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Obi ON, Alqalyoobi S, Maddipati V, Lower EE, Baughman RP. High-Resolution CT Scan Fibrotic Patterns in Stage IV Pulmonary Sarcoidosis: Impact on Pulmonary Function and Survival. Chest 2024; 165:892-907. [PMID: 37879560 DOI: 10.1016/j.chest.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 09/27/2023] [Accepted: 10/15/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Different patterns of fibrosis on high-resolution CT scans (HRCT) have been associated with reduced survival in some interstitial lung diseases. Nothing is known about HRCT scan patterns and survival in sarcoidosis. RESEARCH QUESTION Will a detailed description of the extent and pattern of HRCT scan fibrosis in patients with stage IV pulmonary sarcoidosis impact pulmonary function and survival? STUDY DESIGN AND METHODS Two hundred forty patients with stage IV sarcoidosis at two large tertiary institutions were studied. The earliest HRCT scan with fibrosis was reviewed for extent of fibrosis (< 10%, 10%-20%, and > 20%) and presence of bronchiectasis, upper lobe fibrocystic changes, basal subpleural honeycombing, ground-glass opacities (GGOs), large bullae, and mycetomas. Presence of sarcoidosis-associated pulmonary hypertension (SAPH) and pulmonary function testing performed within 1 year of HRCT were recorded. Patients were followed up until last clinic visit, death, or lung transplantation. RESULTS The mean age was 58.4 years. Seventy-four percent were Black, 63% were female, and mean follow-up was 7.4 years. Death or LT occurred in 53 patients (22%). Thirty-one percent had > 20% fibrosis, 25% had 10%-20% fibrosis, and 44% had < 10% fibrosis. The most common HRCT abnormalities were bronchiectasis (76%), upper lobe fibrocystic changes (36%), and GGOs (28%). Twelve percent had basal subpleural honeycombing, and 32% had SAPH. Patients with > 20% fibrosis had more severe pulmonary impairment, were more likely to have SAPH (53%), and had worse survival (44% mortality; P < .001). Upper lobe fibrocystic changes, basal subpleural honeycombing, and large bullae were associated with worse pulmonary function and worse survival. Patients with basal subpleural honeycombing had the worst pulmonary function and survival (55% mortality; P < .001). GGOs were associated with worse pulmonary function but not worse survival, and mycetomas were associated with worse survival but not worse pulmonary function. A Cox proportional hazards model indicated that basal subpleural honeycombing (hazard ratio, 7.95), diffusion capacity for carbon monoxide < 40% (HR, 5.67) and White race (hazard ratio, 2.61) were independent predictors of reduced survival. INTERPRETATION HRCT scan features of fibrotic pulmonary sarcoidosis had an impact on pulmonary function and survival. Presence of >20% fibrosis and basal subpleural honeycombing are predictive of worse pulmonary function and worse survival in patients with stage IV pulmonary sarcoidosis.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC.
| | - Shehabaldin Alqalyoobi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC; Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY
| | - Veeranna Maddipati
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Elyse E Lower
- Department of Medicine, University of Cincinnati, Cincinnati, OH
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Bailey GL, Wells AU, Desai SR. Imaging of Pulmonary Sarcoidosis-A Review. J Clin Med 2024; 13:822. [PMID: 38337517 PMCID: PMC10856519 DOI: 10.3390/jcm13030822] [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: 01/03/2024] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
Sarcoidosis is the classic multisystem granulomatous disease. First reported as a disorder of the skin, it is now clear that, in the overwhelming majority of patients with sarcoidosis, the lungs will bear the brunt of the disease. This review explores some of the key concepts in the imaging of pulmonary sarcoidosis: the wide array of typical (and some of the less common) findings on high-resolution computed tomography (HRCT) are reviewed and, with this, the concept of morphologic/HRCT phenotypes is discussed. The pathophysiologic insights provided by HRCT through studies where morphologic abnormalities and pulmonary function tests are compared are evaluated. Finally, this review outlines the important contribution of HRCT to disease monitoring and prognostication.
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Affiliation(s)
- Georgina L. Bailey
- Department of Radiology, Royal Brompton Hospital, London SW3 6NP, UK (S.R.D.)
| | - Athol U. Wells
- The Interstitial Lung Disease Unit, Royal Brompton Hospital, London SW3 6NP, UK
- The National Heart & Lung Institute, Imperial College London, London W12 7RQ, UK
- The Margaret Turner-Warwick Centre for Fibrosing Lung Diseases, Imperial College London, London W12 7RQ, UK
| | - Sujal R. Desai
- Department of Radiology, Royal Brompton Hospital, London SW3 6NP, UK (S.R.D.)
- The National Heart & Lung Institute, Imperial College London, London W12 7RQ, UK
- The Margaret Turner-Warwick Centre for Fibrosing Lung Diseases, Imperial College London, London W12 7RQ, UK
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3
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Singh S, Lum J, Majeed A. Effect of Mycetoma in Lung Transplant Patients - a Single Center Experience. Transplant Proc 2023; 55:2197-2202. [PMID: 37758562 DOI: 10.1016/j.transproceed.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/01/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Mycetomas are uncommon in lung transplant recipients. Prior studies have shown increased mortality associated with mycetoma in lung transplant recipients (LTR). We reviewed our center's experience in outcome of LTRs with pre -or post-transplant mycetoma. METHODS We retrospectively reviewed electronic health records of LTRs performed at our institute between January 1, 2013 to December 31, 2020. RESULTS Mycetoma was present in less than 1 percent of LTR patients (7/1086). Mean age at the time of the transplant was 65 years. Idiopathic pulmonary fibrosis (5/7), interstitial lung disease (1/7), and sarcoidosis (1/7) were underlying pulmonary diagnoses. Seventy-one percent (5/7) received single lung transplant and 29% received double lung transplant. Seventy-one percent had negative serum galactomannan vs 29% (2/7) of patients who had positive serum galactomannan (one post and one pre). Fifty-seven percent had positive bronchoalveolar aspergillus galactomannan (23% had negative). A total of 42% (3/7) were found to have mycetoma before transplant and 58% (4/7) had mycetoma post transplant. Chest computed tomography findings in all patients were consistent with mycetoma. CONCLUSIONS In our cohort of patients, mycetoma was not found to be the primary cause of death if diagnosed pre transplant. Transplant recipients with mycetoma pre transplant did not develop invasive fungal infection or mycetoma post transplant. Careful evaluation of lung transplant candidates with mycetoma is critical. Further studies are needed to determine optimal duration of antifungal therapy and to determine if surgical resection may be needed to manage post-lung transplant mycetoma.
