using an Invader assay and polymerase chain reaction-restriction fragment length polymorphism, respectively. Genotype distributions were compared between controls and OAG patients. Age at diagnosis, untreated maximum intraocular pressure, and visual field defects at diagnosis were examined for associations with the polymorphisms.

RESULTS

Distribution of the A-110C genotype (AA versus AC+CC) differed significantly between controls and OAG patients (P = 0.007), POAG patients (P = 0.007), or NTG patients (P = 0.032). The genotype distribution of the G+190C polymorphism did not differ significantly between the controls and any patient group. No significant differences in the clinical characteristics of the patients were detected between genotype-defined groups by logistic regression analysis.

CONCLUSION

The A-110C polymorphism of HSP70-1 may be associated with OAG pathogenesis in Japanese patients.

[Human leukocyte antigens A and B in Turkish patients with sarcoidosis]

OBJECTIVE

Associations between human leukocyte antigens (HLA) and sarcoidosis have been reported in several studies. We aimed to investigate these associations in Turkish patients.

PATIENTS AND METHOD

We performed HLA-A, HLA-B, HLA-C, and HLA-D typing in 83 patients with sarcoidosis and in 250 healthy controls using a microlymphocytotoxicity method to investigate genetic susceptibility to the disease.

RESULTS

Because of significant violation of Hardy-Weinberg equilibrium at HLA-C and HLA-DQB1 loci, only results obtained at other HLA loci were used. Although HLA-A9, HLA-B5, and HLA-B8 allele frequencies were significantly higher in the patient group compared to the controls (odds ratio [OR]= 21.8, P= .015; OR= 9.34, P= .049; OR= 2.26, P= .031, respectively), none of the differences remained significant after applying the Bonferroni correction. HLA-A24, HLA-A26, and HLA-B62 alleles were significantly less frequent in the patient group compared to the controls (OR= 0.48, P= .018; OR= 0.19, P= .003; OR= 0.11, P= .044, respectively). However, the differences also failed to remain significant after Bonferroni correction.

CONCLUSIONS

These results suggest that both HLA may play significant roles (either increasing or reducing risk) in the pathogenesis of sarcoidosis and in its distinct clinical forms and laboratory findings.

Immunopathology of the noninfectious posterior and intermediate uveitides

The posterior and intermediate uveitides share an underlying immune etiology; however, they can be clinically and immunopathologically distinguished. Although the initiating stimuli for posterior and intermediate uveities are not known, it is believed that an exogenous agent (such as a bacterium or a virus) or an endogenous molecule may induce disease. In either case, T-helper lymphocytes in conjunction with human leukocyte antigens are likely to be involved. This review examines the epidemiology, histology, immunopathology, and theories of pathogenesis of several posterior and intermediate uveitides, including sympathetic ophthalmia, Vogt-Koyanagi-Harada syndrome, Behçet's disease, sarcoidosis, intermediate uveitis, white dot syndromes, and birdshot retinochoroidopathy.

Idiopathic systemic granulomatous disease and macrophage expression of PTHrP in a miniature pony

Idiopathic systemic granulomatous disease, which has been reported in horses, cattle and human beings, is characterized by perivascular granulomatous and lymphoplasmacytic inflammation in many organ systems. Diagnosis is based on the exclusion of possible viral, fungal or bacterial causes. The disease was identified in a miniature pony with widespread lymphoplasmacytic and granulomatous inflammation, special staining techniques having revealed no evidence of any aetiological agent. Skin lesions, which were severe, consisted of hyperkeratosis and serocellular crust formation, with inflammatory infiltrates in a perivascular to diffuse pattern in both the superficial and deep dermis. Inflammatory infiltrates were also present in lymph nodes and around the blood vessels in most organs. Immunohistochemically, both CD3-positive T lymphocytes and BLA36-positive B lymphocytes were identified in the inflammatory infiltrates, and macrophages were immunolabelled for parathyroid hormone-related protein, a factor associated with hypercalcaemia in human beings with granulomatous diseases.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

The gene polymorphism of tumor necrosis factor-beta, but not that of tumor necrosis factor-alpha, is associated with the prognosis of sarcoidosis

OBJECTIVES

Few genetic markers for the prognosis of sarcoidosis have been found. Tumor necrosis factor (TNF)-alpha has been implicated in the pathogenesis of sarcoidosis. Induced TNF-alpha or TNF-beta levels have been shown to be associated with the polymorphisms of the TNF genes. We investigated the roles of such polymorphisms in the development and prolongation of sarcoidosis.

