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Guliyeva V, Demirkan FG, Yiğit RE, Esen E, Bayındır Y, Torun R, Kılbas G, Gezgin Yıldırım D, Otar Yener G, Cakan M, Demir F, Özturk K, Baglan E, Yuksel S, Bakkaloglu SA, Bora Makay B, Paç Kısaarslan A, Oray M, Bilginer Y, Eker Ömeroğlu R, Ozen S, Sozeri B, Aktay Ayaz N. A clinical overview of paediatric sarcoidosis: Multicentre experience from Turkey. Mod Rheumatol 2024; 34:639-645. [PMID: 37243724 DOI: 10.1093/mr/road050] [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: 04/03/2023] [Revised: 04/29/2023] [Accepted: 05/25/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES We aimed to outline the demographic data, clinical spectrum, and treatment approach of sarcoidosis in a large group of patients and sought to figure out the variations of early-onset (EOS) and late-onset paediatric sarcoidosis (LOS). METHODS The study followed a retrospective-descriptive design, with the analysis of medical records of cases diagnosed as paediatric sarcoidosis. RESULTS Fifty-two patients were included in the study. The median age at disease onset and follow-up duration were 83 (28.2-119) and 24 (6-48) months, respectively. Ten (19.2%) cases had EOS (before 5th birthday) and 42 (80.7%) cases had LOS. The most common clinical findings at the time of the disease onset were ocular symptoms (40.4%) followed by joint manifestation (25%), dermatological symptoms (13.5%), and features related to multi-organ involvement (11.5%). Anterior uveitis was the most common (55%) one among ocular manifestations. Patients with EOS displayed joint, eye, and dermatological findings more commonly than patients with LOS. The recurrence rate of disease in patients with EOS (5.7%) and LOS (21.1%) were not statistically different (P = .7). CONCLUSIONS Patients with EOS and LOS may present with variable clinical features and studies addressing paediatric sarcoidosis cases in collaboration between disciplines will enhance the awareness of this rare disease among physicians and assist early diagnosis with lesser complications.
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Affiliation(s)
- Vafa Guliyeva
- Department of Pediatric Rheumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Türkiye
| | - Fatma Gul Demirkan
- Department of Pediatric Rheumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Türkiye
| | - Ramazan Emre Yiğit
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Türkiye
| | - Esra Esen
- Department of Pediatric Rheumatology, Erciyes School of Medicine, Erciyes University, Kayseri, Türkiye
| | - Yagmur Bayındır
- Division of Pediatric Rheumatology, Hacettepe School of Medicine, Hacettepe University, Ankara, Türkiye
| | - Ruya Torun
- Division of Pediatric Rheumatology, Dokuz Eylül Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
| | - Gulsah Kılbas
- Department of Pediatric Rheumatology, Pamukkale Faculty of Medicine, Pamukkale University, Denizli, Türkiye
| | - Deniz Gezgin Yıldırım
- Department of Pediatric Rheumatology, Gazi Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Gulcin Otar Yener
- Department of Pediatric Rheumatology, Sanliurfa Training and Research Hospital, Sanliurfa, Türkiye
| | - Mustafa Cakan
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Türkiye
| | - Ferhat Demir
- Department of Pediatric Rheumatology, Acibadem Hospital, Istanbul,Türkiye
| | - Kübra Özturk
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, Türkiye
| | - Esra Baglan
- Department of Pediatric Rheumatology, University of Health Sciences, Dr. Sami Ulus Maternity and Child Health and Diseases Research and Training Hospital, Ankara, Türkiye
| | - Selcuk Yuksel
- Department of Pediatric Rheumatology, Pamukkale Faculty of Medicine, Pamukkale University, Denizli, Türkiye
| | - Sevcan A Bakkaloglu
- Department of Pediatric Rheumatology, Gazi Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Balahan Bora Makay
- Division of Pediatric Rheumatology, Dokuz Eylül Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
| | - Ayşenur Paç Kısaarslan
- Department of Pediatric Rheumatology, Erciyes School of Medicine, Erciyes University, Kayseri, Türkiye
| | - Merih Oray
- Department of Ophthalmology, Istanbul School of Medicine, Istanbul University, Istanbul, Türkiye
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Hacettepe School of Medicine, Hacettepe University, Ankara, Türkiye
| | - Rukiye Eker Ömeroğlu
- Department of Pediatric Rheumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Türkiye
| | - Seza Ozen
- Division of Pediatric Rheumatology, Hacettepe School of Medicine, Hacettepe University, Ankara, Türkiye
| | - Betul Sozeri
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Türkiye
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Türkiye
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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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Gerke AK. Treatment of Granulomatous Inflammation in Pulmonary Sarcoidosis. J Clin Med 2024; 13:738. [PMID: 38337432 PMCID: PMC10856377 DOI: 10.3390/jcm13030738] [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: 01/01/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
The management of pulmonary sarcoidosis is a complex interplay of disease characteristics, the impact of medications, and patient preferences. Foremost, it is important to weigh the risk of anti-granulomatous treatment with the benefits of lung preservation and improvement in quality of life. Because of its high spontaneous resolution rate, pulmonary sarcoidosis should only be treated in cases of significant symptoms due to granulomatous inflammation, lung function decline, or substantial inflammation on imaging that can lead to irreversible fibrosis. The longstanding basis of treatment has historically been corticosteroid therapy for the control of granulomatous inflammation. However, several corticosteroid-sparing options have increasing evidence for use in refractory disease, inability to taper steroids to an acceptable dose, or in those with toxicity to corticosteroids. Treatment of sarcoidosis should be individualized for each patient due to the heterogeneity of the clinical course, comorbid conditions, response to therapy, and tolerance of medication side effects.
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Affiliation(s)
- Alicia K Gerke
- Pulmonary and Critical Care Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
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4
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Belperio JA, Fishbein MC, Abtin F, Channick J, Balasubramanian SA, Lynch Iii JP. Pulmonary sarcoidosis: A comprehensive review: Past to present. J Autoimmun 2023:103107. [PMID: 37865579 DOI: 10.1016/j.jaut.2023.103107] [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: 05/19/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/23/2023]
Abstract
Sarcoidosis is a sterile non-necrotizing granulomatous disease without known causes that can involve multiple organs with a predilection for the lung and thoracic lymph nodes. Worldwide it is estimated to affect 2-160/100,000 people and has a mortality rate over 5 years of approximately 7%. For sarcoidosis patients, the cause of death is due to sarcoid in 60% of the cases, of which up to 80% are from advanced cardiopulmonary failure (pulmonary hypertension and respiratory microbial infections) in all races except in Japan were greater than 70% of the sarcoidosis deaths are due to cardiac sarcoidosis. Scadding stages for pulmonary sarcoidosis associates with clinical outcomes. Stages I and II have radiographic remission in approximately 30%-80% of cases. Stage III only has a 10%-40% chance of resolution, while stage IV has no change of resolution. Up to 40% of pulmonary sarcoidosis patients progress to stage IV disease with lung parenchyma fibroplasia, bronchiectasis with hilar retraction and fibrocystic disease. These patients are at highest risk for the development of precapillary pulmonary hypertension, which may occur in up to 70% of these patients. Sarcoid patients with pre-capillary pulmonary hypertension can respond to targeted pulmonary arterial hypertension medications. Stage IV fibrocytic sarcoidosis with significant pulmonary physiologic impairment, >20% fibrosis on HRCT or pre-capillary pulmonary hypertension have the highest risk of mortality, which can be >40% at 5-years. First line treatment for patients who are symptomatic (cough and dyspnea) with parenchymal infiltrates and abnormal pulmonary function testing (PFT) is oral glucocorticoids, such as prednisone with a typical starting dose of 20-40 mg daily for 2 weeks to 2 months. Prednisone can be tapered over 6-18 months if symptoms, spirometry, PFTs, and radiographs improve. Prolonged prednisone may be required to stabilize disease. Patients requiring prolonged prednisone ≥10 mg/day or those with adverse effects due to glucocorticoids may be prescribed second and third line treatements. Second and third line treatments include immunosuppressive agents (e.g., methotrexate and azathioprine) and anti-tumor necrosis factor (TNF) medication; respectively. Effective treatments for advanced fibrocystic pulmonary disease are being explored. Despite different treatments, relapse rates range from 13% to 75% depending on the stage of sarcoid, number of organs involved, socioeconomic status, and geography. CONCLUSION: The mortality rate for sarcoidosis over a 5 year follow up is approximately 7%. Unfortunately, 10%-40% of patients with sarcoidosis develop progressive pulmonary disease, and >60% of deaths resulting from sarcoidosis are due to advance cardiopulmonary disease. Oral glucocorticoids are the first line treatment, while methotrexate and azathioprine are considered second and anti-TNF agents are third line treatments that are used solely or as glucocorticoid sparing agents for symptomatic extrapulmonary or pulmonary sarcoidosis with infiltrates on chest radiographs and abnormal PFT. Relapse rates have ranged from 13% to 75% depending on the population studied.
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Affiliation(s)
- John A Belperio
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fereidoun Abtin
- Department of Thoracic Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jessica Channick
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shailesh A Balasubramanian
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph P Lynch Iii
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Moor CC, Obi ON, Kahlmann V, Buschulte K, Wijsenbeek MS. Quality of life in sarcoidosis. J Autoimmun 2023:103123. [PMID: 37813805 DOI: 10.1016/j.jaut.2023.103123] [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: 06/06/2023] [Accepted: 10/04/2023] [Indexed: 10/11/2023]
Abstract
Having sarcoidosis often has a major impact on quality of life of patients and their families. Improving quality of life is prioritized as most important treatment aim by many patients with sarcoidosis, but current evidence and treatment options are limited. In this narrative review, we describe the impact of sarcoidosis on various aspects of daily life, evaluate determinants of health-related quality of life (HRQoL), and provide an overview of the different patient-reported outcome measures to assess HRQoL in sarcoidosis. Moreover, we review the current evidence for pharmacological and non-pharmacological interventions to improve quality of life for people with sarcoidosis.
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Affiliation(s)
- Catharina C Moor
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ogugua Ndili Obi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Vivienne Kahlmann
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Katharina Buschulte
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
| | - Marlies S Wijsenbeek
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands.
