Therapy for sarcoidosis: evidence-based recommendations

Emerging Therapeutic Options for Refractory Pulmonary Sarcoidosis: The Evidence and Proposed Mechanisms of Action

Sarcoidosis is a systemic disease with heterogenous clinical phenotypes characterized by non-necrotizing granuloma formation in affected organs. Most disease either remits spontaneously or responds to corticosteroids and second-line disease-modifying therapies. These medications are associated with numerous toxicities that can significantly impact patient quality-of-life and often limit their long-term use. Additionally, a minority of patients experience chronic, progressive disease that proves refractory to standard treatments. To date, there are limited data to guide the selection of alternative third-line medications for these patients. This review will outline the pathobiological rationale behind current and emerging therapeutic agents for refractory or drug-intolerant sarcoidosis and summarize the existing clinical evidence in support of their use.

Coexistence of pulmonary tuberculosis with pulmonary sarcoidosis and skin sarcoidosis: a case report

Background

Necrotising granulomatous diseases of the lungs exhibit a narrow range of differential diagnoses. Tuberculosis accounts for most of these cases, while sarcoidosis is an uncommon entity in this group but both possess similar clinical and radiological similarities. One must consider a diagnosis of sarcoidosis once the standard anti-mycobacterial medications fail to achieve a clinical improvement. The case described highlights the coexistence of tuberculosis and sarcoidosis which is a rare entity in the medical literature.

Case presentation

A 57-year-old male presented with respiratory symptoms and was diagnosed with tuberculosis (TB) demonstrating a polymerase chain reaction (PCR) test positive showing microbial DNA in bronchial washing. The patient started standard anti-TB treatment; however, he did not respond initially. Further investigations led us to diagnose pulmonary followed by skin sarcoidosis, based on histology. After confirmation of sarcoidosis, administered corticosteroids for 6 months simultaneously along with anti-TB treatment; however, anti-TB treatment was prolonged for a total of 9 months. The patient was found clinically symptomless after the completion of treatment during subsequent follow-ups.

Conclusion

The use of corticosteroids as an adjunct with standard anti-TB treatment proves beneficial effects on the recovery of patients having a coexistence of pulmonary mycobacterium tuberculosis and sarcoidosis disease conditions.

Prognostic Factors and Treatments Efficacy in Spinal Cord Sarcoidosis: An Observational Cohort With Long-term Follow-up

BACKGROUND AND OBJECTIVES

Spinal cord sarcoidosis is a rare manifestation of sarcoidosis with a consequent risk of neurological sequelae for the patient. We investigated prognostic factors and efficacy of immunosuppressive treatments in a longitudinal cohort.

METHODS

We retrospectively studied patients with spinal cord sarcoidosis followed between 1995 and 2021 in seven centers in France. Patients with a definite, probable or possible spinal cord sarcoidosis according to the Neurosarcoidosis Consortium Consensus Group criteria and with a spinal cord involvement confirmed by MRI were included. We analyzed relapse or progression rate with a Poisson model, initial Rankin score with a linear model and change in the Rankin score during follow-up with a logistic model.

RESULTS

A total of 97 patients were followed for a median of 7.8 years. Overall mean relapse or progression rate was 0.17 per person-year and decreased over time. At last visit, 46 (47.4%) patients had a loss of autonomy (Rankin score ≥ 2). The main prognostic factors significantly associated with relapse or progression rate were gadolinium enhancement (relative rate [95% CI]: 0.61 [0.4, 0.95]) or meningeal involvement (relative rate [95% CI]: 2.05 [1.31, 3.19]) on spinal cord MRI, and cell count (relative rate [95% CI] per 1 log increase: 1.16 [1.01, 1.33]) on CSF analysis. Relapse or progression rate was not significantly associated with initial Rankin score or EDSS. TNF α antagonists significantly decreased relapse or progression rate compared with corticosteroids alone (relative rate [95% CI]: 0.33 [0.11, 0.98]). Azathioprine was significantly less effective than methotrexate on relapse or progression rate (relative rate [95% CI]: 2.83 [1.04, 7.75]) and change in Rankin score (mean difference [95% CI]: 0.65 [0.23, 1.08]).

