1
|
Chioma OS, Wiggins Z, Rea S, Drake WP. Infectious and non-infectious precipitants of sarcoidosis. J Autoimmun 2024:103239. [PMID: 38821769 DOI: 10.1016/j.jaut.2024.103239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 04/04/2024] [Accepted: 05/02/2024] [Indexed: 06/02/2024]
Abstract
Sarcoidosis is a chronic inflammatory disease that can affect any organ in the body. Its exact cause remains unknown, but it is believed to result from a combination of genetic and environmental factors. Some potential causes of sarcoidosis include genetics, environmental triggers, immune system dysfunction, the gut microbiome, sex, and race/ethnicity. Genetic mutations are associated with protection against disease progression or an increased susceptibility to more severe disease, while exposure to certain chemicals, bacteria, viruses, or allergens can trigger the formation of immune cell congregations (granulomas) in different organs. Dysfunction of the immune system, including autoimmune reactions, may also contribute. The gut microbiome and factors such as being female or having African American, Scandinavian, Irish, or Puerto Rican heritage are additional contributors to disease outcome. Recent research has suggested that certain drugs, such as anti-Programmed Death-1 (PD-1) and antibiotics such as tuberculosis (TB) drugs, may raise the risk of developing sarcoidosis. Hormone levels, particularly higher levels of estrogen and progesterone in women, have also been linked to an increased likelihood of sarcoidosis. The diagnosis of sarcoidosis involves a comprehensive assessment that includes medical history, physical examination, laboratory tests, and imaging studies. While there is no cure for sarcoidosis, the symptoms can often be effectively managed through various treatment options. Treatment may involve the use of medications, surgical interventions, or lifestyle changes. These disparate factors suggests that sarcoidosis has multiple positive and negative exacerbants on disease severity, some of which can be ameliorated and others which cannot.
Collapse
Affiliation(s)
- Ozioma S Chioma
- Division of Infectious Disease, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - ZaDarreyal Wiggins
- Division of Infectious Disease, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Samantha Rea
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wonder P Drake
- Division of Infectious Disease, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
2
|
Miedema J, Cinetto F, Smed-Sörensen A, Spagnolo P. The immunopathogenesis of sarcoidosis. J Autoimmun 2024:103247. [PMID: 38734536 DOI: 10.1016/j.jaut.2024.103247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
Sarcoidosis is a granulomatous multiorgan disease, thought to result from exposure to yet unidentified antigens in genetically susceptible individuals. The exaggerated inflammatory response that leads to granuloma formation is highly complex and involves the innate and adaptive immune system. Consecutive immunological studies using advanced technology have increased our understanding of aberrantly activated immune cells, mediators and pathways that influence the formation, maintenance and resolution of granulomas. Over the years, it has become increasingly clear that disease immunopathogenesis can only be understood if the clinical heterogeneity of sarcoidosis is taken into consideration, along with the distribution of immune cells in peripheral blood and involved organs. Most studies offer an immunological snapshot during disease course, while the cellular composition of both the circulation and tissue microenvironment may change over time. Despite these challenges, novel insights on the role of the immune system are continuously published, thus bringing the field forward. This review highlights current knowledge on the innate and adaptive immune responses involved in sarcoidosis pathogenesis, as well as the pathways involved in non-resolving disease and fibrosis development. Additionally, we describe proposed immunological mechanisms responsible for drug-induced sarcoid like reactions. Although many aspects of disease immunopathogenesis remain to be unraveled, the identification of crucial immune reactions in sarcoidosis may help identify new treatment targets. We therefore also discuss potential therapies and future strategies based on the latest immunological findings.
Collapse
Affiliation(s)
- Jelle Miedema
- Department of Pulmonary Medicine, Center of Expertise for Interstitial Lung Disease, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca' Foncello Hospital, AULSS2 Marca Trevigiana, Italy; Department of Medicine - DIMED, University of Padova, Padova, Italy.
| | - Anna Smed-Sörensen
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| |
Collapse
|
3
|
Rosario KF, Brezitski K, Arps K, Milne M, Doss J, Karra R. Cardiac Sarcoidosis: Current Approaches to Diagnosis and Management. Curr Allergy Asthma Rep 2022; 22:171-182. [PMID: 36308680 DOI: 10.1007/s11882-022-01046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) is an important cause of non-ischemic cardiomyopathy and has specific diagnostic and therapeutic considerations. With advances in imaging techniques and treatment approaches, the approach to monitoring disease progression and management of CS continues to evolve. The purpose of this review is to highlight advances in CS diagnosis and treatment and present a center's multidisciplinary approach to CS care. RECENT FINDINGS In this review, we highlight advances in granuloma biology along with contemporary diagnostic approaches. Moreover, we expand on current targets of immunosuppression focused on granuloma biology and concurrent advances in the cardiovascular care of CS in light of recent guideline recommendations. Here, we review advances in the understanding of the sarcoidosis granuloma along with contemporary diagnostic and therapeutic considerations for CS. Additionally, we highlight knowledge gaps and areas for future research in CS treatment.
Collapse
Affiliation(s)
- Karen Flores Rosario
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kyla Brezitski
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kelly Arps
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Megan Milne
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Ravi Karra
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA.
- Department of Pathology, Duke University Medical Center, Box 102152 DUMC, Durham, NC, 27710, USA.
| |
Collapse
|
4
|
Pulmonary granulomatous inflammation after ceritinib treatment in advanced ALK-rearranged pulmonary adenocarcinoma. Invest New Drugs 2022; 40:1141-1145. [PMID: 35727390 PMCID: PMC9395502 DOI: 10.1007/s10637-022-01270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/13/2022] [Indexed: 02/05/2023]
Abstract
Ceritinib is a new anaplastic lymphoma kinase (ALK) inhibitor that has shown greater potency in patients with advanced ALK-rearranged non-small cell lung cancer, including those who had disease progression in crizotinib treatment. Here we reported, after several months of ceritinib treatment, two patients with advanced ALK-rearranged pulmonary adenocarcinoma exhibited a spectrum of respiratory symptoms like cough and dyspnea, with significantly higher inflammatory indicators. Chest computed tomography (CT) showed multiple bilateral and peripheral lesions in lungs. The prior considerations taken into account were disease progression or infection. However, biopsies of the pulmonary nodules revealed features of granulomatous inflammation without definite cancer cells. We documented for the first time that ceritinib might be associated with pulmonary granulomatous inflammation, and clinicians should be alert to the possibility that the rare adverse event emerged during ceritinib treatment.