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6
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Arps K, Doss J, Geiger K, Flores-Rosario K, DeVore AD, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis. Am J Cardiol 2023; 204:249-256. [PMID: 37556894 DOI: 10.1016/j.amjcard.2023.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023]
Abstract
Cardiac sarcoidosis (CS) is a relapsing-remitting disease, and immune suppression (IS) is the mainstay of therapy. Predictors of relapse for patients with CS in remission are not well characterized. We assessed incidence of relapse in consecutive patients with CS treated with high-dose steroids and/or steroid-sparing agents (SSA) in our center from 2000 to 2020. Remission was defined as reaching maintenance therapy (no IS, SSA, and/or prednisone ≤5 mg/d) for ≥1 month. Relapse was defined as recurrence of CS syndrome requiring IS intensification: heart failure, ventricular arrhythmia, decrease in left ventricular ejection fraction, or increased disease burden on imaging. Among 68 patients, the mean age was 50.7±9.0 years; 25 (37%) were women, and 32 (47%) were Black. In total, 59 patients (87%) reached remission. Over a median follow-up of 39.5 months (interquartile range 17.6, 92.5), 28 (48%) relapsed. Greater percentage of late gadolinium enhancement (LGE) on pretreatment magnetic resonance imaging corresponded with increased likelihood of relapse (odds ratio 1.396 per 5% increase [95% confidence interval (CI) 1.04 to 1.88]; p = 0.028). LGE ≥11% predicted elevated risk of relapse (adjusted odds ratio 4.998 [1.34 to 18.64]; p = 0.017). Shorter time to relapse was observed with isolated CS (adjusted hazard ratio 4.084 [1.44,11.56]; p = 0.008) and LGE ≥11% (adjusted hazard ratio 3.007 [1.01, 8.98]; p = 0.049). Approximately 1 in 2 patients with CS in remission experienced relapse. Greater burden of LGE on cardiac magnetic resonance imaging and isolated CS are associated with greater risk of relapse. Future work is needed to refine risk stratification for relapse and to optimize surveillance strategies on the basis of the burden of disease.
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Affiliation(s)
- Kelly Arps
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
| | - Kelly Geiger
- Duke University Medical Center, Durham, North Carolina
| | | | - Adam D DeVore
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Ravi Karra
- Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sean D Pokorney
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Albert Y Sun
- Duke University Medical Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina
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7
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Patel R, Mistry AM, Mulukutla V, Prajapati K. Cardiac Sarcoidosis: A Literature Review of Current Recommendations on Diagnosis and Management. Cureus 2023; 15:e41451. [PMID: 37546036 PMCID: PMC10404059 DOI: 10.7759/cureus.41451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Cardiac sarcoidosis (CS) is a rare multisystem disorder characterized by granulomatous infiltration of the myocardium, which can lead to significant morbidity and mortality. Its clinical manifestations range from asymptomatic conduction abnormalities to severe heart failure (HF) and sudden cardiac death. This comprehensive review aims to provide an overview of the diagnosis, clinical features, and current medical management strategies for CS. Additionally, the role of implantable cardioverter-defibrillators (ICDs) and the potential use of positron emission tomography in guiding management decisions are explored. A comprehensive understanding of the medical management of CS is essential for improving patient outcomes and guiding future research endeavors.
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Affiliation(s)
- Rutul Patel
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Anuja Mahesh Mistry
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | | | - Krupal Prajapati
- Internal Medicine, Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
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8
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Plichta J, Kuna P, Panek M. Biologic drugs in the treatment of chronic inflammatory pulmonary diseases: recent developments and future perspectives. Front Immunol 2023; 14:1207641. [PMID: 37334374 PMCID: PMC10272527 DOI: 10.3389/fimmu.2023.1207641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
Chronic inflammatory diseases of the lung are some of the leading causes of mortality and significant morbidity worldwide. Despite the tremendous burden these conditions put on global healthcare, treatment options for most of these diseases remain scarce. Inhaled corticosteroids and beta-adrenergic agonists, while effective for symptom control and widely available, are linked to severe and progressive side effects, affecting long-term patient compliance. Biologic drugs, in particular peptide inhibitors and monoclonal antibodies show promise as therapeutics for chronic pulmonary diseases. Peptide inhibitor-based treatments have already been proposed for a range of diseases, including infectious disease, cancers and even Alzheimer disease, while monoclonal antibodies have already been implemented as therapeutics for a range of conditions. Several biologic agents are currently being developed for the treatment of asthma, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis and pulmonary sarcoidosis. This article is a review of the biologics already employed in the treatment of chronic inflammatory pulmonary diseases and recent progress in the development of the most promising of those treatments, with particular focus on randomised clinical trial outcomes.
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9
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Chen AYC, Halani S, Shah R. Dyspnoea in a patient with biopsy-proven pulmonary sarcoidosis: the challenges in diagnosing cardiac sarcoidosis. BMJ Case Rep 2023; 16:e252737. [PMID: 37217232 PMCID: PMC10230939 DOI: 10.1136/bcr-2022-252737] [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: 05/24/2023] Open
Abstract
A man in his 60s with biopsy-proven pulmonary sarcoidosis, not on treatment, presented with 6 weeks of dyspnea to the emergency department. ECG showed first-degree atrioventricular block and CT thorax demonstrated progressive pulmonary sarcoidosis with new multifocal consolidation. Antibiotics were initiated.A brain natriuretic peptide was elevated at 2024 ng/L and echocardiogram showed global left ventricular systolic dysfunction. Coronary angiogram revealed normal coronary arteries, and cardiac positron emission tomography and MRI demonstrated patterns compatible with cardiac sarcoidosis. The patient significantly improved with diuresis; he was started on prednisone, methotrexate and standard heart failure therapies.We outline the difficulties of attributing cardiac causes of dyspnoea in a patient with known pulmonary sarcoidosis given the rarity of cardiac involvement. We review proposed diagnostic criteria for cardiac sarcoidosis using enhanced imaging techniques without requiring invasive myocardial biopsy. This case discussion also highlights nuances in managing cardiac sarcoidosis based on the best available evidence and expert consensus.
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Affiliation(s)
| | - Sheliza Halani
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rupal Shah
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- General Internal Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
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10
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Shah HH, Zehra SA, Shahrukh A, Waseem R, Hussain T, Hussain MS, Batool F, Jaffer M. Cardiac sarcoidosis: a comprehensive review of risk factors, pathogenesis, diagnosis, clinical manifestations, and treatment strategies. Front Cardiovasc Med 2023; 10:1156474. [PMID: 37273881 PMCID: PMC10235776 DOI: 10.3389/fcvm.2023.1156474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/21/2023] [Indexed: 06/06/2023] Open
Abstract
Cardiac Sarcoidosis (CS) is a deadly consequence of systemic sarcoidosis that inflames all three layers of the heart, especially the myocardium-clinical signs of CS range from asymptomatic disease to abrupt cardiac death. CS generally remains undiagnosed secondary to a lack of definitive diagnostic criteria, a high percentage of false negative results on endomyocardial biopsy, and ill-defining clinical manifestations of the disease. Consequently, there is a lack of evidence-based recommendations for CS, and the present diagnostic and therapeutic management depend on expert opinion. The aetiology, risk factors, clinical symptoms, diagnosis, and therapy of CS will be covered in this review. A particular emphasis will be placed on enhanced cardiovascular imaging and early identification of CS. We review the emerging evidence regarding the use of Electrocardiograms (ECGs), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) imaging of the heart to identify and quantify the extent of myocardial inflammation, as well as to guide the use of immunotherapy and other treatment regimens, such as ablation therapy, device therapy, and heart transplantation, to improve patient outcomes.
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11
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Kaneta K, Takahama H, Tateishi E, Irie Y, Moriuchi K, Amano M, Okada A, Amaki M, Kiso K, Kanzaki H, Kusano K, Yasuda S, Izumi C. Clinical Outcomes of Radiologic Relapse in Patients With Cardiac Sarcoidosis Under Immunosuppressive Therapies. Am J Cardiol 2023; 188:24-29. [PMID: 36462271 DOI: 10.1016/j.amjcard.2022.10.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/12/2022] [Accepted: 10/24/2022] [Indexed: 12/02/2022]
Abstract
Although nuclear imaging can detect cardiac involvement of cardiac sarcoidosis (CS), including subclinical states, little is known about the prevalence and outcomes of radiologic relapse under prednisolone (PSL) therapy. This study aimed to investigate the clinical characteristics and outcomes in patients with radiologic relapse. A total of 80 consecutive patients with CS whose disease activity on nuclear imaging decreased at least once after initiation of immunosuppressive therapy were identified through a retrospective chart review. Radiologic relapse of CS was diagnosed using 18F-fluoro-2-deoxyglucose positron emission tomography or gallium-67 scintigraphy. Composite adverse events were defined as at least 1 of the following: all-cause death, hospitalization for heart failure, or lethal arrhythmia. During the follow-up period (median 2.9 years), radiologic relapse was observed in 31 patients (38.8% of overall patients) at 30 months (median) after immunosuppressive therapy initiation. After radiologic relapse was detected, all patients were treated with intensified immunosuppressive therapies (increasing PSL, n = 26 [83.9%], adding other immunosuppressive therapies to PSL, n = 5 [16.1%]). There were no differences in occurrences of composite adverse events in patients with and patients without radiologic relapse. Radiologic relapse under immunosuppressive therapy was observed in many patients with CS, but it was not associated with clinical outcomes under intensified immunosuppressive therapy.
