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Nentwich K, Klingel K, Ene E, Müller J, Berkowitz A, Barth S, Deneke T. Cardiac sarcoidosis in patients with recurrent ventricular arrhythmias refractory to endocardial ablation. Clin Res Cardiol 2024:10.1007/s00392-024-02509-z. [PMID: 39190185 DOI: 10.1007/s00392-024-02509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 07/29/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION The clinical presentation of cardiac sarcoidosis is diverse. Detection of granuloma in histopathological evaluation proves the diagnosis, but endomyocardial biopsy (EMB) is associated with a high sampling error. However, prompt immunosuppressive therapy may significantly affect patient's prognosis. By analyzing our single center cohort of patients with recurrent ventricular arrhythmias (VA) and nonischemic cardiomyopathy after failure of endocardial ablation, we looked for additional markers supporting the diagnosis of cardiac sarcoidosis. METHOD In the last 4 years, 135 patients (mean age 49 y, 63% male) were hospitalized for epicardial ventricular arrhythmia (VA) ablation after failure of endocardial ablation. Nineteen patients had either previously received a diagnosis of cardiac sarcoidosis or were newly diagnosed. The mean follow-up time was 4.3 years. The ECG criteria, primary manifestation, histological findings in EMB, history of VT ablation, distribution of scars on MRI, electroanatomical mapping (EAM), PET CT findings, presence of atrial tachycardias, valve disease and comorbidities were analyzed. RESULTS Six of 19 (32%) patients showed right bundle block; 6 of 19 (32%) had AV nodal disease, including 4 patients with AV-block III; and 14 patients (73%) primarily presented with ventricular arrhythmias (including 3 with cardiac arrest). In all 19 patients cardiac EMB revealed elevated CD68 macrophages and CD3 T lymphocytes, and 7 of 19 were positive for granuloma (36,8%). Six of 6 patients (100%) undergoing PET CT showed acute inflammation. By analyzing the scar distribution, the most common locations were basal anteroseptal, basal inferoseptal, mid inferoseptal, mid inferior and the septal RV/RVOT. (septal substrate in 100%). There was a high correlation between the findings on the MRIs and low voltage in the electroanatomical mapping EAM). All patients received an immunosuppressive therapy. No patient died during follow-up, 1 patient had a high urgent heart transplant after withdrawal of steroid therapy. CONCLUSION Chronic untreated inflammation may be the underlying pathophysiology for patients with unspecific cardiomyopathy and recurrent VA refractory to endocardial and epicardial ablation. Septal substrate in the EAM/MRI, elevated CD3 lymphocytes in the EBM and inflammation in the PET CT may indicate the possible diagnosis of cardiac sarcoidosis. Initializing immunosuppressive therapy in patients with this dedicated constellation with should be taken into consideration.
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Affiliation(s)
- Karin Nentwich
- Department of Cardiology and Invasive Electrophysiology, Campus Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt, Germany.
