Obstructive sarcoidosis

First Report of the Prevalence at Baseline and after 1-Year Follow-Up of Treatable Traits in Interstitial Lung Diseases

Different factors, not limited to the lung, influence the progression of ILDs. A "treatable trait" strategy was recently proposed for ILD patients as a precision model of care to improve outcomes. However, no data have been published so far on the prevalence of TTs in ILD. A prospective, observational, cohort study was conducted within the ILD Program at the IRCCS Humanitas Research Hospital (Milan, Italy) between November 2021 and November 2023. TTs were selected according to recent literature and assigned during multidisciplinary discussion (MDD) to one of the following categories: pulmonary, etiological, comorbidities, and lifestyle. Patients were further divided into four groups according to their post-MDD diagnosis: idiopathic ILD, sarcoidosis, connective tissue disease-ILD, and other ILD. The primary study outcome was the prevalence of each TT in the study population. A total of 116 patients with ILD [63.9% male; median (IQR) age: 69 (54-78) years] were included in the study. All the TTs identified in the literature were found in our cohort, except for intractable chronic cough. We also recognized differences in TTs across the ILD groups, with less TTs in patients with sarcoidosis. This analysis provides the first ancillary characterization of TTs in ILD patients in a real setting to date.

Microvascular damage evaluation based on nailfold videocapillarosopy in sarcoidosis

OBJECTIVES

Microvascular damage is thought to play a role in the pathogenesis of sarcoidosis. We aimed to evaluate the nailfold capillaroscopy (NVC) pattern to detect microvascular changes in patients with sarcoidosis and the relationship of capillaroscopic parameters with clinical variables and disease-related measurements.

PATIENTS AND METHODS

Forty-two patients with sarcoidosis and 42 age- and sex-matched patients with systemic sclerosis (SSc) and healthy individuals were included in this cross-sectional case-control study. Patients aged 18-80 years who met the current American Thoracic Society criteria for sarcoidosis were included. NVC was performed by a digital microscope under a magnification of × 200. Capillary density, number of dilated, giant and neoangiogenic capillaries, capillary loop diameter, capillary shape, micro-hemorrhages, and number of avascular areas, were evaluated by an assessor who was blind to the groups allocation.

RESULTS

Among the capillaroscopic parameters, neoangiogenesis and dilated capillaries, which can be seen in the pattern of scleroderma, were detected in patients with sarcoidosis but not significantly different from the control group (p = 0.055; p = 0.433, respectively). The rate of tortuosity and crossing capillaries of 50% and above was significantly higher in the sarcoidosis group than in SSc and healthy controls (p < 0.05). In patients with sarcoidosis, the only statistically significant finding was; forced expiratory volume (FEV1) in one second was lower in patients with a crossed capillary rate > 50% than in patients with a crossed capillary rate of less than 50% (FEV1; 87.21 ± 19.3, 102.5 ± 14.8, p = 0.04; respectively).

CONCLUSION

Patients with a diagnosis of sarcoidosis have different capillaroscopic patterns. The presence of these nonspecific abnormal patterns may reflect microvascular damage in the pathophysiology of sarcoidosis. Key Points • Microvascular damage may play a role in the pathogenesis of sarcoidosis. • There may be some nonspecific abnormal findings in capillaroscopy findings in sarcoidosis. • Capillaroscopy may be valuable in reflecting sarcoidosis lung injury.

Combined obstructive airflow limitation associated with interstitial lung diseases (O-ILD): the bad phenotype ?

Background

Patients suffering from combined obstructive and interstitial lung disease (O-ILD) represent a pathological entity which still has to be well clinically described. The aim of this descriptive and explorative study was to describe the phenotype and functional characteristics of a cohort of patients suffering from functional obstruction in a population of ILD patients in order to raise the need of dedicated prospective observational studies and the evaluation of the impact of anti-fibrotic therapies.

Methods

The current authors conducted a retrospective study including 557 ILD patients, with either obstructive (O-ILD, n = 82) or non-obstructive (non O-ILD, n = 475) pattern. Patients included were mainly males (54%) with a mean age of 62 years.

