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Sikorova K, Osoegawa K, Kocourkova L, Strnad A, Petrkova J, Fernández-Viña MA, Doubkova M, Petrek M. Association between sarcoidosis and HLA polymorphisms in a Czech population from Central Europe: focus on a relationship with clinical outcome and treatment. Front Med (Lausanne) 2023; 10:1094843. [PMID: 37153085 PMCID: PMC10160604 DOI: 10.3389/fmed.2023.1094843] [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: 11/10/2022] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Background Sarcoidosis is an immune-mediated systemic disease with unknown etiology affecting the lung predominantly. The clinical manifestation of sarcoidosis is rather diverse ranging from Löfgren's syndrome to fibrotic disease. Also, it differs among patients with distinct geographical and ethnic origins, consistent with environmental and genetic factors' role in its pathogenesis. Of those, the polymorphic genes of the HLA system have been previously implicated in sarcoidosis. Therefore, we have performed an association study in a well-defined cohort of Czech patients aiming to define how variation in HLA genes, may contribute to disease origin and development. Materials and methods Total of the 301 Czech unrelated sarcoidosis patients were diagnosed according to international guidelines. In those, HLA typing was performed using next-generation sequencing. The allele frequencies at six HLA loci (HLA-A,-B,-C,-DRB1,-DQA1, and -DQB1) observed in the patients were compared with HLA allele distribution determined in 309 unrelated healthy Czech subjects; sub-analyses of relationships between HLA and distinct sarcoidosis clinical phenotypes were performed. Associations were assessed by two-tailed Fischer's exact test with correction for multiple comparisons. Results We report two variants, HLA-DQB1*06:02, and HLA-DQB1*06:04, as risk factors for sarcoidosis, and three variants, HLA-DRB1*01:01, HLA-DQA1*03:01, and HLA-DQB1*03:02 as protective factors. HLA-B*08:01, HLA-C*07:01, HLA-DRB1*03:01, HLA-DQA1*05:01, and HLA-DQB1*02:01 variants associated with Löfgren's syndrome, a more benign phenotype. HLA- DRB1*03:01 and HLA-DQA1*05:01 alleles were connected with better prognosis-chest X-ray (CXR) stage 1, disease remission, and non-requirement of corticosteroid treatment. The alleles HLA-DRB1*11:01 and HLA-DQA1*05:05 are associated with more advanced disease represented by the CXR stages 2-4. HLA-DQB1*05:03 associated with sarcoidosis extrapulmonary manifestation. Conclusion In our Czech cohort, we document some associations between sarcoidosis and HLA previously described in other populations. Further, we suggest novel susceptibility factors for sarcoidosis, such as HLA-DQB1*06:04, and characterize associations between HLA and sarcoidosis clinical phenotypes in Czech patients. Our study also extends the role of the 8.1 ancestral haplotype (HLA-A*01:01∼HLA-B*08:01∼HLA-C*07:01∼HLA-DRB1*03:01∼HLA-DQA1*05:01∼HLA-DQB1*02:01), already implicated in autoimmune diseases, as a possible predictor of better prognosis in sarcoidosis. The general translational application of our newly reported findings for personalized patient care should be validated by an independent study from another, international referral center.