| | - Karin Klingel
- Institute for Pathology and Neuropathology, Liebemeisterstrasse 8, 72076, Tübingen, Germany
| | - Elena Ene
- Department of Cardiology and Invasive Electrophysiology, Campus Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt, Germany
| | - Julian Müller
- Universitäts-Herzzentrum Freiburg Bad Krozingen Campus Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany
| | - Arthur Berkowitz
- Department of Cardiology and Invasive Electrophysiology, Campus Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt, Germany
| | - Sebastian Barth
- Department of Cardiology and Invasive Electrophysiology, Campus Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt, Germany
| | - Thomas Deneke
- Department of Cardiology and Invasive Electrophysiology, Campus Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt, Germany
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Madiraju A, Bhattaru A, Pham T, Pundyavana A, Rojulpote KV, Raynor WY, Werner TJ, Alavi A. Current uses and understanding of PET imaging in cardiac sarcoidosis. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2024; 14:161-174. [PMID: 39027647 PMCID: PMC11253081 DOI: 10.62347/nanx3492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/30/2024] [Indexed: 07/20/2024]
Abstract
Sarcoidosis is a systemic disease with unclear etiology characterized by the accumulation of noncaseating, immune granulomas in affected tissues. In cardiac sarcoidosis (CS), white blood cells build up within the heart muscles, causing cardiac abnormalities. Accurate and early diagnosis of CS proves challenging. However, usage of positron emission tomography (PET) imaging, namely 18F-FDG-PET, has proven successful in diagnosing inflammatory cardiomyopathy. This review seeks to examine the role of PET in managing ventricular tachycardia in cardiac sarcoidosis. PET, in conjunction with cardiac magnetic resonance imaging (CMR) is also endorsed as the premier method for diagnosis and management of arrhythmias associated with CS by The Heart Rhythm Society. After a CS diagnosis, risk stratification of ventricular arrhythmias is a necessity given the potential for sudden cardiac death. 18F-FDG-PET has been successful in monitoring disease advancement and treatment responses in CS patients. Early stages of CS are often treated with immunosuppression drugs if there are additional signs of VT. Currently, corticosteroid and anti-arrhythmia compounds: methotrexate, cyclophosphamide, infliximab, amiodarone, and azathioprine are used to suppress inflammation. 18F-FDG-PET has certainly proven to be an incredibly useful and accurate diagnostic tool of CS. While late gadolinium enhancement by CMR is efficient in detecting myocardial necrosis and/or advanced fibrosis scarring, 18F-FDG portrays the increased uptake level of glucose metabolism. In combination PET/MRI has proven to be more successful in improving the efficacy of both scans, addressing their drawbacks, and highlighting their advantages. Managing CS patients is highly involved in detecting inflammatory regions of the heart. Early recognition prevents cardiac abnormality, mainly VT and VF in CS patients, and extends lifespan.
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Affiliation(s)
- Alekhya Madiraju
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Abhijit Bhattaru
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
- Division of Cardiology, Department of Medicine, University of PennsylvaniaPhiladelphia, PA, USA
| | - Truongan Pham
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Anish Pundyavana
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Krishna Vamsi Rojulpote
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
- Division of Cardiology, Department of Medicine, University of PennsylvaniaPhiladelphia, PA, USA
| | - William Y Raynor
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Thomas J Werner
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
| | - Abass Alavi
- Department of Radiology, University of PennsylvaniaPhiladelphia, PA, USA
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Vereckei A, Besenyi Z, Nagy V, Radics B, Vágó H, Jenei Z, Katona G, Sepp R. Cardiac Sarcoidosis: A Comprehensive Clinical Review. Rev Cardiovasc Med 2024; 25:37. [PMID: 39077350 PMCID: PMC11263157 DOI: 10.31083/j.rcm2502037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/29/2023] [Accepted: 11/07/2023] [Indexed: 07/31/2024] Open
Abstract
Sarcoidosis is an inflammatory multisystemic disease of unknown etiology characterized by the formation of non-caseating granulomas. Sarcoidosis can affect any organ, predominantly the lungs, lymphatic system, skin and eyes. While > 90% of patients with sarcoidosis have lung involvement, an estimated 5% of patients with sarcoidosis have clinically manifest cardiac sarcoidosis (CS), whereas approximately 25% have asymptomatic, clinically silent cardiac involvement verified by autopsy or imaging studies. CS can present with conduction disturbances, ventricular arrhythmias, heart failure or sudden cardiac death. Approximately 30% of < 60-year-old patients presenting with unexplained high degree atrioventricular (AV) block or ventricular tachycardia are diagnosed with CS, therefore CS should be strongly considered in such patients. CS is the second leading cause of death among patients affected by sarcoidosis after pulmonary sarcoidosis, therefore its early recognition is important, because early treatment may prevent death from cardiovascular involvement. The establishment of isolated CS diagnosis sometimes can be quite difficult, when extracardiac disease cannot be verified. The other reason for the difficulty to diagnose CS is that CS is a chameleon of cardiology and it can mimic (completely or almost completely) different cardiac diseases, such as arrhythmogenic cardiomyopathy, giant cell myocarditis, dilated, restrictive and hypertrophic cardiomyopathies. In this review article we will discuss the current diagnosis and management of CS and delineate the potential difficulties and pitfalls of establishing the diagnosis in atypical cases of isolated CS.