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Affiliation(s)
- Supriya Singh
- Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Infectious Diseases, University of Tennessee Medical Center, Knoxville, Tennessee.
| | - Jessica Lum
- Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Aneela Majeed
- Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio
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4
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Belperio JA, Fishbein MC, Abtin F, Channick J, Balasubramanian SA, Lynch Iii JP. Pulmonary sarcoidosis: A comprehensive review: Past to present. J Autoimmun 2023:103107. [PMID: 37865579 DOI: 10.1016/j.jaut.2023.103107] [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: 05/19/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/23/2023]
Abstract
Sarcoidosis is a sterile non-necrotizing granulomatous disease without known causes that can involve multiple organs with a predilection for the lung and thoracic lymph nodes. Worldwide it is estimated to affect 2-160/100,000 people and has a mortality rate over 5 years of approximately 7%. For sarcoidosis patients, the cause of death is due to sarcoid in 60% of the cases, of which up to 80% are from advanced cardiopulmonary failure (pulmonary hypertension and respiratory microbial infections) in all races except in Japan were greater than 70% of the sarcoidosis deaths are due to cardiac sarcoidosis. Scadding stages for pulmonary sarcoidosis associates with clinical outcomes. Stages I and II have radiographic remission in approximately 30%-80% of cases. Stage III only has a 10%-40% chance of resolution, while stage IV has no change of resolution. Up to 40% of pulmonary sarcoidosis patients progress to stage IV disease with lung parenchyma fibroplasia, bronchiectasis with hilar retraction and fibrocystic disease. These patients are at highest risk for the development of precapillary pulmonary hypertension, which may occur in up to 70% of these patients. Sarcoid patients with pre-capillary pulmonary hypertension can respond to targeted pulmonary arterial hypertension medications. Stage IV fibrocytic sarcoidosis with significant pulmonary physiologic impairment, >20% fibrosis on HRCT or pre-capillary pulmonary hypertension have the highest risk of mortality, which can be >40% at 5-years. First line treatment for patients who are symptomatic (cough and dyspnea) with parenchymal infiltrates and abnormal pulmonary function testing (PFT) is oral glucocorticoids, such as prednisone with a typical starting dose of 20-40 mg daily for 2 weeks to 2 months. Prednisone can be tapered over 6-18 months if symptoms, spirometry, PFTs, and radiographs improve. Prolonged prednisone may be required to stabilize disease. Patients requiring prolonged prednisone ≥10 mg/day or those with adverse effects due to glucocorticoids may be prescribed second and third line treatements. Second and third line treatments include immunosuppressive agents (e.g., methotrexate and azathioprine) and anti-tumor necrosis factor (TNF) medication; respectively. Effective treatments for advanced fibrocystic pulmonary disease are being explored. Despite different treatments, relapse rates range from 13% to 75% depending on the stage of sarcoid, number of organs involved, socioeconomic status, and geography. CONCLUSION: The mortality rate for sarcoidosis over a 5 year follow up is approximately 7%. Unfortunately, 10%-40% of patients with sarcoidosis develop progressive pulmonary disease, and >60% of deaths resulting from sarcoidosis are due to advance cardiopulmonary disease. Oral glucocorticoids are the first line treatment, while methotrexate and azathioprine are considered second and anti-TNF agents are third line treatments that are used solely or as glucocorticoid sparing agents for symptomatic extrapulmonary or pulmonary sarcoidosis with infiltrates on chest radiographs and abnormal PFT. Relapse rates have ranged from 13% to 75% depending on the population studied.
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Affiliation(s)
- John A Belperio
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fereidoun Abtin
- Department of Thoracic Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jessica Channick
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shailesh A Balasubramanian
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph P Lynch Iii
- The Division of Pulmonary and Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Abstract
Sarcoidosis is a heterogeneous disease, which can affect virtually every body organ, even though lungs and intra thoracic lymph nodes are almost universally affected. The presence of noncaseating granulomas is the histopathological hallmark of the disease, and clinical picture depends on the organs affected. Data about interaction between sarcoidosis and comorbidities, such as cardiovascular and pulmonary diseases, autoimmune disorders, malignancy and drug-related adverse events are limited. Several lung conditions can be associated with sarcoidosis, such as pulmonary hypertension and fibrosis, making it difficult sometimes the differentiation between complications and distinctive pathologies. Their coexistence may complicate the diagnosis of sarcoidosis and contribute to the highly variable and unpredictable natural history, particularly if several diseases are recognised. A thorough assessment of specific disorders that can be associated with sarcoidosis should always be carried out, and future studies will need to evaluate sarcoidosis not only as a single disorder, but also in the light of possible concomitant conditions.Key messagesComorbidities in sarcoidosis are common, especially cardiovascular and pulmonary diseases.In the diagnostic workup, a distinction must be made between sarcoidosis-related complaints and complaints caused by other separate disorders. It can be very difficult to distinguish between complications of sarcoidosis and other concomitant conditions.The coexistence of multiple conditions may complicate the diagnosis of sarcoidosis, affect its natural course and response to treatment.
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Affiliation(s)
- Claudio Tana
- Geriatrics Clinic, Medicine Department, SS Annunziata Hospital of Chieti, Chieti, Italy
| | - Marjolein Drent
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands.,ILD Center of Excellence, Department of Respiratory Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands.,ILD Care Foundation Research Team, Ede, The Netherlands
| | - Hilario Nunes
- AP-HP, Hôpital Avicenne, Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares de l'adulte, Université Sorbonne Paris Nord, Bobigny, France
| | - Vasilis Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, UK
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca' Foncello Hospital - AULSS2 Marca Trevigiana and Department of Medicine - DIMED, University of Padova, Italy
| | - Naomi T Jessurun
- ILD Care Foundation Research Team, Ede, The Netherlands.,Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
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Bhalla AS, Das A, Naranje P, Goyal A, Guleria R, Khilnani GC. Dilemma of diagnosing thoracic sarcoidosis in tuberculosis endemic regions: An imaging-based approach. Part 1. Indian J Radiol Imaging 2021; 27:369-379. [PMID: 29379230 PMCID: PMC5761162 DOI: 10.4103/ijri.ijri_200_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Sarcoidosis is a multi-systemic disorder of unknown etiology, although commonly believed to be immune-mediated. Histologically, it is characterized by noncaseating granuloma which contrasts against the caseating granuloma seen in tuberculosis (TB), an infectious disease that closely mimics sarcoidosis, both clinically as well as radiologically. In TB-endemic regions, the overlapping clinico-radiological manifestations create significant diagnostic dilemma, especially since the management options are markedly different in the two entities. Part 1 of this review aims to summarize the clinical, laboratory, and imaging features of sarcoidosis, encompassing both typical and atypical manifestations, in an attempt to distinguish between the two disease entities.
