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Samalia PD, Lim LL, Niederer RL. Insights into the diagnosis and management of sarcoid uveitis: A review. Clin Exp Ophthalmol 2024; 52:294-316. [PMID: 38385625 DOI: 10.1111/ceo.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.
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Affiliation(s)
- Priya D Samalia
- Department of Opthalmology, Te Whatu Ora Southern, Dunedin, New Zealand
- Otago School of Medicine, University of Otago, Dunedin, New Zealand
| | - Lyndell L Lim
- The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
| | - Rachael L Niederer
- Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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2
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Obi ON. Anti-inflammatory Therapy for Sarcoidosis. Clin Chest Med 2024; 45:131-157. [PMID: 38245362 DOI: 10.1016/j.ccm.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
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.
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Affiliation(s)
- Ogugua Ndili Obi
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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3
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Bert A, El Jammal T, Kodjikian L, Gerfaud-Valentin M, Jamilloux Y, Seve P. Hydroxychloroquine Therapy in Sarcoidosis-Associated Uveitis. Ocul Immunol Inflamm 2024; 32:154-160. [PMID: 36749910 DOI: 10.1080/09273948.2023.2165952] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/03/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND/PURPOSE To assess the efficacy and tolerance of hydroxychloroquine in sarcoidosis-associated uveitis. METHODS Retrospective study on all patients with sarcoidosis-associated uveitis who were treated with hydroxychloroquine between 2003 and 2019 in a French university hospital. RESULTS Twenty-seven patients with sarcoidosis-associated uveitis received hydroxychloroquine. The mean duration of treatment was 20.0 ± 10.9 months. At the end of the follow-up, hydroxychloroquine success was achieved in 15 (55.6%) patients. Four of them were also on oral corticosteroids, with a prednisone dose ≤5 mg/day. Under treatment, the median prednisone dose decreased from 20.0 (interquartile range (IQR), 7-25) to 5.0 (IQR, 3-6.5) mg/day (p = .02). The incidence rate of flare decreased from 204.6 to 63.8 per 100 person-years (p = .02). Hydroxychloroquine was discontinued in 12 (44.4%) patients during follow-up, including 8 (29.6%) for ineffectiveness, and three who experienced side effects. CONCLUSION Hydroxychloroquine appears as an interesting option in sarcoidosis-associated uveitis.Abbreviations: AZA: Azathioprine; BAL: Bronchoalveolar Lavage; BCVA: Best-Corrected Visual Acuity; ENT: Ears, Nose and Throat; HCQ: Hydroxychloroquine; IOP: Intra-Ocular Pressure; IQR: interquartile range; MHC: Major Histocompatibility Complex; MMF: Mycophenolate Mofetil; MTX: Methotrexate; PMSI: Programme de Médicalisation du Système d'Information; SAU: Sarcoidosis-Associated Uveitis; SD: Standard Deviation; SUN: Standard Uveitis Nomenclature.
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Affiliation(s)
- Arthur Bert
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University - Lyon 1, Lyon, France
| | - Thomas El Jammal
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University - Lyon 1, Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, University Hospital Lyon Croix-Rousse, University Claude Bernard University - Lyon 1, Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University - Lyon 1, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University - Lyon 1, Lyon, France
| | - Pascal Seve
- Department of Internal Medicine, University Hospital Lyon Croix-Rousse, Claude Bernard University - Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
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4
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Giorgiutti S, Jacquot R, El Jammal T, Bert A, Jamilloux Y, Kodjikian L, Sève P. Sarcoidosis-Related Uveitis: A Review. J Clin Med 2023; 12:jcm12093194. [PMID: 37176633 PMCID: PMC10178951 DOI: 10.3390/jcm12093194] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Sarcoidosis is an inflammatory disease that involves the eyes in 10-55% of cases, sometimes without systemic involvement. All eye structures can be affected, but uveitis is the most common ocular manifestation and causes vision loss. The typical ophthalmological appearance of these uveitis is granulomatous (in cases with anterior involvement), which are usually bilateral and with synechiae. Posterior involvement includes vitritis, vasculitis and choroidal lesions. Tuberculosis is a classic differential diagnosis to be wary of, especially in people who have spent time in endemic areas. The diagnosis is based on histology with the presence of non-caseating epithelioid granulomas. However, due to the technical difficulty and yield of biopsies, the diagnosis of ocular sarcoidosis is often based on clinico-radiological features. The international criteria for the diagnosis of ocular sarcoidosis have recently been revised. Corticosteroids remain the first-line treatment for sarcoidosis, but up to 30% of patients require high doses, justifying the use of corticosteroid-sparing treatments. In these cases, immunosuppressive treatments such as methotrexate may be introduced. More recent biotherapies such as anti-TNF are also very effective (as they are in other non-infectious uveitis etiologies).
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Affiliation(s)
- Stéphane Giorgiutti
- Department of Clinical Immunology and Internal Medicine, National Center for Systemic Autoimmune Diseases (CNR RESO), Strasbourg University Hospital, 67000 Strasbourg, France
- INSERM UMR-S1109, Université de Strasbourg, 67000 Strasbourg, France
| | - Robin Jacquot
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Thomas El Jammal
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
- Laboratory of Tissue Biology and Therapeutic Engineering, CNRS UMR5305, IBCP, University of Lyon, 69007 Lyon, France
| | - Arthur Bert
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- UMR5510 MATEIS, CNRS, INSA Lyon, Université de Lyon 1, 69100 Villeurbanne, France
| | - Pascal Sève
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
- Pôle IMER, Hospices Civils de Lyon, 69002 Lyon, France
- The Health Services and Performance Research (EA 7425 HESPER), Université de Lyon, 69003 Lyon, France
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Sève P, Jacquot R, El Jammal T, Bert A, Jamilloux Y, Kodjikian L, Giorgiutti S. [Sarcoid uveitis: Ophthalmologist's and internist's viewpoints]. Rev Med Interne 2023; 44:112-122. [PMID: 36642624 DOI: 10.1016/j.revmed.2022.10.001] [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: 09/05/2022] [Accepted: 10/01/2022] [Indexed: 01/15/2023]
Abstract
Sarcoidosis is one of the leading causes of inflammatory eye disease. All ocular structures can be affected, but uveitis is the main manifestation responsible for vision loss in ocular sarcoidosis. Typical sarcoid anterior uveitis presents with mutton-fat keratic precipitates, iris nodules, and posterior synechiae. Posterior involvement includes vitritis, vasculitis, and choroidal lesions. Cystoid macular edema is the most important and sight-threatening consequence of sarcoid uveitis. Patients with clinically isolated uveitis at diagnosis rarely develop other organ involvement. Even though, ocular sarcoidosis can have a severe impact on visual prognosis, early diagnosis and a wider range of available therapies (including intravitreal implants) have lessened the functional impact of the disease, particularly in the last decade. Corticosteroids are the cornerstone of treatment for sarcoidosis, but up to 30% of patients achieve remission with requiring high-dose systemic steroids. In these cases, the use of steroid-sparing immunosuppressive therapy (such as methotrexate) is unavoidable. Among these immunosuppressive treatments, anti TNF-α drugs have been a revolution in the management of non-infectious uveitis.
