Analysis of 87 patients with Lofgren's syndrome and the pattern of seasonality of subacute sarcoidosis

Löfgren Syndrome: Clinical Presentation, Clinical Course, and Literature Review

Löfgren syndrome is an acute presentation of sarcoidosis that comprises fever, bilateral and symmetric hilar lymphadenopathies, polyarthritis, and erythema. We present the case of a 34-year-old male patient who presented with ankle monoarthritis without a history of a traumatic event. Contralateral ankle arthritis associated with erythema nodosum and fever developed one week later. Laboratory tests showed anemia, thrombocytosis, and elevated inflammatory parameters. A chest CT revealed symmetrical mediastinal and hilar adenopathies. A transbronchial biopsy was compatible with granulomatous lymphadenitis, and the diagnosis of Löfgren syndrome was confirmed. Our case report and literature review emphasize the wide web of mimicry of acute sarcoidosis. Secondary forms of acute sarcoidosis are likely to benefit from additional and more complex immunomodulatory therapies. Close monitoring and follow-up should be conducted because it is possible that these patients experience higher rates of recurrence or relapse.

Sarcoidosis presenting with and without Löfgren's syndrome: Clinical, radiological and behavioral differences observed in a group of 691patients

OBJECTIVES

Just a few series of Löfgren's syndrome have been reported. Our aim was to describe the epidemiology and clinical profile of sarcoidosis patients presenting with Löfgren's syndrome vs. non-Löfgren's syndrome.

METHODS

Retrospective cohort study of 691consecutive patients with sarcoidosis diagnosed at the Bellvitge University Hospital in Barcelona, Spain, between 1976 and 2018.

RESULTS

Three hundred and nine patients (44.7%) were diagnosed with Löfgren's syndrome and 382with non-Löfgren's syndrome (55.3%). The mean age at diagnosis was 39.8years-old (SD 11.7) vs. 46.6 (SD 14.5) (P<0.001). 249 patients (80.6%) vs. 218 (57.1%) were female (P<0.001), and mostly Caucasians (304, 98.4% vs. 351, 91.9%, P=0.002). Out of the total 309, Löfgren's syndrome patients developed more frequently fever and articular involvement, and 45 (14.6%) presented with isolated periarticular ankle inflammation. When compared, radiological stages at diagnosis were more advanced in non-Löfgren's syndrome patients: stage 0 (2.9% vs. 14.7%), stage I (82.5% vs. 41.4%), stage II (14.6% vs. 29.3%), and stage III/IV (0 vs. 14.7%) (P<0.001). Chronic trend>2years was more prevalent in non-Löfgren's syndrome (66, 22.6% vs. 233, 67.4%; P<0.001), as well as the proportion of patients in whom treatment was needed (58, 18.8% vs. 224, 58.6%; P<0.001). Risk factors related to chronic trend>2 years were older age, stage II at diagnosis and the need of treatment.

CONCLUSIONS

Löfgren's syndrome is a well-differentiated form of sarcoidosis with persuasive different epidemiological, clinical, radiological and prognostic features.

The Diagnosis, Differential Diagnosis, and Treatment of Sarcoidosis

BACKGROUND

Sarcoidosis is a granulomatous inflammatory disease of unknown cause. Its prevalence in Germany is approximately 46 per 100 000 persons.

METHODS

This article is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

A presumptive diagnosis of sarcoidosis is made in any patient with a granulomatous inflammation that is not explained by any other identifiable cause, such as an infection or foreign body. Non-caseating granulomas containing epithelioid cells are its histological hallmark. Recently developed diagnostic techniques, including positron emission tomography and magnetic resonance imaging, have made it easier to detect organ involvement and to assess the activity of the disease. The pattern of organ involvement varies from patient to patient. Many patients have a systemic inflammatory reaction with subfebrile or febrile temperatures, night sweats, weight loss, diminished physical reserve, and fatigue. Sarcoidosis often resolves spontaneously. Detection of organ involvement is not necessarily an indication for treatment, but treatment is clearly needed if there is symptomatic cardiac involvement or any involvement of the central nervous system. Oral corticosteroids are the first line of treatment. Their long-term use can cause serious complications.

CONCLUSION

The treatment of patients with sarcoidosis, particularly those with complicated disease courses, requires close collaboration of the primary care physician with a specialized interdisciplinary center.

Revisiting the role of environmental and climate factors on the epidemiology of Kawasaki disease

Can environmental factors, such as air-transported preformed toxins, be of key relevance to the health outcomes of poorly understood human ailments (e.g., rheumatic diseases such as vasculitides, some inflammatory diseases, or even severe childhood acquired heart diseases)? Can the physical, chemical, or biological features of air masses be linked to the emergence of diseases such as Kawasaki disease (KD), Henoch-Schönlein purpura, Takayasu's aortitis, and ANCA-associated vasculitis? These diseases surprisingly share some common epidemiological features. For example, they tend to appear as clusters of cases grouped geographically and temporarily progress in nonrandom sequences that repeat every year in a similar way. They also show concurrent trend changes within regions in countries and among different world regions. In this paper, we revisit transdisciplinary research on the role of environmental and climate factors in the epidemiology of KD as a paradigmatic example of this group of diseases. Early-warning systems based on environmental alerts, if successful, could be implemented as a way to better inform patients who are predisposed to, or at risk for, developing KD. Further research on the etiology of KD could facilitate the development of vaccines and specific medical therapies.

Indications for performing flexible bronchoscopy: Trends over 34 years at a tertiary care hospital

BACKGROUND AND AIM

Due to its easy maneuverability, patient comfort and documented safety as an outpatient procedure, flexible bronchoscopy (FB) has replaced rigid bronchoscopy for routine diagnostic use. Herein, we report our 34-year experience with outpatient performance of FB.