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Affiliation(s)
- Ashu S Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - A Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - P Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - A Goyal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - R Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
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7
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Chawla RK, Chawla AK, Chaudhary G, Chawla MK, Sareen M. Opaque hemithorax - An interesting case. Indian J Tuberc 2021; 68:420-424. [PMID: 34099214 DOI: 10.1016/j.ijtb.2020.12.007] [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: 10/19/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present an interesting case of left opaque hemithorax in an adult female and discuss its assessment and management. METHODS Design: Case Report. SETTING Tertiary care hospital. PATIENT One. RESULTS 44yrs retropositive female admitted with complaints of acute onset dry cough since 15-20 days, sudden breathlesness since 5 days which was progressive in nature, left sided heaviness in chest since 5 days. CECT Thorax showed complete collapse of left lung with cut off of left main bronchus while video bronchoscopy showed left main bronchus completely blocked with very thick necrotic mass and was difficult to dislodge. Debulking with cryo probe was done and left main bronchus was completely cleared off. Allergen panel showed very high serum IgE, high S.IgE against aspergillus and high specific S.IgG against aspergillus. Patient and her Chest X-ray showed significant improvement post cryo debulking and was discharged satisfactorily on oral voriconazole therapy. CONCLUSION Endobronchial aspergillosis is characterized by massive intrabronchial overgrowth of the aspergillus species, mainly aspergillus fumigatus. Most patients with chronic pulmonary aspergillosis, including those with simple aspergillomas and Aspergillus nodules, have positive Aspergillus IgG antibodies in the blood. We hereby present a case of 44 yrs female presenting with complaints of dry cough and dyspnea and was diagnosed with endobronchial aspergillosis with complete obliteration of left main bronchus by fungal debris in which cryo debulking was done which relieved the symptoms significantly and was discharged in satisfactory condition on oral voriconazole therapy.
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8
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Shaikh F, Abtin FG, Lau R, Saggar R, Belperio JA, Lynch JP. Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display. Semin Respir Crit Care Med 2020; 41:758-784. [PMID: 32777856 DOI: 10.1055/s-0040-1712534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sarcoidosis is a multisystemic granulomatous disorder that can affect virtually any organ. However, pulmonary and thoracic lymph node involvement predominates; abnormalities on chest radiographs are present in 80 to 90% of patients with sarcoidosis. High-resolution computed tomographic (HRCT) scans are superior to chest X-rays in assessing extent of disease, and some CT features may discriminate an active inflammatory component (which may be amenable to therapy) from fibrosis (for which therapy is not indicated). Typical findings on HRCT include micronodules, perilymphatic and bronchocentric distribution, perihilar opacities, and varying degrees of fibrosis. Less common findings on CT include mass-like or alveolar opacities, miliary opacities, mosaic attenuation, honeycomb cysts, and cavitation. With progressive disease, fibrosis, architectural distortion, upper lobe volume loss with hilar retraction, coarse linear bands, cysts, and bullae may be observed. We discuss the salient CT findings in patients with sarcoidosis (with a major focus on pulmonary features) and present classical radiographic and histopathological images of a few extrapulmonary sites.
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Affiliation(s)
- Faisal Shaikh
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Fereidoun G Abtin
- Department of Radiology, Thoracic and Interventional Section, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ryan Lau
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
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9
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Abstract
Introduction: The treatment of pulmonary sarcoidosis is not standardized. Treatment involves a multi-step decision process beginning with whether treatment is warranted, determining initial therapy, then assessing when therapy requires modifications or can be discontinued.Areas covered: This manuscript will address the following issues concerning the treatment of pulmonary sarcoidosis: Treatment indications, initial anti-granulomatous therapy, therapy for chronic and fibrotic disease, glucocorticoid therapy, alternative therapy to glucocorticoids, non-granulomatous therapies, and managing complications of disease. Information was obtained through a literature search of PubMed and Web of Science databases.Expert opinion: Although glucocorticoids are highly effective for pulmonary sarcoidosis, their potential to cause significant side effects often mandates consideration of alternative agents. As the most common indication for the treatment of pulmonary sarcoidosis is quality of life impairment, traditional objective tests of lung function and radiographic imagining often have a minor role in therapeutic decision-making. The development of pulmonary fibrosis from sarcoidosis often causes major morbidity and mortality and should be a major focus of concern.
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Affiliation(s)
- W Ennis James
- Division of Pulmonary and Critical Care Medicine; Program Director, Susan Pearlstine Sarcoidosis Center of Excellence, Medical University of South Carolina, Charleston, SC, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College MC-91, Albany, NY, USA
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10
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Li E, Knight JM, Wu Y, Luong A, Rodriguez A, Kheradmand F, Corry DB. Airway mycosis in allergic airway disease. Adv Immunol 2019; 142:85-140. [PMID: 31296304 DOI: 10.1016/bs.ai.2019.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease. The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.
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Affiliation(s)
- Evan Li
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - J Morgan Knight
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States; Biology of Inflammation Center, Baylor College of Medicine, Houston, TX, United States
| | - Yifan Wu
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Amber Luong
- Department of Otolaryngology, University of Texas Health Science at Houston, Houston, TX, United States
| | - Antony Rodriguez
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States; Biology of Inflammation Center, Baylor College of Medicine, Houston, TX, United States; Michael E. DeBakey VA Center for Translational Research on Inflammatory Diseases, Houston, TX, United States
| | - Farrah Kheradmand
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States; Biology of Inflammation Center, Baylor College of Medicine, Houston, TX, United States; Michael E. DeBakey VA Center for Translational Research on Inflammatory Diseases, Houston, TX, United States
| | - David B Corry
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States; Biology of Inflammation Center, Baylor College of Medicine, Houston, TX, United States; Michael E. DeBakey VA Center for Translational Research on Inflammatory Diseases, Houston, TX, United States.
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11
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Abstract
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.
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Affiliation(s)
- YanLing Ma
- Department of Lung Pathologist, KEck Medical Center of USC, Los Angeles, California
| | - Anthony Gal
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Michael Koss
- Department of Lung Pathologist, KEck Medical Center of USC, Los Angeles, California.