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Affiliation(s)
- Kohei Kaneta
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Emi Tateishi
- Department of Radiology and Nuclear Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Irie
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenji Moriuchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keisuke Kiso
- Department of Radiology and Nuclear Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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12
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Suzuki A, Kamio K, Takeno M, Terasaki Y, Taniuchi N, Sato J, Nishijima N, Saito Y, Seike M, Gemma A, Azuma A. Pulmonary sarcoidosis complicated by rheumatoid arthritis in a patient presenting with progressive fibrosing interstitial lung disease and treated with nintedanib: a case report and literature review. Ther Adv Respir Dis 2023; 17:17534666231158279. [PMID: 36872912 PMCID: PMC9989416 DOI: 10.1177/17534666231158279] [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: 03/07/2023] Open
Abstract
Sarcoidosis is a multisystem disease with an unknown etiology and is characterized by the formation of noncaseating granulomas in the affected organs. We present the case of a 69-year-old male Japanese patient with bilateral hilar lymphadenopathy on chest radiographs for more than 10 years, left without further investigation. The patient reported no clinical symptoms. Chest computed tomography revealed ground-glass opacities and reticular shadows in both lungs, along with bilateral hilar and mediastinal lymphadenopathy. Lymphocytosis was observed in bronchoalveolar lavage fluid. Pathological examination of transbronchial lung biopsy revealed noncaseating, epithelioid granulomas congruous with sarcoidosis, together with other findings. There were no abnormalities on electrocardiogram, echocardiogram, and ophthalmic examination.For progressive dyspnea on exertion, systemic corticosteroid therapy with oral prednisolone (25 mg/day) was initiated in 2017 and gradually tapered. Despite this intervention, the decline in forced vital capacity (FVC) was accelerated. Three years later, the patient noticed swelling in his right wrist. Further investigation revealed elevated anti-cyclic citrullinated peptide antibodies and absence of noncaseating epithelioid granuloma on surgical biopsy, leading to the diagnosis of rheumatoid arthritis (RA). Thereafter, the anti-fibrotic agent nintedanib was initiated, because interstitial lung disease (ILD) was considered to have converted into a progressive fibrosing phenotype (PF-ILD) with overlapping RA-associated lung involvement. With treatment, the progression of decline in FVC was slowed, although home oxygen therapy was introduced.
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Affiliation(s)
- Ayana Suzuki
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
| | - Koichiro Kamio
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugi-machi, Nakahara-ku, Kawasaki-shi 211-8533, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
| | - Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Namiko Taniuchi
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
| | - Junpei Sato
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
| | - Nobuhiko Nishijima
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
| | - Yoshinobu Saito
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masahiro Seike
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akihiko Gemma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Arata Azuma
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki-shi, Japan
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13
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Abstract
Sarcoidosis is a heterogeneous disease, which can affect virtually every body organ, even though lungs and intra thoracic lymph nodes are almost universally affected. The presence of noncaseating granulomas is the histopathological hallmark of the disease, and clinical picture depends on the organs affected. Data about interaction between sarcoidosis and comorbidities, such as cardiovascular and pulmonary diseases, autoimmune disorders, malignancy and drug-related adverse events are limited. Several lung conditions can be associated with sarcoidosis, such as pulmonary hypertension and fibrosis, making it difficult sometimes the differentiation between complications and distinctive pathologies. Their coexistence may complicate the diagnosis of sarcoidosis and contribute to the highly variable and unpredictable natural history, particularly if several diseases are recognised. A thorough assessment of specific disorders that can be associated with sarcoidosis should always be carried out, and future studies will need to evaluate sarcoidosis not only as a single disorder, but also in the light of possible concomitant conditions.Key messagesComorbidities in sarcoidosis are common, especially cardiovascular and pulmonary diseases.In the diagnostic workup, a distinction must be made between sarcoidosis-related complaints and complaints caused by other separate disorders. It can be very difficult to distinguish between complications of sarcoidosis and other concomitant conditions.The coexistence of multiple conditions may complicate the diagnosis of sarcoidosis, affect its natural course and response to treatment.
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Affiliation(s)
- Claudio Tana
- Geriatrics Clinic, Medicine Department, SS Annunziata Hospital of Chieti, Chieti, Italy
| | - Marjolein Drent
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands.,ILD Center of Excellence, Department of Respiratory Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands.,ILD Care Foundation Research Team, Ede, The Netherlands
| | - Hilario Nunes
- AP-HP, Hôpital Avicenne, Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares de l'adulte, Université Sorbonne Paris Nord, Bobigny, France
| | - Vasilis Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, UK
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca' Foncello Hospital - AULSS2 Marca Trevigiana and Department of Medicine - DIMED, University of Padova, Italy
| | - Naomi T Jessurun
- ILD Care Foundation Research Team, Ede, The Netherlands.,Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
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14
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Obi ON, Saketkoo LA, Russell AM, Baughman RP. Sarcoidosis: Updates on therapeutic drug trials and novel treatment approaches. Front Med (Lausanne) 2022; 9:991783. [PMID: 36314034 PMCID: PMC9596775 DOI: 10.3389/fmed.2022.991783] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous inflammatory disease of unknown etiology. It affects the lungs in over 90% of patients yet extra-pulmonary and multi-organ involvement is common. Spontaneous remission of disease occurs commonly, nonetheless, over 50% of patients will require treatment and up to 30% of patients will develop a chronic progressive non-remitting disease with marked pulmonary fibrosis leading to significant morbidity and death. Guidelines outlining an immunosuppressive treatment approach to sarcoidosis were recently published, however, the strength of evidence behind many of the guideline recommended drugs is weak. None of the drugs currently used for the treatment of sarcoidosis have been rigorously studied and prescription of these drugs is often based on off-label” indications informed by experience with other diseases. Indeed, only two medications [prednisone and repository corticotropin (RCI) injection] currently used in the treatment of sarcoidosis are approved by the United States Food and Drug Administration. This situation results in significant reimbursement challenges especially for the more advanced (and often more effective) drugs that are favored for severe and refractory forms of disease causing an over-reliance on corticosteroids known to be associated with significant dose and duration dependent toxicities. This past decade has seen a renewed interest in developing new drugs and exploring novel therapeutic pathways for the treatment of sarcoidosis. Several of these trials are active randomized controlled trials (RCTs) designed to recruit relatively large numbers of patients with a goal to determine the safety, efficacy, and tolerability of these new molecules and therapeutic approaches. While it is an exciting time, it is also necessary to exercise caution. Resources including research dollars and most importantly, patient populations available for trials are limited and thus necessitate that several of the challenges facing drug trials and drug development in sarcoidosis are addressed. This will ensure that currently available resources are judiciously utilized. Our paper reviews the ongoing and anticipated drug trials in sarcoidosis and addresses the challenges facing these and future trials. We also review several recently completed trials and draw lessons that should be applied in future.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States,*Correspondence: Ogugua Ndili Obi,
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, United States,University Medical Center—Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, United States,Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, United States,Department of Undergraduate Honors, Tulane University School of Medicine, New Orleans, LA, United States
| | - Anne-Marie Russell
- Exeter Respiratory Institute University of Exeter, Exeter, United Kingdom,Royal Devon and Exeter NHS Foundation Trust, Devon, United Kingdom,Faculty of Medicine, Imperial College and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, OH, United States
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15
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Rolak SC, Xu TT, Leasure EL. 70-Year-Old Man With Dizziness and Nausea. Mayo Clin Proc 2022; 97:1947-1952. [PMID: 36202501 DOI: 10.1016/j.mayocp.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Stacey C Rolak
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Timothy T Xu
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Emily L Leasure
- Advisor to residents and Consultant in Community Internal Medicine, Mayo Clinic, Rochester, MN.
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16
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Abstract
PURPOSE OF REVIEW Sarcoidosis is a chronic multisystemic inflammatory disease of unknown aetiology with a wide range of highly variable clinical manifestations and unpredictable disease course. Sarcoidosis patients may present with specific organ-related symptoms involving functional impairments, and less specific symptoms. The decision whether and when to treat a sarcoidosis patient with pharmacotherapy depends on two major factors: risk of organ failure and/or death and impairment of quality of life. This decision is complex and not standardized. RECENT FINDINGS Glucocorticoids (GCs) are recommended as initial treatment, when needed. Subsequent GC-sparing alternatives frequently follow. Comorbidities or adverse drug reactions (ADRs) from drugs used in sarcoidosis treatment are sometimes very hard to differentiate from symptoms associated with the disease itself, which may cause diagnostic dilemmas. An ideal approach to minimalize ADRs would involve genetic screening prior to prescribing certain 'high-risk drugs' and therapeutic drug monitoring during treatment. Pharmacogenomic testing aims to guide appropriate selection of medicines, with the potential of reducing unnecessary polypharmacy while improving clinical outcomes. SUMMARY A multidisciplinary approach to the management of sarcoidosis may avoid unnecessary ADRs. It is important to consider the possibility of drug-induced damage in sarcoidosis, especially if the clinical situation deteriorates after the introduction of a particular drug.
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Affiliation(s)
- Marjolein Drent
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht
- ILD Center of Excellence, Department of Respiratory Medicine, St. Antonius Hospital, Nieuwegein
- ILD Care Foundation Research Team, Ede
| | - Naomi T. Jessurun
- ILD Care Foundation Research Team, Ede
- Netherlands Pharmacovigilance Centre Lareb, ‘s-Hertogenbosch
| | - Petal A. Wijnen
- ILD Care Foundation Research Team, Ede
- Central Diagnostic Laboratory, Department of Clinical Chemistry, MUMC, Maastricht, The Netherlands
| | - Otto Bekers
- Central Diagnostic Laboratory, Department of Clinical Chemistry, MUMC, Maastricht, The Netherlands
| | - Aalt Bast
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht
- ILD Care Foundation Research Team, Ede
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17
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Ishizuka M, Uehara M, Katagiri M, Ishida J, Kojima T, Amiya E, Komuro I. Successful treatment of recurrent cardiac sarcoidosis with the combination of corticosteroid and methotrexate monitored by 18F-fluoro-2-deoxyglucose positron emission tomography: case series. Eur Heart J Case Rep 2022; 6:ytac334. [PMID: 36004044 PMCID: PMC9395136 DOI: 10.1093/ehjcr/ytac334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/08/2022] [Accepted: 08/09/2022] [Indexed: 11/12/2022]
Abstract
Background The standard treatment for cardiac sarcoidosis (CS) is corticosteroids, including prednisolone (PSL). Previous studies have shown that the addition of methotrexate (MTX) to PSL is effective for steroid-refractory and recurrent cases. 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) is an essential tool for the diagnosis of CS. However, it is unclear whether FDG-PET is useful for detecting recurrence of CS and monitoring the effectiveness of PSL and MTX combination therapy. Case summary We detected CS recurrence during PSL treatment using FDG-PET. Patient 1 was accompanied by increased FDG uptake in other organs, Patient 2 was complicated with a decrease in left ventricular ejection fraction, and Patient 3 showed enlargement of the late gadolinium enhancement area, which was compatible with the recurrence of CS. We successfully monitored the inflammation activity by FDG-PET and treated recurrent CS by increasing the PSL dose and adding MTX to suppress inflammation. Discussion FDG-PET is useful for detecting CS recurrence and monitoring the effectiveness of PSL and MTX combination therapy. Serial FDG-PET scans indicated that it might be more difficult to suppress inflammation in recurrent CS than in the initial treatment. The use of FDG-PET is necessary to monitor long-term disease activity.
