Current best practice in the management of pulmonary and systemic sarcoidosis

Lung transplantation for sarcoidosis: outcome and prognostic factors

Study question

In patients with sarcoidosis, past and ongoing immunosuppressive regimens, recurrent disease in the transplant and extrapulmonary involvement may affect outcomes of lung transplantation. We asked whether sarcoidosis lung phenotypes can be differentiated and, if so, how they relate to outcomes in patients with pulmonary sarcoidosis treated by lung transplantation.

Patients and methods

We retrospectively reviewed data from 112 patients who met international diagnostic criteria for sarcoidosis and underwent lung or heart–lung transplantation between 2006 and 2019 at 16 European centres.

Results

Patient survival was the main outcome measure. At transplantation, median (interaquartile range (IQR)) age was 52 (46–59) years; 71 (64%) were male. Lung phenotypes were individualised as follows: 1) extended fibrosis only; 2) airflow obstruction; 3) severe pulmonary hypertension (sPH) and airflow obstruction; 4) sPH, airflow obstruction and fibrosis; 5) sPH and fibrosis; 6) airflow obstruction and fibrosis; 7) sPH; and 8) none of these criteria, in 17%, 16%, 17%, 14%, 11%, 9%, 5% and 11% of patients, respectively. Post-transplant survival rates after 1, 3, and 5 years were 86%, 76% and 69%, respectively. During follow-up (median (IQR) 46 (16–89) months), 31% of patients developed chronic lung allograft dysfunction. Age and extended lung fibrosis were associated with increased mortality. Pulmonary fibrosis predominating peripherally was associated with short-term complications.

Answer to the study question

Post-transplant survival in patients with pulmonary sarcoidosis was similar to that in patients with other indications for lung transplantation. The main factors associated with worse survival were older age and extensive pre-operative lung fibrosis.

FDG-PET Scan in Sarcoidosis: Clinical and Imaging Indications

BACKGROUND

Sarcoidosis is an unknown etiology multisystem inflammatory disease in which noncaseating granulomas (a collections of inflammatory cells) form and grow in various organs, involving predominantly lungs, intrathoracic lymph node, skin and eyes. It most commonly affects patients between 20 and 40 years old of age but it could be observed at any age (female predominance; rare in Asians).

DISCUSSION

The areas of the body usually affected by sarcoidosis are lungs, skin, or lymph nodes; pulmonary and mediastinal involvement is seen in over of 90% of patients. Less commonly eyes, liver, heart, and brain are involved. Any organ, however, can be affected. Early diagnosis of sarcoidosis can be difficult due to few signs and symptoms in its early stages, and when disease does occur, it may mimic other pathologies, and is made up with chest X-ray, Computed Tomography (CT)-High Resolution CT (HRCT), gallium scans. Fluoro-Deoxy Glucose- Positron Emission Tomography (FDG-PET) is another useful tool to assess the extent of disease and has a potential to evaluate the clinical management of patients responding or not to the treatment.

CONCLUSION

In this review, we would summarize in brief the clinical indications of PDG-PET in sarcoidosis and report the imaging features of the main organs involved in this disease.

