Update on sarcoidosis

Management of Uveitis and Scleritis in Necrobiotic Xanthogranuloma

Necrobiotic xanthogranuloma (NXG) is a chronic, progressive non-Langerhans histiocytic granulomatous disease. While case reports describing periorbital involvement of NXG are frequent, only a few case reports describing ocular involvement, such as scleritis and uveitis, exist. Herein, we present a case presenting initially as bilateral anterior and posterior scleritis, as well as a chronic bilateral granulomatous panuveitis, and discuss the immunosuppressant options that should be considered for this disease with protean manifestations.

PET scanning in sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder that most commonly presents with pulmonary involvement. The diagnosis is suggested on the basis of clinical and radiologic manifestations and is supported by the histological demonstration of noncaseating granulomas in affected tissues. Different imaging modalities, including chest radiography, X-rays, computed tomography, magnetic resonance imaging, and (67) Ga scintigraphy are currently employed to help diagnose and help plan treatment strategy in sarcoidosis patients. Here, we discuss the potential role of positron emission tomography in the diagnosis, assessment of disease activity, and management of patients with sarcoidosis. We also point out some of the limitations of this technique.

Solitary osseous sarcoidosis: a rare reason for pathologic fracture

Sarcoidosis with osseous involvement as the initial manifestation is rare. Due to lack of other organ involvements, the diagnosis is somehow difficult to establish. We report a case with osseous sarcoidosis as the initial and major manifestation that developed spontaneous bone fracture. Our case emphasizes the importance of histological evidence and exclusion of other diseases i.e. rheumatoid arthritis, before making the diagnosis of osseous sarcoidosis.

Musculoskeletal and other extrapulmonary disorders in sarcoidosis

Sarcoidosis is a multisystemic inflammatory disease, still of unknown origin, characterized by epithelioid non-caseating granuloma in all affected organs. Granuloma formation is lead by a Th1-type response. The exact mechanism that leads to either progression or spontaneous resolution of the disease is not known. Familial aggregation, and the variations in presentation and severity of sarcoidosis according to ethnic background, are suggestive of a polygenic origin that is still to be determined. The contribution of environmental factors, as well as their interactions with genetic factors, remains to be demonstrated. The clinical presentation, musculoskeletal and other extrapulmonary disorders, as well as patients work-up, are reviewed. Sarcoidosis is often a benign disease. Corticosteroids, either alone or in association with other drugs, are still the mainstay of treatment. Defining clearly who will need treatment and what treatment to be used in a particular patient remains controversial.

Rheumatologic manifestations of sarcoidosis

PURPOSE OF REVIEW

This review emphasizes the importance of the rheumatological signs and symptoms in the presentation of sarcoidosis. Often the presence of musculoskeletal findings may lead to the diagnosis of the disease and the institution of the appropriate treatment.

RECENT FINDINGS

There have been significant advances in the treatment of sarcoidosis with the use of biologic agents for recalcitrant and severe manifestations of the disease as well as some new data regarding pathogenetics and new applications of diagnostic imaging studies such as positron emission tomography scanning.

SUMMARY

Although pulmonary disease is the most frequent manifestation of sarcoidosis, musculoskeletal symptoms are not only common, but may be the initial presentation of this systemic inflammatory process and could mimic other arthritic and autoimmune disorders. This article focuses on the rheumatological aspects of sarcoidosis and includes a review of the most recent literature, which shows new data on the diagnosis, pathogenesis, and treatment of this condition.