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Affiliation(s)
- Masato Ishizuka
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Masae Uehara
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Mikako Katagiri
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Toshiya Kojima
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo , 7-3-1 Hongo, Bunkyo-ku , Tokyo 113-8655, Japan
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18
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Distinguishing CNS neurosarcoidosis from multiple sclerosis and an approach to “overlap” cases. J Neuroimmunol 2022; 369:577904. [DOI: 10.1016/j.jneuroim.2022.577904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022]
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19
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Amratia DA, Viola H, Ioachimescu OC. Glucocorticoid therapy in respiratory illness: bench to bedside. J Investig Med 2022; 70:1662-1680. [DOI: 10.1136/jim-2021-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/07/2022]
Abstract
Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.
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20
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Papanikolaou IC, Antonakis E, Pandi A. State-of-the-Art Treatments for Sarcoidosis. Methodist Debakey Cardiovasc J 2022; 18:94-105. [PMID: 35772032 PMCID: PMC9237819 DOI: 10.14797/mdcvj.1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/01/2022] [Indexed: 11/08/2022] Open
Abstract
Sarcoidosis is a heterogeneous disease with various treatment indications. Although it affects mainly the lungs, sarcoidosis can affect every organ, especially when the disease course is chronic and protracted. Regular patient follow-up is recommended for early recognition of active, ongoing organ-specific granulomatous inflammation to avoid progression to irreversible fibrosis. In this review, we elaborate on treatment indications and various anti-sarcoidosis regimens proven useful in clinical trials. We also review specialized treatment of specific disease manifestations, with a focus on cardiac sarcoidosis. We also report on treatment for special conditions such as fatigue and small fiber neuropathy. Treatment for sarcoidosis is an emerging landscape, with new data complementing the existing knowledge.
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21
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Mangialardi P, Harper R, Albertson TE. The pharmacotherapeutics of sarcoidosis. Expert Rev Clin Pharmacol 2022; 15:51-64. [DOI: 10.1080/17512433.2022.2032657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Patrick Mangialardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, CA
- Department of Veterans Affairs, Northern California Health Care System, Department of Medicine, Mather, CA
| | - Richart Harper
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, CA
- Department of Veterans Affairs, Northern California Health Care System, Department of Medicine, Mather, CA
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, CA
- Department of Veterans Affairs, Northern California Health Care System, Department of Medicine, Mather, CA
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22
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Giblin GT, Murphy L, Stewart GC, Desai AS, Di Carli MF, Blankstein R, Givertz MM, Tedrow UB, Sauer WH, Hunninghake GM, Dellaripa PF, Divakaran S, Lakdawala NK. Cardiac Sarcoidosis: When and How to Treat Inflammation. Card Fail Rev 2021; 7:e17. [PMID: 34950507 PMCID: PMC8674699 DOI: 10.15420/cfr.2021.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/18/2021] [Indexed: 12/18/2022] Open
Abstract
Sarcoidosis is a complex, multisystem inflammatory disease with a heterogeneous clinical spectrum. Approximately 25% of patients with systemic sarcoidosis will have cardiac involvement that portends a poorer outcome. The diagnosis, particularly of isolated cardiac sarcoidosis, can be challenging. A paucity of randomised data exist on who, when and how to treat myocardial inflammation in cardiac sarcoidosis. Despite this, corticosteroids continue to be the mainstay of therapy for the inflammatory phase, with an evolving role for steroid-sparing and biological agents. This review explores the immunopathogenesis of inflammation in sarcoidosis, current evidence-based treatment indications and commonly used immunosuppression agents. It explores a multidisciplinary treatment and monitoring approach to myocardial inflammation and outlines current gaps in our understanding of this condition, emerging research and future directions in this field.
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Affiliation(s)
- Gerard T Giblin
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Laura Murphy
- Cardiovascular Imaging Program and Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Garrick C Stewart
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Akshay S Desai
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program and Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Ron Blankstein
- Cardiovascular Imaging Program and Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Michael M Givertz
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Usha B Tedrow
- Cardiac Arrhythmia Service, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - William H Sauer
- Cardiac Arrhythmia Service, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Gary M Hunninghake
- Interstitial Lung Disease Program, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Paul F Dellaripa
- Interstitial Lung Disease Program, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Sanjay Divakaran
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
| | - Neal K Lakdawala
- Center for Advanced Heart Disease, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, US
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23
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Zhou Y, Gerke AK, Lower EE, Vizel A, Talwar D, Strambu I, Francesqui J, Sellares J, Sawahata M, Obi ON, Nagai S, Tanizawa K, Judson MA, Jeny F, Valeyre D, Cunha Castro MD, Pereira C, Balter M, Baughman RP. The impact of demographic disparities in the presentation of sarcoidosis: A multicenter prospective study. Respir Med 2021; 187:106564. [PMID: 34391118 PMCID: PMC9999732 DOI: 10.1016/j.rmed.2021.106564] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To study how demographic differences impact disease manifestation of sarcoidosis using the WASOG tool in a large multicentric study. METHODS Clinical data regarding 1445 patients with sarcoidosis from 14 clinical sites in 10 countries were prospectively reviewed from Feb 1, 2020 to Sep 30, 2020. Organ involvement was evaluated for the whole group and for subgroups differentiated by sex, race, and age. RESULTS The median age of the patients at diagnosis was 46 years old; 60.8% of the patients were female. The most commonly involved organ was lung (96%), followed by skin (24%) and eye (22%). Black patients had more multiple organ involvement than White patients (OR = 3.227, 95% CI: 2.243-4.643) and females had more multiple organ involvement than males (OR = 1.238, 95% CI: 1.083-1.415). Black patients had more frequent involvement of neurologic, skin, eye, extra thoracic lymph node, liver and spleen than White and Asian patients. Women were more likely to have eye (OR = 1.522, 95%CI: 1.259-1.838) or skin involvement (OR = 1.369, 95%CI: 1.152-1.628). Men were more likely to have cardiac involvement (OR = 1.326, 95%CI: 1.096-1.605). A total of 262 (18.1%) patients did not receive systemic treatment for sarcoidosis. Therapy was more common in Black patients than in other races. CONCLUSION The initial presentation and treatment of sarcoidosis was related to sex, race, and age. Black and female individuals are found to have multiple organ involvement more frequently. Age at diagnosis<45, Black patients and multiple organ involvement were independent predictors of treatment.
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Affiliation(s)
- Ying Zhou
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
| | - Alicia K Gerke
- Department of Internal Medicine, Pulmonary and Critical Care, University of Iowa, 200 Hawkins Dr, Iowa City, IA, 52246, USA
| | - Elyse E Lower
- Internal Medicine, University of Cincinnati, University of Cincinnati Medical Center, Cincinnati, OH, 45267-0565, USA
| | - Alexander Vizel
- Kazan State Medical University, Department of Phthisiopulmonology. Butlerov Str., 49. Kazan, Tatarsan Republic. 420012, Russian Federation
| | - Deepak Talwar
- Department of Pulmonary and Sleep Care Medicine, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
| | - Irina Strambu
- Pulmonology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Joel Francesqui
- Servei de Pneumologia, Respiratory Institute, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Jacobo Sellares
- Servei de Pneumologia, Respiratory Institute, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Michiru Sawahata
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, 329-0498, Japan
| | - Ogugua Ndili Obi
- Division of Pulmonary, Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Sonoko Nagai
- Kyoto Central Clinic, Clinical Research Center, Kyoto, Japan
| | - Kiminobu Tanizawa
- Kyoto Central Clinic, Clinical Research Center, Kyoto, Japan; Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Marc A Judson
- Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Florence Jeny
- Service de Pneumologie, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Bobigny, France
| | - Dominique Valeyre
- Service de Pneumologie, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, Bobigny, France
| | - Marina Dornfeld Cunha Castro
- Department of Medicine, Division of Respiratory Diseases, Interstitial Lung Diseases Center, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Carlos Pereira
- Department of Medicine, Division of Respiratory Diseases, Interstitial Lung Diseases Center, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Meyer Balter
- Division of Respirology, Dept of Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Robert P Baughman
- Internal Medicine, University of Cincinnati, University of Cincinnati Medical Center, Cincinnati, OH, 45267-0565, USA
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24
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Park BJ, Ray E, Bathla G, Bruch LA, Streit JA, Cho TA, Hitchon PW. Single Center Experience with Isolated Spinal Cord Neurosarcoidosis. World Neurosurg 2021; 156:e398-e407. [PMID: 34583004 DOI: 10.1016/j.wneu.2021.09.089] [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: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition. METHODS A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case. RESULTS A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved. CONCLUSION Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.
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Affiliation(s)
- Brian J Park
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Girish Bathla
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Leslie A Bruch
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Judy A Streit
- Department of Internal Medicine-Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tracey A Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Kahlmann V, Moor CC, Veltkamp M, Wijsenbeek MS. Patient reported side-effects of prednisone and methotrexate in a real-world sarcoidosis population. Chron Respir Dis 2021; 18:14799731211031935. [PMID: 34569301 PMCID: PMC8477709 DOI: 10.1177/14799731211031935] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Currently prednisone is the first-line pharmacological treatment option for pulmonary sarcoidosis. Methotrexate is used as second-line therapy and seems to have fewer side-effects. No prospective comparative studies of first-line treatment with methotrexate exist. In this study, we evaluated patient reported presence and bothersomeness of side-effects of prednisone and methotrexate in a sarcoidosis population to guide the design of a larger prospective study. During a yearly patient information meeting 67 patients completed a questionnaire on medication use; 11 patients never used prednisone or methotrexate and were excluded from further analysis. Of the remaining 56 patients, 89% used prednisone and 70% methotrexate (present or former). Significantly more side-effects were reported for prednisone than for methotrexate, 78% versus 49% (p = 0.006). In conclusion, methotrexate seems to have fewer and less bothersome side-effects than prednisone. These findings need to be confirmed in a prospective study.