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW Sarcoidosis is a complex granulomatous disease of unknown cause. Several drug categories are able to induce a systemic granulomatous indistinguishable from sarcoidosis, known as drug-induced sarcoidosis-like reaction (DISR). This granulomatous inflammation can resolve if the medication is discontinued. In this review, we discuss recent literature on medication associated with DISR, possible pathophysiology, clinical features, and treatment. RECENT FINDINGS Recently, increasing reports on DISR have expanded the list of drugs associated with the systemic granulomatous eruption. Most reported drugs can be categorized as combination antiretroviral therapy, tumor necrosis factor-α antagonist, interferons, and immune checkpoint inhibitors, but reports on other drugs are also published. The proposed mechanism is enhancement of the aberrant immune response which results in systemic granuloma formation. It is currently not possible to know whether DISR represents a separate entity or is a triggered but 'true' sarcoidosis.As DISRs may cause minimal symptoms, treatment is not always necessary and the benefits of continuing the offending drug should be weighed against clinical symptoms and organ dysfunction. Treatment may involve immunosuppressive medication that is used for sarcoidosis treatment. SUMMARY In this article, we review recent insights in DISR: associated drug categories, clinical presentation, diagnosis, and treatment. Additionally, we discuss possible mechanisms of DISR which can add to our knowledge of sarcoidosis pathophysiology.
Collapse
|
6
|
Nakamura H, Tateyama M, Tasato D, Haranaga S, Higa F, Matsuzaki A, Yoshimi N, Fujita J. Human immunodeficiency virus-associated pulmonary sarcoidosis in a Japanese man as a manifestation of immune reconstitution inflammatory syndrome. Clin Case Rep 2020; 8:3440-3444. [PMID: 33363948 PMCID: PMC7752423 DOI: 10.1002/ccr3.3438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022] Open
Abstract
Asymptomatic pulmonary sarcoidosis can develop after starting antiretroviral therapy. The decision on whether to treat sarcoidosis with corticosteroids should be based on the disease severity.
Collapse
Affiliation(s)
- Hideta Nakamura
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Masao Tateyama
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Daisuke Tasato
- Department of Respiratory MedicineHokubu Chiku Ishikai HospitalNagoJapan
| | - Shusaku Haranaga
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| | - Futoshi Higa
- Department of Respiratory MedicineNational Hospital Organization Okinawa National HospitalGinowanJapan
| | | | - Naoki Yoshimi
- Department of PathologyOkinawa Red Cross HospitalNahaJapan
| | - Jiro Fujita
- Department of Infectious, Respiratory, and Digestive MedicineUniversity of the Ryukyus Graduate of School of MedicineNishiharaJapan
| |
Collapse
|
7
|
Hanberg JS, Akgün KM, Hsieh E, Fraenkel L, Justice AC. Incidence and Presentation of Sarcoidosis With and Without HIV Infection. Open Forum Infect Dis 2020; 7:ofaa441. [PMID: 33123611 DOI: 10.1093/ofid/ofaa441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background Case reports describe incident sarcoidosis in persons with HIV (PWH). The association between HIV and risk of sarcoidosis, and differences in presentation in PWH, have not been systematically assessed. Methods Subjects were selected from the Veterans Aging Cohort Study (VACS), a longitudinal cohort study including veterans with HIV and matched uninfected veterans. This was a prospective observational analysis in which we evaluated both the incidence (via incidence rate ratio) and presentation and treatment (by comparison of rates of organ involvement and use of medications) of sarcoidosis in PWH compared with HIV-negative controls. We also assessed risk factors (via Cox regression) associated with the development of sarcoidosis including CD4 count and viral load trajectory. Results Of 1614 patients evaluated via chart review, 875 (54%) had prevalent sarcoidosis and 325 (20%) had confirmed incident sarcoidosis. Incident sarcoidosis occurred in 59 PWH and 266 uninfected. The incidence of sarcoidosis was lower in PWH than uninfected (incidence rate ratio [IRR], 0.61; 95% CI, 0.46-0.81) and especially low in patients with unsuppressed viremia (IRR, 0.04; 95% CI, 0.02-0.08) compared with uninfected). At diagnosis of sarcoidosis, the median CD4 count among PWH was 409 cells/mm3; 77% had HIV-1 RNA <500 copies/mL. No significant differences were observed between PWH and uninfected in terms of organ involvement, disease severity, or use of oral glucocorticoids. Conclusions HIV, particularly with persistent viremia, was associated with decreased risk of incident sarcoidosis; severity and treatment were similar between PWH and uninfected.
Collapse
Affiliation(s)
- Jennifer S Hanberg
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Kathleen M Akgün
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Evelyn Hsieh
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Section of Rheumatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Liana Fraenkel
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Section of Rheumatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Amy C Justice
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale University School of Public Health, New Haven, Connecticut, USA
| |
Collapse
|
8
|
Abstract
Sarcoidosis is an inflammatory disorder of unknown cause that is characterized by granuloma formation in affected organs, most often in the lungs. Patients frequently suffer from cough, shortness of breath, chest pain and pronounced fatigue and are at risk of developing lung fibrosis or irreversible damage to other organs. The disease develops in genetically predisposed individuals with exposure to an as-yet unknown antigen. Genetic factors affect not only the risk of developing sarcoidosis but also the disease course, which is highly variable and difficult to predict. The typical T cell accumulation, local T cell immune response and granuloma formation in the lungs indicate that the inflammatory response in sarcoidosis is induced by specific antigens, possibly including self-antigens, which is consistent with an autoimmune involvement. Diagnosis can be challenging for clinicians because of the potential for almost any organ to be affected. As the aetiology of sarcoidosis is unknown, no specific treatment and no pathognomic markers exist. Thus, improved biomarkers to determine disease activity and to identify patients at risk of developing fibrosis are needed. Corticosteroids still constitute the first-line treatment, but new treatment strategies, including those targeting quality-of-life issues, are being evaluated and should yield appropriate, personalized and more effective treatments.