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12
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Atypical HRCT manifestations of pulmonary sarcoidosis. Radiol Med 2017; 123:174-184. [DOI: 10.1007/s11547-017-0830-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/30/2017] [Indexed: 01/04/2023]
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13
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Denning DW. Sarcoidosis and aspergillosis: a tough combination. Eur Respir J 2017; 49:49/6/1700574. [DOI: 10.1183/13993003.00574-2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 11/05/2022]
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14
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Uzunhan Y, Nunes H, Jeny F, Lacroix M, Brun S, Brillet PY, Martinod E, Carette MF, Bouvry D, Charlier C, Lanternier F, Planès C, Tazi A, Lortholary O, Baughman RP, Valeyre D. Chronic pulmonary aspergillosis complicating sarcoidosis. Eur Respir J 2017; 49:49/6/1602396. [DOI: 10.1183/13993003.02396-2016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 02/18/2017] [Indexed: 11/05/2022]
Abstract
Chronic pulmonary aspergillosis (CPA) complicating sarcoidosis (SA) is associated with high mortality, and there is a lack of clarity regarding the relative contributions of SA or CPA.This was a retrospective single-centre study on CPA-SA.In total, 65 patients (44 men), aged 41.4±13.5 and 48.3±11.9 years at the time of SA and CPA diagnoses, respectively, were included between 1980 and 2015. Of these, 64 had fibrocystic SA, most often advanced, with composite physiological index (CPI) >40 (65% of patients) and pulmonary hypertension (PH) (31%), and 41 patients (63%) were treated for SA (corticosteroids or immunosuppressive drugs). Chronic cavitary pulmonary aspergillosis (CCPA) was the most frequent CPA pattern. Regarding treatment, 55 patients required long-term antifungals, 14 interventional radiology, 11 resection surgery and two transplantation. Nearly half of the patients (27; 41.5%) died (mean age 55.8 years); 73% of the patients achieved 5-year survival and 61% 10-year survival. Death most often resulted from advanced SA and rarely from haemoptysis. CPI, fibrosis extent and PH predicted survival. Comparison with paired healthy controls without CPA did not show any difference in survival, but a higher percentage of patients had high-risk mould exposure.CPA occurs in advanced pulmonary SA. CPA-SA is associated with high mortality due to the underlying advanced SA rather than to the CPA. CPI, fibrosis extent and PH best predict outcome.
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Jamilloux Y, Bernard C, Lortholary O, Kerever S, Lelièvre L, Gerfaud-Valentin M, Broussolle C, Valeyre D, Sève P. [Opportunistic infections and sarcoidosis]. Rev Med Interne 2016; 38:320-327. [PMID: 27639910 DOI: 10.1016/j.revmed.2016.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 06/14/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
Opportunistic infections (OI) are uncommon in sarcoidosis (1 to 10%) and mostly occur in patients with previously diagnosed disease or can rarely be the presenting manifestation. The most common OIs are, in descending order: aspergillosis, cryptococcosis, and mycobacterial infections. Treatment with corticosteroids is the most frequent risk factor for OI occurrence during sarcoidosis but immunosuppressive drugs and therapy with anti-TNFα are also risk factors. Overall, clinical presentation, treatment, and outcome are identical to that occur in other conditions complicated with the occurrence of OIs. However, some atypical presentations of OIs can mimic sarcoidosis exacerbation and misdiagnosis may lead clinicians to increase immunosuppression, causing worsening of the OI. The meticulous collection of patient's history along with factors differentiating OI from sarcoidosis exacerbation is key factor to optimally manage these patients.
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Affiliation(s)
- Y Jamilloux
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France; International research center on infectiology (CIRI), Inserm U1111, 69007 Lyon, France.
| | - C Bernard
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - O Lortholary
- Necker Pasteur center for infectious diseases and tropical medicine, Necker enfants malades, IHU Imagine, AP-HP, 75743 Paris, France; Institut Pasteur, centre national de référence des mycoses invasives, des antifongiques, et de mycologie moléculaire, 75743 Paris, France; CNRS URA3012, 75743 Paris, France
| | - S Kerever
- ECSTRA, épidémiologie et biostatistiques, UMR 1153, Inserm, 75004 Paris, France
| | - L Lelièvre
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - M Gerfaud-Valentin
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - C Broussolle
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - D Valeyre
- COMUE Sorbonne Paris Cité, hôpital Avicenne et université Paris 13, Assistance publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
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16
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Abstract
In sarcoidosis, reduction in mortality and the prevention of disability due to major organ involvement are treatment goals. Thus, it is important to recognize severe disease and identify patients at higher risk of progression to severe disease. In this article, fibrotic lung disease and cardiac sarcoidosis are reviewed as the major contributors to sarcoidosis mortality and morbidity. In the absence of a standardized definition of severe pulmonary disease, a multidisciplinary approach to clinical staging is suggested, based on symptoms, pulmonary function tests, and imaging findings at presentation, integrated with the duration of disease and longitudinal disease behavior during early follow-up.
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Affiliation(s)
- Vasileios Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Joe Jacob
- Department of Radiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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17
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18
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Jamilloux Y, Valeyre D, Lortholary O, Bernard C, Kerever S, Lelievre L, Neel A, Broussolle C, Seve P. The spectrum of opportunistic diseases complicating sarcoidosis. Autoimmun Rev 2015; 14:64-74. [PMID: 25305373 DOI: 10.1016/j.autrev.2014.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/23/2014] [Indexed: 12/21/2022]
Abstract
Sarcoidosis is an inflammatory disease marked by a paradoxical immune status. The anergic state, which results from various immune defects, contrasts with the inflammatory formation of granulomas. Sarcoidosis patients may be at risk for opportunistic infections (OIs) and a substantial number of cases have been reported, even in untreated sarcoidosis. It is not clear how OIs in patients with sarcoidosis are different from other groups at risk. In this review, we discuss the most common OIs: mycobacterial infection (including tuberculosis), cryptococcosis, progressive multifocal leukoencephalopathy, and aspergillosis. Unlike peripheral lymphocytopenia, corticosteroids are a major risk factor for OIs but the occurrence of Ols in untreated patients suggests more complex predisposing mechanisms. Opportunistic infections presenting with extrapulmonary features are often misdiagnosed as new localizations of sarcoidosis. Aspergillomas mostly develop on fibrocystic lungs. Overall, physicians should be aware of the possible occurrence of OIs during sarcoidosis, even in untreated patients.
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Shino MY, Lynch Iii JP, Fishbein MC, McGraw C, Oyama J, Belperio JA, Saggar R. Sarcoidosis-associated pulmonary hypertension and lung transplantation for sarcoidosis. Semin Respir Crit Care Med 2014; 35:362-71. [PMID: 25007088 DOI: 10.1055/s-0034-1376863] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary hypertension (PH) is a significant complication of sarcoidosis, occurring in approximately 6 to > 20% of cases, and markedly increases mortality among these patients. The clinician should exercise a high index of suspicion for sarcoidosis-associated PH (SAPH) given the nonspecific symptomatology and the limitations of echocardiography in this patient population. The pathophysiology of PH in sarcoidosis is complex and multifactorial. Importantly, there are inherent differences in the pathogenesis of SAPH compared with idiopathic pulmonary arterial hypertension, making the optimal management of SAPH controversial. In this article, we review the epidemiology, diagnosis, prognosis, and treatment considerations for SAPH. Lung transplantation (LT) is a viable therapeutic option for sarcoid patients with severe pulmonary fibrocystic sarcoidosis or SAPH refractory to medical therapy. We discuss the role for LT in patients with sarcoidosis, review the global experience with LT in this population, and discuss indications and contraindications to LT.