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Affiliation(s)
- P Sève
- Service de médecine interne, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Hospices civils de Lyon, Pôle IMER, 69003 Lyon, France; Université de Lyon, Lyon, France; University Lyon, University Claude Bernard-Lyon 1, HESPER EA 7425, 69008 Lyon, France.
| | - R Jacquot
- Service de médecine interne, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - T El Jammal
- Service de médecine interne, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - A Bert
- Service de médecine interne, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - Y Jamilloux
- Service de médecine interne, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - L Kodjikian
- Service d'ophtalmologie, Hospices civils de Lyon, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Université de Lyon, Lyon, France
| | - S Giorgiutti
- Service d'immunologie clinique et médecine interne, CNR RESO, maladies auto-immunes et systémiques rares, Nouvel Hôpital civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Chang EL, Sobrin L. Local versus Systemic Therapy for Noninfectious Uveitis (NIU). Semin Ophthalmol 2023; 38:15-23. [PMID: 36471661 DOI: 10.1080/08820538.2022.2152707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The mainstay of treatment for noninfectious uveitis (NIU) is immunosuppressant therapy. This may come in a localized form that is administered specifically to the eye or a systemic form that penetrates ocular tissues. Over the last twenty years, both local and systemic treatments have undergone advancements in pharmaceutical development. In this review, we will discuss new therapies and analyze the risks and benefits for all existing NIU therapies. Some of these therapies include topical, intravitreal, periocular, and systemic steroids, as well as systemic antimetabolites, tumor necrosis factor-α inhibitors, T-cell inhibitors, anti-CD 20 agents, interleukin-6 inhibitors, alkylating agents, and intravenous immunoglobulin.
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Affiliation(s)
- Eileen L Chang
- Harvard Medical School, Massachusetts Eye & Ear Infirmary, Boston, USA
| | - Lucia Sobrin
- Harvard Medical School, Massachusetts Eye & Ear Infirmary, Boston, USA
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Jamilloux Y, El Jammal T, Bert A, Sève P. [Hydroxychloroquine for non-severe extra-pulmonary sarcoidosis]. Rev Med Interne 2022; 43:406-411. [PMID: 35660263 DOI: 10.1016/j.revmed.2022.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 03/11/2022] [Accepted: 04/21/2022] [Indexed: 01/08/2023]
Abstract
Sarcoidosis can develop into a chronic disease in about 30% of cases. When general treatment is indicated, corticosteroids are the first-line treatment. More than one third of patients treated with corticosteroids receive a steroid-sparing agent. Although methotrexate is the most commonly used sparing agent, synthetic antimalarials have been used for more than fifty years on the basis of small, randomised, therapeutic trials. Despite this low level of evidence, chloroquine or more often hydroxychloroquine are used in daily practice, particularly to treat skin, bone and joint sarcoidosis, as well as hypercalcemia and certain types of uveitis. This review summarises the state of knowledge on steroid-sparing therapy in sarcoidosis, particularly in its extra-pulmonary form. These data support the need for good quality therapeutic trials to validate the use of hydroxychloroquine in this specific indication.
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Affiliation(s)
- Y Jamilloux
- Service de médecine interne, hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 103, grande rue de la Croix Rousse, 69004 Lyon, France; Lyon Immunopathology FEderation (LIFE), Université Claude Bernard-Lyon 1, Lyon, France.
| | - T El Jammal
- Service de médecine interne, hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 103, grande rue de la Croix Rousse, 69004 Lyon, France
| | - A Bert
- Service de médecine interne, hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 103, grande rue de la Croix Rousse, 69004 Lyon, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 103, grande rue de la Croix Rousse, 69004 Lyon, France; Université Claude Bernard-Lyon 1, Research on Healthcare Performance (RESHAPE), Inserm U1290, Lyon, France
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8
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Espinosa G, Herreras JM, Muñoz-Fernández S, García Ruiz de Morales JM, Cordero-Coma M. Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis. Med Clin (Barc) 2020; 155:220.e1-220.e12. [PMID: 32199631 DOI: 10.1016/j.medcli.2019.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience. METHODS A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines. CONCLUSIONS In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
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Affiliation(s)
- Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, España
| | - José M Herreras
- IOBA (Instituto Universitario de Oftalmobiología), Universidad de Valladolid, Valladolid, España; Servicio de Oftalmología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Santiago Muñoz-Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España; Universidad Europea, San Sebastián de los Reyes, Madrid, España
| | - José M García Ruiz de Morales
- Unidad de Uveítis, Servicio de Inmunología, Complejo Asistencial Universitario de León, León, España; Instituto de Biomedicina, Universidad de León (IBIOMED), León, España
| | - Miguel Cordero-Coma
- Instituto de Biomedicina, Universidad de León (IBIOMED), León, España; Unidad de uveítis, Servicio de Oftalmología, Complejo Asistencial Universitario de León, León, España.