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Affiliation(s)
- András Vereckei
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Zsuzsanna Besenyi
- Department of Nuclear Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Viktória Nagy
- Division of Non-Invasive Cardiology, Department of Medicine, University of
Szeged, 6720 Szeged, Hungary
| | - Bence Radics
- Department of Pathology, University of Szeged, 6720 Szeged, Hungary
| | - Hajnalka Vágó
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Zsigmond Jenei
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Gábor Katona
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Róbert Sepp
- Division of Non-Invasive Cardiology, Department of Medicine, University of
Szeged, 6720 Szeged, Hungary
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Kato S, Sakai Y, Okabe A, Kawashima Y, Kuwahara K, Shiogama K, Abe M, Ito H, Morimoto S. Histology of Cardiac Sarcoidosis with Novel Considerations Arranged upon a Pathologic Basis. J Clin Med 2022; 11:jcm11010251. [PMID: 35011991 PMCID: PMC8746035 DOI: 10.3390/jcm11010251] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022] Open
Abstract
Sarcoidosis is a rare disease of isolated or diffuse granulomatous inflammation. Although any organs can be affected by sarcoidosis, cardiac sarcoidosis is a fatal disorder, and it is crucial to accurately diagnose it to prevent sudden death due to dysrhythmia. Although endomyocardial biopsy is invasive and has limited sensitivity for identifying granulomas, it is the only modality that yields a definitive diagnosis of cardiac sarcoidosis. It is imperative to develop novel pathological approaches for the precise diagnosis of cardiac sarcoidosis. Here, we aimed to discuss commonly used diagnostic criteria for cardiac sarcoidosis and to summarize useful and novel histopathologic criteria of cardiac sarcoidosis. While classical histologic observations including noncaseating granulomas and multinucleated giant cells (typically Langhans type) are the most important findings, others such as microgranulomas, CD68+ CD163- pro-inflammatory (M1) macrophage accumulation, CD4/CD8 T-cell ratio, Cutibacterium acnes components, lymphangiogenesis, confluent fibrosis, and fatty infiltration may help to improve the sensitivity of endomyocardial biopsy for detecting cardiac sarcoidosis. These novel histologic findings are based on the pathology of cardiac sarcoidosis. We also discussed the principal histologic differential diagnoses of cardiac sarcoidosis, such as tuberculosis myocarditis, fungal myocarditis, giant cell myocarditis, and dilated cardiomyopathy.
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Affiliation(s)
- Shu Kato
- Postgraduate Clinical Training Center, Fujita Health University Hospital, Aichi 470-1192, Japan;
| | - Yasuhiro Sakai
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
- Correspondence: ; Tel.: +81-562-93-9934
| | - Asako Okabe
- Department of Diagnostic Pathology, Kansai Medical University Hospital, Osaka 573-1191, Japan;
| | - Yoshiaki Kawashima
- Department of Pathology, Fujita Health University Bantane Hospital, Aichi 454-8509, Japan;
| | - Kazuhiko Kuwahara
- Department of Diagnostic Pathology, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
| | - Kazuya Shiogama
- Department of Morphology and Pathological Diagnosis, Fujita Health University School of Medical Sciences, Aichi 470-1192, Japan; (K.S.); (M.A.)
| | - Masato Abe
- Department of Morphology and Pathological Diagnosis, Fujita Health University School of Medical Sciences, Aichi 470-1192, Japan; (K.S.); (M.A.)