DISCUSSION

Regarding the relapse or progression rate, meningeal localization of sarcoidosis was associated with a worse prognosis; TNF α antagonists resulted in a significant decrease compared to corticosteroids alone; and methotrexate was more effective than azathioprine.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that in individuals with spinal cord neurosarcoidosis, TNF α antagonists were associated with decreased relapse or progression rate compared to corticosteroids alone, but other therapies showed no significant benefit.

Association between sarcoidosis and diabetes mellitus: a systematic review and meta-analysis

Background: Sarcoidosis is multisystem inflammatory granulomatosis that can potentially affect any organ of the human body. We aimed to estimate the prevalence of diabetes mellitus (DM) in sarcoidosis patients and determine the association between sarcoidosis and DM.Method: All relevant articles reporting the prevalence of DM in sarcoidosis published until September 19^th, 2020, were retrieved from ten electronic databases. We used the random effect model to perform the meta-analysis.Results: After screening 2,122 records, we included 19 studies (n = 18,686,162). The prevalence of DM in sarcoidosis patients was 12.7% (95% CI 10-16.1). The prevalence was highest in North America with 21.3% (13.5-31.8), followed by Europe 10.4 (7.9-13.7) and Asia 10% (1.8-39.7). Sarcoidosis patients had higher rates of DM compared to controls (OR 1.75; 95% CI 1.49-2.05). Sensitivity analysis, after removing the largest weighted study, did not reveal any effect on the significance of the results (OR 1.73; 95% CI 1.33-2.25).Conclusion: The prevalence of DM in sarcoidosis is considerably high, with increased odds of DM in sarcoidosis compared to healthy controls. Further research with a wide range of confounders is required to confirm the association of sarcoidosis with DM.

Distinguishing Blau Syndrome from Systemic Sarcoidosis

PURPOSE OF REVIEW

The purpose of this review is to provide a framework to distinguish Blau syndrome/Early Onset Sarcoidosis and Sarcoidosis clinically. We also discuss relevant differences in genetics, pathogenesis, and management of these diseases.

RECENT FINDINGS

Blau syndrome and Sarcoidosis share the characteristic histologic finding of noncaseating granulomas as well as some similar clinical characteristics; nevertheless, they are distinct entities with important differences between them. Blau syndrome and Early Onset Sarcoidosis are due to one of numerous possible gain-of-function mutations in NOD2, commonly presenting before age 5 with a triad of skin rash, arthritis, and uveitis. However, as more cases are reported, expanded clinical manifestations have been described. In systemic Sarcoidosis, there are numerous susceptibility genes that have been identified, and disease is thought to result from an environmental exposure in a genetically susceptible host. It most often presents with constitutional symptoms and pulmonary involvement and typically affects adolescents and adults. This paper reviews the similarities and differences between Blau syndrome and Sarcoidosis. We also discuss the importance of distinguishing between them, particularly with regard to prognosis and outcomes.

Infection risk in sarcoidosis patients treated with methotrexate compared to azathioprine: A retrospective 'target trial' emulated with Swedish real-world data

The 6‐month infection risk was 43% lower in patients with sarcoidosis who initiated methotrexate compared to those who started azathioprine. Our findings suggest that unless contraindications exist, methotrexate should be preferred over azathioprine as the primary steroid‐sparing choice in individuals with sarcoidosis.

Background and objective

No clinical trial has examined the risk of infection associated methotrexate and azathioprine, two advocated treatments for sarcoidosis. We aimed to compare the 6‐month risk of infection after the initiation of methotrexate or azathioprine.

Methods

We conducted a retrospective target trial emulation using Swedish pre‐existing data. We searched for eligible participants who were dispensed methotrexate or azathioprine in the Prescribed Drug Register (PDR) every day between January 2007 and June 2013. Adults were eligible if they had ≥2 ICD‐coded visits for sarcoidosis in the National Patient Register (NPR) and were dispensed ≥1 systemic corticosteroid but no methotrexate or azathioprine in the past 6 months (PDR). Within 6 months of methotrexate or azathioprine initiation, diagnosis of infectious disease was identified (visit in the NPR where infectious disease was the primary diagnosis). We estimated RR and risk differences comparing methotrexate (n = 667) to azathioprine initiations (n = 259) using targeted maximum likelihood estimation (TMLE) adjusting for demographic factors, comorbidity and sarcoidosis severity proxies.