EFFICIENCY AND SAFETY OF LEFLUNOMIDE TREATMENT IN PATIENTS WITH PULMONARY SARCOIDOSIS

Patients who have contraindications to the prescription of GCs (glucocorticosteroids), or have developed serious side effects during treatment with GCs, as well as patients with resistance to GCs therapy, are prescribed immunosuppressants. The aim of the research - to study the efficacy of leflunomide monotherapy in patients with pulmonary sarcoidosis with contraindications to prescription or serious side effects of glucocorticosteroids. Fourteen patients with sarcoidosis of the respiratory system of stage II were examined – 12 women and 2 men aged 30 to 69 years. In 10 patients there were contraindications to the appointment of GCs (diabetes mellitus – 5, hypertension – 3, obesity – 1, exacerbation of gastric ulcer – 1), which caused the appointment of immunosuppressive therapy as a starting. In 4 cases, serious side effects of SCs were noted, requiring the drug to be abolished (osteoporosis – 3, steroid diabetes – 1). Leflunomide was administered at a dose of 20 mg per day, daily for 3 months. The evaluation of efficacy was carried out using computed tomography of the thoracic cavity organs, body plethysmography, spirometry and determination of the diffusivity of the lungs. Monotherapy with leflunomide in patients with contraindications to prescription or serious side effects of GCs was successful in 7 out of 13 patients, in 2 patients there was a stabilization of the process, in 4 patients with leflunomide therapy progression of the disease was noted and in 1 case the treatment was discontinued due to serious side effects of preparation. The results obtained make it possible to recommend the use of leflunomide as monotherapy in patients with pulmonary sarcoidosis with contraindications to the prescription and/or poor tolerability of GCs and methotrexate. It is necessary to continue studying the possibilities of combined use of leflunomide with other drugs of the first line.

From granuloma to fibrosis: sarcoidosis associated pulmonary fibrosis

PURPOSE OF REVIEW

Up to twenty percent of patients with sarcoidosis develop pulmonary fibrosis, transforming an often benign disease into a highly morbid and potentially fatal one. We highlight the fibrotic pulmonary sarcoidosis phenotype as an area of intense clinical and translational investigation, review recent developments in treatment, and provide a roadmap for future research in sarcoidosis associated pulmonary fibrosis.

RECENT FINDINGS

Granulomatous inflammation in a lymphatic distribution is the hallmark finding of pulmonary sarcoidosis and the nidus for fibrosis. Recent research demonstrates that fibrotic sarcoidosis begins in the setting of persistent, uncontrolled inflammation, and is aided by pro-fibrotic genetic features and immune responses. Comparison to other fibrotic lung diseases also reveals key features that inform our understanding of common pathways in fibrosis.

SUMMARY

Understanding the mechanisms of fibrotic transformation in sarcoidosis enhances clinical care and facilitates development of novel therapeutic options. The impact of these findings in fibrotic sarcoidosis may be amplified through application to other interstitial lung diseases marked by inflammatory to fibrotic transformation. Important aspects of clinical management of fibrotic sarcoidosis include surveillance for co-morbidities, such as pulmonary hypertension, airway disease, and infection, and assessment for pulmonary disease activity that may benefit from immunosuppression.

Anti-TNFα therapy in inflammatory lung diseases

Increased levels of tumor necrosis factor (TNF) α have been linked to a number of pulmonary inflammatory diseases including asthma, chronic obstructive pulmonary disease (COPD), acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), sarcoidosis, and interstitial pulmonary fibrosis (IPF). TNFα plays multiple roles in disease pathology by inducing an accumulation of inflammatory cells, stimulating the generation of inflammatory mediators, and causing oxidative and nitrosative stress, airway hyperresponsiveness and tissue remodeling. TNFα-targeting biologics, therefore, present a potentially highly efficacious treatment option. This review summarizes current knowledge on the role of TNFα in pulmonary disease pathologies, with a focus on the therapeutic potential of TNFα-targeting agents in treating inflammatory lung diseases.

[Sarcoidosis and uveitis : An update]

