Management of sarcoidosis in clinical practice

Isolated bone marrow sarcoidosis presenting as fever of unknown origin in a case of chronic myeloid leukemia

Background

Isolated involvement of bone marrow in sarcoidosis has not been reported commonly. Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized by the presence of non-caseating granulomatous lesions. There should be high index of suspicion in patients having underlying lymphoproliferative malignancies.

Case presentation

We present a 27-year-old male, known case of chronic myeloid leukemia, presenting as fever of unknown origin diagnosed with isolated bone marrow sarcoidosis.

Repository Corticotropin Injection for the Treatment of Pulmonary Sarcoidosis: A Narrative Review

Although corticosteroids are the standard first-line therapy for pulmonary sarcoidosis, long-term and high-dose use of these drugs are associated with increased risk of adverse events and high healthcare utilization costs. Treatment guidelines for pulmonary sarcoidosis indicate that off-label immunomodulators and biologics may be warranted for severe disease. Repository corticotropin injection (RCI, Acthar^® Gel), a complex mixture of adrenocorticotropic hormone analogs and other pituitary peptides, is one of only two therapies approved by the US Food and Drug Administration for symptomatic pulmonary sarcoidosis and is recommended by current European Respiratory Society treatment guidelines for use on a case-by-case basis. With its unique anti-inflammatory and immunomodulatory mechanism of action through activation of melanocortin receptors in various cell types, RCI has demonstrated steroid-sparing properties. RCI has a long history of use in autoimmune and inflammatory disorders, with proven safety and efficacy for pulmonary sarcoidosis. In this narrative review, we present the clinical evidence for the safety and efficacy of RCI in the treatment of pulmonary sarcoidosis, identify where RCI falls within the current treatment guidelines, and describe the unique mechanism of action of RCI for promoting anti-inflammatory and immunomodulatory effects.

Sarcoidosis: A nationwide registry-based study of incidence, prevalence and diagnostic work-up

INTRODUCTION

The primary objective was to evaluate the prevalence and incidence of sarcoidosis, and secondly, to evaluate differences in incidence by age at diagnosis, gender, region, calendar year and treatment and to evaluate sarcoidosis-related diagnostic work-up.

METHODS

Patients diagnosed with sarcoidosis from 2001 to 2015 and information on diagnostic procedures three months before and after initial diagnosis were identified in the Danish National Patient Register. Incidence proportion and prevalence proportion were calculated using the total population count of Danish citizens.

RESULTS

We identified 8545 sarcoidosis cases. Mean age was 46.0 ± 15.0 years, male gender was overrepresented (56.2%) and systemic corticosteroid was initiated in 46% of cases. The prevalence was 77 per 100,000 citizens in 2015. From 2001 to 2015, the incidence varied from 11.3 to 14.8 per 100,000 per year. The age-associated incidence peaked at 30-39 years in both men (23.6 per 100,000 per year) and women (15.0 per 100,000 per year). Incidence varied from 10.4 to 15.7 per 100,000 per year among regions. In particular, the share of bronchoscopies and chest-computed tomography were high in the region with the highest incidence and low in the region with the lowest incidence. Invasive procedures were more frequently performed in patients treated with systemic corticosteroid.

CONCLUSION

We find an increasing incidence and prevalence of sarcoidosis, with a peak incidence for both men and women between 30 and 39 years of age. The share of procedures performed seems to correlate well with incidence and disease severity.

Novelties in Imaging of Thoracic Sarcoidosis

Sarcoidosis is a systemic granulomatous disease affecting various organs, and the lungs are the most commonly involved. According to guidelines, diagnosis relies on a consistent clinical picture, histological demonstration of non-caseating granulomas, and exclusion of other diseases with similar histological or clinical picture. Nevertheless, chest imaging plays an important role in both diagnostic assessment, allowing to avoid biopsy in some situations, and prognostic evaluation. Despite the demonstrated lower sensitivity of chest X-ray (CXR) in the evaluation of chest findings compared to high-resolution computed tomography (HRCT), CXR still retains a pivotal role in both diagnostic and prognostic assessment in sarcoidosis. Moreover, despite the huge progress made in the field of radiation dose reduction, chest magnetic resonance (MR), and quantitative imaging, very little research has focused on their application in sarcoidosis. In this review, we aim to describe the latest novelties in diagnostic and prognostic assessment of thoracic sarcoidosis and to identify the fields of research that require investigation.

Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis

Pulmonary sarcoidosis presents substantial management challenges, with limited evidence on effective therapies and phenotypes. In the absence of definitive evidence, expert consensus can supply clinically useful guidance in medicine. An international panel of 26 experts participated in a Delphi process to identify consensus on pharmacological management in sarcoidosis with the development of preliminary recommendations.

The modified Delphi process used three rounds. The first round focused on qualitative data collection with open-ended questions to ensure comprehensive inclusion of expert concepts. Rounds 2 and 3 applied quantitative assessments using an 11-point Likert scale to identify consensus.

Key consensus points included glucocorticoids as initial therapy for most patients, with non-biologics (immunomodulators), usually methotrexate, considered in severe or extrapulmonary disease requiring prolonged treatment, or as a steroid-sparing intervention in cases with high risk of steroid toxicity. Biologic therapies might be considered as additive therapy if non-biologics are insufficiently effective or are not tolerated with initial biologic therapy, usually with a tumour necrosis factor-α inhibitor, typically infliximab.

The Delphi methodology provided a platform to gain potentially valuable insight and interim guidance while awaiting evidenced-based contributions.

Expert consensus recommendations for a pulmonary sarcoidosis treatment algorithm from a modified Delphi process include corticosteroids as initial therapy, immunomodulators for steroid-sparing or severe disease, and biologics for very severe diseasehttp://bit.ly/2SmP3uG

The changing face of the European Respiratory Review

Three years have now passed since I took up the post of Chief Editor of the European Respiratory Review (ERR), one of the best experiences in my professional career. When Vincent Cottin handed over the helm to me, the ERR was already in excellent condition after his brilliant leadership and that of his predecessor Marc Humbert. Throughout my term of office I have tried to further open up the ERR to professionals from other areas of medicine and to involve countries that in the past have been less sensitive to our publication; all this thanks to an editorial board made up of junior and senior experts with very different skills and backgrounds.

The changing face of the European Respiratory Reviewhttp://ow.ly/jmVi30mTLTC

Relationship between radiologic patterns, pulmonary function values and bronchoalveolar lavage fluid cells in newly diagnosed sarcoidosis

BACKGROUND

The aim of the present study was to identify specious radiologic and/or physiologic prognostic marker(s), which lead to optimize of the patient follow-up frequency.

METHODS

Eighty consecutive patients with newly diagnosed pulmonary sarcoidosis. Patients underwent chest radiography, high-resolution computed tomography (HRCT) examination, pulmonary function tests (PFT), bronchoscopy with bronchoalveolar lavage (BAL) and lung biopsy, and bronchoalveolar lavage fluid (BALF) cell examination.

RESULTS

The reduction in PFT values seen in radiological sarcoidosis stage III was greater than that seen in stages I and II. The percentage of neutrophils in the lungs was found to increase in stages II and III. PFT indices were correlated negatively with the consolidation and ground glass opacities CT scores, but not with the micronodule or macronodule scores. The rise in the percentage of BALF lymphocytes was associated with the restriction pattern of PFT. The diagnostic value of BALF for sarcoidosis was higher when the typical radiologic patterns of stage I disease were found and that smoking decreased the diagnostic value of CD4/CD8 ratio.

CONCLUSIONS

This study supports the opinion that the staging of the pulmonary sarcoidosis with chest X-rays is still valuable from the prognostic point of view, because significant correlations between the radiologic stages of sarcoidosis and PFT parameters were found. Chest HRCT was significantly superior to chest X-ray in detecting mediastinal and pulmonary parenchymal changes. However, the prognostic role of HRCT needs to be better investigated evaluating serial examinations. Only consolidation and ground glass scores (neither of which are frequently found in sarcoidosis) hold prognostic value, since these were negatively correlated with PFT parameters.