Interferon-alpha therapy associated with the development of sarcoidosis

Granulomatous and Sarcoid-like Immune-Related Adverse Events following CTLA4 and PD1 Blockade Adjuvant Therapy of Melanoma: A Combined Analysis of ECOG-ACRIN E1609 and SWOG S1404 Phase III Trials and a Literature Review

BACKGROUND

Treatment with immune checkpoint inhibitors (ICIs) has been linked to granulomatous and sarcoid-like lesions (GSLs) affecting different organs. This study sought to evaluate GSL incidence in patients with high-risk melanoma treated with cytotoxic T-lymphocyte antigen 4 (CTLA4) or programmed cell death 1 (PD1) blockade adjuvant therapy in two clinical trials: ECOG-ACRIN E1609 and SWOG S1404. Descriptions and GSL severity ratings were recorded.

METHODS

Data were collected from ECOG-ACRIN E1609 and SWOG S1404. Descriptive statistics along with GSL severity grades were reported. Additionally, a literature review for such cases was summarized.

RESULTS

A total of 11 GSL cases were reported among 2878 patients treated with either ICI or with High-Dose Interferon Alfa-2b (HDI) in ECOG-ACRIN E1609 and SWOG S1404 trials. Cases were numerically more commonly reported with ipi10, followed by pembrolizumab, ipi3, and HDI, respectively. Most of the cases were grade III. Further, organs involved included lung, mediastinal lymph nodes, skin and subcutaneous tissue, and eye. Furthermore, a summary of 62 reports in the literature was described.

CONCLUSIONS

GSLs following anti-CTLA4 and anti-PD1 antibody therapy in patients with melanoma were reported unusually. Reported cases ranged in grade from I to III and appeared manageable. Careful attention to these events and their reporting will be essential to better guide practice and management guidelines.

Classic Hodgkin lymphoma with marked granulomatous reaction: A clinicopathologic study of 20 cases

Granulomatous reactions can be associated with various types of lymphoma, most commonly classic Hodgkin lymphoma (CHL). In some cases, the granulomatous reaction is extensive, obscuring the presence of neoplastic cells and potentially leading to delayed diagnosis and treatment. It is unknown if this subgroup of CHL has any unique clinicopathologic features. Here, we assessed the clinical and pathological features of 20 cases of CHL with a marked granulomatous reaction, defined in this study as granulomas representing ≥50% of the total cellularity/space of the specimen. This cohort of patients showed a male predominance (M:F ratio = 1.9:1) and 75% of patients were older than 40 years. Nineteen (95%) patients presented with lymphadenopathy with the neck/supraclavicular areas being most commonly involved (11/19; 58%). Advanced stage (III-IV) disease and B symptoms were present in 69% and 64% of patients, respectively. The morphologic features of these neoplasms fit best with mixed cellularity type. The Hodgkin and Reed-Sternberg (HRS) cells were positive for CD30, PAX5 (weak), pSTAT3 (80%), CD15 (70%), PD-L1 (67%), EBV-encoded small RNA (EBER)/LMP1 (50%) and CD20 (42%), and were negative for CD3, CD5, CD45, ALK and pERK. The histiocytes of the granulomas were positive for PD-L1 (67%), pSTAT3 (50%), and were negative for pERK and cyclin D1. Next generation sequencing using a 162-gene panel was negative for mutations in 4 cases. With a median follow-up of 58.9 months (range, 3.4-199.2 months), the median overall survival was 111 months and the 5-year overall survival was 78%. In summary, patients with CHL and a marked granulomatous reaction can present a diagnostic challenge and the pathologist must be alert to the possible presence of CHL to avert potential misdiagnosis. The histiocytes in the granulomas frequently express PD-L1, likely through the activation of the JAK/STAT pathway, suggesting a potential role for PD-1 blockade therapy in these patients.

Interferon-induced cutaneous sarcoidosis in melanoma

Interferon-induced cutaneous sarcoidosis in the adjuvant treatment of melanoma is a rare side effect. We present the case of a patient who developed two histologically confirmed subcutaneous sarcoid nodules 15 months after starting adjuvant therapy with interferon for lymph node metastatic melanoma in which the primary tumor was not known. The extension study, coinciding with occurrence of the nodules, showed no systemic sarcoidosis. This therefore represents the second reported case of interferon-induced cutaneous sarcoidosis in melanoma therapy. As computed axial tomography-PET or other imaging techniques are unable to differentiate between the radiological signs of melanoma metastasis and sarcoidosis, histological evaluation of the granulomatous lesions is essential with a view to avoiding unnecessary treatments.

Interferon versus methotrexate in intermediate uveitis with macular edema: results of a randomized controlled clinical trial

PURPOSE

To compare interferon (IFN) beta with methotrexate (MTX) in the treatment of intermediate uveitis with macular edema.

DESIGN

Monocentric, prospective, randomized, controlled clinical trial.

