The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital

Sarcoidosis is an enigmatic disease with extremely variable manifestations in pattern, severity and course. Since Longcope and Freiman's descriptive monograph in 1952 (50) summarizing the clinical findings of the first half of this century, new dimensions of assessing the disease and treatment have been added. The impact of corticosteroids is central. The present review extends the studies to the second half of this century. Earlier diagnosis is facilitated and treatment often reverses many of the disease manifestations and improves the quality and extent of life for the patient. The management issues and guidelines outlined in this paper for both intrathoracic and extrathoracic disease are based on several longitudinal studies of the sarcoidosis patients summarized here, and 50 years of clinical experience by the senior author (CJJ) at Johns Hopkins Hospital, a tertiary referral center with an active Sarcoid Clinic. Case reports are presented in the appendix. It is clear that corticosteroids are the most effective therapeutic agent for sarcoidosis, usually with impressive and prompt response. This represents the dramatic difference in this disease after 1950. No more specific or effective immunosuppressive or antiinflammatory agents have been identified. Undesirable side effects are minimal if excessive doses are avoided. The effectiveness of "steroid-sparing agents" such as methotrexate is uncertain. Although irreversible tissue damage from the disease may limit the effectiveness of treatment, benefits of corticosteroids greatly exceed the negative side effects. Since spontaneous remissions without treatment do occur, a period of observation of 2 years are more is warranted if the patient is relatively asymptomatic. Gradual radiographic progression for 2 or more years, even without major symptoms or reduction in pulmonary function, indicates the need for a trial of corticosteroid treatment, especially in white patients where symptoms may lag behind the radiographic changes. Relapses as treatment is withdrawn are frequent, especially in African-American patients, who tend to have more severe and more prolonged disease than white patients. A minimum of 1 year of treatment is recommended unless no improvement is noted after 3 months. Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease. Periodic attempts at tapering are justified. Repeated relapses may indicate the need for life-long treatment. When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents. Many agents related to sarcoidosis require further research. The most important question facing sarcoid researchers today is etiology. It is difficult to design specific therapy when the fundamental causes and disease mechanisms are not established. Rather than being a single disease with a single cause, it is possible that a number of genetic factors and environmental or infectious agents may result in an immune response that is manifested as sarcoidosis. Understanding basic causal mechanisms may help explain the varied disease manifestations and aid in designing curative treatments. Such etiologic questions should be explored from both a basic science and an epidemiologic approach. Therapeutic trials of new drugs such as pentoxyfylline and possibly thalidomide are needed to address their potential as well as limitations of steroid therapy. Finally, for patients who have progressed to organ failure, the problems of sarcoid recurrence in transplanted tissue, increased allograft rejection, and long-term prognosis of solid organ transplants have yet to be resolved. (ABSTRACT TRUNCATED)

Pulmonary sarcoidosis

Sarcoidosis involves the bronchi or lung in more than 90 percent of patients. Intrathoracic manifestations are protean, ranging from asymptomatic bilateral hilar lymphadenopathy to chronic, progressive, (ultimately fatal), respiratory insufficiency. The clinical course is highly variable, and optimal management and treatment are controversial. We review the salient radiographic, physiologic, and histopathologic features of pulmonary sarcoidosis and discuss rare intrathoracic complications (e.g., bronchostenosis, mycetomas, nodular sarcoidosis, necrotizing sarcoid angiitis and granulomatosis, pulmonary vascular and pleural involvement). We discuss the chest radiographic staging system and the role of ancillary diagnostic modalities including high resolution thin section computed tomographic scans (HRCT), bronchoalveolar lavage, radionuclide scan, and serum angiotensin enzyme converting enzyme. Indications for therapy and an overview of therapeutic options are outlined.

Aspergilloma in sarcoid and tuberculosis

The presentation, treatment, and outcome of 28 patients with aspergilloma and cavitary tuberculosis (14) and sarcoidosis (14) were compared. Patients with tuberculosis had localized disease (12 of 14, 86 percent), whereas patients with sarcoidosis had diffuse disease (1 of 14, 7 percent localized). Results indicated that patients with either sarcoid or tuberculosis who developed an aspergilloma had a poor prognosis over the next decade. Patients with sarcoid appeared to have a worse short-term prognosis; surgical resection in the tuberculosis patients may have contributed to their better short-term survival.

Longitudinal study of chronic sarcoidosis with low-dose maintenance corticosteroid therapy. Outcome and complications

A series of 181 patients with chronic persistent sarcoidosis for more than 5 years have been reviewed, with a mean follow-up period of 14 years, and 77% followed for more than 10 years. Efforts to identify more white patients meeting the criteria of such persistent disease were unsuccessful. Seventy-eight percent were black, and 69% were women. Pulmonary disease was the major manifestation in 70% and was present in 88%. The early major disease feature predicts the nature of the long-term manifestation in 94%. Ninety-four percent were treated with prednisone, with 63% for more than 5 years. Fifty-three percent required continued treatment, and of those receiving continued treatment, 91% were maintained on doses of no more than 15 mg daily and 65% on no more than 10 mg of prednisone daily. Relapses were frequent as prednisone was withdrawn, occurring at least once in 75% and several times in 51%. Low-dose prednisone treatment with 5-15 mg daily provides significant benefit. A mean treatment period of 8 years was observed (range: 10 days to 24 years). The benefits of treatment greatly exceed the infrequent complications. In Baltimore, chronic sarcoidosis with persistent disease seems to be more frequently encountered in black patients than in white patients.

Aspergillomas complicating sarcoidosis. A prospective study in 100 patients

During a ten-year study period, we evaluated 100 histologically-proven sarcoid patients for the development of aspergillomas. Serum precipitins against Aspergillus antigens were used to screen all patients regardless of sarcoid stage. Twelve patients had serum precipitins and were further investigated with tomography and serial serum precipitins testing. Ten of these 12 patients had aspergillomas and two patients died of massive hemoptysis. No aspergillomas occurred in stages I, II, or non-cystic stage III patients. All ten aspergillomas developed in the 19 stage III patients with cystic parenchymal damage. We believe that aspergillomas in sarcoidosis are not as rare as previously reported, but occur commonly in chronic cystic sarcoidosis. Additionally, we found serial testing for serum precipitins to be valuable both for the screening of cystic sarcoid patients for aspergillomas and for the management of this complication.