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Affiliation(s)
- Michael Y Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch Iii
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michael C Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Charles McGraw
- Department of Radiological Sciences, UCLA Medical Center, Los Angeles, California
| | - Jared Oyama
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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20
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Spagnolo P, Sverzellati N, Wells AU, Hansell DM. Imaging aspects of the diagnosis of sarcoidosis. Eur Radiol 2014; 24:807-16. [DOI: 10.1007/s00330-013-3088-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/27/2013] [Accepted: 12/12/2013] [Indexed: 01/15/2023]
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21
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Bernard C, Maucort-Boulch D, Varron L, Charlier C, Sitbon K, Freymond N, Bouhour D, Hot A, Masquelet AC, Valeyre D, Costedoat-Chalumeau N, Etienne M, Gueit I, Jouneau S, Delaval P, Mouthon L, Pouget J, Serratrice J, Brion JP, Vaylet F, Bremont C, Chennebault JM, Jaffuel S, Broussolle C, Lortholary O, Sève P. Cryptococcosis in sarcoidosis: cryptOsarc, a comparative study of 18 cases. QJM 2013; 106:523-39. [PMID: 23515400 DOI: 10.1093/qjmed/hct052] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIM To describe the main characteristics and the treatment of cryptococcosis in patients with sarcoidosis. DESIGN Multicenter study including all patients notified at the French National Reference Center for Invasive Mycoses and Antifungals. METHODS Retrospective chart review. Each case was compared with two controls without opportunistic infections. RESULTS Eighteen cases of cryptococcosis complicating sarcoidosis were analyzed (13 men and 5 women). With 2749 cases of cryptococcosis registered in France during the inclusion period of this study, sarcoidosis accounted for 0.6% of all the cryptococcosis patients and for 2.9% of the cryptococcosis HIV-seronegative patients. Cryptococcosis and sarcoidosis were diagnosed concomitantly in four cases; while sarcoidosis was previously known in 14/18 patients, including 12 patients (67%) treated with steroids. The median rate of CD4 T cells was 145 per mm(3) (range: 55-1300) and not related to steroid treatment. Thirteen patients had cryptococcal meningitis (72%), three osteoarticular (17%) and four disseminated infections (22%). Sixteen patients (89%) presented a complete response to antifungal therapy. After a mean follow-up of 6 years, no death was attributable to cryptococcosis. Extra-thoracic sarcoidosis and steroids were independent risk factors of cryptococcosis in a logistic regression model adjusted with the sex of the patients. CONCLUSIONS Cryptococcosis is a significant opportunistic infection during extra-thoracic sarcoidosis, which occurs in one-third of the cases in patients without any treatment; it is not associated to severe CD4 lymphocytopenia and has a good prognosis.
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Affiliation(s)
- C Bernard
- Department of Internal Medicine, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France.
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22
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Kravitz JN, Berry MW, Schabel SI, Judson MA. A Modern Series of Percutaneous Intracavitary Instillation of Amphotericin B for the Treatment of Severe Hemoptysis From Pulmonary Aspergilloma. Chest 2013; 143:1414-1421. [DOI: 10.1378/chest.12-1784] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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23
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Kanne JP, Yandow DR, Haemel AK, Meyer CA. Beyond Skin Deep: Thoracic Manifestations of Systemic Disorders Affecting the Skin. Radiographics 2011; 31:1651-68. [DOI: 10.1148/rg.316115516] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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24
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Brillet PY, Nunes H, Soussan M, Brauner MW. [Pulmonary sarcoidosis imaging]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:94-100. [PMID: 21497723 DOI: 10.1016/j.pneumo.2010.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Accepted: 06/20/2010] [Indexed: 05/30/2023]
Abstract
Sarcoidosis is a juvenile systemic granulomatosis. Its polymorphic clinical presentation depends on its different localisations, thoracic and extrathoracic. The role of imaging is very important for all localisations; but for mediastinopulmonary involvement, which is the most frequent (>90% of cases), it plays a major role in detecting the disease, diagnosing it, its prognosis, decision-making regarding treatment of it and in the monitoring of its development. Standard radiography, which sometimes detects the disease, forms the basis for its four-stage prognostic classification. CT scanning enables the study of mediastinal and hilar lymphadenopathy and the study of parenchyma, making it possible to identify micronodules of lymphatic distributions, alveolar opacities, septal lines, ground-glass hyperintensities, nodules surrounded by a ring of satellite micronodules, peribronchovascular thickening; all potentially reversible lesions. Elsewhere, it highlights irreversible fibrous lesions: hilar peripheral linear opacities; septal linear opacities; bronchial distortion, honeycomb destruction or even perihilar fibrotic masses. Less frequently we can visualise bronchiolar or cystic involvement. Benign in most cases, the sarcoidosis prognosis becomes bleaker in the event of hemoptysis, Aspergillus colonisation or before the onset of pulmonary hypertension.
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Affiliation(s)
- P-Y Brillet
- Service de radiologie, hôpital Avicenne, 125 route de Stalingrad, Bobigny cedex, France.
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25
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Criado E, Sánchez M, Ramírez J, Arguis P, de Caralt TM, Perea RJ, Xaubet A. Pulmonary sarcoidosis: typical and atypical manifestations at high-resolution CT with pathologic correlation. Radiographics 2011; 30:1567-86. [PMID: 21071376 DOI: 10.1148/rg.306105512] [Citation(s) in RCA: 238] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Sarcoidosis is a multisystem disorder that is characterized by noncaseous epithelioid cell granulomas, which may affect almost any organ. Thoracic involvement is common and accounts for most of the morbidity and mortality associated with the disease. Thoracic radiologic abnormalities are seen at some stage in approximately 90% of patients with sarcoidosis, and an estimated 20% develop chronic lung disease leading to pulmonary fibrosis. Although chest radiography is often the first diagnostic imaging study in patients with pulmonary involvement, computed tomography (CT) is more sensitive for the detection of adenopathy and subtle parenchymal disease. Pulmonary sarcoidosis may manifest with various radiologic patterns: Bilateral hilar lymph node enlargement is the most common finding, followed by interstitial lung disease. At high-resolution CT, the most typical findings of pulmonary involvement are micronodules with a perilymphatic distribution, fibrotic changes, and bilateral perihilar opacities. Atypical manifestations, such as masslike or alveolar opacities, honeycomb-like cysts, miliary opacities, mosaic attenuation, tracheobronchial involvement, and pleural disease, and complications such as aspergillomas, also may be seen. To achieve a timely diagnosis and help reduce associated morbidity and mortality, it is essential to recognize both the typical and the atypical radiologic manifestations of the disease, take note of features that may be suggestive of diseases other than sarcoidosis, and correlate imaging features with pathologic findings to help narrow the differential diagnosis.
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Affiliation(s)
- Eva Criado
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain.
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26
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Pena TA, Soubani AO, Samavati L. Aspergillus lung disease in patients with sarcoidosis: a case series and review of the literature. Lung 2011; 189:167-72. [PMID: 21327836 DOI: 10.1007/s00408-011-9280-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 01/20/2011] [Indexed: 11/28/2022]
Abstract
Chronic cavitary pulmonary aspergillosis (CCPA) has been associated with advanced lung diseases. Pulmonary sarcoidosis, a granulomatous inflammatory disorder, is associated with CCPA. We identified CCPA in 2% of cases in a large cohort of sarcoidosis patients. We found a lack of response to medical treatment and poor outcome in this subgroup.