METHODS

SETTING

Specialized uveitis center at the University of Heidelberg. PATIENT OR STUDY POPULATION: Patients with either primary intermediate uveitis or uveitis associated with multiple sclerosis. MAIN INCLUSION CRITERIA: Visual acuity of 20/30 or worse (0.2 logarithm of the minimal angle of resolution) and macular edema of more than 250 μm (central 1-mm in optical coherence tomography; Stratus). Randomization into either IFN beta 44 μg subcutaneously 3 times weekly or 20 mg MTX subcutaneously once weekly.

MAIN OUTCOME MEASURES

At 3 months, the primary outcome parameter of mean change in visual acuity was evaluated and efficacy was determined. Secondary parameters were macular edema by optical coherence tomography, inflammatory activity, and retinal sensitivity by microperimetry (MP-1; Nidek). In case of treatment failure, switching to the other treatment arm was possible.

RESULTS

Nineteen patients were included. Ten were randomized to MTX, and 9 were randomized to IFN beta. At 3 months, visual acuity improved a mean 0.31 logarithm of the minimal angle of resolution (range, -0.02 to -0.96, 15.6 letters on the Early Treatment Diabetic Retinopathy Study chart) in the IFN beta group versus a mean 0.09 logarithm of the minimal angle of resolution (range, 0.12 to -0.38, 4.7 letters) in the MTX arm (P = .0435, Mann-Whitney U test). Macular thickness decreased by a mean of 206 μm (range, -41 to -416 μm) in the IFN arm, but increased by 47 μm (range, 108 to -28 μm) in the MTX group (P < .0001).

CONCLUSIONS

Although the sample size is small, results of the trial support superiority of IFN beta over MTX in the treatment of macular edema in the setting of intermediate uveitis.

Two cases of interferon-alpha-induced sarcoidosis Koebnerized along venous drainage lines: new pathogenic insights and review of the literature of interferon-induced sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin commonly affecting the lung, the lymphoid system and the skin. We report here two cases of cutaneous sarcoidosis in two former intravenous drug users following interferon (IFN)-α and ribavirin therapy for chronic hepatitis C. Both patients developed skin sarcoidosis along venous drainage lines of both forearms, coinciding with the areas of prior drug injections. The unique distribution of the skin lesions suggests that tissue damage induced by repeated percutaneous drug injections represents a trigger for the local skin manifestation of sarcoidosis. Interestingly, skin damage was recently found to induce the local expression IFN-α, a well-known trigger of sarcoidosis in predisposed individuals. Here we review the literature on sarcoidosis elicited in the context of IFN-α therapy and propose a new link between the endogenous expression of IFN-α and the induction of disease manifestations in injured skin.

Interferon-β-induced pulmonary sarcoidosis in a 30-year-old woman treated for multiple sclerosis: a case report

Introduction

With the increasing use of recombinant α and β interferon therapy for the treatment of various disorders, cases of interferon-associated sarcoidosis have been reported in the literature. The majority of these have been cases of interferon-α-induced sarcoidosis. We present the first case, to the best of our knowledge, of interferon-induced pulmonary sarcoidosis in a patient whose multiple sclerosis was treated with interferon-β.

Case presentation

We present the case of a 30-year-old Caucasian woman who presented with unusually persistent bilateral areas of lung consolidation on serial radiographs. Pulmonary sarcoidosis was diagnosed on transbronchial lung biopsy five months after the initiation of treatment with interferon-β for multiple sclerosis.

Conclusions

Sarcoidosis should be considered in the differential diagnosis of a patient who develops clinical or radiological pulmonary disease while undergoing interferon therapy. It is important to note that interferon-induced sarcoidosis, though usually seen in cases with interferon-α, can occur with interferon-β. Neurologists managing patients with multiple sclerosis should be aware of this association between interferon-β and sarcoidosis and promptly refer patients developing respiratory symptoms for further investigation.

Sarcoidosis induced by interferon-α in melanoma patients: incidence, clinical manifestations, and management strategies

Treatment with interferon-α has been recommended for patients with melanoma in case of micrometastases, or high risk melanoma, for example, ulcerated melanoma. Furthermore, regular dermatologic examination and regular imaging to detect recurrence or progression of disease is part of the management of melanoma patients. Sarcoidosis has been described as an adverse effect of treatment with interferon-α. Especially in hepatitis C patients, there is a series of case reports on sarcoidosis induced by interferon treatment whereas in melanoma this has rarely been reported. In a retrospective study, all melanoma patients treated with interferon-α at our hospital between 2007 and 2009 were screened for occurrence of sarcoidosis. Three of 16 melanoma patients treated with interferon-α (19%) presented with sarcoidosis. All 3 patients showed lesions with higher uptake in the positron emission tomography-computed tomography scan leading to the differential diagnosis of melanoma metastases or inflammation. Skin lesions were present in 1 patient. Diagnosis was confirmed by histologic assessment of lesions showing epithelioid granuloma-negative on Ziehl Neelson. Additional work-up included blood and urinalysis, electrocardiography, and ophthalmologic examination. Cessation of interferon-α led to regression of granulomas. Sarcoidosis induced by interferon-α in melanoma patients could be more common than previously thought. This is an important complication to be aware of as it can be mistaken for metastatic spread of melanoma and thus lead to incorrect therapy.

