Therapy for extrapulmonary sarcoidosis

Anti-inflammatory Therapy for Sarcoidosis

Over 50% of patients with sarcoidosis will require anti-inflammatory therapy at some point in their disease course. Indications for therapy are to improve health-related quality of life, prevent or arrest organ dysfunction (or organ failure) or avoid death. Recently published treatment guidelines recommended a stepwise approach to therapy however there are some patients for whom up front combination or more intense therapy maybe reasonable. The last decade has seen an explosion of studies and trials evaluating novel therapeutic agents and treatment strategies. Currently available anti-inflammatory therapies and several novel therapies are discussed here.

Renal manifestations of sarcoidosis: from accurate diagnosis to specific treatment

Sarcoidosis is a multisystem granulomatous disease characterized by epithelioid noncaseating granulomas associated with clinical and radiologic findings. The cause of this disease is still uncertain. Sarcoidosis affects mostly lungs and lymph nodes and is not usually considered a urological disease, therefore, this etiology may be overlooked in several urological disorders, such as hypercalcemia, hypercalciuria and nephrolithiasis. It affects all races and genders. This review aims to describe the urological manifestations of sarcoidosis and to elucidate how the disease may affect the management of numerous urological conditions.

Multisystemic sarcoidosis-important lessons learnt from one of the great imitators

We report a case of a woman who was admitted with a suspicion of metastatic malignancy of unknown primary origin. A few months prior to her admission, she presented to a rheumatologist with acute anterior uveitis, psoriasiform rashes and polyarthritis. A diagnosis of psoriatic arthropathy was made and she was treated accordingly. Soon after she presented with persistent back and right upper quadrant abdominal pain for which she had a CT scan done with evidence of hilar lymphadenopathy, liver hypodensities and lytic-sclerotic bone lesions. She was referred to our hospital for further investigations and management. After re-exploring her clinical presentation and further investigations (including a liver biopsy), a diagnosis of multisystemic sarcoidosis with ocular, reticuloendothelial, hepatic and skeletal involvement was made. The patient was started on systemic glucocorticoids and second line immunosuppressants and demonstrated significant clinical improvement with resolution of her liver granulomata on imaging and improvement in her back pain. The case illustrates the importance of a thorough clinical assessment, review of investigations and an open mind in the evaluation of a patient.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Sarcoidosis and atrial fibrillation: a rare association and interlink with inflammation

We report a case of sarcoidosis presenting initially as atrial fibrillation(AF). His response to anti-arrhythmic treatment strategy was suboptimal. On initiation of immunosuppressive therapy, AF was better controlled. This interesting case highlights a likely link between inflammation and pathogenesis of atrial fibrillation.

Diagnosis and treatment of hepatic sarcoidosis

The presence of granulomas in the liver raises consideration of a wide differential diagnosis, but in most Western series, sarcoidosis accounts for a majority of cases. This review will focus specifically on the diagnosis of and therapy for hepatic sarcoidosis. Sarcoidosis is a systemic granulomatous disease of unknown etiology. Hepatic involvement of sarcoidosis was described in 11.5% of 736 patients enrolled in the ACCESS study. However, presence alone of granulomas in an organ in sarcoidosis does not dictate treatment. The decision to treat should be based on symptoms and severity of disease. Although hepatic involvement usually is asymptomatic, a minority of patients progress to chronic cholestatic disease, portal hypertension, and cirrhosis that may require liver transplantation. Treatment of hepatic sarcoidosis should be reserved for patients who manifest this spectrum of disease. Glucocorticoid treatment is first-line therapy for hepatic sarcoidosis, improving symptoms and abnormal laboratory values but generally having no effect on progression of disease. In addition to glucocorticoids, immunomodulators such as azathioprine, methotrexate, hydroxychloroquine, and infliximab have been used with some positive effects on symptoms, liver enzyme abnormalities, and hepatomegaly, but none has been shown to prevent progression of disease. Ultimately, in cases of overt liver failure, liver transplantation is the definitive treatment. Overall, treatment for hepatic sarcoidosis is targeted toward alleviation of symptoms but has no curative potential at this time. Focus should be on discovering the etiology of the disease to target therapy at prevention, not cure.

[Sarcoidosis]

Sarcoidosis is the most frequent interstitial lung disease of unknown origin affecting patients of younger age in many cases. In Germany its incidence is higher than that of tuberculosis. Diagnosis is made by demonstration of epitheloid, non-necrotizing granuloma in pulmonary parenchyma and by exclusion of other granulomatous disorders such as mycobacteriosis, berylliosis, or hypersensitivity pneumonitis. Its etiology is still elusive and since it is a systemic disease any organ can be involved. The lung is most frequently involved and, therefore, diagnosis can easily be made by bronchoscopy with transbronchial biopsy and bronchoalveolar lavage. Frequently a favorable spontaneous course takes place but in about one third of the cases a chronic course of disease is seen which requires systemic treatment with prednisolone. In progressive disease despite prednisolone treatment the combination with azathioprine or methotrexate might be helpful.

Sarcoidosis, role of tumor necrosis factor inhibitors and other biologic agents, past, present, and future concepts

Tumor necrosis factor is a potent cytokine involved in the inflammatory process of many diseases. Agents that block tumor necrosis factor have been used in the treatment of various immune-mediated diseases, including rheumatoid arthritis, Crohn disease, psoriatic arthritis, and ankylosing spondylitis. Sarcoidosis is an immune-mediated inflammatory disorder of unknown etiology characterized by the formation of noncaseating granulomas. Tumor necrosis factor plays a major role in the inflammatory process seen in sarcoidosis. Sarcoidosis therapies with activity against tumor necrosis factor and specific anti-tumor necrosis factor therapies have been used with variable success. The long-term safety and efficacy of such therapies are yet to be determined in well-designed clinical trials with long-term follow-up.

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

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

Interferon-Induced Sarcoidosis

Rheumatologists are increasingly asked to see patients with hepatitis C who exhibit a variety of clinical and serologic features that mimic systemic rheumatic disease. Treatment with interferons, now the standard of care, can precipitate a variety of inflammatory conditions, including sarcoidosis. We present a case of a 59-year-old former intravenous drug user who developed systemic sarcoidosis while receiving interferon alpha and ribavirin for the treatment of chronic hepatitis C. Because interferons are increasingly prescribed by specialists in a variety of disciplines, rheumatologists should be aware of their potential to induce sarcoidosis as well as various autoimmune diseases.