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Crouser ED, Julian MW, Locke LW, Bicer S, Mitchell JR, Singha A, Kramer PJ, Rajaram MVS, Raman SV. The Renin-Angiotensin-Aldosterone System Regulates Sarcoidosis Granulomatous Inflammation. Am J Respir Crit Care Med 2024; 210:497-507. [PMID: 38941161 DOI: 10.1164/rccm.202402-0265oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/28/2024] [Indexed: 06/30/2024] Open
Abstract
Rationale: Sarcoidosis is a granulomatous disorder of unclear cause notable for abnormal elevation of blood and tissue ACE1 (angiotensin converting enzyme 1) levels and activity. ACE1 regulates the renin-angiotensin-aldosterone system (RAAS), the terminal product of which is aldosterone, which selectively engages mineralocorticoid receptors to promote inflammation. Objectives: We sought to determine whether the RAAS promotes sarcoidosis granuloma formation and related inflammatory responses. Methods: Using an established ex vivo model, we first determined whether aldosterone was produced by sarcoidosis granulomas and verified the presence of CYP11B2, the enzyme required for its production. We then evaluated the effects of selective inhibitors of ACE1 (captopril), angiotensin type 1 receptor (losartan), and mineralocorticoid receptors (spironolactone, eplerenone) on granuloma formation, reflected by computer image analysis-generated granuloma area, and selected cytokines incriminated in sarcoidosis pathogenesis. Measurements and Main Results: Aldosterone was spontaneously produced by sarcoidosis peripheral blood mononuclear cells, and both intra- and extracellular levels steadily increased during granuloma formation. In parallel, peripheral blood mononuclear cells were shown to express more CYP11B2 during granuloma formation. Significant inhibition of sarcoidosis granulomas and related cytokines (TNFα, IL-1β, IFNγ, IL-10) was observed in response to pretreatments with captopril, losartan, spironolactone, or eplerenone, comparable to that of prednisone. Conclusions: The RAAS is intact in sarcoidosis granulomas and contributes significantly to early granuloma formation and to related inflammatory mediator responses, with important implications for clinical management.
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Affiliation(s)
- Elliott D Crouser
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute
| | - Mark W Julian
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute
| | | | - Sabahattin Bicer
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute
- Department of Biomedical Engineering
| | | | - Arindam Singha
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute
| | - Patrick J Kramer
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute
| | - Murugesan V S Rajaram
- Department of Microbial Infection and Immunity, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
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2
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Seman SG, Bicer S, Julian MW, Mitchell JR, Kramer PJ, Crouser ED, Locke LW. Investigating cryopreserved PBMC functionality in an antigen-induced model of sarcoidosis granuloma formation. Biochem Biophys Res Commun 2024; 714:149993. [PMID: 38663096 DOI: 10.1016/j.bbrc.2024.149993] [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: 04/01/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024]
Abstract
Sarcoidosis, a systemic inflammatory disease, poses challenges in understanding its etiology and variable clinical courses. Despite ongoing uncertainty about causative agents and genetic predisposition, granuloma formation remains its hallmark feature. To address this, we developed a validated in vitro human granuloma model using patient-derived peripheral blood mononuclear cells (PBMCs), offering a dynamic platform for studying early granuloma formation and sarcoidosis pathogenesis. However, a current limitation of this model is its dependence on freshly isolated PBMCs obtained from whole blood. While cryopreservation is a common method for long-term sample preservation, the biological effects of freezing and thawing PBMCs on granuloma formation remain unclear. This study aimed to assess the viability and functionality of cryopreserved sarcoidosis PBMCs within the granuloma model, revealing similar granulomatous responses to fresh cells and highlighting the potential of cryopreserved PBMCs as a valuable tool for studying sarcoidosis and related diseases.