Modulation of autonomic balance by tumors and viruses

Autonomic balance, a function generally under host control, is subject to modulation by other signalers. In some cases, modulation of host autonomic function through behavioral and physical stressors exerted by another individual may have negative consequences for the stress recipient by inducing sympathetic bias. Modulation of autonomic function may sometimes benefit one party at the expense of another. Tumors and HIV are examples of illegitimate signalers who may induce host sympathetic bias to promote their own growth and evade host immune surveillance. Paraneoplastic and paraviral syndromes such as hypertrophic osteoarthopathy, QTc prolongation, insomnia, and cachexia could be viewed as epiphenomena related to the tumoral and viral manipulation of host autonomic balance. In a more general framework, other paraneoplastic and paraviral syndromes may represent epiphenomena related to modulation of endocrine, cytokine, and autonomic functions by tumors and viruses to promote their own survival. Spatial distribution of cancers and viruses within the host may reflect affinity for strategic locations that facilitate manipulation of a variety of host functions including autonomic, endocrine, and cytokine regulation. A more general for understanding spatial distribution of diseases based on gradients of autonomic balance in the body are explored. Darwinian perspectives are discussed.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

No linkage of the interleukin-4 receptor locus on chromosome 16p11.2-12.1 with sarcoidosis in German multiplex families

We typed 241 members of 62 sarcoidosis families with 136 affected siblings for three single nucleotide polymorphisms of the interleukin-4 receptor alpha-chain gene (IL4R). Allele frequencies in patients were compared to those of healthy unrelated control individuals. The segregation of the three-point IL4R haplotypes completed by two flanking highly polymorphic microsatellite polymorphisms revealed no evidence for linkage of the IL4R gene locus with sarcoidosis.

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.

Common variable immunodeficiency treated with a recombinant human IgG, tumour necrosis factor-alpha receptor fusion protein

Common variable immunodeficiency (CVI) is characterized by a failure in B-cell differentiation and impaired immunoglobulin secretion, but with a variable clinical presentation, including the development of sarcoidal granulomas and autoimmune diseases, as well as an increased incidence of malignancies. We present a 21-year-old white man who carried a diagnosis of juvenile rheumatoid arthritis and presented 6 years later with scarring alopecia showing sarcoidal granulomas. Further work confirmed the diagnosis of CVI, and with increasing systemic symptoms, it was elected to treat the patient with a tumour necrosis factor (TNF)-alpha antagonist, a TNF-alpha receptor IgG1 fusion protein. The patient showed improvement in his systemic symptoms and some hair regrowth after 3 months of therapy, and continued improvement in his systemic disease with only mild scalp hair thinning in the areas of prior involvement after almost 1 year of therapy. CVI and sarcoid may have overlapping clinical and immunological findings. Previous therapies for CVI, including intravenous immunoglobulin, have not altered the mortality of the disease. TNF-alpha is a primary cytokine and is elevated in CVI, and specific inhibition of TNF-alpha in this patient was effective in moderating his disease, including his skin disease.

Reverse transcriptase-PCR analysis of bacterial rRNA for detection and characterization of bacterial species in arthritis synovial tissue

Onset of rheumatoid arthritis (RA) is widely believed to be preceded by exposure to some environmental trigger such as bacterial infectious agents. The influence of bacteria on RA disease onset or pathology has to date been controversial, due to inconsistencies between groups in the report of bacterial species isolated from RA disease tissue. Using a modified technique of reverse transcriptase-PCR amplification, we have detected bacterial rRNA in the synovial tissue of late-stage RA and non-RA arthritis controls. This may be suggestive of the presence of live bacteria. Sequencing of cloned complementary rDNA (crDNA) products revealed a number of bacterial sequences in joint tissue from each patient, and from these analyses a comprehensive profile of the organisms present was compiled. This revealed a number of different organisms in each patient, some of which are common to both RA and non-RA controls and are probably opportunistic colonizers of previously diseased tissue and others which are unique species. These latter organisms may be candidates for a specific role in disease pathology and require further investigation to exclude them as causative agents in the complex bacterial millieu. In addition, many of the detected bacterial species have not been identified previously from synovial tissue or fluid from arthritis patients. These may not be easily cultivable, since they were not revealed in previous studies using conventional in vitro bacterial culture methods. In situ hybridization analyses have revealed the joint-associated bacterial rRNA to be both intra- and extracellular. The role of viable bacteria or their nucleic acids as triggers in disease onset or pathology in either RA or non-RA arthritis controls is unclear and requires further investigation.