Collapse
|
9
|
Ibrahim IA, Estaitieh OM, Alrabee HA, Alzahrani M. Sarcoidosis and HIV infection in a native Saudi man. BMJ Case Rep 2018; 2018:bcr-2018-224386. [PMID: 30287625 PMCID: PMC6194392 DOI: 10.1136/bcr-2018-224386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sarcoidosis is a rare condition among native Saudis. It typically presents with asymptomatic chest radiographs, exertional breathlessness and cough. The coexistence of sarcoidosis and HIV is also rare, and the overlap of the symptoms makes their differential diagnosis challenging. Nevertheless, the outcome of sarcoidosis is favourable with or without the presence of HIV. We present a case of a 55-year-old native Saudi man with extremely atypical sarcoidosis presentation coexisting with HIV. This case highlights the association between the two pathologies, and the difficulties encountered in establishing a proper diagnosis in the presence of two overlapping diseases.
Collapse
Affiliation(s)
- Islam A Ibrahim
- Internal Medicine, King Fahad Armed Force Hospital, Jeddah, Saudi Arabia
| | - Osama M Estaitieh
- Internal Medicine, King Fahad Armed Force Hospital, Jeddah, Saudi Arabia
| | - Hadeel A Alrabee
- Internal Medicine Services, Maternity and Children's Hospital, Jeddah, Saudi Arabia
| | - Mazen Alzahrani
- Ophthalmology, East Jeddah General Hospital, Jeddah, Saudi Arabia
| |
Collapse
|
10
|
Infección diseminada por Propionibacterium acnes en un varón de 42 años con infección por el VIH. Med Clin (Barc) 2018; 151:125-126. [DOI: 10.1016/j.medcli.2017.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/25/2017] [Accepted: 11/02/2017] [Indexed: 11/18/2022]
|
11
|
Gkiozos I, Kopitopoulou A, Kalkanis A, Vamvakaris IN, Judson MA, Syrigos KN. Sarcoidosis-Like Reactions Induced by Checkpoint Inhibitors. J Thorac Oncol 2018; 13:1076-1082. [PMID: 29763666 DOI: 10.1016/j.jtho.2018.04.031] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/29/2018] [Accepted: 04/30/2018] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are a newly developed component of cancer care that expands the treatment possibilities for patients. Their use has been associated with several immune-related adverse events, including ICI-induced sarcoidosis-like reactions. This article reviews the data concerning ICI-induced sarcoidosis-like reactions currently available in the medical literature. These reactions have been reported in three classes of ICIs: anti-cytotoxic T-lymphocyte associated protein 4 antibodies, programmed death 1 inhibitors and programmed death ligand 1 inhibitors. These reactions are indistinguishable from sarcoidosis with a similar histology, pattern of organ involvement, and pattern of clinical manifestations. The most common locations to observe granulomatous inflammation from these reactions is in intrathoracic locations (the lung and/or mediastinal lymph nodes) and the skin. The median time between initiation of an ICI and the development of a sarcoidosis-like reaction averaged 14 weeks. Clinicians have opted to use corticosteroids and/or discontinue the ICI, or take no action when these reactions have developed. Regardless of whether the clinician performed an intervention or not, these reactions have uniformly improved or resolved after ICI-treatment, which provides additional temporal evidence supporting the presence of a sarcoidosis-like reaction as opposed to sarcoidosis. There is even evidence that the development of an ICI-induced sarcoidosis-like reaction suggests that the ICI is effective as an anti-tumor agent and should be continued. As is the case for sarcoidosis, sarcoidosis-like reactions do not mandate antisarcoidosis therapy, especially if the condition is asymptomatic. When treatment of sarcoidosis-like reaction is required, it may be prudent to continue ICI therapy and add antisarcoidosis therapy because standard antisarcoidosis regimens seem to be effective. Further research into the mechanisms involved in the development of ICI-induced sarcoidosis-like reactions may give insights into the immunopathogenesis of sarcoidosis.
Collapse
Affiliation(s)
- Ioannis Gkiozos
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.
| | - Alexandra Kopitopoulou
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Kalkanis
- Division of Pulmonary and Critical Care Medicine, 401 Military and VA Hospital, Athens, Greece
| | - Ioannis N Vamvakaris
- First Pathology Department, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Konstantinos N Syrigos
- Third Department of Medicine, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
12
|
Chopra A, Nautiyal A, Kalkanis A, Judson MA. Drug-Induced Sarcoidosis-Like Reactions. Chest 2018; 154:664-677. [PMID: 29698718 DOI: 10.1016/j.chest.2018.03.056] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 01/02/2023] Open
Abstract
A drug-induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction that is indistinguishable from sarcoidosis and occurs in a temporal relationship with initiation of an offending drug. DISRs typically improve or resolve after withdrawal of the offending drug. Four common categories of drugs that have been associated with the development of a DISR are immune checkpoint inhibitors, highly active antiretroviral therapy, interferons, and tumor necrosis factor-α antagonists. Similar to sarcoidosis, DISRs do not necessarily require treatment because they may cause no significant symptoms, quality of life impairment, or organ dysfunction. When treatment of a DISR is required, standard antisarcoidosis regimens seem to be effective. Because a DISR tends to improve or resolve when the offending drug is discontinued, this is another effective treatment for a DISR. However, the offending drug need not be discontinued if it is useful, and antigranulomatous therapy can be added. In some situations, the development of a DISR may suggest a beneficial effect of the inducing drug. Understanding the mechanisms leading to DISRs may yield important insights into the immunopathogenesis of sarcoidosis.