| | - Hiroyasu Ito
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
| | - Shin’ichiro Morimoto
- Department of Cardiology, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
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Israeli-Shani L, King DA, Epstein Shochet G, Shitrit D, Wand O. Chylothorax associated with sarcoidosis: a review of the literature. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2022; 39:e2022039. [PMID: 36533603 PMCID: PMC9798341 DOI: 10.36141/svdld.v39i4.12050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To review the medical literature regarding chylothorax associated with sarcoidosis. METHODS A literature review of all reported cases of sarcoidosis-associated chylothorax, we included a novel case report to the analysis. RESULTS Of sixteen cases included in the study, 10 were women (62.5%), mean age 47±17years. In 6 subjects (37.5%) chylothorax was part of the initial presentation of sarcoidosis. Four subjects (25%) additionally suffered from lymphedema and chylous ascites, and one from chylous ascites only. Thoracic lymphadenopathy was reported for 13/16 subjects (81.3%) and lung parenchymal disease in 8/16 (50%). Compression of the thoracic duct was considered as a causative factor in 10 cases (62.5%). One case was attributed to granulomatous pleural inflammation, one to generalized lymphangiectasia, and no specific causative factors were identified in 4 remaining cases (25%). Overall mortality rate was 18.8% (3/16 subjects). Of note, all the subjects treated with corticosteroids survived. CONCLUSIONS Since the association of sarcoidosis with chylothorax is exceedingly rare, alternative etiologies should be pursued even when chylothorax develops in a subject with preexisting sarcoidosis. However, the possibility of sarcoidosis should be entertained when other etiologies for a newly diagnosed chylothorax are ruled out. A multidisciplinary approach is required for optimal management, both for elucidating the diagnosis and for employing therapy, which could be multimodal. A trial of immunosuppressive therapy with corticosteroids should be considered.
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Affiliation(s)
- Lilach Israeli-Shani
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A King
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gali Epstein Shochet
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shitrit
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Wand
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Lower left ventricular ejection fraction and higher serum angiotensin-converting enzyme activity are associated with histopathological diagnosis by endomyocardial biopsy in patients with cardiac sarcoidosis. Int J Cardiol 2020; 321:113-117. [PMID: 32730825 DOI: 10.1016/j.ijcard.2020.07.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The histopathological diagnosis of cardiac sarcoidosis (CS) is challenging because of sampling error in endomyocardial biopsy (EMB) and the determinants of positive EMB are unclear. Reduced left ventricular ejection fraction (LVEF) is a simple parameter of the extent of myocardial damage, and higher serum angiotensin-converting enzyme (ACE) activity would indicate the spread of disease activity in CS patients. Thus, we sought to examine whether these parameters are related to the histopathological diagnosis of CS by EMB. METHODS A total of 94 consecutive clinically diagnosed CS patients between August 1986 and March 2019 who were admitted to two academic hospitals were examined. We determined EMB as positive if non-caseating epithelioid granulomas were confirmed in the myocardial tissue. Patients were divided into two groups according to positive (n = 37) and negative (n = 57) EMB. We assessed the relationship between LVEF, serum ACE activity and positive EMB. RESULTS Multivariable analysis revealed that both LVEF and serum ACE were independently associated with positive EMB (OR 0.83, 95% CI 0.70-0.99; OR 1.39, 95% CI 1.02-1.90, respectively). Moreover, patients with both lower LVEF (<37%, median) and higher ACE activity (≥13.5 IU/L, median) had the highest frequency of positive EMB (p = .003). The combination of lower LVEF and higher serum ACE showed better specificity (91.2%) and positive predictive value (73.7%) than either LVEF or serum ACE alone for positive EMB. CONCLUSIONS Lower LVEF and higher serum ACE activity were associated with positive EMB, suggesting that these parameters might be useful for predicting positive EMB in CS patients.