Results

There were 43 infections in the methotrexate group (adjusted 6‐month risk 6.8%) and 29 infections in the azathioprine group (12.0%). The RR for infectious disease at 6 months associated with methotrexate compared to azathioprine initiation was 0.57 (95% CI: 0.39, 0.82) and the risk difference was −5.2% (95% CI: −8.5%, −1.8%). The RR at 9 months was attenuated to 0.77 (95% CI: 0.52, 1.14).

Conclusion

Methotrexate appears to be associated with a lower risk of infection in sarcoidosis than azathioprine, but randomized trials should confirm this finding.

The long-term prognostic significance of heart failure in sarcoidosis patients ─ a cohort study

OBJECTIVE

To evaluate the proportion and the long-term prognostic significance of heart failure (HF) in sarcoidosis patients.

METHODS

Data extracted from a large Israeli healthcare provider's database were used to study sarcoidosis patients and matched non-sarcoidosis controls since 2000 to 2016. The proportion of HF was compared between the groups, and the associations between sarcoidosis, HF, and all-cause mortality were assessed.

RESULTS

Included were 3,993 sarcoidosis patients and 19,856 age- and sex-matched controls. The proportion of HF patients was higher among the former (10.9% and 5.3%, respectively). A logistic regression model for multivariable analysis for covariates found sarcoidosis to be independently associated with HF (Odds Ratio (OR) 2.09 confidence interval (CI) 1.83-2.39). A total of 710 sarcoidosis patients (17.8%) and 2,121 controls (10.7%) died during the study period (p < 0.001). A multivariable survival analysis found an estimated hazard ratio (HR) of 1.84 (95%CI 1.67-2.02), indicating a significant association between sarcoidosis and risk for all-cause mortality. Our analysis also revealed a significant association between HF and risk for all-cause mortality (HR 3.05, 95%CI 2.77-3.36).

CONCLUSIONS

Sarcoidosis is independently associated with HF, and both are independently associated with all-cause mortality.

Indications for treatment of sarcoidosis

PURPOSE OF REVIEW

To describe the current knowledge on indications for sarcoidosis treatment.

RECENT FINDINGS

Despite the lack of evidence-based recommendations, the sarcoidosis community has adopted the concept of starting systemic anti-inflammatory treatment because of potential danger (risk of severe dysfunction on major organs or death) or unacceptable impaired quality of life (QoL). On the contrary, while QoL and functionality are patients' priorities, few studies have evaluated treatment effect on patient-reported outcomes. The awareness of long-term corticosteroids toxicities and consequences on QoL and the emergence of novel drugs have changed therapeutic management. Second-line therapy, mainly methotrexate and azathioprine, are indicated for corticosteroids sparing or corticosteroids-resistant sarcoidosis. TNF-α inhibitors are a useful third-line therapy in chronic refractory disease. In addition to organ-targeted treatment, efforts should also be taken for treating nonorgan-specific symptoms, such as physical training for fatigue, and various disease complications.

SUMMARY

Clinicians should offer a tailored treatment for each patient and ensure a holistic multidisciplinary approach, including pharmacological and nonpharmacological interventions. Patient-centered communication is critical to drive shared decisions, in particular for the tricky situation of isolated impaired QoL as the unique therapeutic indication. Once treatment is decided, clinicians should define a clear therapeutic plan, including goals and instruments to assess response.

Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis

Pulmonary sarcoidosis presents substantial management challenges, with limited evidence on effective therapies and phenotypes. In the absence of definitive evidence, expert consensus can supply clinically useful guidance in medicine. An international panel of 26 experts participated in a Delphi process to identify consensus on pharmacological management in sarcoidosis with the development of preliminary recommendations.

The modified Delphi process used three rounds. The first round focused on qualitative data collection with open-ended questions to ensure comprehensive inclusion of expert concepts. Rounds 2 and 3 applied quantitative assessments using an 11-point Likert scale to identify consensus.