Collapse
Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY.
| | - Amit Nautiyal
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY
| | - Alexander Kalkanis
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, 401 Military and VA Hospital, Athens, Greece
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY
| |
Collapse
|
13
|
Abstract
In HIV-infected individuals, paradoxical reactions after the initiation of antiretroviral therapy (ART) are associated with a variety of underlying infections and have been called the immune reconstitution inflammatory syndrome (IRIS). In cases of IRIS associated with tuberculosis (TB), two distinct patterns of disease are recognized: (i) the progression of subclinical TB to clinical disease after the initiation of ART, referred to as unmasking, and (ii) the progression or appearance of new clinical and/or radiographic disease in patients with previously recognized TB after the initiation of ART, the classic or "paradoxical" TB-IRIS. IRIS can potentially occur in all granulomatous diseases, not just infectious ones. All granulomatous diseases are thought to result from interplay of inflammatory cells and mediators. One of the inflammatory cells thought to be integral to the development of the granuloma is the CD4 T lymphocyte. Therefore, HIV-infected patients with noninfectious granulomatous diseases such as sarcoidosis may also develop IRIS reactions. Here, we describe IRIS in HIV-infected patients with TB and sarcoidosis and review the basic clinical and immunological aspects of these phenomena.
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Despite the frequent occurrence of worsening pulmonary symptoms in pulmonary sarcoidosis patients, there is little available information concerning this topic. RECENT FINDINGS In this review, we outline the various causes for these symptoms. We propose to partition the various causes for these symptoms into specific categories. SUMMARY We believe that these categories will provide the clinician a framework to evaluate pulmonary sarcoidosis patients with such symptoms in a rigorous way that may be useful in optimizing their care.
Collapse
|
15
|
|
16
|
Rose-Nussbaumer J, Goldstein DA, Thorne JE, Arantes TE, Acharya NR, Shakoor A, Jeng BH, Yeh S, Rahman H, Vemulakonda GA, Flaxel CJ, West SK, Holland GN, Smith JR. Uveitis in human immunodeficiency virus-infected persons with CD4+ T-lymphocyte count over 200 cells/mL. Clin Exp Ophthalmol 2013; 42:118-25. [PMID: 23777456 DOI: 10.1111/ceo.12141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 05/19/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Introduction of highly active antiretroviral therapy has altered the course of disease for persons infected with human immunodeficiency virus by elevating CD4+ T-lymphocyte levels. Changes in the spectrum of systemic diseases encountered in human immunodeficiency virus-positive individuals are reported in the general medical literature. DESIGN Retrospective case series. PARTICIPANTS Sixty-one individuals infected with human immunodeficiency virus, who presented with uveitis when the peripheral CD4+ T-lymphocyte count was over 200 cells/μL. METHODS Standardized data collection at seven tertiary-referral inflammatory eye disease clinics. MAIN OUTCOME MEASURES Standardization of Uveitis Nomenclature anatomic classification and descriptors, cause of uveitis, and visual acuity RESULTS Peripheral CD4+ T cell counts varied between 207 and 1777 (median = 421) cells/μL at the time of diagnosis of uveitis. Uveitis was classified anatomically as anterior (47.5%), intermediate (6.6%), anterior/intermediate (16.4%), posterior (14.8%) and pan (14.8%). Specific causes of uveitis included infections (34.4%), with syphilis responsible for 16.4% of all cases, and defined immunological disorders (27.0%); no cause for the inflammation was identified in 34.4% of persons. Visual acuity was better than 6/15 in 66.7% and 6/60 or worse in 11.8% of 93 eyes at presentation, and better than 6/15 in 82.4% and 6/60 or worse in 8.8% of 34 eyes at 1 year of follow-up. CONCLUSIONS Both infectious and non-infectious forms of uveitis occur in individuals who are infected with human immunodeficiency virus and have preserved or restored peripheral CD4+ T cell levels. Individuals who are human immunodeficiency virus-positive and present with uveitis should be evaluated in the same way all patients with uveitis are assessed.
Collapse
Affiliation(s)
- Jennifer Rose-Nussbaumer
- Casey Eye Institute and Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
Exacerbations of sarcoidosis are common. In particular, exacerbations of pulmonary sarcoidosis are reported in more than one-third of patients. Despite their frequent occurrence, there is little medical evidence concerning the definition, diagnosis, and treatment of pulmonary exacerbations of sarcoidosis. In this article, we propose a definition of acute pulmonary exacerbations of sarcoidosis (APES). We review the meager medical literature concerning the risk factors, diagnosis, and treatment of this condition. Given the limited information concerning APES, we acknowledge that this article is not a definitive resource but, rather, a position paper that will encourage greater consideration of the pathogenesis, diagnostic challenges, and treatment approaches to this condition. We believe that further focus on APES will improve the quality of care of patients with pulmonary sarcoidosis.
Collapse
Affiliation(s)
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY.
| |
Collapse
|
18
|
Abstract
The spectrum of HIV-associated pulmonary diseases is broad. Opportunistic infections, neoplasms, and noninfectious complications are all major considerations. Clinicians caring for persons infected with HIV must have a systematic approach. The approach begins with a thorough history and physical examination and often involves selected laboratory tests and a chest radiograph. Frequently, the clinical, laboratory, and chest radiographic presentation suggests a specific diagnosis or a few diagnoses, which then prompts specific diagnostic testing and treatment. This article presents an overview of the evaluation of respiratory disease in persons with HIV/AIDS.
Collapse
|
19
|
Abstract
Human immunodeficiency virus (HIV) infection causes profound changes in the lung compartment characterized by macrophage and lymphocyte activation, secretion of proinflammatory cytokines and chemokines, and accumulation of CD8 T cells in the alveolar space, leading to lymphocytic alveolitis. Because many of the changes seen in the lung can be attributed to the direct effect of HIV on immune cells, therapy to reduce the HIV burden should have significant beneficial effects. Indeed, antiretroviral therapy rapidly reduces the viral burden in the lung, number of CD8 T cells in the alveolar space, and amount of proinflammatory cytokines and chemokines in bronchoalveolar lavage.
Collapse
Affiliation(s)
- Homer L Twigg
- Division of Pulmonary and Critical Care Medicine, Indiana University Medical Center, Indianapolis, IN 46202, USA.
| | | |
Collapse
|
20
|
Abstract
A spectrum of noninfectious, nonmalignant lymphocytic infiltrative disorders, including nonspecific interstitial pneumonitis and lymphocytic interstitial pneumonitis, was frequently described in HIV-infected adults in the precombination antiretroviral therapy (ART) era. With the advent of ART, these conditions are less commonly encountered when caring for HIV-infected adults, possibly as a consequence of the effects of HIV treatment on pulmonary immunology. By contrast, reports of sarcoidosis among HIV-infected persons were uncommon in the pre-ART era, but sarcoidosis is increasingly recognized since the introduction of ART and may represent an immune reconstitution phenomenon. Other causes of interstitial pneumonitis are infrequently encountered among HIV-infected persons.