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Sève P, Jamilloux Y, Tilikete C, Gerfaud-Valentin M, Kodjikian L, El Jammal T. Ocular Sarcoidosis. Semin Respir Crit Care Med 2020; 41:673-688. [PMID: 32777852 DOI: 10.1055/s-0040-1710536] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sarcoidosis is one of the leading causes of inflammatory eye disease. Any part of the eye and its adnexal tissues can be involved. Uveitis and optic neuropathy are the main manifestations, which may require systemic treatment. Two groups of patients with sarcoid uveitis can be distinguished: one of either sex and any ethnicity in which ophthalmological findings are various and another group of elderly Caucasian women with mostly chronic posterior uveitis. Clinically isolated uveitis revealing sarcoidosis remains a strictly ocular condition in a large majority of cases. Although it can be a serious condition involving functional prognosis, early recognition in addition to a growing therapeutic arsenal (including intravitreal implant) has improved the visual prognosis of the disease in recent years. Systemic corticosteroids are indicated when uveitis does not respond to topical corticosteroids or when there is bilateral posterior involvement, especially macular edema. In up to 30% of the cases that require an unacceptable dosage of corticosteroids to maintain remission, additional immunosuppression is used, especially methotrexate. As with other forms of severe noninfectious uveitis, monoclonal antibodies against tumor necrosis factor-α have been used. However, only very rarely does sarcoid uveitis fail to respond to combined corticosteroids and methotrexate therapy, a situation that should suggest either poor adherence or another granulomatous disease. Optic neuropathy often affects women of African and Caribbean origins. Some authors recommend that patients should be treated with high-dose of corticosteroids and concurrent immunosuppression from the onset of this manifestation, which is associated with a poorer outcome.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France.,Hospices Civils de Lyon, Pôle IMER, Lyon, France.,University Claude Bernard-Lyon 1, HESPER EA 7425, Univ. Lyon, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France
| | - Caroline Tilikete
- Department of Internal Medicine, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France
| | - Laurent Kodjikian
- Neurology D and Neuro-Ophthalmology Unit, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France.,Université de Lyon, Lyon 1 University, Lyon, France.,Lyon Neuroscience Research Center, INSERM U1028 CNRS UMR5292, Team ImpAct, Bron, France.,Department of Ophthalmology, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France
| | - Thomas El Jammal
- Department of Internal Medicine, Hopital de la Croix-Rousse, Université Claude Bernard Lyon I, Lyon, France
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10
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El Jammal T, Jamilloux Y, Gerfaud-Valentin M, Valeyre D, Sève P. Refractory Sarcoidosis: A Review. Ther Clin Risk Manag 2020; 16:323-345. [PMID: 32368072 PMCID: PMC7173950 DOI: 10.2147/tcrm.s192922] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/22/2020] [Indexed: 12/18/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by granuloma formation in various organs (especially lung and mediastinohilar lymph nodes). In more than half of patients, the disease resolves spontaneously. When indicated, it usually responds to corticosteroids, the first-line treatment, but some patients may not respond or tolerate them. An absence of treatment response is rare and urges for verifying the absence of a diagnosis error, the good adherence of the treatment, the presence of active lesions susceptible to respond since fibrotic lesions are irreversible. That is when second-line treatments, immunosuppressants (methotrexate, leflunomide, azathioprine, mycophenolate mofetil, hydroxychloroquine), should be considered. Methotrexate is the only first-line immunosuppressant validated by a randomized controlled trial. Refractory sarcoidosis is not yet a well-defined condition, but it remains a real challenge for the physicians. Herein, we considered refractory sarcoidosis as a disease in which second-line treatments are not sufficient to achieve satisfying disease control or satisfying corticosteroids tapering. Tumor necrosis alpha inhibitors, third-line treatments, have been validated through randomized controlled trials. There are currently no guidelines or recommendations regarding refractory sarcoidosis. Moreover, criteria defining non-response to treatment need to be clearly specified. The delay to achieve response to organ involvement and drugs also should be defined. In the past ten years, the efficacy of several immunosuppressants beforehand used in other autoimmune or inflammatory diseases was reported in refractory cases series. Among them, anti-CD20 antibodies (rituximab), repository corticotrophin injection, and anti-JAK therapy anti-interleukin-6 receptor monoclonal antibody (tocilizumab) were the main reported. Unfortunately, no clinical trial is available to validate their use in the case of sarcoidosis. Currently, other immunosuppressants such as JAK inhibitors are on trial to assess their efficacy in sarcoidosis. In this review, we propose to summarize the state of the art regarding the use of immunosuppressants and their management in the case of refractory or multidrug-resistant sarcoidosis.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
| | | | - Dominique Valeyre
- Department of Pneumology, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
- Hospices Civils de Lyon, Pôle IMER, Lyon, F-69003, France, University Claude Bernard Lyon 1, HESPER EA 7425, LyonF-69008, France
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Pande A, Culver DA. Knowing when to use steroids, immunosuppressants or biologics for the treatment of sarcoidosis. Expert Rev Respir Med 2020; 14:285-298. [PMID: 31868547 DOI: 10.1080/17476348.2020.1707672] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Care of patients with sarcoidosis requires familiarity with its natural history as well as of various immunosuppressants employed in its treatment. We would like to share our approach to management based on our experience and understanding of the relevant literature.Areas covered: Asymptomatic patients with pulmonary sarcoidosis ought to be managed conservatively. Systemic sarcoidosis with burdensome symptoms usually responds to corticosteroids, but one needs to consider the risk of long-term steroid toxicity as well as relapse. Rapidly tapering steroids can decrease cumulative exposure without compromising efficacy. Steroid-sparing anti-sarcoidosis (SSAS) agents take longer to act and are associated with unique but mostly reversible toxicities. Used judiciously and with careful monitoring, they effectively suppress granulomatous inflammation. Patients intolerant of or failing to improve with a particular drug can be switched to another, and occasionally combination therapy with two SSAS agents might prove effective. A small proportion of patients are refractory, but often achieve control and sometimes remission with stepping up to biologic therapy.Expert opinion: Adopting a strategy of early SSAS therapy ought to effectively control sarcoidosis and avoid harm from prolonged corticosteroid dosing.