Prospective evaluation of drug-induced lung toxicity with high-resolution CT and transbronchial biopsy

PURPOSE

This study compared the results of high-resolution computed tomography (HRCT) and cytohistology after transbronchial biopsy in the evaluation of drug-related interstitial lung disease (DR-ILD).

MATERIALS AND METHODS

Patients with a clinical and imaging diagnosis of DR-ILD were prospectively included in a study protocol lasting 5 years. All patients were evaluated by bronchoscopy with transbronchial biopsy or bronchoalveolar lavage (BAL) following an HRCT examination that raised a suspicion of DR-ILD. Two radiologists (one senior and one junior), unaware of the diagnosis, reported the single HRCT findings, their distribution and predominant pattern. In the event of disagreement, the diagnosis was subsequently reached by consensus. Cytohistological examination was considered the gold standard in the diagnosis of DR-ILD. Patients who were unable to undergo the endoscopic procedure were excluded from the study.

RESULTS

The study included 42 patients (25 men, 17 women; age range 20-84 years). Transbronchial biopsy was performed in all but four patients (one case of alveolar haemorrhage and three cases of lipoid pneumonia) in whom the diagnosis was established with BAL. Assessment of the HRCT images revealed the following patterns: noncardiogenic pulmonary oedema (n=13); organising pneumonia (OP) (n=9); hypersensitivity pneumonitis (HP) (n=2); alveolar haemorrhage (AH) (n=2); nonspecific interstitial pneumonia (NSIP) (n=5); lipoid pneumonia (LP) (n=1); sarcoid-like pattern (n=1). Cytohistological diagnosis revealed diffuse alveolar damage (DAD) in 11 patients, OP in seven, HP in three, AH in three, chronic interstitial pneumonia (CIP) in eight, LP in three and pseudosarcoidosis in one. Subdivision of the drugs into antineoplastic and nonantineoplastic agents showed that the most common patterns were CIP (n=6), DAD (n=2) and OP (n=2) in the antineoplastic group and DAD (n=9) and OP (n=5) in the nonantineoplastic group. Sensitivity and specificity of the radiological analysis was excellent, especially for patterns such as OP and DAD (sensitivity 0.86 and specificity 0.88 for OP; sensitivity 1 and specificity 0.93 for DAD).

CONCLUSIONS

HRCT demonstrated excellent sensitivity and specificity. In cases in which its specificity was low, HRCT was nonetheless useful for biopsy planning and clinical-radiological monitoring after discontinuation of the drug treatment.

Development of sarcoidosis following completion of treatment for hepatitis C with pegylated interferon-{alpha}2a and ribavirin: a case report and literature review

Sarcoidosis is a chronic inflammatory multisystem disease of unknown etiology. We report on a woman, aged 57 years, presenting with typical sarcoidosis occurring two months after completion of a six-month course of interferon-α and ribavirin for chronic hepatitis C virus infection. The current observation is interesting with regard to the time elapsed between the occurrence of symptoms and antiviral treatment withdrawal, and spontaneous recovery after ten months of follow-up. Pathophysiological mechanisms involved in the development of antiviral therapy-induced sarcoidosis are discussed.

Irreversible pulmonary hypertension associated with the use of interferon alpha for chronic hepatitis C

The interferons are a complex group of virally induced proteins produced by activated macrophages and lymphocytes, which have become the mainstay of therapy for hepatitis C infection. Sustained viral response (SVR) rates in noncirrhotic patients vary from 40-80% with interferon-based therapy. This, along with transplantation, has drastically changed the course of hepatitis C virus (HCV) infection over the last two decades. Numerous side effects associated with interferon therapy have been reported. These range from transient flu-like symptoms to serious effects such as cardiac arrhythmias, cardiomyopathy, renal and liver failure, polyneuropathy, and myelosuppression. Pulmonary side effects including pneumonitis, pulmonary fibrosis, and reversible pulmonary hypertension have been reported. Herein, we present four cases in which irreversible pulmonary hypertension was diagnosed after prolonged treatment with interferon alpha. In each case, other causes of pulmonary hypertension were systematically eliminated. Pulmonary artery hypertension, which may be irreversible, should be considered in patients being treated with interferon alpha who present with exertional dyspnea and do not have a readily identifiable inflammatory or thromboembolic cause.