Collapse
Affiliation(s)
- Sarah R Doffman
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton BN2 5BE, UK.
| | | |
Collapse
|
21
|
What a differential a virus makes: a practical approach to thoracic imaging findings in the context of HIV infection--part 2, extrapulmonary findings, chronic lung disease, and immune reconstitution syndrome. AJR Am J Roentgenol 2012; 198:1305-12. [PMID: 22623542 DOI: 10.2214/ajr.11.8004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The Centers for Disease Control and Prevention reported more than one million people with HIV infection in the United States in 2006, an increase of 11% over 3 years. Worldwide, nearly 34 million people are infected with HIV. Pulmonary disease accounts for 30-40% of acute hospitalizations of HIV-seropositive patients, underscoring the importance of understanding the range of cardiothoracic imaging findings associated with HIV infection. This article will cover extrapulmonary thoracic diseases, chronic lung diseases, and immune reconstitution inflammatory syndrome in HIV-infected patients. Our approach is focused on the radiologist's perspective by recognizing and categorizing key imaging findings to generate a differential diagnosis. The differential diagnosis can be further refined by incorporating clinical data, such as patient demographics, CD4 count, and presenting symptoms. In addition, with prolonged survival of HIV-infected patients in the era of highly active antiretroviral therapy, radiologists can also benefit from awareness of imaging features of a myriad of chronic cardiopulmonary diseases in this patient population. Finally, the change of imaging findings and clinical status in response to treatment provides important diagnostic information, such as in immune reconstitution syndrome. CONCLUSION Developing a practical approach to key cardiothoracic imaging findings in HIV-infected patients will aid the radiologist in generating a clinically relevant differential diagnosis and interpretation, thereby improving patient care.
Collapse
|
22
|
What a Differential a Virus Makes: A Practical Approach to Thoracic Imaging Findings in the Context of HIV Infection??? Part 1, Pulmonary Findings. AJR Am J Roentgenol 2012; 198:1295-304. [DOI: 10.2214/ajr.11.8003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
23
|
Peixoto de Miranda ÉJ, Munhoz Leite OH, Seixas Duarte MI. Immune reconstitution inflammatory syndrome associated with pulmonary sarcoidosis in an HIV-infected patient: an immunohistochemical study. Braz J Infect Dis 2011. [DOI: 10.1016/s1413-8670(11)70259-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
24
|
Abstract
PURPOSE OF REVIEW Immune reconstitution inflammatory syndrome (IRIS) is a common occurrence in HIV patients starting antiretroviral therapy (ART), and pulmonary involvement is an important feature of tuberculosis-IRIS and pneumocystis-IRIS. Pulmonologists need an awareness of the timing, presentation and treatment of pulmonary IRIS. RECENT FINDINGS Case definitions for tuberculosis-IRIS and cryptococcal-IRIS have been published by the International Network for the Study of HIV-associated IRIS (INSHI). A number of studies have addressed validation of clinical case definitions and the optimal time to commence ART after diagnosis of an opportunistic infection in HIV patients. The pathogenesis of IRIS is being assessed at a molecular level, increasing our understanding of mechanisms and possible targets for future preventive and therapeutic strategies. SUMMARY Tuberculosis-IRIS, nontuberculosis mycobacterial-IRIS and pneumocystis-IRIS occur within days to weeks of starting ART, causing substantial morbidity, but low mortality. Cryptococcal-IRIS usually occurs later in the course of ART, and may be associated with appreciable mortality. Early recognition of unmasking and paradoxical IRIS affecting the lung allows timely initiation of antimicrobial and/or immunomodulatory therapies.
Collapse
|
25
|
Farhat F, Daftary MN, Jennings NM. Pulmonary sarcoidosis in an HIV/human T-cell lymphotrophic viruses I/II coinfected patient. J Natl Med Assoc 2011; 102:1251-3. [PMID: 21287908 DOI: 10.1016/s0027-9684(15)30754-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coexistence of HIV, pulmonary sarcoidosis, and human T-cell lymphotrophic viruses (HTLV) I/II has not been well reported and studied. Although the exact etiology of sarcoidosis is unknown, immunologic abnormalities have been the focus of human immunodeficiency virus (HIV)-related sarcoidosis and it is thought to be a manifestation of immune reconstitution inflammatory syndrome. We report the case of an African American woman with HIV and HTLV I/II coinfection who developed pulmonary sarcoidosis several months after the initiation of antiretroviral therapy. Despite the fact that most common etiologies of pulmonary nodules in HIV patients include mycobacterial and fungal infections, sarcoidosis should be considered in differential diagnosis. This disease may continuously rise due to the increasing number of people who are receiving antiretroviral therapy, leading to an improved immune system.
Collapse
Affiliation(s)
- Faria Farhat
- Division of Infectious Disease, Howard University College of Medicine, 2041 Georgia Ave NW, Washington, DC 20059, USA.
| | | | | |
Collapse
|
26
|
Reich JM. Con: the treatment of the granulomatous response is beneficial in acute sarcoidosis. Respir Med 2010; 104:1778-81; discussion 1782-5. [PMID: 20943361 DOI: 10.1016/j.rmed.2010.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Jerome M Reich
- Earl A Chiles Research Institute, Portland Providence Medical Center, Bldg A, Portland, OR 97213, USA.
| |
Collapse
|
27
|
Grunewald J, Eklund A, Wahlström J. CD4+ T cells in sarcoidosis: targets and tools. Expert Rev Clin Immunol 2010; 2:877-86. [PMID: 20476976 DOI: 10.1586/1744666x.2.6.877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Activated pulmonary T-helper type 1 lymphocytes are essential for the inflammatory process in sarcoidosis. Both the T cells and their mediators promoting inflammation may constitute possible targets for immunotherapy. A particular T-cell subset, the T-cell receptor AV2S3(+) CD4(+) T cells, are found at dramatically increased levels in the bronchoalveolar lavage fluid of a subpopulation of sarcoidosis patients with active disease. This particular T-cell subset may be used as a tool to reveal a sarcoidosis-specific antigen. Recent studies of natural killer T cells and T regulatory cells from patients with sarcoidosis have described abnormalities that may be relevant for the inflammatory process in this disease. These findings are exciting news and may be of help for designing new treatment strategies.
