Therapeutic options for sarcoidosis: new and old

Case Report: Pulmonary and Liver Sarcoidosis Suspected of Metastasis

Introduction: Sarcoidosis is a granulomatous disease with unknown cause that can vary from an asymptomatic condition. Almost half of the patients with sarcoidosis have no symptoms. In this article, we describe a sarcoidosis patient with lung and liver engagement; it may be confused with metastasis.

Case report: A 39-year-old man, with known as hypothyroidism who had come to the emergency ward with dyspnea and coughing after exposure to detergents in a closed environment. The patient smoked for 10 years (3 pack/year). No other findings were found in clinical examinations except for wheezing in the right lung. The patient's chest radiography was shown a mass. For further investigation, spiral CT scan was performed. Large lymph nodes on the right side of the trachea, measuring about 23 mm and a mass of 70 × 77 mm in the vicinity of the right lung hilum and a hypodense nodule in the posterior part of the liver with malignancy suspicious were reported. After several biopsy results was shown chronic granulomatous inflammation, the most important differential diagnosis is tuberculosis (TB) and sarcoidosis. Sputum smear, culture, and PCR were performed for tuberculosis. Also, the level of angiotensin-converting enzyme (ACE) was measured for sarcoidosis. the results ruled out TB and shown a higher level of ACE (ACE = 88 IU/L).After diagnosis treatment started with prednisolone. Now, the patient is in the follow- up.

Conclusion: In hilar lymphadenopathy of lung sarcoidosis is the importance differential diagnosis that should be considered.

A rare comorbidity: neurosarcoidosis and cutaneous sarcoidosis

We present a case of a neurosarcoidosis patient with skin lesions. A 50-year-old woman was admitted with a 1-year history of violaceous, smooth and shiny plaques on her face and right arm. These lesions were biopsied and the histological examination indicated sarcoidosis. The patient had a history of headache and syncope that lasted for about 1 h. Brain CT showed masses measuring 37×20 mm in both frontal lobes. Thoracic and abdominal CT showed many pathologically enlarged lymph nodes. The patient was diagnosed with cutaneous, lung and neuronal sarcoidosis, and treated with 20 mg/day methylprednisolone, 15 mg/week methotrexate, 10 mg/week folic acid, 400 mg/day hydroxychloroquine and 800 mg/day carbamazepine. One month later, the patient's neurological symptoms had improved and her skin lesions had decreased. At 6-month follow-up, the size of the cranial masses had markedly regressed.

Pulmonary sarcoidosis: An important differential diagnosis in transbronchial lung biopsies

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Lungs and lymphatics are the principal sites affected by this disease. The disorder is often not suspected by physicians.

MATERIALS AND METHODS

This was a retrospective study done on 140 transbronchial lung biopsies received for histopathological examination in the Department of Pathology for 1 year in a multispeciality tertiary care hospital, in Delhi.

RESULTS

Out of 140 transbronchial lung biopsies studied, 13 cases of sarcoidosis were diagnosed histopathologically. In these patients a clinical, pathological, and radiological corelation was done. And a final diagnosis of sarcoidosis was given after excluding other granulomatous lesions.

CONCLUSION

Transbronchial lung biopsies have become an important tool in the diagnosis of sarcoidosis in present time. Hence sarcoidosis should be considered as a differential diagnosis when dealing with granulomatous lesions in lung biopsies.

Neuro-ophthalmologic Manifestations of Sarcoidosis

The first-line treatment for the neuro-ophthalmologic manifestations of sarcoidosis is corticosteroid therapy. Prednisone, 0.5 to 1 mg/kg/day, is initially prescribed for 2 to 4 weeks, before a slow taper is begun as the patient's symptoms and examination are monitored. Patients frequently require adjunct therapy, which can be in the form of immunomodulatory drugs such as pentoxyfillin, hydroxychloroquine, or thalidomide, or immunosuppressive drugs such as mycophenolate mofetil, azathioprine, methotrexate, and cyclophosphamide. Individuals with profound visual compromise or progressive disease may benefit from high-dose intravenous methylprednisolone or tumor necrosis factor-alpha antagonists such as infliximab. Attention to the overall medical status of the patient is essential to ensure that an optimal clinical status is achieved.

Tetracyclines: what a rheumatologist needs to know?

Tetracyclines are broad-spectrum antibiotics that act at the ribosomal level. They were first introduced in 1948 and were widely prescribed by dermatologists in the early 1950s for treatment of acne. More recently, biologic actions of tetracyclines affecting inflammation, angiogenesis, and bone metabolism have been researched. The therapeutic effects of tetracycline and its analogues in rheumatic diseases have also been investigated. This article will review the rheumatological use of tetracycline and its analogues.