Safety, Tolerability, and Immunogenicity of Interferons

Interferons (IFNs) are class II cytokines that are key components of the innate immune response to virus infection. Three IFN sub-families, type I, II, and III IFNs have been identified in man, Recombinant analogues of type I IFNs, in particular IFNα2 and IFNβ1, have found wide application for the treatment of chronic viral hepatitis and remitting relapsing multiple sclerosis respectively. Type II IFN, or IFN gamma, is used principally for the treatment of chronic granulomatous disease, while the recently discovered type III IFNs, also known as IFN lambda or IL-28/29, are currently being evaluated for the treatment of chronic viral hepatitis. IFNs are in general well tolerated and the most common adverse events observed with IFNα or IFNβ therapy are “flu-like” symptoms such as fever, headache, chills, and myalgia. Prolonged treatment is associated with more serious adverse events including leucopenia, thrombocytopenia, increased hepatic transaminases, and neuropsychiatric effects. Type I IFNs bind to high-affinity cell surface receptors, composed of two transmembrane polypeptides IFNAR1 and IFNAR2, resulting in activation of the Janus kinases Jak1 and Tyk2, phosphorylation and activation of the latent cytoplasmic signal transducers and activators of transcription (STAT1) and STAT2, formation of a transcription complex together with IRF9, and activation of a specific set of genes that encode the effector molecules responsible for mediating the biological activities of type I IFNs. Systemic administration of type I IFN results in activation of IFN receptors present on essentially all types of nucleated cells, including neurons and hematopoietic stem cells, in addition to target cells. This may well explain the wide spectrum of IFN associated toxicities. Recent reports suggest that certain polymorphisms in type I IFN signaling molecules are associated with IFN-induced neutropenia and thrombocytopenia in patients with chronic hepatitis C. IFNγ binds to a cell-surface receptor composed of two transmembrane polypeptides IFGR1 and IFGR2 resulting in activation of the Janus kinases Jak1 and Jak2, phosphorylation of STAT1, formation of STAT1 homodimers, and activation of a specific set of genes that encode the effector molecules responsible for mediating its biological activity. In common with type I IFNs, IFNγ receptors are ubiquitous and a number of the genes activated by IFNγ are also activated by type I IFNs that may well account for a spectrum of toxicities similar to that associated with type I IFNs including “flu-like” symptoms, neutropenia, thrombocytopenia, and increased hepatic transaminases. Although type III IFNs share the major components of the signal transduction pathway and activate a similar set of IFN-stimulated genes (ISGs) as type I IFNs, distribution of the IFNλ receptor is restricted to certain cell types suggesting that IFNλ therapy may be associated with a reduced spectrum of toxicities relative to type I or type II IFNs. Repeated administration of recombinant IFNs can cause in a break in immune tolerance to self-antigens in some patients resulting in the production of neutralizing antibodies (NABs) to the recombinant protein homologue. Appearance of NABs is associated with reduced pharmacokinetics, pharmacodynamics, and a reduced clinical response. The lack of cross-neutralization of IFNβ by anti-IFNα NABs and vice versa, undoubtedly accounts for the apparent lack of toxicity associated with the presence of anti-IFN NABs with the exception of relatively mild infusion/injection reactions.

Adult respiratory distress syndrome after treatment with pegylated interferon alpha-2a and ribavirin

Pulmonary manifestations of interferon (IFN) use are a rare but well known complication seen with both standard and pegylated interferon alpha-2b (pegIFNalpha-2b) forms of the agent. These are generally of modest intensity and reversible. We report the first case of fulminant adult respiratory distress syndrome (ARDS) associated with pegylated interferon alpha-2a (pegIFNalpha-2a) and ribavirin use for hepatitis C, complicated by subsequent and ultimately fatal sepsis and multiorgan failure. Practicing gastroenterologists and intensivists alike need to be aware of the potential for serious pulmonary sequelae with the use of combination therapy for chronic hepatitis C viral (CHCV) infections.

Infiltrative lung diseases: complications of novel antineoplastic agents in patients with hematological malignancies

Infiltrative lung disease is a well-known complication of antineoplastic agents in patients with hematological malignancies. Novel agents are constantly being added to available treatments. The present review discusses different pulmonary syndromes, pathogenesis and management of these novel agents.

Sarcoidosis and malignancy

Malignancy in patients with sarcoidosis occurs in 3 settings. The first setting relates to patients with hematologic malignancies. It includes the sarcoidosis-lymphoma syndrome, which refers to the development of lymphoma at least 1 to 2 years after the diagnosis of sarcoidosis. It also includes patients with sarcoidosis who develop other hematologic malignancies. In addition, this subset of individuals includes patients with cancer and hematologic malignancies who subsequently develop sarcoidosis. The second setting consists of patients with sarcoidosis who develop solid tumors and oncologic patients in whom sarcoidosis subsequently appears; in addition to melanoma and nonmelanoma skin cancer, the neoplasms most commonly associated involve the cervix, liver, lung, testicles, and uterus. The third setting of malignancy-related sarcoidosis occurs when sarcoidosis presents as a paraneoplastic syndrome for the associated cancer, specifically when the discovery of cancer is concurrent with or within 1 year of the diagnosis of sarcoidosis or vis-a-vis. Antineoplastic treatment of either the hematologic malignancy or the solid tumor has also been observed to either induce the initial onset or flare the activity of sarcoidosis. Malignancy can also be associated with the occurrence of sarcoid reactions that typically are restricted to the regional lymph nodes or the visceral organ of tumor origin; rarely, the sarcoid reaction can also be observed in the skin or is only limited to the skin.

Granulomatous Adenohypophysitis after Interferon and Ribavirin Therapy

OBJECTIVE

To describe a case of granulomatous hypophysitis occurring after treatment with interferon alfa-2b and ribavirin for hepatitis C.