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Affiliation(s)
- Sarah G Seman
- Biomedical Engineering Department, The Ohio State University College of Engineering, The Ohio State University, Columbus, OH, USA.
| | - Sabahattin Bicer
- Biomedical Engineering Department, The Ohio State University College of Engineering, The Ohio State University, Columbus, OH, USA.
| | - Mark W Julian
- Division of Pulmonary, Critical Care and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Jonah R Mitchell
- Biomedical Engineering Department, The Ohio State University College of Engineering, The Ohio State University, Columbus, OH, USA.
| | - Patrick J Kramer
- Division of Pulmonary, Critical Care and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Landon W Locke
- Biomedical Engineering Department, The Ohio State University College of Engineering, The Ohio State University, Columbus, OH, USA.
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van Wijck RTA, Sharma HS, Swagemakers SMA, Dik WA, IJspeert H, Dalm VASH, van Daele PLA, van Hagen PM, van der Spek PJ. Bioinformatic meta-analysis reveals novel differentially expressed genes and pathways in sarcoidosis. Front Med (Lausanne) 2024; 11:1381031. [PMID: 38938383 PMCID: PMC11208482 DOI: 10.3389/fmed.2024.1381031] [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: 02/02/2024] [Accepted: 05/23/2024] [Indexed: 06/29/2024] Open
Abstract
Introduction Sarcoidosis is a multi-system inflammatory disease of unknown origin with heterogeneous clinical manifestations varying from a single organ non-caseating granuloma site to chronic systemic inflammation and fibrosis. Gene expression studies have suggested several genes and pathways implicated in the pathogenesis of sarcoidosis, however, due to differences in study design and variable statistical approaches, results were frequently not reproducible or concordant. Therefore, meta-analysis of sarcoidosis gene-expression datasets is of great importance to robustly establish differentially expressed genes and signalling pathways. Methods We performed meta-analysis on 22 published gene-expression studies on sarcoidosis. Datasets were analysed systematically using same statistical cut-offs. Differentially expressed genes were identified by pooling of p-values using Edgington's method and analysed for pathways using Ingenuity Pathway Analysis software. Results A consistent and significant signature of novel and well-known genes was identified, those collectively implicated both type I and type II interferon mediated signalling pathways in sarcoidosis. In silico functional analysis showed consistent downregulation of eukaryotic initiation factor 2 signalling, whereas cytokines like interferons and transcription factor STAT1 were upregulated. Furthermore, we analysed affected tissues to detect differentially expressed genes likely to be involved in granuloma biology. This revealed that matrix metallopeptidase 12 was exclusively upregulated in affected tissues, suggesting a crucial role in disease pathogenesis. Discussion Our analysis provides a concise gene signature in sarcoidosis and expands our knowledge about the pathogenesis. Our results are of importance to improve current diagnostic approaches and monitoring strategies as well as in the development of targeted therapeutics.
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Affiliation(s)
- Rogier T. A. van Wijck
- Department of Pathology & Clinical Bioinformatics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hari S. Sharma
- Department of Pathology & Clinical Bioinformatics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sigrid M. A. Swagemakers
- Department of Pathology & Clinical Bioinformatics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Willem A. Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hanna IJspeert
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Virgil A. S. H. Dalm
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Allergy & Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul L. A. van Daele
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Allergy & Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - P. Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Allergy & Clinical Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Peter J. van der Spek
- Department of Pathology & Clinical Bioinformatics, Erasmus MC University Medical Center, Rotterdam, Netherlands
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4
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Bhargava M, Crouser ED. Application of laboratory models for sarcoidosis research. J Autoimmun 2024:103184. [PMID: 38443221 DOI: 10.1016/j.jaut.2024.103184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
This manuscript will review the implications and applications of sarcoidosis models towards advancing our understanding of sarcoidosis disease mechanisms, identification of biomarkers, and preclinical testing of novel therapies. Emerging disease models and innovative research tools will also be considered.
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Affiliation(s)
- Maneesh Bhargava
- University of Minnesota Medical Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, 420 Delaware Street SE, MMC 276. Minneapolis, MN 55455, USA
| | - Elliott D Crouser
- Ohio State University Wexner Medicine Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, 241 W. 11th Street, Suite 5000, Columbus, OH 43201, USA.