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Affiliation(s)
- Vivienne Kahlmann
- Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Catharina C Moor
- Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology, 6028St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marlies S Wijsenbeek
- Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Stievenart J, Le Guenno G, Ruivard M, Rieu V, André M, Grobost V. Cardiac sarcoidosis: systematic review of literature on corticosteroid and immunosuppressive therapies. Eur Respir J 2021; 59:13993003.00449-2021. [PMID: 34531273 PMCID: PMC9068974 DOI: 10.1183/13993003.00449-2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
Background Cardiac sarcoidosis (CS) is a life-threatening condition in which clear recommendations are lacking. We aimed to systematically review the literature on cardiac sarcoidosis treated by corticosteroids and/or immunosuppressive agents in order to update the management of CS. Methods Using PubMed, Embase and Cochrane Library databases, we found original articles on corticosteroid and standard immunosuppressive therapies for CS that provided at least a fair Scottish Intercollegiate Guidelines Network (SIGN) overall assessment of quality and we analysed the relapse rate, major cardiac adverse events (MACEs) and adverse events. We based our methods on the PRISMA statement and checklist. Results We retrieved 21 studies. Mean quality provided by SIGN assessment was 6.8 out of 14 (range 5–9). Corticosteroids appeared to have a positive impact on left ventricular function, atrioventricular block and ventricular arrhythmias. For corticosteroids alone, nine studies (45%, n=351) provided data on relapses, representing an incidence of 34% (n=119). Three studies (14%, n=73) provided data on MACEs (n=33), representing 45% of MACEs in patients treated by corticosteroid alone. Nine studies provided data on adjunctive immunosuppressive therapy, of which four studies (n=78) provided data on CS relapse, representing an incidence of 33% (n=26). Limitations consisted of no randomised control trial retrieved and unclear data on MACEs in patients treated by combined immunosuppressive agents and corticosteroids. Conclusion Corticosteroids should be started early after diagnosis but the exact scheme is still unclear. Studies concerning adjunctive conventional immunosuppressive therapies are lacking and benefits of adjunctive immunosuppressive therapies are unclear. Homogenous data on CS long-term outcomes under corticosteroids, immunosuppressive therapies and other adjunctive therapies are lacking. Corticosteroids are the mainstay treatment for cardiac sarcoidosis. Conventional immunosuppressive agents might be of interest at diagnosis. Cohort studies are clearly heterogeneous. Large cohort and prospective studies using “strong” end-points are lacking.https://bit.ly/3t9Rv8O
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Affiliation(s)
- Julien Stievenart
- Internal Medicine Department, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Clermont-Ferrand, France
| | - Guillaume Le Guenno
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Marc Ruivard
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Virginie Rieu
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Marc André
- Internal Medicine Department, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Clermont-Ferrand, France.,Université Clermont Auvergne, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Inserm U1071, INRA USC2018, M2iSH, Clermont-Ferrand, France
| | - Vincent Grobost
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
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Efficacy and Tolerability of Methotrexate and Methylprednisolone in a Comparative Assessment of the Primary and Long-Term Outcomes in Patients with Pulmonary Sarcoidosis. Diagnostics (Basel) 2021; 11:diagnostics11071289. [PMID: 34359372 PMCID: PMC8304978 DOI: 10.3390/diagnostics11071289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 07/16/2021] [Indexed: 01/08/2023] Open
Abstract
Background: There is insufficient information in the literature on the comparative efficacy and tolerability of methotrexate (MTX) and methylprednisolone (MP) in patients with pulmonary sarcoidosis in assessing primary outcomes and the relapse rate. Purpose: The aim of our study was to evaluate primary and long-term outcomes of using MTX and MP in patients with pulmonary sarcoidosis. Methods: A total of 143 patients with newly diagnosed pulmonary sarcoidosis, verified by high-resolution computed tomography (CT) data, were examined. Corticosteroid (CS) therapy was used in 97 patients using MP at a dose of 0.4 mg/kg body weight for 4 weeks, followed by a dose reduction to 0.1 mg/kg by the end of the sixth month. The total duration of CS therapy was 12 months on average. Forty-six patients were treated with MTX at a dose of 10 mg/week (28) and 15 mg/week (18) per os for 6 to 12 months. The study of the relapse rate was conducted within 12 months after the CT data normalization in 60 patients after CS therapy and in 24 after MTX treatment. Results: MP treatment was successfully completed in 68 (70.1%), and MTX in 29 (60.4%) patients. In five MP patients (5.2%) and in five (10.9%) MTX, treatment was discontinued due to serious side effects. In seven (7.2%) MP patients and ten (21.7%) MTX patients, treatment required additional therapy due to the lack of efficacy. Progression with MP treatment (17–17.5%) was more common than with MTX (2–4.3%; Chi square = 4.703, p = 0.031). Relapses after MP therapy were observed in 26 (43.3%) patients, and after MTX therapy in 2 (8.3%; Chi square = 9.450, p = 0.003). Conclusion: In patients with pulmonary sarcoidosis, MTX monotherapy does not differ significantly from MP monotherapy in terms of the level of efficacy and the rate of serious side effects. Increasing the MTX dose from 10 to 15 mg/week accelerates the rate of regression of sarcoidosis, improves treatment efficacy, and does not affect the rate of serious side effects. When using MTX, there is a significant decrease in the incidence of treatment resistance and the relapse rate.
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Abstract
Sarcoidosis is a chronic inflammatory disease of unknown etiology that affects many systemic organs, including the eye. The eye is the second most frequently affected organ in patients with sarcoidosis after lung disease. Approximately 30-50% of patients with systemic sarcoidosis develop uveitis, which is a sight-threatening intraocular inflammatory disorder. Sarcoidosis is the leading cause of uveitis in Japan and is one of the major clinical entities in many countries. Therefore, uveitis in association with sarcoidosis (ocular sarcoidosis) is considered essential in clinical practice in ophthalmology. The current review focuses on distinguishing features of ocular sarcoidosis, diagnosis, management, and discussion of the etiology of ocular sarcoidosis.
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Affiliation(s)
- Hiroshi Takase
- Department of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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State-Level Health Disparity Is Associated with Sarcoidosis Mortality. J Clin Med 2021; 10:jcm10112366. [PMID: 34072248 PMCID: PMC8199085 DOI: 10.3390/jcm10112366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sarcoidosis is associated with significant morbidity and rising health care utilization, which contribute to the health care burden and disease outcome. In the United States (US), evaluation of sarcoidosis mortality by individual states has not been investigated. METHODS We examined sarcoidosis mortality data for 1999-2018 from the Centers for Disease Control and Prevention (CDC). America's Health Rankings (AHR) assesses the nation's health on a state-by-state basis to determine state health rankings. The numbers of certified Sarcoidosis Clinics within the US were obtained from World Association for Sarcoidosis and Other Granulomatous Disorders (WASOG) and Foundation for Sarcoidosis Research (FSR). The associations between sarcoidosis mortality and state health disparities were calculated by linear regression analyses. RESULTS From 1999 to 2018, the mean age-adjusted mortality rate (AAMR) in all populations, African Americans and European Americans were 2.9, 14.8, and 1.4 per 1,000,000 population, respectively. South Carolina had the highest AAMR for all populations (6.6/1,000,000) and African Americans (20.8/1,000,000). Both Utah and Vermont had the highest AAMR for European Americans (2.6/1,000,000). New York State and South Atlantic had the largest numbers of FSR-WASOG Sarcoidosis Clinics (6 and 13, respectively). States with better health rankings were significantly associated with lower AAMR in all population (R2 = 0.170, p = 0.003) but with higher AAMR in European Americans (R2 = 0.223, p < 0.001). CONCLUSIONS There are significant variations in sarcoidosis mortality within the US. Sarcoidosis mortality was strongly associated with state health disparities. The current study suggests sarcoidosis mortality could be an indicator to reflect the state-level health care disparities in the US.
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30
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Ulcerative cutaneous sarcoidosis successfully treated with infliximab. Clin Rheumatol 2021; 40:4349-4354. [PMID: 33728543 DOI: 10.1007/s10067-021-05689-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 12/23/2022]
Abstract
Sarcoidosis is a systemic inflammatory disorder with cutaneous involvement present in 25% of cases. We present a patient with ulcerative sarcoidosis to highlight this unusual presentation of a relatively rare cutaneous condition that was treated successfully using infliximab. The drug is effective in cutaneous sarcoidosis, but relapses can occur after discontinuation. In this article, we reviewed the clinical features and therapeutic modalities for ulcerative cutaneous sarcoidosis.
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31
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Obi ON, Lower EE, Baughman RP. Biologic and advanced immunomodulating therapeutic options for sarcoidosis: a clinical update. Expert Rev Clin Pharmacol 2021; 14:179-210. [PMID: 33487042 DOI: 10.1080/17512433.2021.1878024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Sarcoidosis is a multi-organ disease with a wide range of clinical manifestations and outcomes. A quarter of sarcoidosis patients require long-term treatment for chronic disease. In this group, corticosteroids and cytotoxic agents be insufficient to control diseaseAreas covered: Several biologic agents have been studied for treatment of chronic pulmonary and extra-pulmonary disease. A review of the available literature was performed searching PubMed and an expert opinion regarding specific therapy was developed.Expert opinion: These agents have the potential of treating patients who have progressive disease. Many of these agents have different mechanisms of action, response rates, and toxicity profiles.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Elyse E Lower
- Department of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert P Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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32
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Effects of immunotherapies and clinical outcomes in neurosarcoidosis: a retrospective cohort study. J Neurol 2021; 268:2466-2472. [PMID: 33515298 DOI: 10.1007/s00415-021-10421-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/12/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Neurosarcoidosis is associated with a significant degree of morbidity and mortality and its treatments are varied and complex. There is a paucity of information in current literature on patterns of treatment and long term outcomes. This study aimed to evaluate the clinical outcomes and responses to immunosuppressive therapy in a large cohort of neurosarcoidosis patients . METHODS We enrolled 80 patients with a diagnosis of neurosarcoidosis. Prescription patterns and clinical outcomes before and after treatment and differences between the treatment groups were compared using Kruskal-Wallis and Mann-Witney U tests. RESULTS Patients with cranial mononeuropathy other than optic neuropathy were more likely to be treated with steroids alone whereas patients with other presentations were likely to require second and third level treatments. These included azathioprine, methotrexate, mycophenolate, infliximab, and cyclophosphamide often used in combination. Prednisolone alone at onset failed in 67% of patients but appeared most effective in those with isolated facial nerve palsy. Patients treated with prednisolone plus a standard immunosuppression first line generally did well except for those with brain parenchymal disease and /or hydrocephalus who responded better to the addition of infliximab, or cyclophosphamide. Triple therapy with prednisolone + azathioprine + infliximab was associated with significantly greater improvement on the Modified Rankin Scale than prednisolone alone whether used first line (p = 0.001 corrected) or subsequently (p = 0.021 corrected). Overall favourable outcomes in the form of improvement of MRS were reported in 87%, CONCLUSIONS: Our results provides evidence that early immunosuppressive treatments, with azathioprine, methotrexate and infliximab could effectively improve clinical outcomes in many patients with neurosarcoidosis.