METHODS

Clinical, radiologic, laboratory, and pathologic assessments of a woman with granulomatous hypophysitis and interferon-induced thyroiditis are presented.

RESULTS

A 42-year-old woman with hepatitis C was treated with interferon alfa-2b and ribavirin for 5 months. She was referred after symptoms of thyrotoxicosis developed, in conjunction with laboratory and radiographic evidence of thyroiditis. During the initial evaluation, she was weak and hypotensive; biochemical evaluation showed undetectable plasma cortisol and corticotropin concentrations. Magnetic resonance imaging revealed diffuse enlargement of the pituitary gland, which encroached on but did not compress the optic chiasm. Treatment with supraphysiologic doses of prednisone resulted in clinical and radiographic improvement. Once physiologic doses of glucocorticoids were instituted, however, follow-up magnetic resonance imaging showed substantial progression of the diffuse pituitary enlargement and mild compression of the optic chiasm. Surgical debulking of the mass and histologic evaluation showed chronic, noncaseating granulomatous hypophysitis. An extensive evaluation for secondary causes of granulomatous inflammation of the pituitary revealed only an elevated angiotensin-converting enzyme level; no organisms were identified. After 2 courses of high-dose glucocorticoids, she had radiographic evidence of decreased size of the pituitary lesion but continued to have multiple anterior pituitary hormone deficiencies.

CONCLUSION

Granulomatous hypophysitis and sarcoidosis of the pituitary are rare disorders. Hypophysitis should be considered in patients receiving interferon and ribavirin therapy who have symptoms consistent with pituitary dysfunction.

Cutaneous, pulmonary and hepatic sarcoidosis associated with autoimmune complications during interferon-alpha treatment for hepatitis C virus infection

A patient with hepatitis C virus (HCV) infection was diagnosed with cutaneous, pulmonary and hepatic sarcoidosis following interferon alpha therapy. There are only a few cases of sarcoidosis associated with this treatment. This is the first case who not only developed sarcoidosis, but also autoimmune hypothyroidism and thrombocytopenia during interferon alpha therapy due to the immunomodulatory effects of the drug.

Sarcoidosis caused by interferon therapy

Interferon alpha (IFN-alpha) is an immunomodulator that is used as an antiviral agent in active chronic viral hepatitis C. IFN therapy can cause an induction or exacerbation of sarcoidosis. Although several reports in the gastroenterology literature have suggested an association between IFN therapy and sarcoidosis, this association has rarely been described elsewhere. A 47-year-old woman developed sarcoidosis after cessation of treatment with IFN and ribavirin for chronic hepatitis C. Her sarcoidosis showed liver, pulmonary and skin involvement. She continues to be monitored regularly in the Department of Pulmonary Diseases without steroid therapy. Her sarcoidosis improved spontaneously. We conclude that patients should be monitored for sarcoidosis during and after IFN therapy.

Interferon-induced sarcoidosis

Interferons (IFNs) are widely used for the treatment of various medical diseases. They have marked immunomodulatory effects, and many reports have been published associating IFN therapy with the induction of autoimmune phenomena and other disorders of immune regulation such as sarcoidosis. The clinical presentation of IFN-induced sarcoidosis (IIS) is insidious and can be confused with common constitutional side effects of these drugs. The age of onset of IIS is later than that of naturally occurring sarcoidosis. The most common organs involved are the lungs and skin. In the majority of cases, IIS follows a benign course. As we show in an illustrative case report, complete resolution after discontinuation of IFN therapy can be expected. This review summarises 65 cases of IIS reported in the literature and highlights the pathophysiology, clinical features, diagnostic modalities and therapeutic options for this increasingly recognised phenomenon.

[Pulmonary sarcoidosis associated with pegylated interferon in the treatment of chronic hepatitis C]

Treatment with pegylated interferon is usually used in active chronic hepatitis C in association with ribavirin. The adverse effects of interferon include influenza-like syndrome and mild respiratory manifestations, which are highly frequent. Among the immunomodulatory effects is the possibility of inducing or exacerbating autoimmune phenomena such as cutaneous or systemic sarcoidosis. We present a new case of pulmonary sarcoidosis induced by pegylated interferon in a 35 year-old woman with chronic hepatitis C who developed respiratory symptoms 4 months after starting therapy with pegylated interferon associated with ribavirin. Radiological images showed a micronodular pattern in both pulmonary fields together with hilar and mediastinal adenopathies. Transbronchial biopsy confirmed the presence of sarcoidal granulomas. After the diagnosis of pulmonary sarcoidosis, antiviral therapy was suspended with subsequent resolution of the clinical symptoms.

Granulomatous reactions cause symptoms or clinically imitate treatment resistance in small lymphocytic lymphoma/chronic lymphocytic leukaemia more frequently than in other non-Hodgkin lymphomas

AIMS

The electronic database of the institute of pathology, Medical University of Innsbruck, was reviewed and patient histories studied to analyse systematically the coincidence of granulomatous reactions and lymphomas in a large patient collective, and to find distinct clinicopathological correlations. Five cases of small lymphocytic lymphoma/chronic lymphocytic leukaemia (CLL) associated with granulomatous reactions in lymph nodes and bone marrow were identified, all clinically associated with signs of progressive disease.