Key consensus points included glucocorticoids as initial therapy for most patients, with non-biologics (immunomodulators), usually methotrexate, considered in severe or extrapulmonary disease requiring prolonged treatment, or as a steroid-sparing intervention in cases with high risk of steroid toxicity. Biologic therapies might be considered as additive therapy if non-biologics are insufficiently effective or are not tolerated with initial biologic therapy, usually with a tumour necrosis factor-α inhibitor, typically infliximab.

The Delphi methodology provided a platform to gain potentially valuable insight and interim guidance while awaiting evidenced-based contributions.

Expert consensus recommendations for a pulmonary sarcoidosis treatment algorithm from a modified Delphi process include corticosteroids as initial therapy, immunomodulators for steroid-sparing or severe disease, and biologics for very severe diseasehttp://bit.ly/2SmP3uG

Mycophenolate mofetil as an alternative treatment in sarcoidosis

INTRODUCTION

In sarcoidosis although no better drug therapy than corticosteroids (CS) has emerged, alternative immunosuppressive agents are used when indicated. Mycophenolate mofetil (MMF) presents rapid action, a considerable safety profile and absence of lung toxicity. Few data exist so far on its use in patients with sarcoidosis. This is a retrospective study on the effectiveness and safety of MMF in patients with sarcoidosis.

MATERIALS AND METHODS

All patients with biopsy proven sarcoidosis treated for at least 1 year with MMF from 2008 to 2017 in our department are evaluated.

RESULTS

Eight patients with both pulmonary and extrapulmonary disease are included in the analysis. During follow-up, symptoms and chest radiological findings improved in all. A statistically significant improvement of FEV₁ and FVC is reported (p = 0.010 and p = 0.021 respectively). Cardiac and renal disease resolved during treatment while dermal disease significantly improved. MMF permitted CS dose reduction from 15.0 (10.0, 35.0) to 2.5 (0.0, 5.0) mg prednisolone (or equivalent), p = 0.016. All patients but one, tolerated well MMF.

CONCLUSION

MMF as an alternative drug in systemic sarcoidosis, proved safe and effective, permitting the reduction of the dose of oral CS and leading to clinical, functional and radiological improvement.

Effectiveness and tolerability of methotrexate in pulmonary sarcoidosis: A single center real-world study

Background

Pulmonary sarcoidosis patients who get disease progression despite corticosteroid treatment or can't tolerate corticosteroid required second-line drug. Methotrexate (MTX) is the most widely used in our clinical practice. Data on its safety and efficacy at different doses are still limited, especially for those without folic acid supplements.

Objective

To report effectiveness of different MTX dosages and tolerability of MTX in pulmonary sarcoidosis without folic acid supplements.

Methods

A retrospective study on pulmonary sarcoidosis patients receiving MTX therapy with various dose ≥3 months was conducted. The primary outcome was change in high-resolution computed tomography (HRCT) before and after MTX therapy. Other efficacy parameters included SGRQ score, prednisone dose change, discontinuation and relapse-free survival. Response-linked factors and safety outcomes were also analyzed.

Results

Overall, 49 patients (81.7%) were assessed as MTX responders by HRCT and there was no significant difference in clinical response rate among three groups with different doses. The health-related quality of life (HRQL) of the responders improved obviously, which was evidenced by SGRQ score declining from 16.7(IQR: 7.9-26.4) to 10.7(IQR: 4.8-19.3) (P=0.029). The corticosteroids sparing effect was confirmed in "responders" group (P<0.001). When MTX was discontinued in 11 responders with complete improvement, 2 patients experienced relapses within 15.5 (range: 1-30) months (mean follow-up time of these 11 responders: 13.5±13.0 months). No clinical characteristics were found related to MTX effectiveness. Adverse events occurred in 31.7% of the patients, with gastrointestinal-related being the commonest. Drug discontinuation owing to adverse events occupied 6.7% of the subjects.

Conclusions

Nearly 80% of the sarcoidosis subjects had well response to MTX. Its effectiveness was irrelevant to the treatment dosages and baseline characteristics. A quite low relapse rate was witnessed in those complete responders discontinuing MTX therapies. The steroid-sparing effect, well drug tolerability and low drug withdrawal rate were observed in these patients even without folic acid supplements in clinical practice.