SUBJECTS AND MEASUREMENTS

One hundred ten Japanese patients with sarcoidosis and 161 control subjects were genotyped for three biallelic polymorphisms in the promoter region of TNF-alpha gene by direct sequencing of polymerase chain reaction (PCR) products. A polymorphism of the TNF-beta gene (TNFB*1/TNFB*2) was detected by NCO: I restriction fragment length polymorphism analysis of PCR products spanning intron 1 and exon 2 of the TNF-beta gene.

RESULTS

None of the polymorphisms conferred susceptibility to sarcoidosis. However, our study identified the allele TNFB*1, detected by the presence of a NCO: I restriction site, as a marker of prolonged clinical course, with the resolution of sarcoidosis being defined as the disappearance of all clinical symptoms, physical signs of active lesions, abnormal chest radiograph findings, and abnormal results of pulmonary function and biochemical tests. When the probability of remission in patients homozygous for TNFB*2 was defined as 1.00, it was 0.48 (95% confidence interval, 0.26 to 0.88; p < 0.05) in patients with TNFB*1 (genotypes TNFB*1/1 and TNFB*1/2).

CONCLUSIONS

The TNFB*1 allele is a marker for prolonged clinical course in patients with sarcoidosis. Our study is the first to link a cytokine gene polymorphism to the prognosis of sarcoidosis.

Familial sarcoidosis is linked to the major histocompatibility complex region

Sarcoidosis is a systemic granulomatous disorder associated with high CD4+ cell activity, but no pathogen is detectable. Clustering in families occurs, and the existence of a genetic predisposition to sarcoidosis is widely accepted. The major histocompatibility complex (MHC) is believed to contribute to this susceptibility. Many studies testing this hypothesis have produced conflicting results. We have genotyped 122 affected siblings from 55 families for seven DNA polymorphisms that flank and cover the MHC region on chromosome 6, and for HLA-DPB1, a candidate gene for granulomatous disorders. Multipoint nonparametric linkage (NPL) analysis showed linkage (NPL score > 2.5; p < 0.006) for the entire MHC region with a maximum NPL score of 3.2 (p = 0.0008) at marker locus D6S1666 in the Class III gene cluster. There was a significant excess of marker haplotype sharing among affected siblings. However, the frequency of HLA-DPB1 alleles on 104 shared chromosomes did not differ from that of a control group of founders from the family panel. Transmission disequilibrium was found for allele DPB1*0201, but only nine families contributed to this result. We conclude that genes of the MHC are involved in the genetic predisposition to sarcoidosis, but HLA-DPB1 alone does not sufficiently explain this fact.

Polymorphism of heat-shock protein gene HSP70-2 in Crohn disease: possible genetic marker for two forms of Crohn disease

BACKGROUND

Previous reports have shown that heat-shock protein 70 (HSP70) may be associated with Crohn disease. However, genetic analysis of the HSP70 gene in Crohn disease has not been done. The aim of this study is to investigate whether HSP70-2 gene polymorphism is involved in susceptibility to Crohn disease in the Japanese population and whether it correlates with clinical manifestation of the disease.

METHODS

A total of 108 genetically unrelated patients with Crohn disease and 108 healthy controls were typed for HSP70-2 PstI polymorphism by restriction fragment length polymorphism analysis (alleles A and B). Patients with Crohn disease were classified into two types: either perforating or non-perforating.

RESULTS

Genotype and allele frequency did not differ between patients and controls. In patients with Crohn disease, allele A frequency was significantly higher in the non-perforating than in the perforating type (P = 0.02). When patients with Crohn disease of more than 6.7 years' duration were assessed, the differences in genotype and allele frequency between the two groups became more significant (P < 0.001 and P < 0.001, respectively).

CONCLUSIONS

These data suggest that HSP70-2 gene polymorphic allele A is a possible genetic marker of less severe clinical phenotype in Japanese patients with Crohn disease.