Sarcoidosis presenting as "corset-like" myelopathy: a description of six cases and literature review

Sarcoidosis of the spinal cord is rare, even more so as the initial presentation of the disease. We describe six cases of spinal cord sarcoidosis and delineate a distinguishing feature which may allow for a timely diagnosis. All patients were admitted with complaints of a "corset-like" pressure in the lower chest and later developed cranial nerve palsies (two patients), parasthesias/paraparesis (two patients), fever of unknown origin (one patient), and bilateral proptosis (one patient). Serological tests, immunological screening, cerebrospinal fluid (CSF) analysis, bacteriological and viral testing were performed in all patients. Spinal and cerebral MRI, high-resolution computed tomography (HRCT) of the chest and gallium scan suggested the diagnosis of neurosarcoidosis of the spine while a biopsy of mediastinal lymph nodes, extra-ocular muscles, or spinal cord confirmed it. CSF showed inflammatory signs in 66% of patients and serum ACE levels were increased in a similar fraction. MRI revealed a gadolinium-enhanced thickening of the cord at the thoracic level in three patients whereas three other patients had normal spinal MRI despite similar symptoms. The presence of mediastinal lymphadenopathy on HRCT of the chest suggested the diagnosis in a third of patients. Patients were treated with steroid, immunosuppressive therapy and/or biologic therapies, with complete resolution in one case, improvement in four, and a somewhat deteriorating course, with development of spinal cord atrophy in the final case. As spinal cord involvement of sarcoidosis is extremely rare, making the diagnosis in the absence of systemic disease is challenging. The cases herein described suggest that sensory disturbance in a "corset-like" distribution may be indicative of neurosarcoidosis, especially when accompanied by extra-axial involvement such as cranial nerve palsies. This should prompt an evaluation for systemic involvement, keeping in mind that serum ACE and chest radiographs may be normal in the presence of primarily CNS-limited disease.

Sarcoidosis: clinical presentation, diagnosis, and approach to treatment

Sarcoidosis is an idiopathic granulomatous disease. It usually affects the lung but may involve any organ. The diagnosis may be problematic because known causes of granulomatous inflammation must be excluded. Sarcoidosis may remit spontaneously or remain stable. Therefore, therapy is not mandated for the disease. This report reviews the clinical presentation, diagnostic approach, and treatment of sarcoidosis.

Solitary pituitary sarcoidosis with normal endocrine function

✓ Sarcoidosis is a multisystemic granulomatous disease characterized by noncaseating epithelioid granulomata that affects the lung in over 90% of patients and the central nervous system (CNS) in 5–9%. Neurosarcoidosis often occurs as multifocal meningeal and parenchymal lesions, and its diagnosis is particularly difficult in the absence of concomitant systemic disease. Hypothalamic-pituitary sarcoidosis occurs in fewer than 10% of patients with neurosarcoidosis and has been previously reported in association with profound endocrinological dysfunction. The authors report the case of a patient with isolated pituitary sarcoidosis who was first evaluated for visual symptoms and showed no preoperative endocrinological dysfunction or evidence of multisystemic or other CNS involvement. To the authors' knowledge, only 1 other such presentation is previously reported in the English literature. Such presentations are diagnostically and therapeutically challenging, and definitive diagnosis requires obtaining a biopsy specimen of the lesion with histological proof of noncaseating epithelioid granuloma, as well as the exclusion of other possible entities.

Sarcoidosis

Sarcoidosis is a multisystemic disorder of unknown cause characterized by the formation of immune granulomas in involved organs. It is an ubiquitous disease with incidence (varying according to age, sex, race and geographic origin) estimated at around 16.5/100,000 in men and 19/100,000 in women. The lung and the lymphatic system are predominantly affected but virtually every organ may be involved. Other severe manifestations result from cardiac, neurological, ocular, kidney or laryngeal localizations. In most cases, sarcoidosis is revealed by persistent dry cough, eye or skin manifestations, peripheral lymph nodes, fatigue, weight loss, fever or night sweats, and erythema nodosum. Abnormal metabolism of vitamin D3 within granulomatous lesions and hypercalcemia are possible. Chest radiography is abnormal in about 90% of cases and shows lymphadenopathy and/or pulmonary infiltrates (without or with fibrosis), defining sarcoidosis stages from I to IV. The etiology remains unknown but the prevailing hypothesis is that various unidentified, likely poorly degradable antigens of either infectious or environmental origin could trigger an exaggerated immune reaction in genetically susceptible hosts. Diagnosis relies on compatible clinical and radiographic manifestations, evidence of non-caseating granulomas obtained by biopsy through tracheobronchial endoscopy or at other sites, and exclusion of all other granulomatous diseases. The evolution and severity of sarcoidosis are highly variable. Mortality is estimated at between 0.5–5%. In most benign cases (spontaneous resolution within 24–36 months), no treatment is required but a regular follow-up until recovery is necessary. In more serious cases, a medical treatment has to be prescribed either initially or at some point during follow-up according to clinical manifestations and their evolution. Systemic corticosteroids are the mainstay of treatment of sarcoidosis. The minimal duration of treatment is 12 months. Some patients experience repeated relapses and may require long-term low-dose corticosteroid therapy during years. Other treatments (immunosuppressive drugs and aminoquinolins) may be useful in case of unsatisfactory response to corticosteroids, poor tolerance and as sparing agents when high doses of corticosteroids are needed for a long time. In some strictly selected cases refractory to standard therapy, specific antiTNF-α agents may offer precious improvement. Some patients benefit from topical corticosteroids.