METHODS

Cases were acquired by reviewing an electronic database comprising approximately 715,000 patients diagnosed between 1993 and 2003. Histochemical, immunohistochemical, and molecular techniques were used to verify diagnosis and associated infectious diseases. Clinical data were obtained from reviewing the charts.

RESULTS

Of 2044 bone marrow and 411 lymph node non-Hodgkin lymphoma biopsy samples, CLL was most frequently associated with bone marrow (two cases) and lymph node granulomas (three cases). These granulomas were mostly composed of epithelioid cells, with or without giant cells, and in all but one case did not show necrosis. All patients with CLL had clinical symptoms primarily caused by the granulomatous disease: two suffered from acid fast bacilli infections (Mycobacterium tuberculosis and mycobacteria other than tuberculosis) and three presented with clinical manifestations of sarcoidosis (the reason a diagnostic biopsy was performed).

CONCLUSIONS

Granulomatous reactions in patients with CLL might obscure diagnosis and imitate disease progression and Richter's transformation. Careful histological examination, exclusion of infectious agents, and a detailed clinical history are essential for correct diagnosis.

Sarcoidosis occurring after interferon-alpha therapy for chronic hepatitis C: Report of two cases

We report two patients who were diagnosed with sarcoidosis after receiving interferon (IFN)-alpha therapy for chronic hepatitis C, and conduct a review the relevant literature. The first patient was a 52-year-old female who developed multiple subcutaneous nodules 2 months after finishing IFN-alpha therapy. A skin biopsy from subcutaneous nodules on the right elbow joint revealed sarcoid granulomata. These lesions resolved spontaneously 4 months later. The second patient, a 57-year-old male, developed bilateral hilar and mediastinal lymph node enlargement 2 years after finishing IFN-alpha 2a therapy. A transbronchial lung biopsy demonstrated sarcoid granulomata. In addition, he had uveitis and left ulnar nerve involvement. His eye and nerve involvement gradually improved over 20 months. It is feasible that IFN therapy has been a trigger for sarcoidosis in these patients.

Uterine Sarcoidosis Potentially Associated With Interferon-α Use for Chronic Hepatitis C Infection

BACKGROUND

A regimen including interferon-alpha has become the standard of care in the treatment of chronic hepatitis C over the last decade. One rare adverse effect associated with the use of interferon-alpha is a granulomatous pulmonary reaction.

CASE

A unique case of uterine sarcoidosis associated with the use of interferon-alpha for chronic hepatitis C infection is presented.

CONCLUSION

Gynecologists should be aware of a potential association between interferon-alpha therapy and granulomatous reactions occurring not only in the lung but also in the female genital tract.

Sarcoidosis in patients with chronic hepatitis C virus infection: analysis of 68 cases

We describe the clinical characteristics, the patterns of association, and the role of antiviral therapies in patients with sarcoidosis associated with chronic hepatitis C virus (HCV) infection. Sixty-eight patients were included in the current study, 56 cases identified in the literature search plus 12 unpublished cases from our department. In 50 HCV patients, sarcoidosis appeared after starting antiviral therapy. Antiviral therapy associated with triggered sarcoidosis consisted of alpha-interferon monotherapy in 20 cases and combined therapy with alpha-interferon and ribavirin in 30. Sarcoidosis appeared during the first 6 months after starting therapy in 66% of patients. The clinical picture of sarcoidosis included predominantly pulmonary disease in 38 (76%) patients and cutaneous sarcoidosis in 30 (60%). Antiviral therapy was discontinued in 60% of patients and continued or adjusted in 14%, while sarcoidosis appeared after completed therapy in the remaining cases. Specific therapy for sarcoidosis was started in only 21 patients, mainly with oral corticosteroids. The outcome of patients was detailed in 46 cases: remission or improvement was observed in 38/46 (83%) patients, stabilization of sarcoidosis in 5/46 (11%), and reactivation of sarcoidosis after an initial improvement in 3/46 (6%). Finally, 18 treatment-naive HCV patients presented sarcoidosis, with 14/18 (87%) patients presenting with pulmonary involvement and 8/18 (44%) with cutaneous involvement. In summary, sarcoidosis may be observed in HCV patients in 2 different situations: triggered by antiviral therapy (in 75% of cases) and unrelated to treatment. Sarcoidosis during antiviral therapy may present mainly as cutaneous or pulmonary disease, with a benign, uncomplicated evolution in more than 85% of cases. However, more complicated cases are observed, especially in HCV patients with preexisting sarcoidosis and/or with previous antiviral treatment. Clinicians should be aware of the possibility that sarcoidosis may initially manifest or be reactivated during or shortly after treatment with antiviral therapy in patients with chronic HCV infection.