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Affiliation(s)
- Aman Pande
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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13
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Salah S, Abad S, Monnet D, Brézin A. Sarcoidosis. J Fr Ophtalmol 2018; 41:e451-e467. [DOI: 10.1016/j.jfo.2018.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/09/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
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Sève P, Kodjikian L, Jamilloux Y. Manifestations ophtalmologiques de la sarcoïdose : que doit savoir l’interniste ? Rev Med Interne 2018; 39:728-737. [DOI: 10.1016/j.revmed.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/21/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
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Diwo E, Sève P, Trad S, Bielefeld P, Sène D, Abad S, Brézin A, Quartier P, Koné Paut I, Weber M, Chiquet C, Errera MH, Sellam J, Cacoub P, Kaplanski G, Kodjikian L, Bodaghi B, Saadoun D. [Therapeutic strategy for the treatment of non-infectious uveitis proposed by an expert panel]. Rev Med Interne 2018; 39:687-698. [PMID: 29610003 DOI: 10.1016/j.revmed.2018.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/01/2018] [Indexed: 02/07/2023]
Abstract
Conventional immunosuppressive drugs, anti-TNF alpha and other biotherapies used in clinical practice are capable of controlling non-infectious anterior uveitis, posterior uveitis and panuveitis. The present work has been led by a multidisciplinary panel of experts, internists, rheumatologists and ophthalmologists and is based on a review of the literature. In case of corticodependency or sight-threatening disease, conventional immunosuppressive drugs (methotrexate, azathioprine and mycophenolate mofetil) and/or anti-TNF alpha (adalimumab, infliximab) are used to achieve and maintain remission. Interferon is an efficient immunomodulatory treatment, as a second-line therapy, for some therapeutic indications (refractory macular edema, Behçet's vascularitis). Other biologics, especially tocilizumab, are showing promising results. Local treatments (corticosteroids, sirolimus etc.) are adjuvant therapies in case of unilateral inflammatory relapse. Therapeutic response must be evaluated precisely by clinical examination and repeated complementary investigations (laser flare photometry, multimodal imaging, perimetry, electroretinography measures).
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Affiliation(s)
- E Diwo
- Ophthalmology department, DHU ViewRestore, Pitié Salpêtrière hospital, Paris, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Faculté de médecine Lyon-Sud, université Claude Bernard-Lyon 1, France
| | - S Trad
- Service de médecine interne, hôpital Ambroise Paré, 92100 Boulogne-Billancourt, France
| | - P Bielefeld
- Internal medicine and systemic diseases department, médecine interne 2, university hospital Dijon Bourgogne, France; Service de médecine interne, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), Bobigny, France; Faculté de médecine SMBH, université Paris 13, Sorbonne Paris Cité, Bobigny, France; UMR1125, LI2P, université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - D Sène
- Internal medicine department, Lariboisière hospital, AP-HP, Paris, France; Inserm UMR 1149, Paris Diderot university, Paris, France
| | - S Abad
- Service de médecine interne, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), Bobigny, France; Faculté de médecine SMBH, université Paris 13, Sorbonne Paris Cité, Bobigny, France; UMR1125, LI2P, université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - A Brézin
- Service d'ophtalmologie, hôpital Cochin, université Paris Descartes, Paris, France
| | - P Quartier
- Unité d'immunologie-hématologie et rhumatologie pédiatriques, institut IMAGINE, centre de référence des maladies rhumatologiques inflammatoires et autoimmunes systémiques rares de l'enfant (RAISE), université Paris-Descartes university, hôpital Necker-Enfants-Malades, Assistance publique Hôpitaux de Paris, Paris, France
| | - I Koné Paut
- Paediatric rheumatology department, centre de références des maladies autoinflammatoires et de l'amylose inflammatoire, CEREMAIA, university of Paris Sud, Bicêtre hospital, AP-HP, Paris, France
| | - M Weber
- Department of ophthalmology, Nantes university, Nantes university hospital, Nantes, France
| | - C Chiquet
- Department of ophthalmology, Grenoble-Alpes university, Grenoble Alpes university hospital, Grenoble, France
| | - M H Errera
- Department of ophthalmology at Quinze-Vingts National Eye Hospital and DHU Sight Restore, Paris, France; Sorbonne universities, UPMC université Paris 06, Paris, France
| | - J Sellam
- Service de rhumatologie, CRSA Inserm UMRS_938, DHU i2B, hôpital Saint-Antoine, Sorbonne Université, AP-HP, France
| | - P Cacoub
- Inflammation-immunopathology-biotherapy department (DHU i2B), Sorbonne universités, UPMC université Paris 06, UMR 7211, 75005 Paris, France; Inserm, UMR_S 959, 75013 Paris, France; CNRS, FRE3632, 75005 Paris, France; Department of internal medicine and clinical immunology, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Centre national de référence des maladies autoimmunes systémiques rares, centre National de référence des maladies autoinflammatoires et de l'amylose, France
| | - G Kaplanski
- Service de médecine interne et immunologie clinique, Aix-Marseille université, hôpital de la conception, 147, boulevard Baille, 1305 Marseille, France
| | - L Kodjikian
- Department of ophthalmology, Croix-Rousse university hospital, Hospices Civils de Lyon, university of Lyon I, 69004 Lyon, France; CNRS UMR 5510 Mateis, 69621 Villeurbanne, France
| | - B Bodaghi
- Ophthalmology department, DHU ViewRestore, Pitié Salpêtrière hospital, Paris, France.
| | - D Saadoun
- Inflammation-immunopathology-biotherapy department (DHU i2B), Sorbonne universités, UPMC université Paris 06, UMR 7211, 75005 Paris, France; Inserm, UMR_S 959, 75013 Paris, France; CNRS, FRE3632, 75005 Paris, France; Department of internal medicine and clinical immunology, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Centre national de référence des maladies autoimmunes systémiques rares, centre National de référence des maladies autoinflammatoires et de l'amylose, France.
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Brito-Zerón P, Pérez-Alvarez R, Pallarés L, Retamozo S, Baughman RP, Ramos-Casals M. Sarcoidosis: an update on current pharmacotherapy options and future directions. Expert Opin Pharmacother 2017; 17:2431-2448. [PMID: 27817209 DOI: 10.1080/14656566.2016.1258061] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Sarcoidosis is a systemic disease of unknown etiology characterized by the development of non-caseating epitheloid granulomas. The lungs are the most commonly involved organ (>90% of cases), followed by the lymph nodes, the skin, and the eyes. Areas covered: This review summarizes current pharmacotherapy options and future directions for the development of new therapies. Glucocorticoids are the first-line therapy for sarcoidosis. For patients with the most severe forms of sarcoidosis (who will need glucocorticoids for long periods) and for those intolerant or refractory, immunosuppressive drugs are used as sparing agents. The management of extrathoracic sarcoidosis must be tailored to the specific organ or organs involved; however, there is limited data from controlled trials to guide the treatment of these patients. The emergence of biological therapies has increased the therapeutic armamentarium available to treat sarcoidosis, with monoclonal anti-TNF agents being the most promising, but their use is still limited by a lack of licensing and costs. Expert commentary: The treatment of sarcoidosis is still not totally standardized. New effective therapies are urgently needed to enable the reduction or replacement of long-term therapy with glucocorticoids in patients with sarcoidosis.