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Affiliation(s)
- K. Sikorova
- Department of Pathological Physiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - K. Osoegawa
- Histocompatibility & Immunogenetics Laboratory, Stanford Blood Center, Palo Alto, CA, United States
| | - L. Kocourkova
- Laboratory of Cardiogenomics–Experimental Medicine, University Hospital Olomouc, Olomouc, Czechia
| | - A. Strnad
- Department of Pathological Physiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - J. Petrkova
- Laboratory of Cardiogenomics–Experimental Medicine, University Hospital Olomouc, Olomouc, Czechia
| | - M. A. Fernández-Viña
- Histocompatibility, Immunogenetics, and Disease Profiling Laboratory, Department of Pathology, Stanford Blood Center, Stanford University School Medicine, Palo Alto, CA, United States
| | - M. Doubkova
- Department of Pulmonary Diseases and Tuberculosis, Faculty of Medicine of Masaryk University, University Hospital Brno, Brno, Czechia
| | - M. Petrek
- Department of Pathological Physiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- *Correspondence: M. Petrek,
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Castro MDC, Pereira CADC, Soares MR. Prognostic features of sarcoidosis course in a Brazilian cohort. J Bras Pneumol 2022; 48:e20210366. [PMID: 35137872 PMCID: PMC8836631 DOI: 10.36416/1806-3756/e20210366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/03/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: To identify predictive features associated with the course of sarcoidosis at initial evaluation and to develop a predictive score. Methods: This was a retrospective study involving pulmonary sarcoidosis patients, classified as having a self-limited or persistent course of disease, comparing data between the outcomes by univariate analysis. Features related to persistent disease were selected by multivariate analysis and a prognostic score was designed. Results: The sample comprised 200 patients (mean age = 49 years). The median duration of symptoms to diagnosis was 12 months, and delayed diagnosis (> 12 months) was found in 43% of the cases. The most common radiological stage was II; 37% had reduced FVC. Relevant systemic involvement was detected in 37% of the patients. Treatment for tuberculosis was prescribed in 44 patients prior to sarcoidosis diagnosis. Treatment for sarcoidosis was required in 77% of the sample, and the disease course was persistent in 115 cases. Excluding 40 patients with fibrotic disease, prognostic factors to persistent disease were parenchymal involvement, delayed diagnosis, dyspnea, relevant systemic involvement, and reduced FVC. On the basis of the analysis, a 3-letter scoring system (A, B and C) was developed according to the selected factors. The positive predictive values for persistent course for A (≤ 1 point) and C scores (≥ 4 points) were 12.5% and 81.8%, respectively. Conclusions: A score can be derived by selected features at initial evaluation, allowing the prediction of outcomes in a significant number of sarcoidosis patients.
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Affiliation(s)
| | | | - Maria Raquel Soares
- . Departamento de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Cameli P, Caffarelli C, Refini RM, Bergantini L, d'Alessandro M, Armati M, Tomai Pitinca MD, Sestini P, Gonnelli S, Bargagli E. Hypercalciuria in Sarcoidosis: A Specific Biomarker With Clinical Utility. Front Med (Lausanne) 2020; 7:568020. [PMID: 33195314 PMCID: PMC7658263 DOI: 10.3389/fmed.2020.568020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/28/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Changes in calcium metabolism are quite common in sarcoidosis: hypercalciuria is linked to a persistent clinical phenotype and more active disease. No data is yet available on the specificity of parameters of calcium metabolism as biomarkers for distinguishing different chronic interstitial lung diseases (ILD). Here we assessed calcium metabolism in an Italian population of sarcoidosis patients, which included a group with stage IV fibrotic disease, and compared the results with those of idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis (cHP) patients. Population and Methods: We recruited sarcoidosis, IPF and cHP patients retrospectively. All patients were diagnosed through multidisciplinary discussion and were monitored at the Regional ILD Referral Centre in Siena. Clinical, radiological, functional, immunological and laboratory parameters were collected and entered in an electronic database for data analysis. Results: A total of 305 patients (237 sarcoidosis, 40 IPF and 28 cHP) were enrolled. Sarcoidosis patients included a predominance of females and were significantly younger than IPF and cHP patients (p < 0.0001 for both). In the sarcoidosis population, 17 patients (7.2%) showed radiological evidence of lung fibrosis, according the Scadding classification; fibrotic disease was also confirmed by CT scan. Concerning calcium metabolism, sarcoidosis patients showed significantly higher serum and urinary concentrations of calcium than IPF and cHP patients (p = 0.0004 and p < 0.0001, respectively). These findings were also confirmed when comparing groups with fibrotic sarcoidosis, IPF and cHP (p = 0.0237 and p = 0.0138). According to receiver operating characteristics (ROC) curve analysis, urinary calcium showed better diagnostic accuracy than serum calcium in discriminating sarcoid and non-sarcoid lung fibrosis (AUC 0.7658 vs. 0.6205; p = 0.0026 vs. p = 0.1820). Discussion: Our results confirmed that changes in calcium metabolism, particularly hypercalciuria, occur in a substantial percentage of patients with sarcoidosis. Higher serum and urinary concentrations of calcium were found than in IPF and cHP; the same results were observed when the comparison was limited to patients with fibrotic sarcoidosis, supporting the hypothesis that dysregulation of calcium metabolism may be a special feature of sarcoid granulomas. Hypercalciuria distinguished fibrotic sarcoidosis from IPF and cHP, suggesting that assessment of calcium metabolism may be useful in the diagnostic pathway of ILDs.