Collapse
Affiliation(s)
- Johan Grunewald
- Karolinska Institutet/Karolinska University Hospital, Lung Research Laboratory L4:01 Respiratory Medicine Unit, Department of Medicine, 171 76 Stockholm, Sweden.
| | | | | |
Collapse
|
28
|
Chan ASY, Sharma OP, Rao NA. Review for Disease of the Year: Immunopathogenesis of Ocular Sarcoidosis. Ocul Immunol Inflamm 2010; 18:143-51. [DOI: 10.3109/09273948.2010.481772] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
29
|
Crothers K, Huang L. Pulmonary complications of immune reconstitution inflammatory syndromes in HIV-infected patients. Respirology 2009; 14:486-94. [PMID: 19192228 DOI: 10.1111/j.1440-1843.2008.01468.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) describes a paradoxical worsening of clinical status related to recovery of the immune system, as can occur after the initiation of highly active antiretroviral therapy (HAART) in HIV-infected patients. Most commonly, IRIS results from opportunistic infections that can unmask or develop paradoxical worsening following HAART. Cancers, autoimmune conditions and sarcoidosis have also been associated with IRIS. Pulmonary complications may be frequently encountered. This article reviews the types and clinical presentation of IRIS, with a focus on the pulmonary manifestations. Management and outcome of IRIS are considered.
Collapse
Affiliation(s)
- Kristina Crothers
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
| | | |
Collapse
|
30
|
George MP, Kannass M, Huang L, Sciurba FC, Morris A. Respiratory symptoms and airway obstruction in HIV-infected subjects in the HAART era. PLoS One 2009; 4:e6328. [PMID: 19621086 PMCID: PMC2709444 DOI: 10.1371/journal.pone.0006328] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 06/18/2009] [Indexed: 01/16/2023] Open
Abstract
Background Prevalence and risk factors for respiratory symptoms and airway obstruction in HIV-infected subjects in the era of highly active antiretroviral therapy (HAART) are unknown. We evaluated respiratory symptoms and measured airway obstruction to identify the impact of HAART and other risk factors on respiratory symptoms and pulmonary function. Methodology/Principal Findings Two hundred thirty-four HIV-infected adults without acute respiratory symptoms were recruited from an HIV clinic. All subjects were interviewed and performed spirometry. Multivariate linear and logistic regressions were performed to determine predictors of respiratory symptoms, forced expiratory volume in one second (FEV1) percent predicted, and FEV1/forced vital capacity (FEV1/FVC). Thirty-one percent of subjects reported at least one respiratory symptom. Smoking status (current or former versus never) (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.41–5.22, p = 0.003), higher log plasma HIV viral levels (OR = 1.12, 95%CI = 1.02–1.24, p = 0.02), and lower FEV1/FVC (OR = 1.06 for every 0.01 decrease in FEV1/FVC, 95%CI = 1.02–1.14, p = 0.001) were independent predictors of respiratory symptoms. Age (p = 0.04), pack-year smoking history (p<0.001), previous bacterial pneumonia (p = 0.007), and HAART use (p = 0.04) were independent predictors of decreased FEV1/FVC. Conclusions/Significance Respiratory symptoms remain common in HIV-infected subjects, especially in those with a smoking history. Subjects who were older, had a greater pack-year history of smoking, or previous bacterial pneumonia had lower FEV1/FVC ratios. Interestingly, use of HAART was independently associated with a decreased FEV1/FVC, possibly secondary to an immune response to subclinical infections, increased autoimmunity, or other factors associated with HAART use.
Collapse
Affiliation(s)
- M. Patricia George
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Mouhamed Kannass
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California and Will Rogers Pulmonary Research Institute, Los Angeles, California, United States of America
| | - Laurence Huang
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Frank C. Sciurba
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Alison Morris
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California and Will Rogers Pulmonary Research Institute, Los Angeles, California, United States of America
- * E-mail:
| |
Collapse
|
31
|
Littlewood KE. The immunocompromised adult patient and surgery. Best Pract Res Clin Anaesthesiol 2008; 22:585-609. [DOI: 10.1016/j.bpa.2008.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
32
|
|
33
|
|
34
|
|
35
|
de Jager M, Blokx W, Warris A, Bergers M, Link M, Weemaes C, Seyger M. Immunohistochemical features of cutaneous granulomas in primary immunodeficiency disorders: a comparison with cutaneous sarcoidosis. J Cutan Pathol 2008; 35:467-72. [PMID: 18201241 DOI: 10.1111/j.1600-0560.2007.00854.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cutaneous granulomas can occur in patients with a primary immunodeficiency disorder. In some cases, an infectious cause cannot be revealed. The pathogenesis of these granulomas still remains to be elucidated. The aim of this study was to study differences or overlap between these rare granulomas and sarcoidosis-related granulomas. METHODS Markers for T-cell subsets (CD3, CD4, CD8 and CD45RO), Langerhans' cells (CD1a), macrophages (CD68), B cells (CD20) and NK cells (CD56) were stained immunohistochemically. The amount of CD4+ and CD8+ cells in the granulomas was counted. Results were compared with the CD4+/CD8+ ratio in peripheral blood. RESULTS In the granulomas of two of three patients with a primary immunodeficiency disorder, the cytotoxic T cells (CD8+) outnumbered the T-helper cells (CD4+) with a counted CD4+/CD8+ ratio <<1. In contrast, the granulomas in the cutaneous sarcoidosis patients showed a predominance of CD4+ cells, with CD4+/CD8+ ratios >2. CONCLUSIONS A lower CD4+/CD8+ ratio was found in the cutaneous granulomas of patients with a primary immunodeficiency disorder (unclassified combined immunodeficiency, autoimmune lymphoproliferative syndrome and ataxia teleangiectasia) as compared with the patients with cutaneous sarcoidosis. The possible implications of these findings are discussed in this paper.