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33
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Thillai M, Atkins CP, Crawshaw A, Hart SP, Ho LP, Kouranos V, Patterson K, Screaton NJ, Whight J, Wells AU. BTS Clinical Statement on pulmonary sarcoidosis. Thorax 2020; 76:4-20. [PMID: 33268456 DOI: 10.1136/thoraxjnl-2019-214348] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Muhunthan Thillai
- Cambridge Interstitial Lung Disease Unit, Royal Papworth Hospital, Cambridge, Cambridgeshire, UK
| | - Christopher P Atkins
- Department of Respiratory Medicine, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Anjali Crawshaw
- Interstitial Lung Disease Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School/University of Hull, Cottingham, UK
| | - Ling-Pei Ho
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, Oxford, UK.,Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Vasileios Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, London, UK
| | - Karen Patterson
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | | | | | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, London, UK
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34
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Abstract
Sarcoidosis is a systemic disease of unknown etiology defined by the presence of noncaseating granulomatous inflammation that can cause organ damage and diminished quality of life. Treatment is indicated to protect organ function and decrease symptomatic burden. Current treatment options focus on interruption of granuloma formation and propagation. Clinical trials guiding evidence for treatment are lacking due to the rarity of disease, heterogeneous clinical course, and lack of prognostic biomarkers, all of which contribute to difficulty in clinical trial design and implementation. In this review, a multidisciplinary treatment approach is summarized, addressing immunuosuppressive drugs, managing complications of chronic granulomatous inflammation, and assessing treatment toxicity. Discovery of new therapies will depend on research into pathogenesis of antigen presentation and granulomatous inflammation. Future treatment approaches may also include personalized decisions based on pharmacogenomics and sarcoidosis phenotype, as well as patient-centered approaches to manage immunosuppression, symptom control, and treatment of comorbid conditions.
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Affiliation(s)
- Alicia K. Gerke
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
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35
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Kahlmann V, Janssen Bonás M, Moor CC, van Moorsel CHM, Kool M, Kraaijvanger R, Grutters JC, Overgaauw M, Veltkamp M, Wijsenbeek MS. Design of a randomized controlled trial to evaluate effectiveness of methotrexate versus prednisone as first-line treatment for pulmonary sarcoidosis: the PREDMETH study. BMC Pulm Med 2020; 20:271. [PMID: 33076885 PMCID: PMC7574228 DOI: 10.1186/s12890-020-01290-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treatment of pulmonary sarcoidosis is recommended in case of significant symptoms, impaired or deteriorating lung function. Evidence-based treatment recommendations are limited and largely based on expert opinion. Prednisone is currently the first-choice therapy and leads to short-term improvement of lung function. Unfortunately, prednisone often has side-effects and may be associated with impaired quality of life. Methotrexate is presently considered second-line therapy, and appears to have fewer side-effects. OBJECTIVE The primary objective of this trial is to investigate the effectiveness and tolerability of methotrexate as first-line therapy in patients with pulmonary sarcoidosis compared with prednisone. The primary endpoint of this study will be the change in hospital-measured Forced Vital Capacity (FVC) between baseline and 24 weeks. Secondary objectives are to gain more insights in response to therapy in individual patients by home spirometry and patient-reported outcomes. Blood biomarkers will be examined to find predictors of response to therapy, disease progression and chronicity, and to improve our understanding of the underlying disease mechanism. METHODS/DESIGN In this prospective, randomized, non-blinded, multi-center, non-inferiority trial, we plan to randomize 138 treatment-naïve patients with pulmonary sarcoidosis who are about to start treatment. Patients will be randomized in a 1:1 ratio to receive either prednisone or methotrexate in a predefined schedule for 24 weeks, after which they will be followed up in regular care for up to 2 years. Regular hospital visits will include pulmonary function assessment, completion of patient-reported outcomes, and blood withdrawal. Additionally, patients will be asked to perform weekly home spirometry, and record symptoms and side-effects via a home monitoring application for 24 weeks. DISCUSSION This study will be the first randomized controlled trial comparing first-line treatment of prednisone and methotrexate and provide valuable data on efficacy, safety, quality of life and biomarkers. If this study confirms the hypothesis that methotrexate is as effective as prednisone as first-line treatment for sarcoidosis but with fewer side-effects, this will lead to improvement in care and initiate a change in practice. Furthermore, insights into the immunological mechanisms underlying sarcoidosis pathology might reveal new therapeutic targets. TRIAL REGISTRATION The study was registered on the 19th of March 2020 in the International Clinical Trial Registry, www.clinicaltrials.gov; ID NCT04314193 .
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Affiliation(s)
- Vivienne Kahlmann
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Montse Janssen Bonás
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Catharina C Moor
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Coline H M van Moorsel
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirjam Kool
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Raisa Kraaijvanger
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan C Grutters
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mayka Overgaauw
- Sarcoidosis patient association, Sarcoidose.nl, Alkmaar, the Netherlands
| | - Marcel Veltkamp
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marlies S Wijsenbeek
- Department of Respiratory Medicine, Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical Center, Rotterdam, the Netherlands.
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Kharoubi S. [Heerfordt's syndrome: about a case and literature review]. Pan Afr Med J 2020; 37:117. [PMID: 33425150 PMCID: PMC7755359 DOI: 10.11604/pamj.2020.37.117.25338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/26/2020] [Indexed: 11/11/2022] Open
Abstract
Le syndrome de Heerfordt est une manifestation rare de la sarcoïdose associant dans sa forme classique une uvéite, parotidomégalie, paralysie faciale et fièvre. C'est une forme active de la maladie dont le diagnostic est facilité par la biopsie salivaire. Il s'agit d'une observation clinique d'une patiente âgée de 17 ans présentant une uvéite, une parotidomégalie droite et une paralysie faciale droite d'apparition brutale. Après un bilan biologique et une imagerie (échographie parotidienne), une biopsie des glandes salivaires accessoires a conduit au diagnostic de sarcoïdose. Un bilan pré thérapeutique a permis d'instituer une corticothérapie par voie orale avec une évolution favorable et rémission totale. Le syndrome de Heerfordt est une forme clinique rare de sarcoïdose avec un profil évolutif favorable dans la majorité des cas. Il nécessite une approche diagnostique précise (éliminer les diagnostics différentiels surtout les formes incomplètes) en insistant sur les progrès thérapeutiques dans ce domaine.
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Affiliation(s)
- Smail Kharoubi
- Service ORL, CHU Annaba Faculté de Médecine, Universite Badji Mokhtar, Annaba, Algérie
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37
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Baughman RP, Cremers JP, Harmon M, Lower EE, Drent M. Methotrexate in sarcoidosis: hematologic and hepatic toxicity encountered in a large cohort over a six year period. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2020; 37:e2020001. [PMID: 33264378 PMCID: PMC7690061 DOI: 10.36141/svdld.v37i3.9362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Methotrexate (MTX) is a second line agent for treatment of sarcoidosis. Its long term safety and efficacy in sarcoidosis remains unclear. METHODS This was a retrospective review of patients seen at the University of Cincinnati Sarcoidosis Clinic over a six year period. For each visit, complete blood count, liver function testing, and dosing and outcome of MTX was noted. For efficacy, we compared the outcome of therapy of a matching subgroup of patients treated with either MTX or infliximab for one year and results scored as improved, stable, or worse based on response of the target organ. RESULTS Over six years, 1606 sarcoidosis patients were seen with a total of 13,576 clinical visits. During the study period, 607 patients (38% of total) were receiving MTX and had available blood work. Moderate elevation of alanine aminotransferase (ALT) (>3 times upper limit normal) was seen in nine (1.6%) patients. White blood count of <1500 cells per cu mm was seen in one patient. At six months, over half of the 44 patients initiated on infliximab and with at least six months of follow-up were better, while only 23% of the 44 of a matched subset of MTX treated patients were better (Chi square=10.566, p=0.0143). At the 12 month assessment, the infliximab treated patients were still more likely to be better than those treated with MTX (Chi square=10.033, p=0.0183). Only 23% of those treated with MTX were worse at twelve months. CONCLUSION In our study, MTX therapy was associated with very few hepatic or hematologic complications. MTX was less likely than infliximab to improve clinical status. However, only 20% were worse after one year of MTX. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (3): e2020001).
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Affiliation(s)
| | | | - Martina Harmon
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Elyse E. Lower
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Marjolein Drent
- ild care foundation research team, Ede, the Netherlands
- ILD Center of Excellence, Department of Respiratory Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmacology and Toxicology, FHML, University Maastricht, the Netherlands
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Takase H, Acharya NR, Babu K, Bodaghi B, Khairallah M, McCluskey PJ, Tesavibul N, Thorne JE, Tugal-Tutkun I, Yamamoto JH, Rao NA, Smith JR, Mochizuki M. Recommendations for the management of ocular sarcoidosis from the International Workshop on Ocular Sarcoidosis. Br J Ophthalmol 2020; 105:1515-1519. [PMID: 32933934 DOI: 10.1136/bjophthalmol-2020-317354] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 08/15/2020] [Accepted: 08/22/2020] [Indexed: 12/29/2022]
Abstract
AIMS To establish expert recommendations for the management of ocular sarcoidosis (OS). METHODS A question-based survey on the management of OS was circulated to international uveitis experts (members of the International Uveitis Study Group and the International Ocular Inflammation Society) electronically. Subsequently, a consensus workshop was conducted at the 7th International Workshop on Ocular Sarcoidosis (IWOS) in June 2019 in Sapporo, Japan as part of the Global Ocular Inflammation Workshops. Statements on the management of OS that were supported by a two-thirds majority of 10 international panel members of the workshop, after discussion and voting, were taken as consensus agreement. RESULTS A total of 98 participants from 29 countries responded to the questionnaire survey. The subsequent consensus workshop established recommendations for the management of OS in five sections. The first section concerned evaluation and monitoring of inflammation. The second, third and fourth sections described ocular manifestations that were indications for treatment, and the management of anterior uveitis, intermediate uveitis and posterior uveitis. In the fifth section, the use of systemic corticosteroids and systemic immunosuppressive drugs were detailed. CONCLUSIONS Recommendations for management of OS were formulated through an IWOS consensus workshop.