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Affiliation(s)
- Pilar Brito-Zerón
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,b Autoimmune Diseases Unit, Department of Medicine , Hospital CIMA- Sanitas , Barcelona , Spain
| | | | - Lucio Pallarés
- d Systemic Autoimmune Diseases Unit, Department of Internal Medicine , Hospital de Son Espases , Palma de Mallorca , Spain
| | - Soledad Retamozo
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,e Hospital Privado , Centro Médico de Córdoba , Córdoba , Argentina
| | - Robert P Baughman
- f Department of Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
| | - Manuel Ramos-Casals
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,g Department of Medicine , University of Barcelona , Barcelona , Spain
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[Sarcoidosis and uveitis : An update]. Ophthalmologe 2016; 114:525-533. [PMID: 27904945 DOI: 10.1007/s00347-016-0405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Ocular involvement in sarcoidosis is present in up to one third of patients and is frequently manifested before the underlying systemic disease has been diagnosed. With a view to the therapeutic consequences an early diagnosis of the underlying disease is advantageous. In cases of visual loss early diagnostic measures include invasive procedures, such as ultrasound-guided bronchoalveolar lavage and transbronchial biopsy, if nodular conjunctival or cutaneous manifestations which would confirm the diagnosis are not present. Sufficiently sensitive biomarkers of disease activity have not yet been identified. As elevated activity of angiotensin-converting enzyme (ACE) and lysozyme are associated with disease activity they may be supportive of but not specific for the diagnosis. Other indicators include calcemia, calciuria, augmented activity of hepatic enzymes, cutaneous anergy and hilar changes in the lungs. In patients with newly diagnosed anterior uveitis presenting with granulomatous mutton-fat corneal precipitates, snow balls and vitreous body base condensates with mild retinal periphlebitis in intermediate uveitis as well as multifocal choroiditis (creamy choroidal lesions at different stages of activity and approximately 500 µm in diameter), a diagnosis of sarcoidosis has to be considered and tuberculosis should be excluded, even in the absence of a known systemic disease. Anterior uveitis is frequently a self-limiting condition, which can be well-controlled with topical steroids. On the other hand, intermediate, posterior and panuveitis are typically associated with a chronic course and require systemic therapy to prevent severe loss of vision. If the response to systemic corticosteroids is insufficient, treatment with immunomodulatory agents and biologics is initiated at progressively earlier stages, with a view to averting permanent organ damage and frequently with a positive impact on the short and long-term outcomes, even in therapy-refractive cases.
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Paovic J, Paovic P, Sredovic V, Jovanovic S. Clinical Manifestations, Complications and Treatment of Ocular Sarcoidosis: Correlation between Visual Efficiency and Macular Edema as Seen on Optical Coherence Tomography. Semin Ophthalmol 2016:1-8. [PMID: 27628176 DOI: 10.1080/08820538.2016.1206576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sarcoidosis is a chronic systemic autoimmune disease which belongs to a group of systemic granulomatous diseases. It can be confirmed through characteristic systemic and ocular manifestations and histological findings. Biopsy is the golden standard for diagnosing sarcoidosis. Ocular sarcoidosis can be confirmed, probable, or possible. Over a two-year period, ocular manifestations were studied on a sample of 52 patients, each followed for four months and diagnosed with some form of systemic sarcoidosis. Most frequent systemic manifestations in patients with ocular sarcoidosis were pulmonary, skin, glandular, and systemic generalized sarcoidosis. The disease was diagnosed four times more frequently in females than males (42:10, respectively; p < 0.05). Most frequent, and statistically significant, manifestation of ocular sarcoidosis is anterior uveitis (64.61%; p < 0.01). Macular edema and periphlebitis associated with periarteritis were frequent, and statistically significant (43.90% and 29.26%, respectively; p < 0.05). Overall, with regards to gender and location (right eye; left eye), visual acuity was >0.5 and of statistical significance (76.92%; p < 0.01). The most common therapy consisted of systemic corticosteroids (26.67%) and/or a combination of corticosteroids and immunosuppressive drugs (23.33%). In 16 eyes treated with repeated doses of sub-Tenon's injections, both initial and control visual acuity correlated with average thickness. There was positive correlation between several optical coherence tomography findings before and after treatment.
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Affiliation(s)
- Jelena Paovic
- a University Eye Clinic , Clinical Center of Serbia , Belgrade , Serbia
| | - Predrag Paovic
- a University Eye Clinic , Clinical Center of Serbia , Belgrade , Serbia
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Abstract
Treatment of sarcoidosis is not required in all patients with the diagnosis. The decision to treat and the strategy for how to treat usually require input and shared decision making by the patient. Some common consequences of sarcoidosis are not caused by granulomatous inflammation, but may be the dominant disease manifestation and should be actively considered when formulating a treatment plan. The medication regimen should be tailored to each patient. Steroid-sparing medications should be prescribed early as part of a long-term strategy.
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Affiliation(s)
- Marlies S Wijsenbeek
- Department of Pulmonary Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Abstract
Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.
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Affiliation(s)
- Sirichai Pasadhika
- Vitreoretinal and Uveitis Service, Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA.
| | - James T Rosenbaum
- Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA
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22
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Yee AM. Sarcoidosis: Rheumatology perspective. Best Pract Res Clin Rheumatol 2016; 30:334-356. [DOI: 10.1016/j.berh.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/12/2016] [Indexed: 02/07/2023]
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Kheir V, Vaudaux J, Guex-Crosier Y. Review of the latest systemic treatments for chronic non-infectious uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1586/17469899.2016.1153425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
PURPOSE OF REVIEW Sarcoidosis is a granulomatous disease which affects multiple organs. Its therapeutic management is very challenging due to the heterogeneity in disease manifestation and clinical course, as well as the potential side effects of the immunosuppressive therapy. An overview of presently available second-line and third-line systemic agents is provided. RECENT FINDINGS Because curative treatment is currently not available for sarcoidosis, nonspecific immunosuppression with prednisone remains the first-choice therapy. However, as chronic use of corticosteroids is accompanied with severe adverse events, timely implementation of appropriate steroid-sparing cytotoxic agents is important. Commonly prescribed second-line agents in sarcoidosis are methotrexate, azathioprine, leflunomide and hydroxychloroquine. Nevertheless, the evidence supporting their use is limited. Third-line treatment options, including tumor necrosis factor-alpha inhibitors infliximab and adalimumab and the experimental therapeutic rituximab, are currently reserved for patients refractory to standard therapy. SUMMARY A better insight into the advantages and disadvantages of second-line and third-line treatment is important. The long-term effects of immunosuppressive agents, the optimal starting and maintenance dosages, and the best interval and discontinuation regimens should be elucidated. Identified associations of polymorphisms with treatment response suggest a step towards personalized medicine. Future research should focus on the role for pharmacogenetic and phenotypic predictors of treatment response and toxicity.