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Affiliation(s)
- Tahuanty A Pena
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Wayne State University School of Medicine, 3990 John R, 3 Hudson, Detroit, MI 48201, USA
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27
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Kravitz JN, Steed LL, Judson MA. Intracavitary voriconazole for the treatment of hemoptysis complicating Pseudallescheria angusta pulmonary mycetomas in fibrocystic sarcoidosis. Med Mycol 2010; 49:198-201. [PMID: 20831365 DOI: 10.3109/13693786.2010.512619] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pulmonary mycetomas often occur in fibrocystic sarcoidosis. When this condition is complicated by hemoptysis, definitive surgery is usually precluded because of poor lung function. Intracavitary antifungal therapy has been described for the treatment of symptomatic pulmonary mycetomas. We report the first use of intracavitary voriconazole in the management of a Pseudallescheria angusta pulmonary mycetoma complicated by hemoptysis in a patient with fibrocystic sarcoidosis and renal transplant.
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Affiliation(s)
- Jared N Kravitz
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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28
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Hede J, Bahot R, Shah JR. Aspergilloma in sarcoidosis. Lung India 2010; 26:127-9. [PMID: 20531995 PMCID: PMC2876698 DOI: 10.4103/0970-2113.56347] [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] [Indexed: 12/03/2022] Open
Abstract
This is a case report of a 48-year-old man, followed up for nearly 30 years who initially developed sarcoidosis at the age of 18 that went into remission after 8 years of treatment. Ten years later, he developed sputum-positive tuberculosis and was cured with anti-tubercular treatment. Following this, there was progression of sarcoidosis to stage IV fibrocystic disease. Ten years later, he had massive hemoptysis during which time, aspergilloma was detected in a sarcoid cystic cavity.
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Affiliation(s)
- Jagruti Hede
- Department of Chest Diseases, Jaslok Hospital and Research Centre, Mumbai - 400 026, India
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29
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Panjabi C, Sahay S, Shah A. Aspergilloma formation in cavitary sarcoidosis. J Bras Pneumol 2009; 35:480-3. [PMID: 19547859 DOI: 10.1590/s1806-37132009000500015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 09/01/2008] [Indexed: 11/22/2022] Open
Abstract
Pulmonary cavitation is rather uncommon in patients with sarcoidosis, and aspergilloma is even more uncommon in such cases. Here, we present the case of a 63-year-old female patient with cavitary lung disease who had been under treatment for TB for 9 months. A diagnosis of pulmonary sarcoidosis was established based on the fiberoptic bronchoscopy finding of noncaseating granuloma. Treatment with corticosteroids led to a dramatic improvement in symptoms. While under treatment for sarcoidosis, the patient developed an aspergilloma. She presented immediate skin test reactivity to Aspergillus fumigatus, as well as positivity for A. fumigatus serum precipitins. This is the first reported case of aspergilloma formation in a patient with cavitary sarcoidosis in India.
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Affiliation(s)
- Chandramani Panjabi
- Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
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30
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31
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Massive Hemoptysis in a Patient With Sarcoidosis. J Bronchology Interv Pulmonol 2009; 16:135-7. [DOI: 10.1097/lbr.0b013e3181a08e41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Complications infectieuses de la sarcoïdose. Presse Med 2009; 38:317-23. [DOI: 10.1016/j.lpm.2008.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 11/20/2008] [Accepted: 11/20/2008] [Indexed: 11/22/2022] Open
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33
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Lebeaux D, Lanternier F, Lefort A, Lecuit M, Lortholary O. Risque infectieux fongique au cours des maladies systémiques. Presse Med 2009; 38:260-73. [DOI: 10.1016/j.lpm.2008.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 11/19/2008] [Accepted: 11/19/2008] [Indexed: 11/24/2022] Open
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34
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Armengol G, Bernet J, Lahaxe L, Lévesque H, Marie I. [Uncommon manifestation revealing sarcoidosis]. Rev Med Interne 2008; 30:53-7. [PMID: 18835653 DOI: 10.1016/j.revmed.2008.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 07/08/2008] [Accepted: 07/31/2008] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Bilateral hilar lymphadenopathy, with or without lung parenchymal infiltrates, is the most common radiographic finding in patients with sarcoidosis. Atypical pulmonary findings have been uncommonly reported and include multiple large lung nodules, cavitation, lobar collapse, pleural effusions or pneumothorax. OBSERVATION We report a 21-year-old non caucasian patient who presented with pulmonary nodular infiltration and sinonasal involvement revealing sarcoidosis. Thoracic and sinus computed tomographic scan showed both multiple excavated large lung nodules and micronodules, hilar lymphadenopathy and sinus thickening. Laboratory studies disclosed elevated angiotensin converting enzyme serum level (120UI/L). Outcome was favorable after institution of corticosteroids (at an initial dose of prednisone of 1mg/kg/day); at eight-month-follow-up, the patient was asymptomatic, while receiving prednisone 22.5mg/day. CONCLUSION In patients exhibiting unusual pulmonary manifestations, diagnosis of sarcoidosis relies on compatible clinical signs, evidence of non-caseating granulomas, and exclusion of underlying conditions including infections, malignancy and other granulomatous diseases (Wegener disease, pneumoconiosis).
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Affiliation(s)
- G Armengol
- Département de médecine interne, CHU de Rouen-Boisguillaume, 147, avenue du Maréchal-Juin, 76031 Rouen cedex, France
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35
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Akbar JJ, Meyer CA, Shipley RT, Vagal AS. Cardiopulmonary Imaging in Sarcoidosis. Clin Chest Med 2008; 29:429-43, viii. [DOI: 10.1016/j.ccm.2008.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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36
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Hours S, Nunes H, Kambouchner M, Uzunhan Y, Brauner MW, Valeyre D, Brillet PY. Pulmonary cavitary sarcoidosis: clinico-radiologic characteristics and natural history of a rare form of sarcoidosis. Medicine (Baltimore) 2008; 87:142-151. [PMID: 18520323 DOI: 10.1097/md.0b013e3181775a73] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Pulmonary cavitary lesions in the absence of concomitant comorbidities are an uncommon and often confusing manifestation of sarcoidosis. We retrospectively reviewed the clinical and high-resolution computed tomography (HRCT) characteristics and the natural history of a series of 23 patients with pulmonary cavitary lesions found on HRCT extracted from a large cohort of patients with pulmonary sarcoidosis. The estimated prevalence of cavitary sarcoidosis was 2.2%. Cavitary lesions developed in patients with severe and active sarcoidosis (serum angiotensin-converting enzyme [SACE] > or =2 times the upper limit of normal range: 63.6%). Twelve (52.2%) patients had evidence of radiographic stage IV, 9 of whom (75%) had persistently increased SACE. As found on HRCT, cavitary lesions were multiple in 21 patients (91.3%), including 5 patients with 10 or more cavities. The size of cavitary lesions was variable, with a median diameter of 20 mm (range, 11-100 mm). Follow-up was available for 20 patients with a median follow-up of 6.25 years (range, 6 months to 15 years). Seven patients (35%) experienced some type of complication related to cavitary lesions, including 6 episodes of hemoptysis in 5 patients and aspergilloma occurrence in 3 patients. As seen on HRCT, the evolution of the number and size of cavitary lesions was variable, with a complete resolution of the largest cavitary lesion in only 5 patients (25%). During follow-up, wall thickening was always associated with a further infectious complication. In summary, cavitary lesions are rare in pulmonary sarcoidosis and usually occur in active and severe sarcoidosis. Their evolution is unpredictable, and complications are frequent.