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5
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Weeratunga P, Moller DR, Ho LP. Immune mechanisms of granuloma formation in sarcoidosis and tuberculosis. J Clin Invest 2024; 134:e175264. [PMID: 38165044 PMCID: PMC10760966 DOI: 10.1172/jci175264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Sarcoidosis is a complex immune-mediated disease characterized by clusters of immune cells called granulomas. Despite major steps in understanding the cause of this disease, many questions remain. In this Review, we perform a mechanistic interrogation of the immune activities that contribute to granuloma formation in sarcoidosis and compare these processes with its closest mimic, tuberculosis, highlighting shared and divergent immune activities. We examine how Mycobacterium tuberculosis is sensed by the immune system; how the granuloma is initiated, formed, and perpetuated in tuberculosis compared with sarcoidosis; and the role of major innate and adaptive immune cells in shaping these processes. Finally, we draw these findings together around several recent high-resolution studies of the granuloma in situ that utilized the latest advances in single-cell technology combined with spatial methods to analyze plausible disease mechanisms. We conclude with an overall view of granuloma formation in sarcoidosis.
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Affiliation(s)
- Praveen Weeratunga
- MRC Translational Immunology Discovery Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Ling-Pei Ho
- MRC Translational Immunology Discovery Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
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6
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Li L, Vestal B, Mroz MM, Liu S, MacPhail K, Griffin TJ, Yang IV, Maier LA, Bhargava M. Compartment-specific protein interactions in beryllium lung disease. ERJ Open Res 2023; 9:00138-2023. [PMID: 37965231 PMCID: PMC10641575 DOI: 10.1183/23120541.00138-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/14/2023] [Indexed: 11/16/2023] Open
Abstract
The study provides insights into proteins that may be relevant in BeS and CBD. It provides a framework to investigate the global changes in lung compartment-specific inflammatory cells to better understand the potential interplay of proteins in CBD. https://bit.ly/3PLNTXC.
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Affiliation(s)
- Li Li
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, CO, USA
- Division of Pulmonary and Critical Care Sciences, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brian Vestal
- Center for Genes, Environment and Health, National Jewish Health, Denver, CO, USA
- Department of Biostatistics and Bioinformatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Margaret M. Mroz
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sucai Liu
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Kristyn MacPhail
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Tim J. Griffin
- Department of Biochemistry, Molecular Biology, and Biophysics, Center for Mass Spectrometry and Proteomics, University of Minnesota, Minneapolis, MN, USA
| | - Ivana V. Yang
- Division of Pulmonary and Critical Care Sciences, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lisa A. Maier
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, CO, USA
- Division of Pulmonary and Critical Care Sciences, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maneesh Bhargava
- Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Hwang E, Abdelghaffar M, Shields BE, Damsky W. Molecularly Targeted Therapies for Inflammatory Cutaneous Granulomatous Disorders: A Review of the Evidence and Implications for Understanding Disease Pathogenesis. JID INNOVATIONS 2023; 3:100220. [PMID: 37719661 PMCID: PMC10500476 DOI: 10.1016/j.xjidi.2023.100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 09/19/2023] Open
Abstract
Inflammatory cutaneous granulomatous diseases, including granuloma annulare, cutaneous sarcoidosis, and necrobiosis lipoidica, are distinct diseases unified by the hallmark of macrophage accumulation and activation in the skin. There are currently no Food and Drug Administration-approved therapies for these conditions except prednisone and repository corticotropin injection for pulmonary sarcoidosis. Treatment of these diseases has generally been guided by low-quality evidence and may involve broadly immunomodulatory medications. Development of new treatments has in part been limited by an incomplete understanding of disease pathogenesis. Recently, there has been substantial progress in better understanding the molecular pathogenesis of these disorders, opening the door for therapeutic innovation. Likewise, reported outcomes of treatment with immunologically targeted therapies may offer insights into disease pathogenesis. In this systematic review, we summarize progress in deciphering the pathomechanisms of these disorders and discuss this in the context of emerging evidence on the use of molecularly targeted therapies in treatment of these diseases.