Spectrum of pulmonary toxicity associated with the use of interferon therapy for hepatitis C: case report and review of the literature

Hepatitis C is one of the leading causes of liver disease in the United States, and current recommendations for its treatment include the use of interferon (IFN). Pulmonary side effects, although uncommon, have been reported in association with the use of IFN. We report a case of interstitial granulomatous pneumonitis that occurred after therapy with IFN and ribavirin, and we review the literature concerning this entity and other forms of IFN-associated pulmonary toxicity in patients with hepatitis C. The purpose of the present study is to increase awareness of the unusually wide spectrum of pulmonary toxicities associated with the use of IFN and ribavirin, with the anticipation that IFN will be used more frequently in the future for the treatment of hepatitis C.

Interferon-induced granulomatous lung disease

PURPOSE OF REVIEW

Interferon therapy can induce or exacerbate sarcoidosis. With the increasing use of interferons it is highly likely that more cases of sarcoidosis will be encountered by clinicians. We describe three unusual cases of interferon-induced sarcoidosis and review the most recent relevant literature on this subject.

RECENT FINDINGS

Interferons, on account of their antiviral antigrowth and immunomodulatory effects, are used to treat various internal and dermatological diseases. Exogenously administered interferons stimulate the Th-1 response, which plays a major role in granuloma formation. In most of the patients with interferon-induced sarcoidosis, the disease subsides when interferon is discontinued. Occasionally, treatment with corticosteroids may become necessary.

SUMMARY

Interferon therapy can induce or exacerbate sarcoidosis, the disease disappears when interferon is discontinued, sometimes treatment with corticosteroids is required.

[Sarcoidosis granuloma on a tattoo induced by interferon alpha]

BACKGROUND

The side effects attributed to interferon alpha are numerous, including autoimmune events such as lupus, arthritis or thyroiditis. Emergence of sarcoidosis in patients with interferon alpha therapy is much more rare. We describe a case occurring in a patient treated for melanoma.

CASE REPORT

A 54 Year-old woman who had been treated for fifty Months with low dose interferon alpha (Roféron(R), 3 millions units, three times a week) for a melanoma of the scalp (adjuvant therapy), developed labial nodules on a permanent tattoo. The diagnosis of sarcoid granuloma was confirmed by histopathologic analysis. Physical examination revealed dyspnea on exertion with a moderate pulmonary interstitial infiltrate on the CT Scan. The diagnosis of cutaneous and pulmonary sarcoidosis in association with interferon alpha therapy was made. Within 4 weeks, skin nodules began to regress although interferon was pursued at the same dose. Four Months later, at the end of interferon therapy, the nodules had totally disappeared.

DISCUSSION

About forty cases of cutaneous or systemic sarcoidosis in patients treated with interferon alpha have been reported, but none of these cases concerned patients treated for melanoma. Interferon alpha might promote the development of sarcoid granuloma by inducing a switch of cytokine secretion from a Th2 to a Th1 cytokine pattern. It is very important to recognize cutaneous sarcoidosis during interferon alpha treatment because pulmonary sarcoidosis can be confused with common general side effects observed with such treatment.

Pegylated interferon and ribavirin-induced interstitial pneumonitis with ARDS

A 49-year-old man with cirrhosis due to hepatitis C virus developed interstitial pneumonitis documented by surgical lung biopsy specimen evaluation after two weekly doses of pegylated interferon-alpha(2)b in combination with ribavirin. He developed ARDS and died after 26 days of hospitalization from multisystem organ failure. This case suggests that interstitial pulmonary disease can occur with pegylated interferon-alpha(2)b therapy.

Sarcoidosis preceding chronic myelomonocytic leukemia. Report of two cases

We report 2 patients who had sarcoidosis with skin involvement associated with bilateral anterior uveitis. During the follow-up, they developed chronic myelomonocytic leukemia. This association is of particular interest as sarcoidosis and chronic myelomonocytic leukemia may be considered as disorders of a common monocyte-macrophage cell lineage.

Interferon-induced sarcoidosis

Interferons have been used as therapy of both malignant and nonmalignant diseases and commonly in the treatment of hepatitis C virus infection. Although the most commonly encountered side effects of interferon therapy include nonspecific constitutional symptoms, pulmonary involvement is rare. Here, we provide two documented cases of sarcoidosis appearing in patients receiving interferon therapy for hepatitis C infection, because there have only been a few reports of this association. Physicians should be aware of this uncommon yet clinically important complication, because imaging these patients may obviate more invasive procedures.

Interferons and their application in the diseases of the lung

Interferons (IFNs) are a family of cytokine mediators that are critically involved in alerting the cellular immune system to viral infections of host cells. There are three major classes of IFNs, as follows: IFN-alpha; IFN-beta; and IFN-gamma. IFNs are being investigated and applied in various respiratory disorders, including interstitial lung diseases, lung cancer, malignant mesothelioma, malignant pleural effusions, and respiratory infections. Recent promising preliminary results concerning patients with idiopathic pulmonary fibrosis who have been treated with IFN-gamma1b should prompt the performance of further confirmatory well-designed multicenter trials. IFN-gamma is emerging as an important cytokine for use in the treatment of patients with infectious diseases, including multidrug-resistant pulmonary TB. A better understanding of IFN biology, indications, side effect profiles, and toxicity management will aid in optimizing its use in the treatment of patients. The purpose of this article is, therefore, to review the current clinical use of IFNs in the treatment of patients with respiratory diseases.