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Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown etiology that most commonly affects the lungs. Treatment of sarcoidosis can be challenging as it is often difficult to measure disease activity and distinguish active inflammation from fibrosis. Identifying the inflammatory mediators in sarcoidosis has led to the development and use of novel therapeutic agents. The goal of pharmacotherapy is to decrease granuloma accumulation, ameliorate symptoms and improve organ function. Systemic corticosteroids remain the first line treatment. Other immunosuppressive agents may be considered for the patients who respond poorly to corticosteroids or who experience significant adverse effects. An overview of pharmacotherapy of sarcoidosis is provided here.
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Vertigo as a predominant manifestation of neurosarcoidosis. Case Rep Med 2015; 2015:397046. [PMID: 25922606 PMCID: PMC4398954 DOI: 10.1155/2015/397046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 03/26/2015] [Indexed: 12/03/2022] Open
Abstract
Sarcoidosis is a granulomatous disease of unknown etiology that affects multiple organ systems. Neurological manifestations of sarcoidosis are less common and can include cranial neuropathies and intracranial lesions. We report the case of a 21-year-old man who presented with vertigo and uveitis. Extensive workup including brain imaging revealed enhancing focal lesions. A lacrimal gland biopsy confirmed the diagnosis of sarcoidosis. The patient was initially treated with prednisone, which did not adequately control his symptoms, and then was switched to methotrexate with moderate symptomatic improvement. Our patient had an atypical presentation with vertigo as the predominant manifestation of sarcoidosis. Patients with neurosarcoidosis typically present with systemic involvement of sarcoidosis followed by neurologic involvement. Vertigo is rarely reported as an initial manifestation. This case highlights the importance of consideration of neurosarcoidosis as an entity even in patients that may not have a typical presentation or systemic involvement of disease.
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Jamilloux Y, Kodjikian L, Broussolle C, Sève P. Sarcoidosis and uveitis. Autoimmun Rev 2014; 13:840-9. [DOI: 10.1016/j.autrev.2014.04.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 03/30/2014] [Accepted: 03/30/2014] [Indexed: 12/23/2022]
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Uveitis profile and treatment response in Iranian patients with sarcoidosis. Int Ophthalmol 2014; 35:395-402. [PMID: 24917524 DOI: 10.1007/s10792-014-9960-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 05/26/2014] [Indexed: 12/19/2022]
Abstract
The aim of the study was to assess the clinical features and treatment responses in Iranian patients with sarcoid uveitis. A retrospective review of patients diagnosed with sarcoid uveitis from 1996 to 2010 was performed in a referral clinic in Tehran, Iran. Demographic and clinical features of patients, treatment modalities and therapeutic responses, and outcomes were recorded. Sixty-six eyes from 36 patients were studied. Twenty cases had biopsy-proven sarcoidosis. Mean duration of follow-up was 44.7 ± 45 months (range 3-175). Thirty-six eyes (54.5 %) had intermediate uveitis, 25 (37.9 %) panuveitis, and 5 (7.6 %) anterior uveitis. Twenty patients (55.5 %) responded to both systemic and/or topical corticosteroids, and 16 (44.4 %) required immunomodulatory drugs for control of uveitis. All of the patients finally responded to treatment in the form of inflammation reduction and/or vision improvement. The average time interval before initial clinical response following treatment was 3.2 ± 3 months (range 1-72). This study disclosed a higher predominance of females and intermediate form of uveitis in Iranian patients with sarcoid uveitis. Use of immunomodulatory drugs combined with corticosteroids resulted in good visual outcome and control of uveitis with a possible fewer corticosteroid side effects.
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Szepessy Z. Uveitis in sarcoidosis. Orv Hetil 2013; 154:1798-801. [DOI: 10.1556/oh.2013.29724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This case report demonstrates signs of uveitis and difficulties of the differential diagnosis of sarcoidosis as the cause of uveitis. A 57-year-old woman, who had visual loss in her both eyes, developed bilateral panuveitis: bilateral precipitates on the cornea with posterior synechia and infiltrates in the vitreous, and multifocal, peripheral retinochoroiditis. Chest X-ray revealed an infiltrate and numerous smaller granulomas in both lungs. The presumptive diagnosis was tuberculosis, however, biopsy of the pulmonal lesion showed sarcoidosis. Pulmonary and ophthalmologic findings rapidly disappeared with corticosteroid therapy. The author concludes that sarcoidosis may present with different signs of uveitis. Histopathology is of great importance for the differentiation between sarcoidosis and tuberculosis, which is very important for the therapy. Orv. Hetil., 154(45), 1798–1801.
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Affiliation(s)
- Zsuzsanna Szepessy
- Semmelweis Egyetem, Általános Orvostudományi Kar Szemészeti Klinika Budapest Mária u. 39. 1085
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Babu K. Sarcoidosis in tuberculosis-endemic regions: India. J Ophthalmic Inflamm Infect 2013; 3:53. [PMID: 23803558 PMCID: PMC3698001 DOI: 10.1186/1869-5760-3-53] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/19/2013] [Indexed: 11/15/2022] Open
Abstract
Sarcoidosis is a multisystem inflammatory disease of unknown etiology affecting multiple organs. Earlier reports suggested that sarcoidosis was a disease of the developed world. However, recent reports suggest that the disease is found in the developing countries as well. Clinical, radiological, and histopathological similarities with tuberculosis pose a great challenge in countries endemic for tuberculosis. Mantoux test, high resolution computed tomography, and transbronchial lymph node and lung biopsies are diagnostic modalities, which play an important role in the diagnosis of sarcoid. In this review, we look at the epidemiology of sarcoid in tuberculosis-endemic regions, the sarcoidosis-tuberculosis link, clinical profile, diagnostic modalities, dilemma in the diagnosis, and the treatment of this disease.