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Affiliation(s)
- Hiroshi Takase
- Department of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nisha R Acharya
- Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| | - Kalpana Babu
- Prabha Eye Clinic and Research Centre, Vittala International Institute of Ophthalmology, Bangalore, India
| | - Bahram Bodaghi
- Department of Ophthalmology, IHU FOReSIGHT, Sorbonne-APHP, Paris, France
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Peter J McCluskey
- Save Sight Institute, Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nattaporn Tesavibul
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jennifer E Thorne
- Division of Ocular Immunology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, BaltimoreMD, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Joyce H Yamamoto
- Department of Ophthalmology, Faculdade de Medicina LIM-33 FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Justine R Smith
- Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Manabu Mochizuki
- Department of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan .,Miyata Eye Hospital, Miyakonojo, Japan
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Poudel J, Risal U, Sigdel KR, Paudyal BP, Adhikari S, Basnyat B. Case Report: Co-existence of sarcoidosis and Takayasu arteritis. Wellcome Open Res 2020; 5:73. [PMID: 32885051 PMCID: PMC7450474 DOI: 10.12688/wellcomeopenres.15837.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 11/20/2022] Open
Abstract
Takayasu arteritis is a rare systemic large vessel vasculitis affecting the aorta and its branches. Sarcoidosis, too, is an inflammatory disease. Both entities are granulomatous conditions with a questionable association in their etiopathogenesis. Only a few cases of their coexistence have been reported in the literature. To our knowledge, no such cases have been reported from Nepal. We report a Nepalese woman who presented with non-productive cough, progressive shortness of breath and chest tightness of 3 years duration. She had a history of recurrent bilateral granulomatous uveitis over the previous 3 years. Examination revealed clubbing of digits, absent pulses over the left radial, ulnar and brachial arteries, and a weak pulse over the right arm including the bilateral carotid arteries. Pulmonary function test showed restrictive pattern, a high-resolution computed tomography (HRCT) scan of the chest revealed findings suggestive of pulmonary sarcoidosis. A CT angiogram suggested large vessel vasculitis. Bronchoscopy with biopsy revealed granulomatous inflammation, negative for malignancy and tuberculosis. She was hence, diagnosed with co-existing Takayasu arteritis and sarcoidosis, and treated with Prednisolone 60 mg once daily with dramatic improvement over 4 days and was discharged stable on domiciliary oxygen. She is currently on azathioprine 50 mg, prednisolone 10 mg without the need for supplemental oxygen. This case report highlights the importance of a proper physical examination as a guide to the use of modern technology in making a correct diagnosis. Furthermore, in countries where tuberculosis is endemic, it should always come as the most important differential diagnosis of granulomatous inflammation.
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Affiliation(s)
- Jiwan Poudel
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujjwol Risal
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Keshav Raj Sigdel
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Sudeep Adhikari
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddha Basnyat
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
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40
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Hu MK, Mathur A, Dempsey OJ. Pulmonary Sarcoidosis: A Clinical Update. J R Coll Physicians Edinb 2020; 50:322-329. [DOI: 10.4997/jrcpe.2020.324] [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] Open
Abstract
Sarcoidosis remains difficult to diagnose, assess and treat. The last decade has brought significant diagnostic and therapeutic advances in the field of sarcoidosis including endobronchial ultrasound, 18F-fluorodeoxyglucose positron emission tomography and biologics. In this article we use clinical vignettes to discuss commonly encountered cases to illustrate and explain the application of these, and other advances.
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Affiliation(s)
- May Khei Hu
- Academic Foundation Doctor, Department of Respiratory Medicine, Clinic C, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Abhinav Mathur
- Honorary Research Fellow, School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
| | - Owen J Dempsey
- Consultant Respiratory Physician, Department of Respiratory Medicine, Clinic C, Aberdeen Royal Infirmary, Aberdeen, UK
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42
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Maksimovic V, Pavlovic-Popovic Z, Vukmirovic S, Cvejic J, Mooranian A, Al-Salami H, Mikov M, Golocorbin-Kon S. Molecular mechanism of action and pharmacokinetic properties of methotrexate. Mol Biol Rep 2020; 47:4699-4708. [PMID: 32415503 DOI: 10.1007/s11033-020-05481-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/30/2020] [Indexed: 12/21/2022]
Abstract
Since its discovery in 1945, methotrexate has become a standard therapy for number of diseases, including oncological, inflammatory and pulmonary ones. Major physiological interactions of methotrexate include folate pathway, adenosine, prostaglandins, leukotrienes and cytokines. Methotrexate is used in treatment of pulmonary sarcoidosis as a second line therapy and is drug of choice in patients who are not candidates for corticosteroid therapy, with recommended starting weekly dose of 5-15 mg. Number of studies dealt with methotrexate use in rheumatoid arthritis and oncological patients. Authors are conducting research on oral methotrexate use and pharmacokinetics in chronic sarcoidosis patients and have performed literature research to better understand molecular mechanisms of methotrexate action as well as high level pharmacokinetic considerations. Polyglutamation of methotrexate affects its pharmacokinetic and pharmacodynamic properties and prolongs its effect. Bile excretion plays significant role due to extensive enterohepatic recirculation, although majority of methotrexate is excreted through urine. Better understanding of its pharmacokinetic properties in sarcoidosis patients warrant optimizing therapy when corticosteroids are contraindicated in these patients.
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Affiliation(s)
- V Maksimovic
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia.
| | - Z Pavlovic-Popovic
- Institute of Pulmonary Diseases, Sremska Kamenica, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - S Vukmirovic
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - J Cvejic
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - A Mooranian
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
| | - H Al-Salami
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
| | - M Mikov
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - S Golocorbin-Kon
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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43
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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: 40] [Impact Index Per Article: 10.0] [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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44
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Poudel J, Risal U, Sigdel KR, Paudyal BP, Adhikari S, Basnyat B. Case Report: Co-existence of sarcoidosis and Takayasu arteritis. Wellcome Open Res 2020; 5:73. [DOI: 10.12688/wellcomeopenres.15837.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 11/20/2022] Open
Abstract
Takayasu arteritis is a rare systemic large vessel vasculitis affecting the aorta and its branches. Sarcoidosis, too, is an inflammatory disease. Both entities are granulomatous conditions with a question of possible linkquestionable association in their etiopathogenesis. Only a few cases of their coexistence have been reported in the literature. To our knowledge, no such cases have been reported from Nepal. We report a Nepalese woman who presented with non-productive cough, progressive shortness of breath and chest tightness of 3 years duration. She had a history of recurrent bilateral granulomatous uveitis over the previous 3 years. Examination revealed clubbing of digits, absent pulses over the left radial, ulnar and brachial arteries, and a weak pulse over the right arm including the bilateral carotid arteries. Pulmonary function test showed restrictive pattern, a high-resolution computed tomography (HRCT) scan of the chest revealed findings suggestive of pulmonary sarcoidosis. A CT aortogram suggested large vessel vasculitis. Bronchoscopy with biopsy revealed granulomatous inflammation, negative for malignancy and tuberculosis. She was hence, diagnosed with co-existing Takayasu arteritis and sarcoidosis, and treated with Prednisolone 60 mg once daily with dramatic improvement over 4 days and was discharged stable on domiciliary oxygen. She is currently on azathioprine 50 mg, prednisolone 10 mg without the need for supplemental oxygen. This case report highlights the importance of a proper physical examination as a guide to the use of modern technology in making a correct diagnosis. Furthermore, in countries where tuberculosis is endemic, it should always come as the most important differential diagnosis of granulomatous inflammation.
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45
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Pendela VS, Munoz A, Chhabria M, Kudaravalli P, Soliman M, Soliman Y. Appendiceal sarcoidosis presenting as acute appendicitis. Proc (Bayl Univ Med Cent) 2020; 33:384-385. [PMID: 32675957 DOI: 10.1080/08998280.2020.1744794] [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: 02/20/2020] [Revised: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022] Open
Abstract
Sarcoidosis is a chronic inflammatory multisystem disease. The stomach is the most commonly involved gastrointestinal organ. Symptomatic appendicular sarcoidosis is extremely rare. We present a case of a 49-year-old woman with abdominal pain. An ultrasound of the abdomen was suggestive of acute appendicitis. Laparoscopic appendectomy was performed and the pathology revealed nonnecrotizing granulomas. Biopsy of the mediastinal lymph nodes suggested noncaseating granulomas. She was treated with steroid therapy followed by mycophenolate mofetil. Our case demonstrates the importance of considering appendiceal sarcoid among the differentials in a patient with systemic sarcoidosis presenting with an acute abdomen.
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Affiliation(s)
| | - Anisleidys Munoz
- Department of Internal Medicine, Rochester General HospitalRochesterNew York
| | - Mamta Chhabria
- Department of Internal Medicine, Rochester General HospitalRochesterNew York
| | - Pujitha Kudaravalli
- Department of Internal Medicine, State University of New York Upstate Medical UniversitySyracuseNew York
| | - Megan Soliman
- Carilion Clinic, Virginia Tech Carilion School of MedicineRoanokeVirginia
| | - Youssef Soliman
- Division of Gastroenterology, Carilion Clinic, Virginia Tech Carilion School of MedicineRoanokeVirginia
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46
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Aryal S, Nathan SD. Contemporary optimized practice in the management of pulmonary sarcoidosis. Ther Adv Respir Dis 2020; 13:1753466619868935. [PMID: 31409257 PMCID: PMC6696842 DOI: 10.1177/1753466619868935] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pulmonary sarcoidosis is the most common form of sarcoidosis, accounting for the initial presentation in over 70% patients and with eventual presence in 90% of patients with sarcoidosis. However, the course of the disease is often unpredictable; its manifestations can be highly variable and its treatment may not be effective in all patients. As such, the optimized treatment of pulmonary sarcoidosis often requires a thoughtful personalized approach with the need to get the patient involved in decisions of management. In many patients with pulmonary sarcoidosis, the disease is self-limited and nonprogressive, thus treatment is not necessary. In other patients, the presence of significant symptoms or functional limitation often associated with worsening radiological changes and pulmonary function tests warrants treatment. Corticosteroids are the first-line treatment for pulmonary sarcoidosis; antimetabolites are second-line agents, with methotrexate being most commonly employed. Antitumor necrosis alpha antibodies, especially infliximab, are emerging as potential third-line agents. A high index of suspicion should be held for pulmonary hypertension and other comorbidities that may complicate the course of patients with advanced sarcoidosis. Lung transplantation may be the only option for patients who have refractory disease despite maximal medical therapy.