Neurosarcoidosis presenting as a cerebellar mass

CASE REPORT

A 74-year-old farmer presented with worsening headaches, gait unsteadiness, and writing difficulties. On examination, he had a tendency to fall to the right and right-sided dysmetria and dysdiadochokinesis. Magnetic resonance imaging initially showed abnormalities in the right cerebellar hemisphere, suggestive of subacute infarct or infiltrating malignancy. Suboccipital craniotomy and biopsy revealed noncaseating granulomas suggestive of sarcoidosis. He was initially treated with steroids and later switched to Infliximab. On follow-up 5 months later, symptoms and imaging had improved.

DISCUSSION

Sarcoidosis affects the central nervous system in about 5% of patients. It usually manifests with cranial nerve palsies. It may rarely mimic a tumor as in this patient. Despite the dearth of controlled studies addressing neurosarcoidosis treatment, excellent responses to corticosteroids have been documented. Infliximab has been used as a steroid-sparing agent in neurosarcoidosis. We present this case of neurosarcoidosis presenting as a cerebellar mass to increase awareness of this condition.

Neurosarcoïdose : état des connaissances

The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.

Sarcoidosis in chronic granulomatous disease

In addition to increased susceptibility to infections in patients with chronic granulomatous disease (CGD), a higher incidence of sterile inflammatory disorders in these patients has been noted. However, sarcoidosis has not been reported previously in CGD. In this report, we describe two patients who have CGD and a disorder consistent with sarcoidosis on the basis of unequivocal clinical-radiographic presentations, their responses to treatment, and serum angiotensin-converting enzyme levels. Serum angiotensin-converting enzyme levels were measured in 26 other patients with CGD to establish an appropriate reference range. A possible relationship between CGD and sarcoidosis is discussed.

Pulmonary sarcoidosis

Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.

Corticosteroids for pulmonary sarcoidosis

BACKGROUND

Pulmonary sarcoidosis is a common condition with an unpredictable course. Oral (OCS) or inhaled steroids (ICS) are widely used in its treatment, but there is no consensus about when and in whom therapy should be initiated, what dose should be given and for how long. Corticosteroids given for several months have deleterious side-effects so it is important to know whether they have any maintained benefit in pulmonary sarcoidosis.

OBJECTIVES

To determine the randomised controlled trial (RCT) evidence for the benefit of corticosteroids (oral or inhaled) in the treatment of pulmonary sarcoidosis.

SEARCH STRATEGY

MEDLINE, EMBASE and CENTRAL were searched using predefined terms. Bibliographies of retrieved RCTs and reviews were searched for additional RCTs. Pharmaceutical companies and authors of identified RCTs were contacted for other published and unpublished studies. Searches are current as of May 2004.

SELECTION CRITERIA

Two reviewers independently assessed full text articles for inclusion based upon the following criteria: the study had to be a RCT or controlled clinical trial in adults with histological evidence of pulmonary sarcoidosis, treated with OCS (oral steroids) or ICS (oral steroids), compared with a control.

DATA COLLECTION AND ANALYSIS

Study quality was assessed and data extracted independently by two reviewers. The primary outcome was CXR (chest x-ray). Outcomes were analysed as continuous and dichotomous outcomes, using standard statistical techniques. Heterogeneity was explored where it was identified.

MAIN RESULTS

Twelve RCTs of variable quality involving 1051 participants met the inclusion criteria of the review. The oral steroid dose was equivalent to prednisolone 4-40 mg/day. OCS: there was an improvement in CXR over 3-24 months (Relative Risk (RR): 1.46 [1.01 to 2.09], 3 studies), but this finding requires cautious interpretation. No other significant differences were identified on secondary outcomes. ICS: Data were inadequate to perform meaningful analysis of data on CXR. Two studies showed no improvement in lung function, In one study there was an improvement in diffusing capacity in the treated group. There were no data on side-effects. In one study symptoms improved at the end of six months of treatment.