MATERIALS AND METHODS

This was a retrospective analysis of all FB procedures performed between September 1979 and November 2013 (period I: 1979-1990; period II: 1991-2000; period III: 2001-2013) in a tertiary care hospital. Demographic profile of patients, indications for performing FB, and annual and seasonal trends were noted from the records.

RESULTS

A total of 24,814 bronchoscopies were performed during the study period. The mean (SD) age of patients (71.6% males) was 48.4 (15.5) years. The number of procedures performed per decade showed an absolute increase by 322%. The most common indication for FB was suspected bronchogenic carcinoma (32.2%) followed by pulmonary infections (18.6%) and interstitial lung diseases (13%). The proportion of annual cases due to interstitial lung diseases (3.9% in period I to 16.2% in period III) increased over the years, whereas disorders such as hemoptysis and pleural effusion showed a declining trend as an indication for FB. A seasonal trend was observed for diseases such as sarcoidosis, bronchogenic carcinoma and pulmonary infections. Six deaths were encountered during the study period in patients undergoing FB.

CONCLUSION

FB is increasingly being performed in the diagnosis of respiratory disorders and is a safe outpatient procedure. Although bronchogenic carcinoma remains a common indication for performing FB, benign conditions such as pulmonary infections and sarcoidosis constitute important indications in the Indian scenario.

[Löfgren syndrome: a study of 80 cases]

BACKGROUND AND OBJECTIVE

Löfgren's syndrome is characterized by hiliar adenopathies, erythema nodosum and arthritis. It is a benign variant of sarcoidosis, common in the Mediterranean area. To describe the clinical characteristics, treatment and outcome of a series of patients diagnosed with Löfgren's syndrome.

PATIENTS AND METHODS

Retrospective design (1984-2013).

SETTING

Two university hospitals with a reference population of 1,015,000 inhabitants.

RESULTS

Eighty patients were diagnosed: 29 men and 51 women (mean age 42.3 years). Forty eight patients (60%) presented with the classical triad: hiliar adenopathies, erythema nodosum and arthritis; 18 (22%) with hiliar adenopathy and arthritis; 13 (16%) hiliar adenopathies and erythema nodosum. All showed abnormalities in the chest study. According to the radiological pattern, patients were classified in stage i-ii. Biopsy was performed in 39 patients and was diagnostic in 28. Treatment was based on non-steroidal anti-inflammatory drugs (54 patients, 67%) and corticosteroids (33 patients, 41%). Fourteen patients (17%) suffered a recurrence of the disease.

CONCLUSIONS

Löfgren's syndrome is a benign form of sarcoidosis with a well defined clinical pattern. Biopsy is usually not required. Recurrence is scarce. The disease has a good prognosis.

Cutaneous sarcoidosis: updates in the pathogenesis

Sarcoidosis is a multiorgan granulomatous disease in which the skin is one of the frequently involved target organs. Cutaneous involvement occurs in a third of patients with sarcoidosis and has protean manifestations. More than a century has passed since the initial description of sarcoidosis, but its cause continues to be an enigma. Recent studies have introduced several new insights into the pathogenesis of this disease. The aim of this literature review was to provide a comprehensive overview on the current updates in the pathogenesis of sarcoidosis. This review has revealed that several genetic polymorphisms are associated with an increased risk of developing sarcoidosis, suggesting that genetic susceptibility to sarcoidosis is probably polygenic. Environmental factors may also modify the susceptibility to sarcoidosis. Evidence favouring an infectious aetiology has been accumulating, but the results of studies are conflicting. The current concept is that the pathogenesis of sarcoidosis involves a T-helper-1-mediated immune response to environmental antigens in a genetically susceptible host. The studies carried out on sarcoidosis have largely focused on the pulmonary aspects and have been mainly conducted by respiratory physicians. In contrast, research conducted on the cutaneous aspects of sarcoidosis is comparatively limited. Although tremendous advances have been made, there is a significant gap between the vast knowledge accumulated on sarcoidosis in recent years and the understanding of this disease.

Seasonality of the onset of symptoms, tuberculin test anergy and Kveim positive reaction in a large cohort of patients with sarcoidosis

BACKGROUND AND OBJECTIVES

Sarcoidosis is a systemic granulomatous disease of unknown aetiology and pathogenesis. This study evaluated the seasonal variation in the onset of symptoms, Tuberculin anergy and Kveim positive reaction in a cohort of 492 patients with sarcoidosis and in a subgroup of 248 patients with known Kveim test responses.

METHODS

The medical records of 492 patients with sarcoidosis were retrospectively reviewed. Roger's test for cyclic variation was used to assess the statistical significance of the observed seasonal variation.

RESULTS

For all sarcoidosis patients (n = 492) the onset of symptoms was most frequent in spring (61.8%) and least frequent in summer (31.7%) (P < 0.001). For patients with Tuberculin anergy (n = 364) the onset of symptoms was most frequent in spring and least frequent in autumn (P < 0.001); there was no seasonal variation among Tuberculin positive patients (n = 128). Of those patients with a Kveim test result (n = 248), the onset of symptoms was most frequent in spring and least frequent in summer (P < 0.001); there was no seasonal variation for patients with a negative Kveim results (n = 50 patients).

CONCLUSIONS

The onset of the symptoms was most frequent in spring and least frequent in the second half of the year (summer or autumn) in patients with sarcoidosis, Tuberculin anergy and a positive Kveim reaction. The significance of this finding in relation to aetiology and clinical utility needs to be further assessed.