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Affiliation(s)
- Kalpana Babu
- Vittala International Institute of Ophthalmology, Hosakerehalli, Bangalore, Karnataka, 560085, India.
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Beegle SH, Barba K, Gobunsuy R, Judson MA. Current and emerging pharmacological treatments for sarcoidosis: a review. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:325-38. [PMID: 23596348 PMCID: PMC3627473 DOI: 10.2147/dddt.s31064] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The treatment of sarcoidosis is not standardized. Because sarcoidosis may never cause significant symptoms or organ dysfunction, treatment is not mandatory. When treatment is indicated, oral corticosteroids are usually recommended because they are highly likely to be effective in a relative short period of time. However, because sarcoidosis is often a chronic condition, long-term treatment with corticosteroids may cause significant toxicity. Therefore, corticosteroid sparing agents are often indicated in patients requiring chronic therapy. This review outlines the indications for treatment, corticosteroid treatment, and corticosteroid sparing treatments for sarcoidosis.
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Affiliation(s)
- Scott H Beegle
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA
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Abstract
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.
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Brill AK, Ott SR, Geiser T. Effect and Safety of Mycophenolate Mofetil in Chronic Pulmonary Sarcoidosis: A Retrospective Study. Respiration 2012; 86:376-83. [DOI: 10.1159/000345596] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 10/25/2012] [Indexed: 11/19/2022] Open
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Sarcoidosis: a comprehensive review and update for the dermatologist: part I. Cutaneous disease. J Am Acad Dermatol 2012; 66:699.e1-18; quiz 717-8. [PMID: 22507585 DOI: 10.1016/j.jaad.2011.11.965] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 11/14/2011] [Accepted: 11/17/2011] [Indexed: 11/23/2022]
Abstract
Sarcoidosis is a common systemic, noncaseating granulomatous disease of unknown etiology. The development of sarcoidosis has been associated with a number of environmental factors and genes. Cutaneous sarcoidosis, the "great imitator," can baffle clinicians because of its diverse manifestations and its ability to resemble both common and rare cutaneous diseases. Depending on the type, location, and distribution of the lesions, treatment can prevent functional impairment, symptomatic distress, scarring, and disfigurement. Numerous therapeutic options are available for the treatment of cutaneous sarcoidosis, but there are few well designed trials to guide practitioners on evidence-based, best practice management. In part I, we review the current knowledge and advances in the epidemiology, etiology, pathogenesis, and genetics of sarcoidosis, discuss the heterogeneous manifestations of cutaneous sarcoidosis, and provide a guide for treatment of cutaneous sarcoidosis.
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Abstract
Neuro-ophthalmic disease occurs in about a third of patients with neurosarcoidosis. Optic nerve involvement is the most common manifestation, but other cranial nerves and the optic chiasm can be involved. However, there are several other common diseases that cause optic neuropathy, including multiple sclerosis. The diagnosis of sarcoidosis can often be made based on the multi-organ nature of the disease and ancillary testing. Most patients with neuro-ophthalmic sarcoidosis require systemic therapy. While corticosteroids are usually the first step in therapy, cytotoxic agents such as methotrexate and azathioprine have been useful as steroid-sparing agents for chronic disease. The monoclonal antibodies directed against tumor necrosis factor have been reported as effective in refractory cases of neuro-ophthalmic disease.
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Affiliation(s)
| | | | - Karl C Golnik
- Department of Ophthalmology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Kolomeyer AM, Ragam A, Shah K, Jachens AW, Tu Y, Chu DS. Mycophenolate Mofetil in the Treatment of Chronic Non-infectious, Non-necrotizing Scleritis. Ocul Immunol Inflamm 2012; 20:113-8. [DOI: 10.3109/09273948.2012.655398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Turkcuoglu P, Chang PY, Rentiya ZS, Channa R, Ibrahim M, Hatef E, Sophie R, Sadaka A, Wang J, Sepah YJ, Do DV, Foster CS, Nguyen QD. Mycophenolate mofetil and fundus autofluorescence in the management of recurrent punctate inner choroidopathy. Ocul Immunol Inflamm 2011; 19:286-92. [PMID: 21770809 DOI: 10.3109/09273948.2011.580072] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To compare the frequencies of attacks before and after immunomodulatory therapy (IMT) with mycophenolate mofetil (MMF) in recurrent punctate inner choroidopathy (PIC) and to report fundus autofluorescence (FAF) findings. METHODS Eight patients who had at least two recurrent episodes of increased activity before MMF and 12 months of documented clinical course before and after MMF were included. The frequencies of attacks before and after MMF were compared. FAF images evaluated. RESULTS Before MMF, the 8 patients experienced 19 attacks of recurrent disease activity; during MMF therapy, 3 (38%) patients experienced 6 recurrent episodes. The attack frequencies were 1.09 ± 0.75 before and 0.23 ± 0.32 during treatment (p = .036). Among the 6 patients who had FAF, surrounding hyperautofluorescent halo was detected in 4 and recurrence occurred in 2 who did not show any changes on the intensity during treatment. CONCLUSION In the index study, the employment of MMF has decreased frequency of attacks in recurrent PIC. FAF may be employed to monitor and predict the response to treatment.
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Affiliation(s)
- Peykan Turkcuoglu
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Hegde S, Annamalai R, Biswas J. Extensive herpes zoster involvement following mycophenolate mofetil therapy for sarcoidosis. J Ophthalmic Inflamm Infect 2011; 2:47-8. [PMID: 21947930 PMCID: PMC3302999 DOI: 10.1007/s12348-011-0041-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 09/13/2011] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sandhya Hegde
- Medical Research Foundation, Sankara Nethralaya, Chennai, India
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Abstract
PURPOSE To compare the evidence base and systemic treatment strategies for sarcoidosis. METHODS Medline and EMBASE literature search on "sarcoidosis AND treatment", "sarcoidosis AND uveitis AND treatment", and "sarcoidosis AND eye AND treatment". The search was limited to randomized controlled trials (RCTs) and meta-analyses. RESULTS A total of 19 RCTs for the systemic treatment of extraocular sarcoidosis were identified. The majority were on corticosteroid-oral and inhaled. There were two meta-analyses on corticosteroid, including a Cochrane review. Only two RCTs were indentified for the treatment of intraocular sarcoidosis, one on etanercept, and the other from 1967 on prednisolone or oxyphenbutazone vs. placebo. There were no meta-analyses. Due to the paucity of RCTs other treatment studies were included but these were limited to only a few immunosuppressive agents and on small numbers of patients. CONCLUSION Limited high-quality evidence exists for the systemic treatment of sarcoidosis, in particular intraocular disease.