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Affiliation(s)
- Erica Hwang
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, Bahrain
| | - Bridget E. Shields
- Department of Dermatology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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8
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Single-cell and spatial transcriptomics reveal aberrant lymphoid developmental programs driving granuloma formation. Immunity 2023; 56:289-306.e7. [PMID: 36750099 PMCID: PMC9942876 DOI: 10.1016/j.immuni.2023.01.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/27/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
Granulomas are lumps of immune cells that can form in various organs. Most granulomas appear unstructured, yet they have some resemblance to lymphoid organs. To better understand granuloma formation, we performed single-cell sequencing and spatial transcriptomics on granulomas from patients with sarcoidosis and bioinformatically reconstructed the underlying gene regulatory networks. We discovered an immune stimulatory environment in granulomas that repurposes transcriptional programs associated with lymphoid organ development. Granuloma formation followed characteristic spatial patterns and involved genes linked to immunometabolism, cytokine and chemokine signaling, and extracellular matrix remodeling. Three cell types emerged as key players in granuloma formation: metabolically reprogrammed macrophages, cytokine-producing Th17.1 cells, and fibroblasts with inflammatory and tissue-remodeling phenotypes. Pharmacological inhibition of one of the identified processes attenuated granuloma formation in a sarcoidosis mouse model. We show that human granulomas adopt characteristic aspects of normal lymphoid organ development in aberrant combinations, indicating that granulomas constitute aberrant lymphoid organs.
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Offman E, Singh N, Julian MW, Locke LW, Bicer S, Mitchell J, Matthews T, Anderson K, Crouser ED. Leveraging in vitro and pharmacokinetic models to support bench to bedside investigation of XTMAB-16 as a novel pulmonary sarcoidosis treatment. Front Pharmacol 2023; 14:1066454. [PMID: 37021060 PMCID: PMC10067675 DOI: 10.3389/fphar.2023.1066454] [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: 10/20/2022] [Accepted: 02/24/2023] [Indexed: 04/07/2023] Open
Abstract
Background: Sarcoidosis is a chronic, multisystem inflammatory disorder characterized by non-caseating epithelioid granulomas; infiltration of mononuclear cells; and destruction of microarchitecture in the skin, eye, heart, and central nervous system, and the lung in >90% of cases. XTMAB-16 is a chimeric anti-tumor necrosis factor alpha (TNFα) antibody, distinct from other anti-TNF antibodies based on its molecular structure. The efficacy of XTMAB-16 has not been clinically demonstrated, and it is still undergoing clinical development as a potential treatment for sarcoidosis. The current study demonstrates the activity of XTMAB-16 in a well-established in vitro sarcoidosis granuloma model, although XTMAB-16 is not yet approved by the United States Food and Drug Administration (FDA) for treatment of sarcoidosis, or any other disease. Objective: To provide data to guide safe and efficacious dose selection for the ongoing clinical development of XTMAB-16 as a potential treatment for sarcoidosis. Methods: First, XTMAB-16 activity was evaluated in an established in vitro model of granuloma formation using peripheral blood mononuclear cells from patients with active pulmonary sarcoidosis to determine a potentially efficacious dose range. Second, data obtained from the first-in-human study of XTMAB-16 (NCT04971395) were used to develop a population pharmacokinetic (PPK) model to characterize the pharmacokinetics (PK) of XTMAB-16. Model simulations were performed to evaluate the sources of PK variability and to predict interstitial lung exposure based on concentrations in the in vitro granuloma model. Results: XTMAB-16 dose levels of 2 and 4 mg/kg, once every 2 weeks (Q2W) or once every 4 weeks (Q4W) for up to 12 weeks, were supported by data from the non-clinical, in vitro secondary pharmacology; the Phase 1 clinical study; and the PPK model developed to guide dose level and frequency assumptions. XTMAB-16 inhibited granuloma formation and suppressed interleukin-1β (IL-1β) secretion in the in vitro granuloma model with a half maximal inhibitory concentration (IC50) of 5.2 and 3.5 μg/mL, respectively. Interstitial lung concentrations on average, following 2 or 4 mg/kg administered Q2W or Q4W, are anticipated to exceed the in vitro IC50 concentrations. Conclusion: The data presented in this report provide a rationale for dose selection and support the continued clinical development of XTMAB-16 for patients with pulmonary sarcoidosis.