Collapse
Affiliation(s)
- Michelle de Jager
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
36
|
Fernández-Fernández FJ, Buño-Ramilo B. "Sarcoidosis in a patient with rheumatoid arthritis treated with etanercept: the critical role of the CD4+ cell dependent type 1 helper T response". Intern Med 2008; 47:1635. [PMID: 18797127 DOI: 10.2169/internalmedicine.47.1389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
37
|
Grunewald J. Clinical aspects and immune reactions in sarcoidosis. CLINICAL RESPIRATORY JOURNAL 2007; 1:64-73. [DOI: 10.1111/j.1752-699x.2007.2007.00019.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
38
|
Haramati LB, Jenny-Avital ER, Alterman DD. Thoracic manifestations of immune restoration syndromes in AIDS. J Thorac Imaging 2007; 22:213-20. [PMID: 17721329 DOI: 10.1097/rti.0b013e3180332e10] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune restoration syndromes (IRS) in AIDS constitute a group of illness characterized by a pathologic inflammatory response in patients with late-stage AIDS who start highly active antiretroviral therapy. Although there is no standardized definition or therapy, IRS have partial immune restoration associated with an increase in their CD-4 cell count and a decrease in their viral load. Patients with IRS show a paradoxical reaction that is, clinical worsening rather than improvement on therapy, associated with a recognized or occult infection. Symptoms include new or worsening fever, lymphadenopathy, pulmonary, visceral, central nervous system, or cutaneous disease which may be severe and occasionally life threatening and must be differentiated from disease progression. In this paper, we review the clinical and associated thoracic imaging findings of IRS associated with specific infections including mycobacterial and fungal infections, cytomegalovirus, Pneumocystis jiroveci pneumonia and also Kaposi sarcoma and sarcoidosis. Recognition of the imaging findings in the appropriate clinical setting presents an opportunity to make a timely diagnosis. With appropriate management, IRS usually does not alter long-term prognosis.
Collapse
Affiliation(s)
- Linda B Haramati
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.
| | | | | |
Collapse
|
39
|
Abstract
Activated pulmonary CD4(+) T lymphocytes of the Th-1 type are essential for the inflammatory process in sarcoidosis, and IFN-gamma production is crucial for the characteristic granuloma formation. Both the T cells and their inflammatory mediators may constitute possible targets for immunotherapy. A particular T-cell subset, the T-cell receptor (TCR) AV2S3(+) bronchoalveolar lavage (BAL) CD4(+) T cells, is found at dramatically increased levels in the BAL fluid of human leukocyte antigen (HLA)-DRB1*0301-positive and/or HLA-DRB3*0101-positive patients with sarcoidosis. The AV2S3(+) BAL CD4(+) T cells strongly associate with the sarcoid inflammation, and future studies on this particular T-cell subset to reveal their specificity may lead to the identification of sarcoidosis-specific antigen(s). T-cell subpopulations with regulatory functions (i.e., natural killer T cells and T regulatory cells) have recently been described as abnormal in sarcoidosis. Dysfunctional regulatory T cells may allow T effector cells to contribute to the formation of granulomas, and they may thus be relevant for the inflammatory process in this disease. These findings are exciting news and will be of help in designing new treatment strategies.
Collapse
Affiliation(s)
- Johan Grunewald
- Department of Medicine, Division of Respiratory Medicine, Lung Research Laboratory L4:01, Karolinska University Hospital Solna, S-171 76 Stockholm, Sweden.
| | | |
Collapse
|
40
|
Abstract
Sarcoidosis is an immune system disorder characterised by non-necrotising granulomas. Pulmonary involvement is the most common presentation of sarcoidosis, but it can manifest in any organ. Other commonly involved organ systems include the lymph nodes (especially the intrathoracic nodes); the skin; the eyes; the liver; the heart; and the nervous, musculoskeletal, renal, and endocrine systems. The typical and atypical imaging features of multisystemic involvement of sarcoidosis have been discussed with review of the gamut of radiological manifestations of thoracic, cardiac, CNS, abdominal and musculoskeletal sarcoidosis.
Collapse
Affiliation(s)
- Achala S Vagal
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH 45267-0761, USA
| | | | | |
Collapse
|
41
|
Abstract
Highly active antiretroviral therapy (HAART) has dramatically altered the spectrum of morbidity and mortality in HIV-infected patients. This has been attributed to improvements in the lung microenvironment leading to enhanced pulmonary immunity, either by preventing the progressive loss of immune function or by actually promoting immune restoration. However, these changes have been accompanied by the recognition of new pulmonary complications in HIV-infected subjects, especially those associated with immune reconstitution. In this review we will describe how HIV infection alters the normal pulmonary environment, highlight the effect of HAART on these perturbations, and discuss potential complications of HAART in the lung, focusing on the pulmonary immune reconstitution inflammatory syndrome.
Collapse
Affiliation(s)
- Homer L Twigg
- Division of Pulmonary and Critical Care Medicine, Indiana University Medical Center, Indianapolis, Indiana
| | | |
Collapse
|
42
|
Papadaki TG, Kafkala C, Zacharopoulos IP, Seyedahmadi B J, Dryja T, Foster CS. Conjunctival non-caseating granulomas in a human immunodeficiency virus (HIV) positive patient attributed to sarcoidosis. Ocul Immunol Inflamm 2006; 14:309-11. [PMID: 17056466 DOI: 10.1080/09273940600899676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To report a rare case of isolated ocular sarcoidosis in an HIV positive patient. DESIGN Case report. METHODS A 47-year-old HIV+ Caucasian male was referred for chronic bilateral follicular conjunctivitis. RESULTS A conjunctival biopsy that was performed on the right eye showed sarcoidosis. General medical evaluation including a spiral thin cut chest CT scan revealed no systemic involvement. The ocular signs and symptoms resolved completely with topical corticosteroid treatment. CONCLUSIONS HIV infection and sarcoidosis rarely coexist, presumably because their immunopathogenesis mechanisms diverge. In the absence of systemic involvement, a definite diagnosis can only be made by biopsy of the ocular tissues.