Atypical Cutaneous Presentations of Sarcoidosis: Two Case Reports and Review of the Literature

PURPOSE OF REVIEW

The goal of this review is to provide the reader with an updated summary of the cutaneous manifestations of systemic sarcoidosis, with a particular emphasis on the predilection of sarcoidosis for scars, tattoos, and other areas of traumatized skin.

RECENT FINDINGS

While the mechanism underlying the propensity for traumatized skin to develop sarcoidosis lesions remains unclear, several theories have been proposed including the idea that cutaneous sarcoidosis represents an exuberant, antigen-driven foreign-body response, as well as the theory that traumatized skin represents an immunocompromised district with altered local immune trafficking and neural signaling. In this review, we present two cases in which the development of cutaneous lesions in scars and tattoos was integral to the diagnosis of systemic sarcoidosis. We then review the various cutaneous manifestations of systemic sarcoidosis, the clinical characteristics and differential diagnosis of scar and tattoo sarcoidosis, the proposed mechanism by which traumatized skin is prone to developing sarcoidosis lesions, and current treatments for cutaneous sarcoidosis.

Sarcoidosis: a state of the art review from the Thoracic Society of Australia and New Zealand

Sarcoidosis is a systemic disease of unknown aetiology, characterised by non-caseating granulomatous inflammation. It most commonly manifests in the lungs and intrathoracic lymph nodes but can affect any organ. This summary of an educational resource provided by the Thoracic Society of Australia and New Zealand outlines the current understanding of sarcoidosis and highlights the need for further research. Our knowledge of the aetiology and immunopathogenesis of sarcoidosis remains incomplete. The enigma of sarcoidosis lies in its immunological paradox of type 1 T helper cell-dominated local inflammation co-existing with T regulatory-induced peripheral anergy. Although specific aetiological agents have not been identified, mounting evidence suggests that environmental and microbial antigens may trigger sarcoidosis. Genome-wide association studies have identified candidate genes conferring susceptibility and gene expression analyses have provided insights into cytokine dysregulation leading to inflammation. Sarcoidosis remains a diagnosis of exclusion based on histological evidence of non-caseating granulomas with compatible clinical and radiological findings. In recent years, endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes has facilitated the diagnosis, and whole body positron emission tomography scanning has improved localisation of disease. No single biomarker is adequately sensitive and specific for detecting and monitoring disease activity. Most patients do not require treatment; when indicated, corticosteroids remain the initial standard of care, despite their adverse side effect profile. Other drugs with fewer side effects may be a better long term choice (eg, methotrexate, hydroxychloroquine, azathioprine, mycophenolate), while tumour necrosis factor-α inhibitors are a treatment option for patients with refractory disease.

Sarcoidosis in the United States Military Health System

Rationale: Sarcoidosis is an inflammatory disorder of unclear etiology with historical significance in the U.S. Department of Defense (DoD). Objectives: This study sought to characterize the sarcoidosis population within the DoD Military Health System (MHS). Methods: Adult patients with sarcoidosis were identified in the DoD MHS database from 01-JAN-2004 through 31-DEC-2013. Patients required ≥3 encounters with a sarcoidosis diagnosis and continuous MHS eligibility. Index was defined as date of first sarcoidosis encounter. Comorbidities were assessed within the pre-index and follow-up periods. Additionally, a subset of sarcoidosis patients was identified as having conditions that can be associated with cardiac sarcoidosis. Measurements and Main Results: The final sarcoidosis cohort was 9,908 patients, 57% female, and had a mean (SD) age of 53.1 (13.6) years. The region with the largest population was the east coast (45.6%). The top 5 pre-index comorbidities were hypertension (51.7%), fatigue (27.0%), anemia (21.4%), diabetes, type II (19.6%), and coronary heart disease (16.5%). Prevalence of the following conditions increased ≥2-fold from pre-index to follow-up: leukocytopenia, pulmonary hypertension, chronic kidney disease, thrombocytopenia, hypercalcemia, venous thromboembolism, congestive heart failure, seizure disorder, stroke/TIA, hypercalciuria, and arthritis. Of the sarcoidosis cohort, 21.8% (n=2,164) were identified as having cardiac conditions that can be associated with cardiac sarcoidosis. The top conditions in this cohort were cardiac arrhythmia (75.6%), congestive heart failure (20.4%), and cardiomyopathy (13.6%). Conclusions: The MHS has a large population of sarcoidosis patients, of which 22% had cardiac conditions that can be associated with granulomatous inflammation of the heart. Prevalence of numerous comorbid conditions increased after sarcoidosis diagnosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 261-267).