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Affiliation(s)
| | | | - Mark W. Julian
- Division of Pulmonary, Critical Care and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, United States
| | - Landon W. Locke
- Department of Microbial Infection and Immunity, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | - Sabahattin Bicer
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | - Jonah Mitchell
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | | | | | - Elliott D. Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine, The Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, United States
- *Correspondence: Elliott D. Crouser,
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10
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Weeratunga P, Moller DR, Ho LP. Immune mechanisms in fibrotic pulmonary sarcoidosis. Eur Respir Rev 2022; 31:220178. [PMID: 36543347 PMCID: PMC9879330 DOI: 10.1183/16000617.0178-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
Sarcoidosis is an immune-mediated disorder. Its immunopathology has been steadily mapped out over the past few decades. Despite this, the underpinning mechanisms for progressive fibrotic sarcoidosis is an almost uncharted area. Consequently, there has been little change in the clinical management of fibrotic sarcoidosis over the decades and an unfocused search for new therapeutics. In this review, we provide a comprehensive examination of the relevant immune findings in fibrotic and/or progressive pulmonary sarcoidosis and propose a unifying mechanism for the pathobiology of fibrosis in sarcoidosis.
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Affiliation(s)
- Praveen Weeratunga
- Oxford Sarcoidosis Clinic, Oxford Interstitial Lung Disease Service, Oxford, UK
- MRC Human Immunology Unit, University of Oxford, Oxford, UK
| | - David R Moller
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ling-Pei Ho
- Oxford Sarcoidosis Clinic, Oxford Interstitial Lung Disease Service, Oxford, UK
- MRC Human Immunology Unit, University of Oxford, Oxford, UK
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11
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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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12
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Abstract
PURPOSE OF REVIEW This review aims to describe how the clinical manifestations of sarcoidosis may be shaped by the effects of sex hormones and by age dependent changes in immune functions and physiology This review is intended to highlight the need to consider the effects of sex and sex in future studies of sarcoidosis. RECENT FINDINGS The clinical manifestations of sarcoidosis differ based on sex and gender There is emerging evidence that female and male hormones and X-linked genes are important determinants of immune responses to environmental antigens, which has important implications for granuloma formation in the context of sarcoidosis Furthermore, sex hormone levels predictably change throughout adolescence and adulthood, and this occurs in parallel with the onset immune senescence and changes in physiology with advanced age. SUMMARY Recent studies indicate that sex and age are important variables shaping the immune response of humans to environmental antigens We posit herein that sex and age are important determinants of sarcoidosis clinical phenotypes Many gaps in our understanding of the roles played by sex and gender in sarcoidosis, and these need to be considered in future studies.
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Affiliation(s)
- Arindam Singha
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, Ohio
| | - Marina Kirkland
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wonder Drake
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, Ohio
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13
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Wu JH, Imadojemu S, Caplan AS. The Evolving Landscape of Cutaneous Sarcoidosis: Pathogenic Insight, Clinical Challenges, and New Frontiers in Therapy. Am J Clin Dermatol 2022; 23:499-514. [PMID: 35583850 DOI: 10.1007/s40257-022-00693-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Sarcoidosis is a multisystem disorder of unknown etiology characterized by accumulation of granulomas in affected tissue. Cutaneous manifestations are among the most common extrapulmonary manifestations in sarcoidosis and can lead to disfiguring disease requiring chronic therapy. In many patients, skin disease may be the first recognized manifestation of sarcoidosis, necessitating a thorough evaluation for systemic involvement. Although the precise etiology of sarcoidosis and the pathogenic mechanisms leading to granuloma formation, persistence, or resolution remain unclear, recent research has led to significant advances in our understanding of this disease. This article reviews recent advances in epidemiology, sarcoidosis clinical assessment with a focus on the dermatologist's role, disease pathogenesis, and new therapies in use and under investigation for cutaneous and systemic sarcoidosis.
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Affiliation(s)
- Julie H Wu
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA
| | - Sotonye Imadojemu
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA.