Results

Patients with O-ILD exhibited a characteristic functional profile with reduced percent predicted forced expired volume in 1 s (FEV1) [65% (53–77) vs 83% (71–96), p < 0.00001], small airway involvement assessed by maximum expiratory flow (MEF) 25/75 [29% (20–41) vs 81% (64–108), p < 0.00001], reduced sGaw [60% (42–75) vs 87% (59–119), p < 0.01] and sub-normal functional residual capacity (FRC) [113% (93–134) vs 92% (75–109), p < 0.00001] with no impaired of carbon monoxide diffusing capacity of the lung (DLCO) compared to those without obstruction. Total lung capacity (TLC) was increased in O-ILD patients [93% (82–107) vs 79% (69–91), p < 0.00001]. Of interest, DLCO sharply dropped in O-ILD patients over a 5-year follow-up. We did not identify a significant increase in mortality in patients with O-ILD. Interestingly, the global mortality was increased in the specific sub-group of patients with O-ILD and no progressive fibrosing ILD phenotype and in those with connective tissue disease associated ILD especially in case of rheumatoid arthritis.

Conclusions

The authors individualized a specific functional-based pattern of ILD patients with obstructive lung disease, who are at risk of increased mortality and rapid DLCO decline over time. As classically those patients are excluded from clinical trials, a dedicated prospective study would be of interest in order to define more precisely treatment response of those patients.

Mechanobiology of Pulmonary Diseases: A Review of Engineering Tools to Understand Lung Mechanotransduction

Cells within the lung micro-environment are continuously subjected to dynamic mechanical stimuli which are converted into biochemical signaling events in a process known as mechanotransduction. In pulmonary diseases, the abrogated mechanical conditions modify the homeostatic signaling which influences cellular phenotype and disease progression. The use of in vitro models has significantly expanded our understanding of lung mechanotransduction mechanisms. However, our ability to match complex facets of the lung including three-dimensionality, multicellular interactions, and multiple simultaneous forces is limited and it has proven difficult to replicate and control these factors in vitro. The goal of this review is to (a) outline the anatomy of the pulmonary system and the mechanical stimuli that reside therein, (b) describe how disease impacts the mechanical micro-environment of the lung, and (c) summarize how existing in vitro models have contributed to our current understanding of pulmonary mechanotransduction. We also highlight critical needs in the pulmonary mechanotransduction field with an emphasis on next-generation devices that can simulate the complex mechanical and cellular environment of the lung. This review provides a comprehensive basis for understanding the current state of knowledge in pulmonary mechanotransduction and identifying the areas for future research.

Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display

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.

Incidence, Etiology, and Clinicopathologic Features of Endobronchial Benign Lesions: A 10-Year Consecutive Retrospective Study

BACKGROUND

Airways can be affected by non-neoplastic lesions leading to critical stenosis of the lumen. Incidence, etiology, and clinical significance of endobronchial benign lesions are not systematically characterized.This study aimed to assess the epidemiology of nonmalignant processes involving the bronchial tree on clinical, pathologic, endoscopic, and radiologic grounds.

METHODS

We retrospectively analyzed bronchoscopy procedures over 10 years at the Bronchoscopy Unit of Modena University Hospital. All the endoscopically growing benign lesions with histologic confirmation were considered. For each lesion, we evaluated demographics, clinical features and outcome, the endoscopic aspect and radiologic characteristics by means of computed tomography as assessed by 2 experienced radiologists blinded with regard to the diagnosis.

RESULTS

Over the study period, we analyzed 10,431 bronchoscopies and identified 2075 cases of tracheobronchial alterations. Among these, 11.2% had a benign etiology with an average annual incidence of 23 new cases/year and a general incidence of 2.2%. Anthrachosis was the most prevalent bronchial lesion. In total, 22% of benign lesions presented airway stenosis >50% and required bronchoscopic treatment. Bronchial stenosis was most frequently observed in tuberculosis (P=0.031) and aspergillosis (P=0.020) when compared with sarcoidosis. Immunosuppressive status was significantly associated with endobronchial aspergillosis (P=0.0001) and the 1-year survival from diagnosis resulted significantly lower irrespectively to the immune system condition.

CONCLUSIONS

A consistent proportion of endobronchial benign lesions are reported. One fifth of these are associated with critical stenosis of the airway lumen, requiring rigid bronchoscopy. Among these, aspergillosis is characterized by the poorest prognosis, regardless of host immunity status.

Lung volumes and airway resistance in patients with a possible restrictive pattern on spirometry

Objective:

Many patients with proportional reductions in FVC and FEV1 on spirometry show no reduction in TLC. The aim of this study was to evaluate the role that measuring lung volumes and airway resistance plays in the correct classification of patients with a possible restrictive pattern on spirometry.