An atypical case of neurosarcoidosis presenting with neovascular glaucoma

Background

Sarcoidosis, a multisystem, granulomatous disorder, sometimes manifests with a neuro-ophthalmic subtype. The latter can pose a diagnostic challenge, especially when ocular symptoms appear before systemic involvement, as the clinical picture then can be non-specific and systemic laboratory and standard imaging investigations can be negative.

Findings

A 71-year-old woman presented with a 4-month history of sudden-onset visual loss in the left eye. Slit lamp examination revealed anterior chamber cells, iris, and angle neovascularization. Fundoscopy showed a pale edematous optic nerve head surrounded with intraretinal hemorrhages and yellow retinal infiltrates. The vasculature was very narrow to absent. Indeed, fluorescein angiography filling was limited to the (juxta-)papillary region. An extensive systemic work-up revealed a monoclonal gammopathy and absence of any inflammatory markers. On MRI, a mass infiltration of the intraorbital and the intracranial optic nerve was visible. Additional PET-CT scan revealed hilar lymph nodes. A transbronchial biopsy demonstrating a non-caseating granulomatous lesion led to the diagnosis of sarcoidosis and thus neurosarcoidosis. Treatment with high-dose prednisone and azathioprine was started to avoid progression and subsequent visual loss in the other eye.

Conclusions

A patient with neurosarcoidosis presenting with compressive ischemic optic disc edema and neovascular glaucoma is described, increasing the diversity of clinical presentations and confirming the diagnostic challenge of neurosarcoidosis.

Concomitant presentation of sarcoidosis and pulmonary tuberculosis with ARDS: A diagnostic dilemma and therapeutic challenge

Tuberculosis and sarcoidosis are chronic multisystem granulomatous conditions which have different aetiology and management but may mimic each other clinically, radiologically and pathologically. Both these diseases usually have a sub acute or chronic presentation and it is rather uncommon for them to coexist or present with acute respiratory failure. We report a case of a 57-year-old male who presented with pyrexia of unknown origin with chronic cough. He was initially diagnosed to have sarcoidosis based on clinico-radiological and histologic evidence and was started on corticosteroids. However, he presented within two weeks with acute respiratory distress and on further investigation was diagnosed with co-existing pulmonary tuberculosis.

Efficacy of additional treatment with azathioprine in a patient with prednisolone-dependent gastric sarcoidosis

Gastric sarcoidosis with noncaseating granuloma is rare. Although corticosteroid produces a dramatic clinical response, it is unknown whether azathioprine show efficacy in prednisolone-dependent cases. Here, we report a case of gastric sarcoidosis in a 25-year-old man with severe epigastlargia. Gastroendoscopy revealed multiple map-like ulcerations. Histological examination showed multiple noncaseating granulomatous lesions in gastric mucosa, which were incompatible with diagnoses of Crohn’s disease or tuberculosis. He was started on prednisolone at 30 mg/d, and his symptoms improved within 7-d. The prednisolone was gradually tapered by 5 mg every 2-wk, but oral azathioprine at 50 mg was added after symptoms recurred at tapered dose of 10 mg. Endoscopy 4-wk later showed healing ulcers, and, lymphocytic infiltration was absent. The efficacy of additional azathioprine in gastric sarcoidosis is not well defined. Here, we report a case of prednisolone-dependent gastric sarcoidosis that improved after additional azathioprine, and also review the literature concerning the treatment, especially for prednisolone-dependent cases.

Physical activity and training in sarcoidosis: review and experience-based recommendations

INTRODUCTION

Sarcoidosis is a multisystemic inflammatory disorder with a great variety of symptoms, including fatigue, dyspnea, pain, reduced exercise tolerance and muscle strength. Physical training has the potential to improve exercise capacity and muscle strength, and reduce fatigue. The aim of this review and survey was to present information about the role of physical training in sarcoidosis and offer practical guidelines.