- New York University Sarcoidosis Program, New York University Grossman School of Medicine, New York, NY, USA.
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14
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Liu A, Sharma L, Yan X, Dela Cruz CS, Herzog EL, Ryu C. Emerging insights in sarcoidosis: moving forward through reverse translational research. Am J Physiol Lung Cell Mol Physiol 2022; 322:L518-L525. [PMID: 35196896 PMCID: PMC8957321 DOI: 10.1152/ajplung.00266.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/13/2021] [Accepted: 02/22/2022] [Indexed: 11/22/2022] Open
Abstract
Sarcoidosis is a chronic granulomatous disease of unknown etiology that primarily affects the lungs. The development of stage IV or fibrotic lung disease accounts for a significant proportion of the morbidity and mortality attributable to sarcoidosis. Further investigation into the active mechanisms of disease pathogenesis and fibrogenesis might illuminate fundamental mediators of injury and repair while providing new opportunities for clinical intervention. However, progress in sarcoidosis research has been hampered by the heterogeneity of clinical phenotypes and the lack of a consensus modeling system. Recently, reverse translational research, wherein observations made at the patient level catalyze hypothesis-driven research at the laboratory bench, has generated new discoveries regarding the immunopathogenic mechanisms of pulmonary granuloma formation, fibrogenesis, and disease model development. The purpose of this review is to highlight the promise and possibility of these novel investigative efforts.
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Affiliation(s)
- Angela Liu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Lokesh Sharma
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Xiting Yan
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Charles S Dela Cruz
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Erica L Herzog
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Changwan Ryu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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15
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Ganesan N, Ronsmans S, Vanoirbeek J, Hoet PHM. Assessment of Experimental Techniques That Facilitate Human Granuloma Formation in an In Vitro System: A Systematic Review. Cells 2022; 11:cells11050864. [PMID: 35269486 PMCID: PMC8909410 DOI: 10.3390/cells11050864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
The process of granuloma formation is complex, and due to species differences, the validity of animal studies is somewhat questioned. Moreover, the large number of animals needed to observe the different stages of development also raises ethical questions. Therefore, researchers have explored the use of human peripheral blood mononuclear cells (PBMCs), a heterogeneous population of immune cells, in an in vitro model. This review included in vitro studies that focused on exposing PBMCs—from healthy, sensitized, or diseased individuals—to antigens derived from infectious agents—such as mycobacteria or Schistosoma spp.—or inorganic antigens—such as beryllium. The reviewed studies mainly explored how human in vitro granuloma models can contribute towards understanding the pathogenesis of granulomatous diseases, especially during the early stages of granuloma formation. The feasibility of granuloma modelling was thus largely assessed via experimental techniques including (1) granuloma scoring indices (GI), (2) cell surface markers and (3) cytokine secretion profiling. While granuloma scoring showed some similarities between studies, a large variability of culture conditions and endpoints measured have been identified. The lack of any standardization currently impedes the success of a human in vitro granuloma model.
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Affiliation(s)
- Nirosha Ganesan
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3001 Leuven, Belgium; (N.G.); (J.V.)
| | - Steven Ronsmans
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, 3001 Leuven, Belgium;
| | - Jeroen Vanoirbeek
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3001 Leuven, Belgium; (N.G.); (J.V.)
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, 3001 Leuven, Belgium;
| | - Peter H. M. Hoet
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3001 Leuven, Belgium; (N.G.); (J.V.)