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Affiliation(s)
- Paolo Cameli
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Carla Caffarelli
- Internal Medicine Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Rosa Metella Refini
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Miriana d'Alessandro
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Martina Armati
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Maria Dea Tomai Pitinca
- Internal Medicine Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Piersante Sestini
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Stefano Gonnelli
- Internal Medicine Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical, Surgical and Neurosciences Sciences, Siena University Hospital, Siena, Italy
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4
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Castro MDC, Pereira CADC. Nonlife-Threatening Sarcoidosis. Semin Respir Crit Care Med 2020; 41:733-740. [PMID: 32777854 DOI: 10.1055/s-0040-1710371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown etiology. The outcome is quite variable and is mainly related to persistent inflammatory processes and the development of fibrosis. Many prognostic factors have been described, but the disease evolution is not yet entirely known. The nonthreatening course is characterized by spontaneous involution or stability after treatment withdrawal. Löfgren's syndrome is a subset within the spectrum of sarcoidosis phenotypes, composed of acute onset of fever, bilateral hilar lymphadenopathy, erythema nodosum and/or bilateral ankle periarticular inflammation/arthritis, specifically characterized by a self-limiting disease course. In contrast, advanced fibrotic sarcoidosis with pulmonary hypertension phenotype is correlated with a poor prognosis. Further studies are necessary to detail phenotypes to better understand the mechanisms of the disease and plan future clinical therapeutic studies.
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Affiliation(s)
- 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 Alberto de Castro Pereira
- Department of Medicine, Division of Respiratory Diseases, Interstitial Lung Diseases Center, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Fang C, Zhang Q, Wang N, Jing X, Xu Z. Effectiveness and tolerability of methotrexate in pulmonary sarcoidosis: A single center real-world study. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2019; 36:217-227. [PMID: 32476957 PMCID: PMC7247084 DOI: 10.36141/svdld.v36i3.8449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/14/2019] [Indexed: 12/16/2022]
Abstract
Background Pulmonary sarcoidosis patients who get disease progression despite corticosteroid treatment or can't tolerate corticosteroid required second-line drug. Methotrexate (MTX) is the most widely used in our clinical practice. Data on its safety and efficacy at different doses are still limited, especially for those without folic acid supplements. Objective To report effectiveness of different MTX dosages and tolerability of MTX in pulmonary sarcoidosis without folic acid supplements. Methods A retrospective study on pulmonary sarcoidosis patients receiving MTX therapy with various dose ≥3 months was conducted. The primary outcome was change in high-resolution computed tomography (HRCT) before and after MTX therapy. Other efficacy parameters included SGRQ score, prednisone dose change, discontinuation and relapse-free survival. Response-linked factors and safety outcomes were also analyzed. Results Overall, 49 patients (81.7%) were assessed as MTX responders by HRCT and there was no significant difference in clinical response rate among three groups with different doses. The health-related quality of life (HRQL) of the responders improved obviously, which was evidenced by SGRQ score declining from 16.7(IQR: 7.9-26.4) to 10.7(IQR: 4.8-19.3) (P=0.029). The corticosteroids sparing effect was confirmed in "responders" group (P<0.001). When MTX was discontinued in 11 responders with complete improvement, 2 patients experienced relapses within 15.5 (range: 1-30) months (mean follow-up time of these 11 responders: 13.5±13.0 months). No clinical characteristics were found related to MTX effectiveness. Adverse events occurred in 31.7% of the patients, with gastrointestinal-related being the commonest. Drug discontinuation owing to adverse events occupied 6.7% of the subjects. Conclusions Nearly 80% of the sarcoidosis subjects had well response to MTX. Its effectiveness was irrelevant to the treatment dosages and baseline characteristics. A quite low relapse rate was witnessed in those complete responders discontinuing MTX therapies. The steroid-sparing effect, well drug tolerability and low drug withdrawal rate were observed in these patients even without folic acid supplements in clinical practice.