AREAS COVERED

A systematic literature review guided an international consensus effort among sarcoidosis experts to establish practice-basic recommendations for the implementation of exercise as treatment for patients with various manifestations of sarcoidosis. International sarcoidosis experts suggested considering physical training in symptomatic patients with sarcoidosis. Expert commentary: There is promising evidence of a positive effect of physical training. Recommendations were based on available data and expert consensus. However, the heterogeneity of these patients will require modification and program adjustment of the standard rehabilitation format for e.g. COPD or interstitial lung diseases. An optimal training program (types of exercise, intensities, frequency, duration) still needs to be defined to optimize training adjustments, especially reduction of fatigue. Further randomized controlled trials are needed to consolidate these findings and optimize the comprehensive care of sarcoidosis patients.

Cough in Sarcoidosis

Sarcoidosis is a granulomatous disorder that frequently affects the lungs. Cough is commonly reported by patients and can significantly reduce health-related quality of life. The mechanism of cough is unknown but airway inflammation, mechanical distortion from pulmonary fibrosis and disruption of the vagus nerve are possible. Recent evidence suggests cough reflex hypersensitivity may also be an important mechanism and predictor of the frequency of cough. The investigation of cough should evaluate common causes such as asthma, gastro-oesophageal reflux and rhinitis. In patients with suspected cough due to sarcoidosis, a trial of corticosteroids should be considered. The severity of cough should be evaluated with validated outcome measures such as visual analogue scales, cough severity diary, health-related quality of life questionnaires such as the Leicester Cough Questionnaire and objective cough monitors. Future studies are needed to identify targets for therapeutic development.

Cardiac sarcoidosis: diagnosis and management

Cardiac sarcoidosis is one of the most serious and unpredictable aspects of this disease state. Heart involvement frequently presents with arrhythmias or conduction disease, although myocardial infiltration resulting in congestive heart failure may also occur. The prognosis in cardiac sarcoidosis is highly variable, which relates to the heterogeneous nature of heart involvement and marked differences between racial groups. Electrocardiography and echocardiography often provide the first clue to the diagnosis, but advanced imaging studies using positron emission tomography and MRI, in combination with nuclear isotope perfusion scanning are now essential to the diagnosis and management of this condition. The identification of clinically occult cardiac sarcoidosis and the management of isolated and/or asymptomatic heart involvement remain both challenging and contentious. Corticosteroids remain the first treatment choice with the later substitution of immunosuppressive and steroid-sparing therapies. Heart transplantation is an unusual outcome, but when performed, the results are comparable or better than heart transplantation for other disease states. We review the epidemiology, developments in diagnostic techniques and the management of cardiac sarcoidosis.

Coexistence of pulmonary tuberculosis and sarcoidosis: a diagnostic dilemma

Tuberculosis and sarcoidosis are multisystem diseases having different aetiology and management; however, they have similar clinical and histological characteristics. Very rarely they may coexist. We report a rare case of a 38-year-old woman who presented with chronic cough, low-grade fever and respiratory distress that was initially diagnosed as miliary tuberculosis. Diagnosis was supported by positive mycobacterial culture and initially responded to antitubercular treatment, but later recurrences led to further investigations and the diagnosis of coexisting sarcoidosis.

A practical approach to cutaneous sarcoidosis

Sarcoidosis is a chronic inflammatory disorder that has the potential to affect multiple organs, including the skin. Its cutaneous manifestations are varied and can provide clues to underlying systemic manifestations. Unfortunately, they also can be disfiguring. Therapy is usually directed at the organ system most severely affected, which often may help cutaneous disease. However, cutaneous disease may be recalcitrant to treatment directed at extracutaneous disease, or it may be severe enough to require targeted therapy. This article focuses on the dermatologist's role in recognizing and diagnosing cutaneous sarcoidosis, evaluating patients for systemic disease involvement, and treating the skin manifestations of sarcoidosis.

Distribution of low-density lipoprotein and high-density lipoprotein subclasses in patients with sarcoidosis

CONTEXT

Systemic inflammatory diseases are associated with proatherogenic lipoprotein profile, but there is a lack of information regarding overall distributions of lipoprotein subclasses in sarcoidosis.