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Affiliation(s)
| | - Steven D Nathan
- Inova Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA 22042-3300, USA
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47
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Rahaghi FF, Baughman RP, Saketkoo LA, Sweiss NJ, Barney JB, Birring SS, Costabel U, Crouser ED, Drent M, Gerke AK, Grutters JC, Hamzeh NY, Huizar I, Ennis James W, Kalra S, Kullberg S, Li H, Lower EE, Maier LA, Mirsaeidi M, Müller-Quernheim J, Carmona Porquera EM, Samavati L, Valeyre D, Scholand MB. Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis. Eur Respir Rev 2020; 29:29/155/190146. [PMID: 32198218 PMCID: PMC9488897 DOI: 10.1183/16000617.0146-2019] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/07/2020] [Indexed: 12/27/2022] Open
Abstract
Pulmonary sarcoidosis presents substantial management challenges, with limited evidence on effective therapies and phenotypes. In the absence of definitive evidence, expert consensus can supply clinically useful guidance in medicine. An international panel of 26 experts participated in a Delphi process to identify consensus on pharmacological management in sarcoidosis with the development of preliminary recommendations. The modified Delphi process used three rounds. The first round focused on qualitative data collection with open-ended questions to ensure comprehensive inclusion of expert concepts. Rounds 2 and 3 applied quantitative assessments using an 11-point Likert scale to identify consensus. Key consensus points included glucocorticoids as initial therapy for most patients, with non-biologics (immunomodulators), usually methotrexate, considered in severe or extrapulmonary disease requiring prolonged treatment, or as a steroid-sparing intervention in cases with high risk of steroid toxicity. Biologic therapies might be considered as additive therapy if non-biologics are insufficiently effective or are not tolerated with initial biologic therapy, usually with a tumour necrosis factor-α inhibitor, typically infliximab. The Delphi methodology provided a platform to gain potentially valuable insight and interim guidance while awaiting evidenced-based contributions. Expert consensus recommendations for a pulmonary sarcoidosis treatment algorithm from a modified Delphi process include corticosteroids as initial therapy, immunomodulators for steroid-sparing or severe disease, and biologics for very severe diseasehttp://bit.ly/2SmP3uG
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48
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Moor CC, Kahlmann V, Culver DA, Wijsenbeek MS. Comprehensive Care for Patients with Sarcoidosis. J Clin Med 2020; 9:E390. [PMID: 32024123 PMCID: PMC7074229 DOI: 10.3390/jcm9020390] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/21/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease, associated with significant morbidity and impaired quality of life. Treatment is aimed at recovering organ function, reducing symptom burden and improving quality of life. Because of the heterogeneity and variable disease course, a comprehensive, multidisciplinary approach to care is needed. Comprehensive care includes not only pharmacological interventions, but also supportive measures aimed at relieving symptoms and improving quality of life. The purpose of this review is to summarize the most recent knowledge regarding different aspects of care and propose a structured approach to sarcoidosis management.
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Affiliation(s)
- Catharina C. Moor
- Department of Respiratory Medicine, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Vivienne Kahlmann
- Department of Respiratory Medicine, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Daniel A. Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Marlies S. Wijsenbeek
- Department of Respiratory Medicine, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
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49
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Birnie D, Beanlands RSB, Nery P, Aaron SD, Culver DA, DeKemp RA, Gula L, Ha A, Healey JS, Inoue Y, Judson MA, Juneau D, Kusano K, Quinn R, Rivard L, Toma M, Varnava A, Wells G, Wickremasinghe M, Kron J. Cardiac Sarcoidosis multi-center randomized controlled trial (CHASM CS- RCT). Am Heart J 2020; 220:246-252. [PMID: 31911261 DOI: 10.1016/j.ahj.2019.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022]
Abstract
Approximately 5% of patients with sarcoidosis have clinically manifest cardiac involvement. Clinical features of Cardiac Sarcoidosis are dependent on the location, extent, and activity of the disease. First line therapy is usually with prednisone and this is recommended based on clinician experience, expert opinion and small observational cohorts. There are no published clinical trials in cardiac sarcoidosis and multiple experts in the field have called for randomized clinical trials to answer important patient care questions. Corticosteroid are associated with multiple adverse effects including hypertension, diabetes, weight gain, osteoporosis, and increased risk of infections. In contrast Methotrexate is generally well tolerated and is increasingly used in other forms of sarcoidosis. OBJECTIVES The Cardiac Sarcoidosis Multi-Center Randomized Controlled Trial (CHASM CS-RCT; NCT03593759) is a multicenter randomized controlled trial designed to evaluate the optimal initial treatment strategy for patients with active cardiac sarcoidosis. We hypothesize that (1) a low dose prednisone/methotrexate combination will have non-inferior efficacy to standard dose prednisone and that (2) the low dose prednisone/ methotrexate combination will result in significantly better quality of life than standard dose prednisone, as a result of reduced burden of side effects. METHODS/DESIGN Eligible study subjects will have active clinically manifest cardiac sarcoidosis presenting with one or more of the following clinical findings: advanced conduction system disease, significant sinus node dysfunction, non-sustained or sustained ventricular arrhythmia, left ventricular dysfunction or right ventricular dysfunction. Subjects will be randomized in a 1:1 ratio to prednisone 0.5 mg/kg/day for 6 months (maximum dose 30 mg daily) OR to prednisone 20 mg daily for 1 month, then 10 mg daily for 1 month, then 5 mg daily for one month then stop AND methotrexate 15-20 mg once weekly for 6 months. The primary endpoint is summed perfusion rest score on 6-month PET (blinded core-lab review). The summed perfusion rest score is measure of myocardial fibrosis/scar. The design is non-inferiority with a sample size of 97 per group. DISCUSSION Given the multiorgan system potential adverse side effects of prednisone, proving noninferiority of an alternate regimen would be sufficient to make the alternative compare favorably to standard dose steroids. This is the first ever clinical trial in cardiac sarcoidosis and thus in addition to the listed goals of the trial, we will also establish a multi-center, multinational cardiac sarcoidosis clinical trials network. Such a collaborative infrastructure will enable a new era of high quality data to guide physicians when treating cardiac sarcoidosis patients.
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Affiliation(s)
- David Birnie
- University of Ottawa Heart Institute, ON, Canada.
| | | | - Pablo Nery
- University of Ottawa Heart Institute, ON, Canada
| | | | | | | | - Lorne Gula
- London Health Sciences Centre, On, Canada
| | - Andrew Ha
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Yuko Inoue
- National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Daniel Juneau
- Centre Hospitalier de l'Université de Montréal, Department of Radiology and Nuclear Medicine, Montréal, QC, Canada
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Suita, Japan; Libin Cardiovascular Institute of Alberta, Alberta, Canada
| | | | - Lena Rivard
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Mustafa Toma
- Imperial College Healthcare NHS Trust, London, UK
| | | | - George Wells
- University of Ottawa Heart Institute, ON, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, VA, USA
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50
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Drent M, Proesmans VLJ, Elfferich MDP, Jessurun NT, de Jong SMG, Ebner NM, Lewis EDO, Bast A. Ranking Self-reported Gastrointestinal Side Effects of Pharmacotherapy in Sarcoidosis. Lung 2020; 198:395-403. [PMID: 31960165 PMCID: PMC7105437 DOI: 10.1007/s00408-020-00323-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical manifestations of sarcoidosis vary widely, depending on the intensity of the inflammation and the organ systems affected. So far, no curative treatment exists; the disease can only be suppressed. All treatment options cause side effects affecting quality of life. The aim of this study was to establish and rank the prevalence of self-reported gastrointestinal side effects of drugs used in the treatment of sarcoidosis. METHODS A cross-sectional web-based anonymous survey about complaints and side effects was conducted among sarcoidosis patients in the Netherlands, United Kingdom, and United States of America. RESULTS Of the participants, 70% were being treated with one or more drugs. The most important reported side effect was weight gain, associated with increased appetite among prednisone users (as monotherapy as well as in combination with other drugs). Methotrexate (MTX) users especially experienced nausea, with monotherapy as well as combination therapy. Vomiting and weight loss were most prominent among azathioprine and mycophenolate mofetil (MMF) users, whereas diarrhoea was frequently mentioned by MMF and MTX users. The reported side effects of hydroxychloroquine were generally rather mild. CONCLUSION The current study ranked the gastrointestinal side effects associated with pharmacotherapy in sarcoidosis patients. Pharmacotherapy does have multiple gastrointestinal side effects. The strongest association between a reported side effect and drug use was that of weight gain associated with increased appetite among prednisone users. It would therefore be useful for future research to look further into dietary interventions to counter these side effects and reduce their burden.
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Affiliation(s)
- M Drent
- Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands. .,Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands. .,ild care foundation Research Team, Ede, The Netherlands.
| | - V L J Proesmans
- ild care foundation Research Team, Ede, The Netherlands.,Venlo Campus, Maastricht University, Venlo, The Netherlands
| | | | - N T Jessurun
- ild care foundation Research Team, Ede, The Netherlands.,Netherlands' Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - S M G de Jong
- ild care foundation Research Team, Ede, The Netherlands.,Venlo Campus, Maastricht University, Venlo, The Netherlands
| | - N M Ebner
- ild care foundation Research Team, Ede, The Netherlands.,Venlo Campus, Maastricht University, Venlo, The Netherlands
| | - E D O Lewis
- ild care foundation Research Team, Ede, The Netherlands.,Venlo Campus, Maastricht University, Venlo, The Netherlands
| | - A Bast
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,ild care foundation Research Team, Ede, The Netherlands.,Venlo Campus, Maastricht University, Venlo, The Netherlands
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