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Affiliation(s)
- Sandrine Hours
- From Université Paris 13 (HN, YU, MWB, DV, P-YB), UPRES EA 2363, Bobigny, France; Services de Pneumologie (SH, HN, YU, DV), Anatomie pathologique (MK), Radiologie (P-YB, MWB), AP-HP Hoôpital universitaire Avicenne, Bobigny, France
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Abstract
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8 + T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/ salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.
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Affiliation(s)
- YanLing Ma
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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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.
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Affiliation(s)
- Achala S Vagal
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH 45267-0761, USA
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Roehrl MHA, Croft WJ, Liao Q, Wang JY, Kradin RL. Hemorrhagic pulmonary oxalosis secondary to a noninvasive Aspergillus niger fungus ball. Virchows Arch 2007; 451:1067-73. [PMID: 17786471 DOI: 10.1007/s00428-007-0487-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
We report a case of hemorrhagic pulmonary oxalosis secondary to a noninvasive Aspergillus niger fungus ball. A patient with cavitary lung disease and hemoptysis developed progressive lung infiltrates and intractable metabolic acidosis leading to death. At autopsy, aspergillomas were identified in both the right upper and middle lobes surrounded by a large rim of necrotic and hemorrhagic parenchyma. Microscopic examination showed extensive crystal deposition and vascular thrombosis. Fungal growth was limited to the intraluminal mycelia, and no tissue or blood vessel invasion was present. Remote crystal deposits were also localized in the absence of fungal organisms to the contralateral lung and to the tubules of both kidneys. The crystals were birefringent in polarized light and stained with colloidal iron. X-ray powder diffractometry and electron impact ionization mass spectrometry identified the crystals as calcium oxalate monohydrate. Furthermore, non-necrotizing granulomatous lesions were identified in the lungs, liver, and spleen, consistent with sarcoidosis, and may have predisposed this patient to developing pulmonary aspergillomas.
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Affiliation(s)
- Michael H A Roehrl
- Department of Pathology and Laboratory Medicine, James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Dannaoui E, Garcia-Hermoso D, Naccache JM, Meneau I, Sanglard D, Bouges-Michel C, Valeyre D, Lortholary O. Use of voriconazole in a patient with aspergilloma caused by an itraconazole-resistant strain of Aspergillus fumigatus. J Med Microbiol 2006; 55:1457-1459. [PMID: 17005798 DOI: 10.1099/jmm.0.46639-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The case is reported of a patient with cavitary sarcoidosis complicated by an aspergilloma caused by an itraconazole-resistant strain of Aspergillus fumigatus, who was treated with voriconazole. The authors suggest that susceptibility testing of A. fumigatus strains is of value during long-term therapy with itraconazole, and that voriconazole may be a good option for treatment of patients infected with itraconazole-resistant strains of A. fumigatus.
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Affiliation(s)
- E Dannaoui
- Université Paris Descartes, Faculté de Médecine, AP-HP, Hôpital Européen Georges Pompidou, Unité de Parasitologie - Mycologie, 75015 Paris, France
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS FRE2849, Institut Pasteur, 75724 Paris Cedex 15, France
| | - D Garcia-Hermoso
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS FRE2849, Institut Pasteur, 75724 Paris Cedex 15, France
| | - J M Naccache
- Service de Pneumologie, Hôpital Avicenne, 93009 Bobigny, France
| | - I Meneau
- Institute of Microbiology, University Hospital Lausanne, CH-1011 Lausanne, Switzerland
| | - D Sanglard
- Institute of Microbiology, University Hospital Lausanne, CH-1011 Lausanne, Switzerland
| | - C Bouges-Michel
- Laboratoire de Parasitologie-Mycologie, Hôpital Avicenne, 93009 Bobigny, France
| | - D Valeyre
- Service de Pneumologie, Hôpital Avicenne, 93009 Bobigny, France
| | - O Lortholary
- Université Paris Descartes, Faculté de Médecine, AP-HP, Hôpital Necker-Enfants-Malades, Service des Maladies Infectieuses et Tropicales, 75743 Paris Cedex 15, France
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS FRE2849, Institut Pasteur, 75724 Paris Cedex 15, France
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Hope WW, Walsh TJ, Denning DW. The invasive and saprophytic syndromes due to Aspergillus spp. Med Mycol 2005; 43 Suppl 1:S207-38. [PMID: 16110814 DOI: 10.1080/13693780400025179] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.
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Affiliation(s)
- W W Hope
- University of Manchester and Wythenshawe Hospital, Manchester UK
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Fajraoui N, Bouhaouala MH, Charfi MR, Zidi A, Annabi H. Une manifestation inhabituelle de la sarcoïdose thoracique : la cavité pulmonaire primaire. Rev Med Interne 2005; 26:73-6. [PMID: 15639332 DOI: 10.1016/j.revmed.2004.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 09/13/2004] [Indexed: 10/26/2022]
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Hennebicque AS, Nunes H, Brillet PY, Moulahi H, Valeyre D, Brauner MW. CT findings in severe thoracic sarcoidosis. Eur Radiol 2004; 15:23-30. [PMID: 15449010 DOI: 10.1007/s00330-004-2480-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2004] [Revised: 06/30/2004] [Accepted: 08/02/2004] [Indexed: 11/25/2022]
Abstract
Severe thoracic sarcoidosis includes manifestations with significant clinical and functional impairment and a risk of mortality. Severe thoracic sarcoidosis can take on various clinical presentations and is associated with increased morbidity. The purpose of this article was to describe the CT findings in severe thoracic sarcoidosis and to explain some of their mechanisms. Subacute respiratory insufficiency is a rare and early complication due to a high profusion of pulmonary lesions. Chronic respiratory insufficiency due to pulmonary fibrosis is a frequent and late complication. Three main CT patterns are identified: bronchial distortion, honeycombing and linear opacities. CT can be helpful in diagnosing some mechanisms of central airway obstruction such as bronchial distortion due to pulmonary fibrosis or an extrinsic bronchial compression by enlarged lymph nodes. An intrinsic narrowing of the bronchial wall by endobronchial granulomatous lesions may be suggested by CT when it shows evidence of bronchial mural thickening. Pulmonary hypertension usually occurs in patients with end-stage pulmonary disease and is related to fibrotic destruction of the distal capillary bed and to the resultant chronic hypoxemia. Several other mechanisms may contribute to the development of pulmonary hypertension including extrinsic compression of major pulmonary arteries by enlarged lymph nodes and secondary pulmonary veno-occlusive disease. Aspergilloma colonization of a cavity is the main cause of hemoptysis in sarcoidosis. Other rare causes are bronchiesctasis, necrotizing bronchial aspergillosis, semi-invasive pulmonary aspergillosis, erosion of a pulmonary artery due to a necrotic sarcoidosis lesion, necrosis of parenchymal sarcoidosis lesions and specific endobronchial macroscopic lesions.