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Oe Y, Ishibashi-Ueda H, Matsuyama TA, Kuo YH, Nagai T, Ikeda Y, Ohta-Ogo K, Noguchi T, Anzai T. Lymph Vessel Proliferation on Cardiac Biopsy May Help in the Diagnosis of Cardiac Sarcoidosis. J Am Heart Assoc 2020; 8:e010967. [PMID: 30636545 PMCID: PMC6497329 DOI: 10.1161/jaha.118.010967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background The diagnosis of cardiac sarcoidosis ( CS ) is challenging because endomyocardial biopsy has only a 20% to 30% sensitivity rate for diagnosis and it presents with similar clinical features of idiopathic dilated cardiomyopathy ( DCM ). Lymphatic vessel proliferation in pulmonary sarcoidosis has been previously demonstrated. In this study, we compared endomyocardial biopsy samples obtained from patients with CS and DCM to determine whether lymph vessel counts using D2-40 immunostaining can be utilized as a complementary tool to distinguish CS from DCM . Methods and Results Endomyocardial biopsy tissues were obtained from 62 patients with CS (30 patients with a diagnosis made histologically, 32 patients with a diagnosis made clinically), and hematoxylin/eosin, Masson trichrome, and D2-40 immunostaining were performed. Their results were compared with those from 53 patients with DCM. The histological CS group showed significantly increased lymphatic vessels (12.0 [4.0-40.0] versus 2.6 [1.9-3.4], P<0.0001) and more severe mosaic fibrosis ( P<0.0001) compared with the DCM group. The optimal threshold was 7.5 lymphatic vessels, and this resulted in a sensitivity of 0.67 and specificity of 0.96. The clinical CS group diagnosed according to Japanese Circulation Society 2016 criteria showed increased lymphatic vessels (4.0 [3.3-9.0] versus 2.6 [1.9-3.4], P<0.0001), more severe mosaic fibrosis ( P<0.0001), more inflammatory cell infiltration (53% versus 0%, P<0.0001), and fatty infiltration within fibroblasts (50% versus 17%, P=0.0012) compared with the DCM group. The optimal threshold of lymphatic vessels was 3.5, which resulted in a sensitivity of 0.75 and specificity of 0.68. Conclusions Lymphatic vessel counts using D2-40 immunostaining may help to distinguish clinical CS without granuloma from DCM .
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Affiliation(s)
- Yukiko Oe
- 1 Division of Pulmonary and Critical Care Medicine and Allergy and Rheumatology Department of Medicine Rutgers New Jersey Medical School Newark NJ.,2 Department of Pathology National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Taka-Aki Matsuyama
- 3 Department of Legal Medicine Showa University School of Medicine Tokyo Japan
| | - Yen-Hong Kuo
- 4 Biostatistics Core Office of Research Administration Hackensack Meridian Health Neptune NJ
| | - Toshiyuki Nagai
- 5 Department of Cardiovascular Medicine Hokkaido University Graduate School of Medicine Hokkaido Japan.,6 Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Yoshihiko Ikeda
- 2 Department of Pathology National Cerebral and Cardiovascular Center Osaka Japan
| | - Keiko Ohta-Ogo
- 2 Department of Pathology National Cerebral and Cardiovascular Center Osaka Japan
| | - Teruo Noguchi
- 6 Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Toshihisa Anzai
- 5 Department of Cardiovascular Medicine Hokkaido University Graduate School of Medicine Hokkaido Japan.,6 Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
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Patterson KC, Queval CJ, Gutierrez MG. Granulomatous Inflammation in Tuberculosis and Sarcoidosis: Does the Lymphatic System Contribute to Disease? Bioessays 2019; 41:e1900086. [PMID: 31588585 DOI: 10.1002/bies.201900086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/09/2019] [Indexed: 12/22/2022]
Abstract
A striking and unexplained feature of granulomatous inflammation is its anatomical association with the lymphatic system. Accumulating evidence suggests that lymphatic tracks and granulomas may alter the function of each other. The formation of new lymphatics, or lymphangiogenesis, is an adaptive response to tumor formation, infection, and wound healing. Granulomas also may induce lymphangiogenesis which, through a variety of mechanisms, could contribute to disease outcomes in tuberculosis and sarcoidosis. On the other hand, alterations in lymph node function and lymphatic draining may be primary events which attenuate the risk and severity of granulomatous inflammation. This review begins with an introduction of granulomatous inflammation and the lymphatic system. A role of the lymphatic system in tuberculosis and sarcoidosis is then hypothesized. With a focus on lymphangiogenesis in these diseases, and on the potential for this process to promote dissemination, parallels are established with the well-established role of lymphangiogenesis in tumor biology.
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Affiliation(s)
- Karen C Patterson
- Brighton and Sussex Medical School, 94N-SRd, Falmer, Brighton, BN1 9PX, UK.,Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Christophe J Queval
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Maximiliano G Gutierrez
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
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