Manifestation of sarcoidosis during interferon and ribavirin therapy for chronic hepatitis C: a report of two cases

Two patients with chronic hepatitis C were treated with alpha 2 beta (alpha2beta) interferon and ribavirin for 6 months. Neither patient responded to therapy. Both patients developed painless skin nodules, the histology of which was compatible with sarcoidosis. During therapy, both patients also had an elevation of angiotensin converting enzyme (ACE) levels. ACE levels reverted to normal and the skin lesions resolved a few months after cessation of interferon/ribavirin therapy. A repeat liver biopsy in one patient at the end of therapy revealed multiple hepatic granulomas (which were not evident on biopsy before therapy). In conclusion, interferon/ribavirin therapy can evoke a sarcoid-like response, with skin lesions, hepatic granuloma, and elevation of ACE levels. These appear to have been reversible in the above cases.

Immune-mediated complications during interferon therapy in hematological patients

Interferon (IFN), a leukocyte-derived cytokine, has been used to treat several hematological malignancies. The most common adverse effects of IFN are flu-like symptoms. Autoimmune side effects are infrequent but may be hazardous and irreversible. These may occur in several ways: autoantibodies may either appear during the treatment or existing titers may rise, subclinical autoimmune phenomena may become clinically manifest or autoimmune diseases may appear de novo. The main categories of IFN immune-mediated side effects are: thyroid, hematological, connective tissue, renal and miscellaneous disorders. The most common ones are thyroid disorders, which manifest either as hypo- or hyperthyroidism. Patients with pre-existing autoantibodies are more susceptible to the exacerbation of thyroid autoimmunity, probably since IFN enhances the levels of autoimmunity. Hematological disorders include autoimmune anemia and thrombocytopenia and thrombotic thrombocytopenic purpura. The immunological derangement of autoimmune hemolytic anemia manifests as enhanced destruction of antibody-coated red blood cells and induction of autoreactive B cells secreting these antibodies. Although autoimmune thrombocytopenia is rare, a sharp reduction in the platelet counts, beyond that expected from the antiproliferative effects of IFN, should raise this possibility. Thrombotic thrombocytopenic purpura has recently been included among the autoimmune disorders. Sporadic cases have been reported in association with IFN treatment. The clinical spectrum of IFN-induced connective tissue disorders ranges from typical systemic lupus erythematosus to seropositive or seronegative rheumatoid arthritis. Some authors also reported on the development of Behçet's disease in chronic myeloid leukemia patients treated with IFN. The underlying reason for the skin hyperreactivity in Behçet's disease and the effect of IFN treatment in these patients may be altered neutrophil activity in both disorders. Several series evaluated the incidence of Raynaud's phenomenon in patients treated with IFN for hematological disorders. Some of them reported on a rather high incidence of nailfold capillary microscopy abnormalities with or without Raynaud's phenomenon. Whether IFN-induced Raynaud's phenomenon is immune-mediated or directly caused vasospasm, is still unknown although the occurrence of several autoantibodies suggests an immune mechanism. Adverse effects of IFN therapy on the kidney include proteinuria and rarely nephrotic syndrome or acute and chronic renal failure. The mechanism of renal injury is unclear although an immune mechanism is suggested. Sporadic cases of other immune-mediated side effects have been published. These include dermatological adverse effects manifesting as psoriasis, pemphigus and vitiligo, and also rare cases of sarcoidosis, hepatitis, colitis or cryoglobulinemia. In conclusion, patients treated with IFN should be monitored for symptoms of autoimmunity. Patients with previous autoimmune phenomena should be treated, if possible, with alternative drugs since there is risk of exacerbation of these manifestations in these patients.

Cutaneous sarcoidosis during interferon alfa and ribavirin treatment of hepatitis C virus infection: two cases

Interferon-induced sarcoidosis is well documented. We report two new cases of sarcoidosis in two patients with hepatitis C virus infection treated with interferon alfa and ribavirin. These patients developed cutaneous sarcoidosis about 3 months after the beginning of the combination therapy. Spontaneous regression of the lesions was noted after discontinuation of the treatment. There have been more than 20 observations of the appearance or aggravation of this granulomatosis with interferon alfa and more recently with the combination of interferon alfa plus ribavirin. Dermatological signs are found in 50% of cases, and are often diagnostic. Other clinical symptoms of sarcoidosis resemble side-effects of interferon. The evolution is fairly stereotypical and is marked by a regression of the lesions following a dose reduction or curtailment of interferon. Interferon alfa acts by stimulating the T-helper (Th) 1 immune response. In addition to its antiviral action, ribavirin also enhances the Th1 response. Indeed, the superiority of the combination of interferon alfa and ribavirin in terms of antiviral action is corroborated by the enhancement of a Th1-type immune reaction by this combination. At the same time, this immune cell reaction triggers a greater granulomatous reaction.