Methods:

This was a prospective study involving adults with reduced FVC and FEV1, as well as an FEV1/FV(C) ratio within the predicted range. Restrictive lung disease (RLD) was characterized by TLC below the 5th percentile, as determined by plethysmography. Obstructive lung disease (OLD) was characterized by high specific airway resistance, significant changes in post-bronchodilator FEV1, or an FEF25-75% < 50% of predicted, together with a high RV/TLC ratio. Nonspecific lung disease (NLD) was characterized by TLC within the predicted range and no obstruction. Combined lung disease (CLD) was characterized by reduced TLC and findings indicative of airflow obstruction. Clinical diagnoses were based on clinical suspicion, a respiratory questionnaire, and the review of tests of interest.

Results:

We included 300 patients in the study, of whom 108 (36%) were diagnosed with RLD. In addition, 120 (40%) and 72 (24%) were diagnosed with OLD/CLD and NLD, respectively. Among the latter, 24 (33%) were clinically diagnosed with OLD. In this sample, 151 patients (50.3%) were obese, and obesity was associated with all patterns of lung disease.

Conclusions:

Measuring lung volumes and airway resistance is often necessary in order to provide an appropriate characterization of the pattern of lung disease in patients presenting with a spirometry pattern suggestive of restriction. Airflow obstruction is common in such cases.

Objetivo:

Muitos pacientes com redução proporcional de CVF e VEF1 na espirometria não têm CPT reduzida. O objetivo deste estudo foi avaliar o papel da medida dos volumes pulmonares e da resistência das vias aéreas para a classificação correta de pacientes com possível restrição à espirometria.

Métodos:

Estudo prospectivo de adultos com CVF e VEF1 reduzidos e relação VEF1/CV(F) na faixa prevista. Distúrbio ventilatório restritivo (DVR) foi definido por CPT < 5º percentil por pletismografia. Distúrbio ventilatório obstrutivo (DVO) foi caracterizado por resistência específica de vias aéreas elevada, resposta significativa do VEF1 pós-broncodilatador e/ou um FEF25-75% < 50% do previsto associado a uma relação VR/CPT elevada. Distúrbio ventilatório inespecífico (DVI) foi caracterizado por CPT na faixa prevista e ausência de obstrução. Distúrbio ventilatório combinado (DVC) foi caracterizado por CPT reduzida e achados indicativos de obstrução ao fluxo aéreo. Os diagnósticos clínicos foram baseados em suspeita clínica, um questionário respiratório e revisão de exames de interesse.

Resultados:

Foram incluídos 300 pacientes no estudo, dos quais 108 (36%) tiveram diagnóstico de DVR, enquanto 120 (40%) foram diagnosticados com DVO ou DVC e 72 (24%) com DVI. Destes últimos, 24 (33%) tinham diagnóstico clínico de DVO. Nesta amostra, 151 pacientes (50,3%) eram obesos, e isso se associou com todos os padrões de distúrbios funcionais.

Conclusões:

Medidas dos volumes pulmonares e da resistência das vias aéreas são frequentemente necessárias para a caracterização adequada do tipo de distúrbio funcional em casos com possível restrição à espirometria. A obstrução ao fluxo aéreo é comum nesses casos.

Clinical and Biological Insights from the University of California San Francisco Prospective and Longitudinal Cohort

INTRODUCTION

Sarcoidosis is a systemic inflammatory disease characterized by non-necrotizing granulomas in involved organs, most commonly the lung. Description of patient characteristics in the Western United States is limited. Furthermore, blood-based measures that relate to clinical sarcoidosis phenotypes are lacking. We present an analysis of a prospective, longitudinal sarcoidosis cohort at a Northern Californian academic medical center.

METHODS

We enrolled 126 sarcoidosis subjects and 64 healthy controls and recorded baseline demographic and clinical characteristics. We used regression models to identify factors independently associated with pulmonary physiology. We tested whether blood transcript levels at study entry could relate to longitudinal changes in pulmonary physiology.

RESULTS

White, non-Hispanics composed ~70% of subjects. Hispanics and Blacks had a diagnostic biopsy at an age ~7 years younger than whites. Obstructive, but not restrictive, physiology characterized Scadding Stage IV patients. Subjects reporting use of immunosuppression had worse FEV1%p, FVC%p, and DLCO%p compared to subjects never treated, regardless of Scadding stage. We defined sarcoidosis disease activity by a drop in pulmonary function over 36 months and found that subjects meeting this definition had significant repression of blood gene transcripts related to T cell receptor signaling pathways, referred to as the "TCR factor."