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Long-term results of therapy with mycophenolate mofetil in chronic non-infectious uveitis. Graefes Arch Clin Exp Ophthalmol 2011; 249:1235-43. [PMID: 21720813 DOI: 10.1007/s00417-011-1731-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/21/2011] [Accepted: 04/22/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Short-term studies have shown mycophenolate mofetil (MMF) to be a useful immunosuppressive agent for the treatment of intraocular inflammation. The aim of our study was to assess the long-term efficacy and tolerability of MMF in patients with chronic non-infectious uveitis, as well as to analyze disease course following discontinuation of therapy. METHODS This is a retrospective case series on 60 uveitis patients treated with MMF with a follow-up period of at least 5 years. The main outcome measures were: control of inflammation, corticosteroid-sparing potential, side-effects, ability to stop/taper MMF treatment because of effective control of inflammation and relapse rate after therapy discontinuation. RESULTS Control of intraocular inflammation (efficacy of MMF), defined as inactive disease under prednisolone dose of ≤ 10 mg daily, was achieved in 43 of 60 patients (72%) after 1 year of MMF treatment at a rate of 0.72 per patient-year (PY), and in 45 of 55 patients (82%) after 2 years therapy (rate: 0.41/PY). An improvement (3 lines) or stabilization of visual acuity was observed in 49 patients (82%), and a worsening in 11 patients (18%, 95% CI: 10-30%). The probability of discontinuing prednisolone, estimated by the Kaplan-Meier method, was 40% after 5 years therapy. The probability of discontinuing mycophenolate mofetil due to efficacy was 33% after 5 years treatment. Recurrences of uveitis occurred in six of 21 patients (29%, rate: 0.11/PY) after MMF discontinuation due to efficacy. The treatment was stopped because of inefficacy in 12 patients (rate: 0.05/PY) and because of side-effects in four patients (rate: 0.02/PY). The rate of adverse effects during MMF therapy was 0.17/PY. CONCLUSIONS Our data show that mycophenolate mofetil is generally effective and well tolerated in the treatment of chronic non-infectious uveitis.
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Enteric-coated Mycophenolate Sodium as a Corticosteroid-sparing Agent for the Treatment of Autoimmune Scleritis. Cornea 2011; 30:260-4. [DOI: 10.1097/ico.0b013e3181e9af18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Uvéites sarcoïdosiques : actualités diagnostiques et thérapeutiques. Rev Med Interne 2011; 32:86-92. [PMID: 20970226 DOI: 10.1016/j.revmed.2010.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 07/26/2010] [Accepted: 09/20/2010] [Indexed: 12/23/2022]
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Abstract
PURPOSE OF REVIEW Almost 100 years after its original description, sarcoidosis remains an enigmatic disease with unclear etiology and capricious symptomology, as well as a diagnostic challenge. This review coalesces current literature on the neuro-ophthalmic manifestations of sarcoidosis and discusses the epidemiology, etiology, clinical presentation, diagnosis, and management of this disease. RECENT FINDINGS Recent investigations strongly identify a genetic component as well as a host of candidate antigenic triggers. Certain human leukocyte antigen polymorphisms may influence not only the susceptibility of individuals to sarcoidosis but also the course of the disease. Diagnostic advances include the finding of two additional potential biomarkers of sarcoidosis as well as the use of positron emission tomography technology in localization of disease sites for biopsy. In addition to the concomitant and alternative use of immunosuppressive agents to steroid therapy, disease remission in refractory neuro-ophthalmic sarcoidosis with tumor necrosis factor alpha inhibitors has also been reported. SUMMARY Sarcoidosis can affect any part of the visual system; the most common neuro-ophthalmic presentation is optic neuropathy. Diagnosing the disease is problematic as the clinical presentation is nonspecific which may be associated with many other pathologies and no diagnostic finding is pathognomonic. In recent years, progress has been made in identifying new biomarkers and developing imaging techniques. Although corticosteroids remain the mainstay of therapy, many new pharmacological agents have been added to the treatment arsenal.
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Affiliation(s)
- Yanny L Phillips
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, Michigan, USA
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Aouizerate J, Matignon M, Kamar N, Thervet E, Randoux C, Moulin B, Raffray L, Buchler M, Villar E, Mahevas M, Desvaux D, Dahan K, Diet C, Audard V, Lang P, Grimbert P. Renal transplantation in patients with sarcoidosis: a French multicenter study. Clin J Am Soc Nephrol 2010; 5:2101-8. [PMID: 20671220 DOI: 10.2215/cjn.03970510] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Sarcoidosis is a multisystem disorder of unknown etiology. The outcome of renal transplantation on patients with sarcoidosis is not well known. A few case reports have described recurrence of sarcoidosis after transplant. Here, we report for the first time results and outcome of renal transplantation in a series of patients with sarcoidosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Eighteen patients with sarcoidosis who underwent renal transplantation were identified retrospectively in eight French renal transplantation departments. Patient medical charts, demographics, and the outcome of renal transplantation were reviewed. RESULTS Initial renal disease was related to sarcoidosis in 10 patients. At the end of the follow-up (median, 42 months), patient and death-censored graft survival were 94.4% and the mean GFR was 60 ml/min per 1.73 m(2). Five patients (27%) experienced recurrence of sarcoidosis including extra-renal involvement in two patients and renal involvement in three patients. Median GFR was lower in the group of patients with renal recurrence compared with that of the entire cohort: 31 ml/min per 1.73 m(2). Recurrence occurred shortly after transplantation (median period, 13 months). Risk factors for recurrence included primary renal disease related to sarcoidosis and a shorter delay between the last episode of sarcoidosis and renal transplantation. CONCLUSIONS Our results indicate that renal transplantation may be carried out safely in transplant candidates with sarcoidosis. Recurrence is not rare and is likely to affect graft outcome. These results fully justify a specific clinical and histologic monitoring mainly during the early posttransplant period.
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Affiliation(s)
- Jessie Aouizerate
- Nephrology and Transplantation Department, Henri Mondor Hospital, AP-HP, Institut Francilien de Recherche en Néphrologie et Transplantation and Paris XII University, Créteil, France
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