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Affiliation(s)
| | | | | | | | - Zuojun Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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6
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Ramos-Casals M, Retamozo S, Sisó-Almirall A, Pérez-Alvarez R, Pallarés L, Brito-Zerón P. Clinically-useful serum biomarkers for diagnosis and prognosis of sarcoidosis. Expert Rev Clin Immunol 2019; 15:391-405. [DOI: 10.1080/1744666x.2019.1568240] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Rheumatology Unit, Instituto Modelo de Cardiología Privado S.R.L, Córdoba, Argentina
- Rheumatology Unit, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Antoni Sisó-Almirall
- Centre d’Assistència Primària ABS Les Corts, CAPSBE, Barcelona, Spain
- Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain
| | - Roberto Pérez-Alvarez
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Department of Internal Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Lucio Pallarés
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Systemic Autoimmune Diseases Uni, Department of Internal Medicine, Hospital de Son Espases, Palma de Mallorca, Spain
| | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- SarcoGEAS-SEMI Study Group, Study Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA, Sanitas, Spain
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7
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Karakaya B, Schimmelpennink MC, Kocourkova L, van der Vis JJ, Meek B, Grutters JC, Petrek M, van Moorsel CHM. Bronchoalveolar lavage characteristics correlate with HLA tag SNPs in patients with Löfgren's syndrome and other sarcoidosis. Clin Exp Immunol 2019; 196:249-258. [PMID: 30585624 DOI: 10.1111/cei.13257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2018] [Indexed: 12/19/2022] Open
Abstract
Genetic susceptibility for sarcoidosis and Löfgren's syndrome (LS) has been associated with prognosis. Human leukocyte antigen (HLA)-DRB1*03 is over-represented in LS, and is associated with a good prognosis, whereas HLA-DRB1*15-positive patients have a more chronic course of sarcoidosis. These HLA-DRB1 types can be easily tagged by single nucleotide polymorphisms (SNPs). Our aim was to evaluate the association between these tag SNPs and bronchoalveolar lavage (BAL) characteristics. In 29 patients, both complete HLA-DRB1* locus genotyping and SNP tagging was performed in parallel. HLA-DRB1 type was inferred from the presence of *03 tag rs2040410 allele A and referred to as *03. HLA-DRB1*15 was inferred from the presence of tag SNP rs3135388 allele A and referred to as *15. For BAL analysis, 122 patients with LS and 165 patients with non-LS sarcoidosis were included. BAL lymphocyte subsets were analyzed by flow cytometry. The presence of tag SNPs completely corresponded with HLA-DRB1*03/*15 genotypes in all 29 patients in whom both HLA-DRB1* genotyping and SNP tagging was performed. In all patients together, *03+ /*15- patients showed a higher CD4+ /CD8+ ratio than *03- /*15+ (P = 0·004) and *03- /*15- (P = 0·001). LS patients with *03+ /*15- had a lower BAL lymphocyte count compared to *03- /*15+ patients (P = 0·011). Non-LS sarcoidosis patients with *03+ /*15- patients showed a decreased CD103+ CD4+ /CD4+ ratio compared to *03- /*15+ patients (P = 0·045) and *03- /*15- patients (P = 0·018). We found that HLA-DRB1*03 and HLA-DRB1*15 can be approximated by genotyping of tag SNPs and corresponds with the degree of lymphocytosis and cell phenotypes in BAL in both LS and non-LS sarcoidosis patients.