AUTHORS' CONCLUSIONS

Oral steroids improved the chest X-ray and a global score of CXR, symptoms and spirometry over 3-24 months. However, there is little evidence of an improvement in lung function. There are limited data beyond two years to indicate whether oral steroids have any modifying effect on long-term disease progression. Oral steroids may be of benefit for patients with Stage 2 and 3 disease with moderate to severe or progressive symptoms or CXR changes.

Neurosarcoidosis: a clinical dilemma

Sarcoidosis is an inflammatory multisystem disorder of unknown cause. Practically no organ is immune to sarcoidosis; most commonly, in up to 90% of patients, it affects the lungs. The nervous system is involved in 5-15% of patients. Neurosarcoidosis is a serious and commonly devastating complication of sarcoidosis. Clinical diagnosis of neurosarcoidosis depends on the finding of neurological disease in multisystem sarcoidosis. As the disease can present in many different ways without biopsy evidence, solitary nervous-system sarcoidosis is difficult to diagnose. Corticosteroids are the drug of first choice. In addition, several cytotoxic drugs, including methotrexate, have been used to treat sarcoidosis. The value of new drugs such as anti-tumour necrosis factor alpha will be assessed. In this review we describe the clinical manifestations of neurosarcoidosis, diagnostic dilemmas and considerations, and therapy.

Neurological complications of sarcoidosis

PURPOSE OF REVIEW

The neurological manifestations of sarcoidosis, which occur in 5% of patients with the condition, present in a variety of ways that can be assigned to several broad categories. A comprehensive approach to the diagnosis and management of neurosarcoidosis involves an appreciation of the strategies to confirm a diagnosis of sarcoidosis and neurosarcoidosis and the available therapeutic options.

RECENT FINDINGS

In addition to traditional approaches to the diagnosis of sarcoidosis, positron emission tomography can be used to identify otherwise occult sites of systemic inflammation which can be targeted for biopsy. Although corticosteroids remain the mainstay of treatment, other immunosuppressive and immunomodulatory agents can be used in the multi-modality therapy of sarcoidosis.

SUMMARY

Neurosarcoidosis can be 'staged' with the use of neurodiagnostic testing and diagnosed with varying degrees of certainty. Treatment should be approached within the context of the anticipated clinical course of the patient, avoidance of adverse drug effects, and, as necessary, from the perspective of the comprehensive management of a chronic disease.

Intramedullary neurosarcoidosis in the medulla oblongata: a case report

OBJECTIVE

We present a rare case of neurosarcoidosis mimicking an intramedullary tumor in the medulla oblongata. The features of the clinical presentation, magnetic resonance (MRI) appearances, and management strategy are discussed.

CASE PRESENTATION

A 59-year-old man without evidence of systemic sarcoidosis was presented with a history of progressive numbness and deep sensation disturbance in bilateral lower extremities. MR imaging revealed an enhanced intra-axial mass lesion on the dorsal side of medulla. Under neurophysiological monitoring, tumor biopsy was performed. Pathologic evaluation revealed noncaseating granuloma composed of large epithelioid cells with multinucleated giant cells, suggesting sarcoidosis. Findings of comprehensive hematologic laboratory studies; cerebrospinal fluid examination; and examinations for bacteria, fungi, and acid fast bacilli were all negative. This mass lesion was diagnosed as medullary neurosarcoidosis, and then high-dose steroid therapy was tried. On follow-up, nearly complete resolution of the neurosarcoidosis on MRI was revealed.

CONCLUSION

To our knowledge, this is the first reported case of neurosarcoidosis manifested in the medulla oblongata. A biopsy is sufficient for a diagnosis and high-dose steroid is recommended.

Sarcoidosis: benefits of a multidisciplinary approach

It is well established that sarcoidosis is a multisystem disorder of unknown cause(s). Practically no organ is immune to sarcoidosis. It subsides in most cases, but it may worsen and become chronic in others. Pulmonary problems may persist, but also devastating extrapulmonary complications may become apparent. Appropriate management of sarcoidosis is mandatory as it predominantly affects fairly young adults. This requires the attention of pulmonologists as well as specialists from other medical disciplines. Accordingly, when treating sarcoidosis patients, a multidisciplinary approach is recommended that focuses attention on somatic as well as psychosocial aspects of this erratic disorder. Specialists from all participating medical disciplines-including respiratory diseases-may benefit from a multidisciplinary approach and be stimulated to enhance their professional interest and knowledge of sarcoidosis. The benefit of such an approach should be explored in the near future.