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, 3001 Leuven, Belgium;
- Correspondence:
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16
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Jeny F, Bernaudin JF, Valeyre D, Kambouchner M, Pretolani M, Nunes H, Planès C, Besnard V. Hypoxia Promotes a Mixed Inflammatory-Fibrotic Macrophages Phenotype in Active Sarcoidosis. Front Immunol 2021; 12:719009. [PMID: 34456926 PMCID: PMC8385772 DOI: 10.3389/fimmu.2021.719009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background Macrophages are pivotal cells in sarcoidosis. Monocytes-derived (MD) macrophages have recently been demonstrated to play a major role especially in pulmonary sarcoidosis. From inflammatory tissues to granulomas, they may be exposed to low oxygen tension environments. As hypoxia impact on sarcoidosis immune cells has never been addressed, we designed the present study to investigate MD-macrophages from sarcoidosis patients in this context. We hypothesized that hypoxia may induce functional changes on MD-macrophages which could have a potential impact on the course of sarcoidosis. Methods We studied MD-macrophages, from high active sarcoidosis (AS) (n=26), low active or inactive sarcoidosis (IS) (n=24) and healthy controls (n=34) exposed 24 hours to normoxia (21% O2) or hypoxia (1.5% O2). Different macrophage functions were explored: hypoxia-inducible factor-1α (HIF-1α) and nuclear factor-kappa B (NF-κB) activation, cytokines secretion, phagocytosis, CD80/CD86/HLA-DR expression, profibrotic response. Results We observed that hypoxia, with a significantly more pronounced effect in AS compared with controls and IS, increased the HIF-1α trans-activity, promoted a proinflammatory response (TNFα, IL1ß) without activating NF-κB pathway and a profibrotic response (TGFß1, PDGF-BB) with PAI-1 secretion associated with human lung fibroblast migration inhibition. These results were confirmed by immunodetection of HIF-1α and PAI-1 in granulomas observed in pulmonary biopsies from patients with sarcoidosis. Hypoxia also decreased the expression of CD80/CD86 and HLA-DR on MD-macrophages in the three groups while it did not impair phagocytosis and the expression of CD36 expression on cells in AS and IS at variance with controls. Conclusions Hypoxia had a significant impact on MD-macrophages from sarcoidosis patients, with the strongest effect seen in patients with high active disease. Therefore, hypoxia could play a significant role in sarcoidosis pathogenesis by increasing the macrophage proinflammatory response, maintaining phagocytosis and reducing antigen presentation, leading to a deficient T cell response. In addition, hypoxia could favor fibrosis by promoting profibrotic cytokines response and by sequestering fibroblasts in the vicinity of granulomas.
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Affiliation(s)
- Florence Jeny
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- AP-HP, Pulmonology Department, Avicenne Hospital, Bobigny, France
| | - Jean-François Bernaudin
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- Faculty of Medicine, Sorbonne University, Paris, France
| | - Dominique Valeyre
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- AP-HP, Pulmonology Department, Avicenne Hospital, Bobigny, France
| | - Marianne Kambouchner
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- AP-HP, Pathology Department, Avicenne Hospital, Bobigny, France
| | - Marina Pretolani
- Inserm UMR1152, Physiopathology and Epidemiology of Respiratory Diseases, Paris, France
- Faculty of Medicine, Bichat Hospital, Paris University, Paris, France
- Laboratory of Excellence, INFLAMEX, Paris University, DHU FIRE, Paris, France
| | - Hilario Nunes
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- AP-HP, Pulmonology Department, Avicenne Hospital, Bobigny, France
| | - Carole Planès
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
- AP-HP, Physiology Department, Avicenne Hospital, Bobigny, France
| | - Valérie Besnard
- INSERM UMR 1272, Sorbonne Paris-Nord University, Bobigny, France
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17
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Valeyre D, Bernaudin JF. Management of Sarcoidosis, a Selection of Topical Items Updating. J Clin Med 2020; 9:jcm9103220. [PMID: 33036457 PMCID: PMC7599542 DOI: 10.3390/jcm9103220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/01/2022] Open
Affiliation(s)
- Dominique Valeyre
- UMR INSERM 1272 Université Sorbonne Paris Nord, 93000 Bobigny, France;
- APHP Hôpital Avicenne, 93000 Bobigny, France
- Groupe Hospitalier Paris-Saint Joseph, 75014 Paris, France
- Correspondence:
| | - Jean-François Bernaudin
- UMR INSERM 1272 Université Sorbonne Paris Nord, 93000 Bobigny, France;
- APHP Hôpital Avicenne, 93000 Bobigny, France
- Faculté de Médecine, Sorbonne Université, 75013 Paris, France
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