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Affiliation(s)
- B Karakaya
- Department of Pulmonology, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - M C Schimmelpennink
- Department of Pulmonology, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - L Kocourkova
- Department of Pathological Physiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - J J van der Vis
- Department of Pulmonology, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands.,Department of Clinical Chemistry, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - B Meek
- Medical Immunology and Microbiology Department, St Antonius Hospital, Nieuwegein, the Netherlands
| | - J C Grutters
- Department of Pulmonology, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, the Netherlands
| | - M Petrek
- Department of Pathological Physiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic.,University Hospital Olomouc, Olomouc, the Czech Republic
| | - C H M van Moorsel
- Department of Pulmonology, ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, the Netherlands
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Silva AL, Melo N, Caetano Mota P, Lima B, Pereira JM, Cunha R, Guimarães S, Souto-Moura C, Morais A. Pulmonary Sarcoidosis: Prognostic Factors at Diagnosis in Patients from North of Portugal. ACTA ACUST UNITED AC 2018; 16:468-472. [PMID: 30559057 DOI: 10.1016/j.reuma.2018.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sarcoidosis is a multisystemic granulomatous disease that affects the lungs in more than 90% of the patients. It is associated with a variable clinical course and considering all the different forms of disease presentation, there are an absence of reliable clinical prognostic markers that can predict the outcome at diagnosis. OBJECTIVE The aim of our study was to investigate prognostic factors at diagnosis in a population of sarcoidosis patients from Northern Portugal. METHODS A group of 110 patients with chronic evolution was compared with 129 patients with disease resolution regarding their clinical, radiologic and laboratorial features. RESULTS We found a positive association between the chronic forms and lung function impairment, radiologic stage II, lower lymphocyte CD4/CD8 and extrapulmonary disease. Löfgren syndrome and asthenia instead had a protective significant association to chronicity. Our final logistic regression model found a significant independent association between age (adjusted OR=1.06), extrapulmonary involvement (adjusted OR=2.68), Löfgren's syndrome (adjusted OR=0.15) with outcome toward chronicity. CONCLUSIONS In this first study searching for prognostic factors at diagnosis in a Northern Portuguese population, we found clinical prognosis factors that have been described in other populations that should be considered whenever sarcoidosis is identified.
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Affiliation(s)
- Ana Luísa Silva
- Faculdade de Medicina-Universidade do Porto, Porto, Portugal
| | - Natalia Melo
- Pneumology Department and Diffuse Lung Disease Study Group/Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Patricia Caetano Mota
- Faculdade de Medicina-Universidade do Porto, Porto, Portugal; Pneumology Department and Diffuse Lung Disease Study Group/Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Bruno Lima
- Oficina de Biostatística, Ermesinde, Portugal
| | - José Miguel Pereira
- Radiology Department and Diffuse Lung Disease Study Group/ Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Rui Cunha
- Radiology Department and Diffuse Lung Disease Study Group/ Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Susana Guimarães
- Pathology Department and Diffuse Lung Disease Study Group/ Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Conceição Souto-Moura
- Pathology Department and Diffuse Lung Disease Study Group/ Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Antonio Morais
- Faculdade de Medicina-Universidade do Porto, Porto, Portugal; Pneumology Department and Diffuse Lung Disease Study Group/Centro Hospitalar Universitário de São João, Porto, Portugal.
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