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Affiliation(s)
- Anne-Sophie Hennebicque
- Department of Radiology, Fédération MARTHA and EA 2363, UFR Bobigny, Université Paris 13 et AP-HP Hôpital Avicenne, 125, route de Stalingrad, 93009 Bobigny, France
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Buckingham SJ, Hansell DM. Aspergillus in the lung: diverse and coincident forms. Eur Radiol 2003; 13:1786-800. [PMID: 12783174 DOI: 10.1007/s00330-002-1813-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2002] [Revised: 11/29/2002] [Accepted: 12/16/2002] [Indexed: 01/15/2023]
Abstract
Pulmonary disease caused by the fungus Aspergillus has traditionally been regarded as belonging to one of the following, apparently distinct, entities: saprophytic aspergilloma; allergic bronchopulmonary aspergillosis (ABPA); and invasive aspergillosis (IPA); which may be further categorised as angioinvasive, acute or chronic airway invasive) [1]. It is not always obvious that there is overlap between these entities, and that in any given patient more than one Aspergillus-related pathological process can co-exist [2]. The aim of this article is to review the clinical and imaging features of the main categories of Aspergillus-related pulmonary disease and, in particular, to highlight the overlap between them.
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Affiliation(s)
- Susan J Buckingham
- Department of Radiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Marr KA, Patterson T, Denning D. Aspergillosis. Pathogenesis, clinical manifestations, and therapy. Infect Dis Clin North Am 2002; 16:875-94, vi. [PMID: 12512185 DOI: 10.1016/s0891-5520(02)00035-1] [Citation(s) in RCA: 263] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diseases caused by Aspergillus species are increasing in importance, especially among immunocompromised hosts. Clinical manifestations are variable, ranging from allergic to invasive disease, largely depending on the status of the host's immune system. This article focuses on the pathogenesis and clinical manifestations of diseases caused by Aspergillus species, with more detailed discussion on therapy of the most morbid manifestation, invasive aspergillosis.
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Affiliation(s)
- Kieren A Marr
- Program in Infectious Diseases, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue, N. D3-100, Seattle, WA 98109, USA.
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Abstract
Sarcoidosis is a multisystemic disease characterized by a nonnecrotizing granulomatous inflammatory process that can progress through various stages of activity. The distinctive histology of sarcoidosis is often associated with various morphologic findings in the lung and other organs. The rare variants, necrotizing sarcoidal granulomas and nodular sarcoidosis, share some of the histologic features of typical sarcoidosis, but may have different clinical and pathologic manifestations. The clinician and pathologist should be aware of the diverse pathologic appearances of sarcoidosis.
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Affiliation(s)
- Anthony A Gal
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine and Hospital, Atlanta, Georgia 30322, USA.
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49
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Abstract
Aspergillus is a genus of fungi commonly found in all environments. Remarkably, only a few species cause disease and equally remarkably, those same species cause multiple diseases. In the lung, exposure to the fungus, the immunological status of the individual and the condition of the lung determine the pattern of disease. In asthmatic patients and those with cystic fibrosis, allergic bronchopulmonary aspergillosis (ABPA) is a complication that reduces pulmonary function and, in asthmatics, is substantially improved by itraconazole therapy. Patients with pre-existing lung cavities develop aspergillomas (fungal masses inside the cavity). Aspergillomas carry a 40% 5 years survival, and it not clear whether antifungal therapy is helpful. Similar in presentation to aspergilloma is chronic necrotizing pulmonary aspergillosis (CNPA). Development of new or expansion of existing pulmonary cavities with surrounding paracavitary shadowing is the hallmark of CNPA These two entities are probably a continuum of the same pathological process. Patients with CNPA respond to systemic antifungal therapy, but this may need to be lifelong. Surgery is appropriate for isolated aspergillomas, but not pleural or multicavity lesions. Aspergillus empyema is a complication of aspergilloma and CNPA, or surgery for these diseases and is slow to respond to treatment.
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MESH Headings
- Antifungal Agents/therapeutic use
- Aspergillosis/diagnosis
- Aspergillosis/drug therapy
- Aspergillosis/etiology
- Aspergillosis/pathology
- Aspergillosis, Allergic Bronchopulmonary/diagnosis
- Aspergillosis, Allergic Bronchopulmonary/drug therapy
- Aspergillosis, Allergic Bronchopulmonary/etiology
- Aspergillosis, Allergic Bronchopulmonary/pathology
- Chronic Disease
- Cystic Fibrosis/complications
- Empyema
- Humans
- Lung Diseases, Fungal/diagnosis
- Lung Diseases, Fungal/drug therapy
- Lung Diseases, Fungal/etiology
- Lung Diseases, Fungal/pathology
- Necrosis
- Radiography, Thoracic
- Tomography, X-Ray Computed
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Affiliation(s)
- D W Denning
- Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, UK.
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Abstract
Aspergillus fumigatus is one of the most ubiquitous of the airborne saprophytic fungi. Humans and animals constantly inhale numerous conidia of this fungus. The conidia are normally eliminated in the immunocompetent host by innate immune mechanisms, and aspergilloma and allergic bronchopulmonary aspergillosis, uncommon clinical syndromes, are the only infections observed in such hosts. Thus, A. fumigatus was considered for years to be a weak pathogen. With increases in the number of immunosuppressed patients, however, there has been a dramatic increase in severe and usually fatal invasive aspergillosis, now the most common mold infection worldwide. In this review, the focus is on the biology of A. fumigatus and the diseases it causes. Included are discussions of (i) genomic and molecular characterization of the organism, (ii) clinical and laboratory methods available for the diagnosis of aspergillosis in immunocompetent and immunocompromised hosts, (iii) identification of host and fungal factors that play a role in the establishment of the fungus in vivo, and (iv) problems associated with antifungal therapy.
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Affiliation(s)
- J P Latgé
- Laboratoire des Aspergillus, Institut Pasteur, 75015 Paris, France.
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