CONCLUSION

Obstructive pulmonary physiology defined Stage IV patients which were mostly white, non-Hispanics. Genes comprising the composite gene expression score, TCR factor, may represent a blood-derived measure of T-cell activity and an indirect measure of active sarcoidosis inflammation. Validation of this measure could translate into individualized treatment for sarcoidosis patients.

Radiologic Features of World Trade Center-related Sarcoidosis in Exposed NYC Fire Department Rescue Workers

PURPOSE

An increased incidence of sarcoidosis has been demonstrated in firefighters, supporting the concern that occupational/environmental exposure may pose an etiologic risk factor. This incidence increased further after September 11, 2001 following exposure to World Trade Center (WTC) dust and gases. We review computed tomography (CT) features in this population, comparing the range of findings and physiological correlates with those typically reported in unexposed individuals with pulmonary sarcoidosis.

MATERIALS AND METHODS

With CT imaging we retrospectively identified 46 patients with WTC-related sarcoidosis, between March 18, 2002 and April 5, 2014. Scans were independently reviewed by 2 dedicated thoracic radiologists and assessed for disease patterns and correlation with pulmonary functions.

RESULTS

The majority (37/46; 80%) had symmetric mediastinal and hilar lymphadenopathy. Similarly, most (38/46; 83%) had perilymphatic nodules. Foci of ill-defined ground glass attenuation were present in 6 (13%). Coalescent nodularity was present in 15 (33%). Only 3 (7%) had parenchymal reticulation. A mixed pattern of lung findings was present in 21 (46%). When all forms of parenchymal disease were scored by zonal distribution, 21 (46%) had parenchymal disease predominantly involving mid and upper lungs; 11/46 (24%) had a random distribution without zonal predominance; 6/46 (13%) demonstrated atypical lower zone predominance. Whereas 15/46 (33%) had obstructive airways disease on pulmonary function tests, there were no CT findings that were predictive of obstructive airways disease.

CONCLUSIONS

The majority of cases of WTC-related sarcoidosis demonstrated typical radiographic appearances of sarcoidosis, with symmetric hilar and mediastinal lymphadenopathy and mid to upper lung perilymphatic nodules; these findings were consistent with other previously reported cases of sarcoid-like granulomatous disease in association with various alternate underlying etiologies. There was no correlation between disease patterns or extent on CT and pulmonary function testing, likely at least in part due to the overall mild extent of disease in this population.

Clinical phenotypes in sarcoidosis

PURPOSE OF REVIEW

To describe the methods for derivation of clinical phenotypes in general and how they should be applied in sarcoidosis, taking into account the dimensions of the disease. The results from the small number of studies in this area are summarized.

RECENT FINDINGS

Clinical phenotypes are determined by diverse ways. In sarcoidosis, some studies defined clinical phenotypes based on severity of disease and outcome after treatment of variable duration. A second approach to characterize clinical phenotypes is by using analytic or multivariate techniques. This approach considers several domains of disease and does not make assumptions a priori, with the hypothesis being developed after the results. A small study used factorial analysis for this purpose. Some well defined clinical phenotypes are described and future directions for research are given.

SUMMARY

Clinical phenotypes, by examining relationships between several domains in sarcoidosis, are likely to better delineate the underlying processes and pathways. Larger studies with appropriate methods should be performed to better delineate clinical phenotypes in sarcoidosis.

Sarcoidosis of the upper and lower airways

Sarcoidosis is a systemic granulomatous disease of undetermined etiology characterized by a variable clinical presentation and disease course. Although clinical granulomatous inflammation may occur within any organ system, more than 90% of sarcoidosis patients have lung disease. Sarcoidosis is considered an interstitial lung disease that is frequently characterized by restrictive physiologic dysfunction on pulmonary function tests. However, sarcoidosis also involves the airways (large and small), causing obstructive airways disease. It is one of a few interstitial lung diseases that affects the entire length of the respiratory tract - from the nose to the terminal bronchioles - and causes a broad spectrum of airways dysfunction. This article examines airway dysfunction in sarcoidosis. The anatomical structure of the airways is the organizational framework for our discussion. We discuss sarcoidosis involving the nose, sinuses, nasal passages, larynx, trachea, bronchi and small airways. Common complications of airways disease, such as, atelectasis, fibrosis, bullous leions, bronchiectasis, cavitary lesions and mycetomas, are also reviewed.

Clinical and Radiographic Indices Associated With Airflow Limitation in Patients With Sarcoidosis

BACKGROUND

Airflow limitation is found in some patients with sarcoidosis, and it is associated with a poor prognosis. The aim of this study was to investigate clinical and radiographic indices associated with airflow limitation in patients with sarcoidosis.