Ocular involvement in sarcoidosis is present in up to one third of patients and is frequently manifested before the underlying systemic disease has been diagnosed. With a view to the therapeutic consequences an early diagnosis of the underlying disease is advantageous. In cases of visual loss early diagnostic measures include invasive procedures, such as ultrasound-guided bronchoalveolar lavage and transbronchial biopsy, if nodular conjunctival or cutaneous manifestations which would confirm the diagnosis are not present. Sufficiently sensitive biomarkers of disease activity have not yet been identified. As elevated activity of angiotensin-converting enzyme (ACE) and lysozyme are associated with disease activity they may be supportive of but not specific for the diagnosis. Other indicators include calcemia, calciuria, augmented activity of hepatic enzymes, cutaneous anergy and hilar changes in the lungs. In patients with newly diagnosed anterior uveitis presenting with granulomatous mutton-fat corneal precipitates, snow balls and vitreous body base condensates with mild retinal periphlebitis in intermediate uveitis as well as multifocal choroiditis (creamy choroidal lesions at different stages of activity and approximately 500 µm in diameter), a diagnosis of sarcoidosis has to be considered and tuberculosis should be excluded, even in the absence of a known systemic disease. Anterior uveitis is frequently a self-limiting condition, which can be well-controlled with topical steroids. On the other hand, intermediate, posterior and panuveitis are typically associated with a chronic course and require systemic therapy to prevent severe loss of vision. If the response to systemic corticosteroids is insufficient, treatment with immunomodulatory agents and biologics is initiated at progressively earlier stages, with a view to averting permanent organ damage and frequently with a positive impact on the short and long-term outcomes, even in therapy-refractive cases.

Lung transplantation for pulmonary sarcoidosis. Twenty-five years of experience in the USA

OBJECTIVE

Lung transplantation is the ultimate treatment for end-stage pulmonary sarcoidosis. Post-transplant survival outcomes remain unclear.

METHODS

Survival models were used to assess survival and graft outcomes in patients with sarcoid among 20,896 lung transplants performed in the USA.

RESULTS

695 lung recipients were transplanted for pulmonary sarcoidosis. Sarcoid lung recipients had similar median survival rate (69.7 months (IQR 60.2-79.3)) compared with the non-sarcoid lung recipients (63.1 months (IQR 61.4-64.8), p=0.88). In multivariate Cox regression, sarcoidosis was not independently associated with worse mortality (HR 0.96 (95% CI 0.85 to 1.08), p=0.51). Among the sarcoid lung recipients, double lung transplantation (HR 0.76 (0.58 to 0.99), p=0.04) and lung allocation score era (HR 0.74 (0.56 to 0.97), p=0.03) were associated with improved survival.

CONCLUSIONS

Recipients of lung transplants for pulmonary sarcoidosis had similar outcomes compared with non-sarcoid lung recipients.

The Management of Sarcoidosis: A Primary Care Approach

Sarcoidosis is an idiopathic inflammatory disorder characterized by noncaseating granulomas, which can affect any organ system. The lungs are most commonly affected but extrapulmonary sites may cause the initial and/or sole symptoms. In this review, the disease manifestations and treatment are described, with particular emphasis on the management of each affected organ system. Diagnosis and management can be difficult and greatly affect quality of life, but despite these challenges, it is possible to successfully manage patients with sarcoidosis in the primary care setting.

Systemic sarcoidosis mimicking malignant metastatic disease

We present a case of systemic sarcoidosis involving the liver, pancreas, lungs, mediastinal and intraabdominal lymph nodes and bones. Multiple organ system manifestations mimicked malignant metastatic disease. The diagnosis was established with clinical, radiological, and pathological findings after neoplasm was ruled out by pathological tests. The patient showed rapid symptom remission with systemic steroid treatment.

New-Onset Sarcoidosis After Remission of Cushing's Syndrome

Exposure to high levels of endogenous or exogenous glucocorticoids suppresses the inflammatory response genes. Excessive endogenous hypercortisolism may mask the active inflammatory diseases. Rebound immune modulation may occur after Cushing's syndrome (CS) remission, leading to the new onset of autoimmune diseases. Here, we report a 27-year-old female patient who was recently diagnosed with sarcoidosis after remission of CS. Normal thorax imaging showed that the patient was free of disease during the course of CS and without any symptoms of sarcoidosis. After complete remission of CS, she was diagnosed with sarcoidosis based on clinical and radiological evidence. Excessive hypercortisolism may suppress the active inflammatory stage of sarcoidosis. However, the disease became apparent after the reduction of cortisol levels following the treatment of CS.