Collapse
Affiliation(s)
- Thekla G Papadaki
- Massachusetts Eye Research and Surgery Institute, Ocular Immunology and Uveitis Foundation and the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | | |
Collapse
|
43
|
Jyonouchi H, Lien KW, Aguila H, Spinnato GG, Sabharwal S, Pletcher BA. SAPHO osteomyelitis and sarcoid dermatitis in a patient with DiGeorge syndrome. Eur J Pediatr 2006; 165:370-3. [PMID: 16491384 DOI: 10.1007/s00431-006-0082-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Accepted: 12/07/2005] [Indexed: 02/06/2023]
Abstract
We report the development and spontaneous resolution of annular erythematous skin lesions consistent with sarcoid dermatitis in a child with DiGeorge syndrome (DGS) carrying the 22q11.2 microdeletion. The skin lesion developed after she was treated with isoniazid (INH) following exposure to active tuberculosis (TB). After resolution of the skin lesions, this child developed sterile hyperplastic osteomyelitis consistent with SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) osteomyelitis in her right mandible triggered by an odontogenic infection. This child had congenital heart disease, dysmorphic facies, recurrent sinopulmonary infection, gastroesophageal reflux disease, scoliosis, reactive periostitis, and developmental delay. She had a low CD4 and CD8 T cell count with a normal 4/8 ratio, but normal cell proliferation and T cell cytokine production in response to mitogens. When she was presented with sterile osteomyelitis of right mandible, she revealed polyclonal hypergammaglobulinemia with elevated erythrocyte sedimentation rate (ESR)/angiotensin converting enzyme (ACE) levels, but negative CRP. Autoimmune and sarcoidosis workup was negative. Inflammatory parameters gradually normalized following resolution of odontogenic infection and with the use of non-steroidal anti-inflammatory drugs (NSAIDs). The broad clinical spectrum of DGS is further expanded with the development of autoimmune and inflammatory complications later in life. This case suggests that patients with the DGS can present with unusual sterile inflammatory lesions triggered by environmental factors, further broadening the clinical spectrum of this syndrome.
Collapse
Affiliation(s)
- Harumi Jyonouchi
- Division of Pulmonary, Allergy/Immunology, and Infectious Diseases, Department of Pediatrics, University of Medicine and Dentistry of New Jersey (UMDNJ)-New Jersey Medical School, Newark, NJ 07101-1709, USA.
| | | | | | | | | | | |
Collapse
|
44
|
|
45
|
Abstract
An asymptomatic, homosexual, white man was found to have an abnormal chest x ray. A presumptive diagnosis of sarcoidosis was made, but pulmonary function tests and a transbronchial biopsy were normal. He then remained asymptomatic for 10 years until he developed a progressive spastic paraparesis. At this point, antibodies to human T cell lymphotropic virus type 1 (HTLV-1) were identified in the serum and cerebrospinal fluid, and the diagnosis of HTLV-1 associated myelopathy was made, the history suggesting sexual exposure to HTLV-1 many years previously. HTLV-1 is associated with a spectrum of immune related disorders, including a pulmonary sarcoid-like syndrome. Infection with this chronic proinflammatory retrovirus should be considered in the differential diagnosis of all immune disorders in at risk individuals.
Collapse
Affiliation(s)
- D H McKee
- Department of Neurology, Greater Manchester Centre for Clinical Neurosciences, Hope Hospital, Stott Lane, Salford M6 8HD, UK.
| | | | | |
Collapse
|
46
|
Abstract
Since the first description more than a century ago, intensive research continues to focus on sarcoidosis. Based on our current knowledge, sarcoidosis can be considered as an immune syndrome resulting from a variable combination of predisposing genetic, ethnic, and environmental factors. Over the last few years, several teams have proposed a link between certain genetic polymorphisms, particularly of the HLA system, and the risk of development or progression of sarcoidosis. Other pathogenic mechanisms involved in the formation of the sarcoid granuloma are becoming more clear and have led to the development of new therapeutic approaches such as anti-TNF currently being evaluated in multicentric trials.
Collapse
Affiliation(s)
- Abdellatif Tazi
- Service de Pneumologie, Hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75475 Paris Cedex 10.
| |
Collapse
|
47
|
Abstract
Neurosarcoidosis is an uncommon presentation of sarcoidosis. It is associated with significant morbidity and poor outcome. In the past decade, there has been significant progress in our understanding of the immunopathogenesis of the disease, but the etiology of this enigmatic condition still eludes us. Improved insight has paved the way for development of different treatment strategies against critical immunologic stages of the disease.
Collapse
|
48
|
Foulon G, Wislez M, Naccache JM, Blanc FX, Rabbat A, Israël-Biet D, Valeyre D, Mayaud C, Cadranel J. Sarcoidosis in HIV‐Infected Patients in the Era of Highly Active Antiretroviral Therapy. Clin Infect Dis 2004; 38:418-25. [PMID: 14727215 DOI: 10.1086/381094] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2003] [Accepted: 09/23/2003] [Indexed: 11/03/2022] Open
Abstract
To analyze the impact of highly active antiretroviral therapy (HAART) on the characteristics and outcome of sarcoidosis in patients infected with human immunodeficiency virus (HIV), we identified HIV-infected patients in whom sarcoidosis was diagnosed between 1996 and 2000 from the admission registers of the pneumology departments of 12 hospitals in the Paris region (France). Sarcoidosis was diagnosed in 11 HIV-infected patients, of whom 8 were receiving HAART. HIV infection was diagnosed before sarcoidosis in 9 cases. At diagnosis of sarcoidosis, the mean CD4 cell count (+/-SD) was 390+/-213 cells/mm(3), and the mean plasma virus load was 4002+/-10,183 copies/mL. Sarcoidosis occurred several months after HAART introduction, when the CD4 cell count had increased and the plasma HIV load had decreased. Clinical and radiological characteristics, laboratory values for bronchoalveolar lavage fluid samples, and outcome after a long follow-up were similar for the patients receiving HAART and for HIV-uninfected patients.
Collapse
Affiliation(s)
- Guillaume Foulon
- Service de Pneumologie et Réanimation Respiratoire, Hôpital Tenon, Paris, France
| | | | | | | | | | | | | | | | | |
Collapse
|