METHODS

A prospective, observational study was performed on 228 consecutive sarcoidosis patients followed up at our patient clinic at the Central Clinic of Kyoto. Patients underwent pulmonary function tests, and high-resolution CT (HRCT) of the lung was evaluated for the presence of lymph node enlargement, lung opacity, reticular shadow, and thickening of bronchovascular bundles (BVB). Airflow limitation was defined as FEV(1)/FVC < 70%. Airway reversibility was tested in subjects with airflow limitation. The frequency of airflow limitation was evaluated, and clinical and radiographic parameters were compared between patients with and without airflow limitation.

RESULTS

Among all 228 subjects, 20 subjects (8.8%) had airflow limitation, and none showed airway reversibility. Patients with airflow limitation were predominantly male, smokers, and had advanced chest radiographic stage, increased frequency of lung opacities, reticular shadows, and thickened BVB on HRCT. Stepwise regression analysis showed that chest radiographic stage IV, higher age, smoking, and thickened BVB were independently associated with lower FEV(1)/FVC.

CONCLUSION

The frequency of airflow limitation was 8.8% in Japanese sarcoidosis patients. Chest radiographic stage IV, higher age, smoking, and thickened BVB were associated with airflow limitation in patients with sarcoidosis.

Pulmonary sarcoidosis: comparison of findings of inspiratory and expiratory high-resolution CT and pulmonary function tests between smokers and nonsmokers

OBJECTIVE

The purpose of our study was to compare the high-resolution CT and pulmonary function test findings of smokers and nonsmokers with pulmonary sarcoidosis.

MATERIALS AND METHODS

Full inspiratory and expiratory high-resolution CT of the thorax and pulmonary function tests were performed in 46 patients (23 smokers and 23 lifelong nonsmokers) with histologically proven sarcoidosis. The median interval between high-resolution CT and pulmonary function tests was 8 days (range, 0-27 days). High-resolution CT findings were categorized into six patterns, and the overall extent of each pattern was scored independently (high-resolution CT score). Correlation between each high-resolution CT score with each pulmonary functional parameter was performed using Spearman's rank correlation and stepwise multiple regression analysis.

RESULTS

Air trapping on expiration (45/46 patients, 98%) and small nodules on inspiration (all 46 patients, 100%) were the most common findings. Smokers had a greater extent of emphysema than nonsmokers (p = 0.002). No significant difference was seen in the extent of air trapping, consolidation, ground-glass attenuation, reticular opacities, or small nodules between smokers and nonsmokers. On Spearman's rank correlation, the extent of air trapping negatively correlated with forced vital capacity in smokers (p < 0.05) but not in nonsmokers. The extent of small nodules negatively correlated with forced vital capacity and positively correlated with the ratio of forced expiratory volume in 1 sec to forced vital capacity in nonsmokers (p < 0.05, both) but not in smokers, respectively. On stepwise multiple regression analysis, the extent of air trapping on CT was independently associated with decreased forced vital capacity (p < 0.05), and cigarette smoking was the main determinant of decrease in maximum midexpiratory flow and forced expiratory flow at 50% of vital capacity (p < 0.01).

CONCLUSION

Cigarette smoking confounds the correlation between the CT and pulmonary function test findings in patients with sarcoidosis. Therefore, smoking history must be taken into account when correlating the extent of parenchymal sarcoidosis on CT with functional impairment.

Respiratory failure in interstitial lung disease

PURPOSE OF REVIEW

Respiratory failure associated with interstitial lung disease (ILD) occurs commonly, often as a terminal event after a prolonged course of illness. Diagnosis and management of the underlying ILD and respiratory failure pose great challenges.

RECENT FINDINGS

Respiratory failure in the absence of a clearly identifiable cause has a high mortality and frequent complications. Patients with idiopathic pulmonary fibrosis who are admitted with respiratory failure have a grim prognosis and may not benefit from prolonged aggressive therapy including mechanical ventilation. Presence of diffuse alveolar damage or usual interstitial pneumonia on lung biopsy specimens from patients with respiratory failure may be a marker of poor prognosis. Recently, the importance of the clinical-radiologic-pathologic diagnosis has been emphasized.

SUMMARY

The prognosis and treatment may vary according to the type of ILD and the cause of the respiratory failure, which must therefore be established before treatment is initiated. Prevention of iatrogenesis and timely application of palliation are as important as specific treatment of underlying ILD.