OBJECTIVE

To investigate whether patients with sarcoidosis have altered distributions of plasma low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particles.

DESIGN

Seventy-seven patients with biopsy-proven sarcoidosis (29 with acute and 48 with chronic sarcoidosis) treated with corticosteroids and 77 age- and sex-matched controls were included in the study. Low-density lipoprotein and HDL subclasses were determined by gradient gel electrophoresis, while inflammatory markers and lipid parameters were measured by standard laboratory methods.

RESULTS

Compared to controls, patients had fewer LDL I subclasses (P < .001), but more LDL II and III (P < .001) subclasses. This pattern was evident in both acute and chronic disease groups. Patients also had smaller HDL size (P < .001) and higher proportions of HDL 2a (P = .006) and 3a particles (P = .004). Patients with chronic sarcoidosis had smaller LDL size than those with acute disease (P = .02) and higher proportions of HDL 3a subclasses (P = .04) than controls. In acute sarcoidosis, relative proportions of LDL and HDL particles were associated with levels of inflammatory markers, whereas in chronic disease an association with concentrations of serum lipid parameters was found.

CONCLUSIONS

The obtained results demonstrate adverse lipoprotein subfraction profile in sarcoidosis with sustained alterations during disease course. Evaluation of LDL and HDL particles may be helpful in identifying patients with higher cardiovascular risk, at least for prolonged corticosteroid therapy due to chronic disease course.

Bilateral Vocal Cord Carcinoma in a Sarcoidosis Patient during Infliximab Therapy

Introduction. Although the role of TNF-α in tumor development is not fully understood, an increased risk of malignancy with TNF-α-inhibitors, such as infliximab, has been suggested. Case Presentation. We present a 54-year-old nonsmoking female sarcoidosis patient. After seven months of infliximab therapy a T1aN0M0 larynx carcinoma of the right vocal cord was found and excised. Within a year, whilst still on treatment, a second larynx carcinoma of the opposite vocal cord appeared. Discussion. A bilateral vocal cord tumor is rare, especially in a never smoker. Evidence on the role of infliximab in carcinogenesis is inconclusive. To date, there are no follow-up studies evaluating malignancy risk of infliximab therapy in sarcoidosis patients. No studies in other diseases focus on laryngeal carcinomas during infliximab use. We argue that infliximab treatment might have attributed to the rapid progression of vocal cord carcinomas in this patient with an a priori low risk tumor profile. This case illustrates that caution remains warranted in patients with previous malignancies when considering initiation of TNF-α-inhibitors.

A predictive tool for an effective use of (18)F-FDG PET in assessing activity of sarcoidosis

Background

¹⁸F-FDG PET/CT (PET) is useful in assessing inflammatory activity in sarcoidosis. However, no appropriate indications are available. The aim of this study was to develop a prediction rule that can be used to identify symptomatic sarcoidosis patients who have a high probability of PET-positivity.

Methods

We retrospectively analyzed a cohort of sarcoidosis patients with non organ specific persistent disabling symptoms (n = 95). Results of soluble interleukin-2 receptor (sIL-2R) assessment and high-resolution computed tomography (HRCT) were included in the predefined model. HRCT scans were classified using a semi-quantitative scoring system and PET findings as positive or negative, respectively. A prediction model was derived based on logistic regression analysis. We quantified the model’s performance using measures of discrimination and calibration. Finally, we constructed a prediction rule that should be easily applicable in clinical practice.

Results

The prediction rule showed good calibration and good overall performance (goodness-of-fit test, p = 0.78, Brier score 20.1%) and discriminated between patients with positive and negative PET findings (area under the receiver-operating characteristic curve, 0.83). If a positive predictive value for the presence of inflammatory activity of ≥90% is considered acceptable for clinical decision-making without referral to PET, PET would be indicated in only 29.5% of the patients. Using a positive predictive value of 98%, about half of the patients (46.3%) would require referral to PET.

Conclusions

The derived and internally validated clinical prediction rule, based on sIL-2R levels and HRCT scoring results, appeared to be useful to identify sarcoidosis patients with a high probability of inflammatory activity. Using this rule may enable a more effective use of PET scan for assessment of inflammatory activity in sarcoidosis.