Interferon-alpha Induced Sarcoidosis with Cutaneous Involvement along the Lines of Venous Drainage

Scar sarcoidosis: Clinical features and prognostic significance

BACKGROUND AND AIM

Only a few series of patients with scar sarcoidosis (SS) have been reported. Our aim was to analyse the clinical features of SS patients and their relationship to the prognosis of sarcoidosis.

METHODS

Patients with systemic sarcoidosis with SS diagnosed between 1980-2017 at Bellvitge University Hospital, were enrolled. Their clinical charts were reviewed to collect the following data: age, sex, ethnicity, number of lesions, location of SS, origin of the scar, association with erythema nodosum or other specific cutaneous lesions, radiological stage at diagnosis, chronic systemic sarcoidosis activity.

RESULTS

Forty two of 728 patients with systemic sarcoidosis presented SS (31 females and 11 males, mean age 47.71±13.747 years). SS was present at the onset of systemic sarcoidosis in 35/42 cases (83.33%). Twelve patients had simultaneously erythema nodosum. In 14 patients SS was the only specific cutaneous lesion of sarcoidosis. Foreign bodies were observed in 16 of 26 biopsied SS lesions (61.54%). Radiological stage at diagnosis was 0 for 2 patients, I for 22, II for 13, III for 4, and IV for 1. The activity of systemic sarcoidosis persisted for more than 5 years in 16/42 patients with SS (38.1%) vs. 186/686 patients with systemic sarcoidosis (27.11%), However the differences were not significant (p=0.154).

CONCLUSIONS

SS was observed in 5.77% of our patients with systemic sarcoidosis. It is usually present at the onset of the disease and is an useful sign for suspicion of a diagnosis of sarcoidosis, but it carries no prognostic significance.

Interferon-induced sarcoidosis with uveitis as the initial symptom: a case report and review of the literature

Background

In recent years, numerous studies have reported the development or exacerbation of sarcoidosis due to interferon therapy. However, ocular lesions rarely present as initial symptoms. Herein, we describe a rare case of interferon-α-induced sarcoidosis with uveitis as the initial symptom, and present a review of the relevant literature.

Case presentation

This case involved a 62-year-old-Japanese woman with a history of a combination treatment of pegylated interferon-α-2a, ribavirin, and simeprevir, after which she developed granulomatous panuveitis. She was subsequently diagnosed with sarcoidosis following histological examination of skin biopsy specimens. In addition to reporting this case, we performed a literature review of 27 cases (24 case reports) of histopathologically diagnosed interferon-α-induced sarcoidosis published between January 2009 and November 2018.

Conclusions

Among the reviewed cases, 23 (85.1%) cases developed skin lesions and 19 (70.1%) had lung lesions. Only three cases (11.1%) had accompanying eye lesions. Interferon-α therapy was discontinued in 16 cases (52.9%), and the majority exhibited improvement after systemic corticosteroid treatment. There are few reported cases of interferon-α-induced sarcoidosis with uveitis as the initial symptom. However, if uveitis develops during or after interferon-α treatment, it might represent an initial symptom of interferon-α-induced sarcoidosis, as observed in the present case.

Drug-Induced Sarcoidosis-Like Reactions

A drug-induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction that is indistinguishable from sarcoidosis and occurs in a temporal relationship with initiation of an offending drug. DISRs typically improve or resolve after withdrawal of the offending drug. Four common categories of drugs that have been associated with the development of a DISR are immune checkpoint inhibitors, highly active antiretroviral therapy, interferons, and tumor necrosis factor-α antagonists. Similar to sarcoidosis, DISRs do not necessarily require treatment because they may cause no significant symptoms, quality of life impairment, or organ dysfunction. When treatment of a DISR is required, standard antisarcoidosis regimens seem to be effective. Because a DISR tends to improve or resolve when the offending drug is discontinued, this is another effective treatment for a DISR. However, the offending drug need not be discontinued if it is useful, and antigranulomatous therapy can be added. In some situations, the development of a DISR may suggest a beneficial effect of the inducing drug. Understanding the mechanisms leading to DISRs may yield important insights into the immunopathogenesis of sarcoidosis.

A Case of Subcutaneous Sarcoidosis Occurring along the Superficial Veins of the Forearms: A Distinctive Cutaneous Manifestation Masquerading Venous Tropic Action in the Underlying Systemic Disease?

Sarcoidosis is a multisystem disease of unknown etiology, developing granulomas in any tissues and organs. Approximately 25% of sarcoidosis patients have cutaneous involvement with various clinical manifestations, which are categorized into specific or nonspecific diseases based on the histopathology; the former represents the typical sarcoid granulomas. Subcutaneous sarcoidosis is one of the specific skin lesions and often affects extremities, to a much lesser extent with other anatomical sites. Herein, we report the case of an 82-year-old Japanese man with subcutaneous sarcoidosis whose skin nodules exclusively overlay the lines of superficial veins on the forearms. This rare clinical presentation was discussed with the literature reported thus far to access the underlying disease pathophysiology from the viewpoint of tropic response to the venous system in systemic sarcoidosis.

[Sarcoïdose in patient with chronic hepatitis C treated with pegylated interferon]

Induced sarcoïdosis during therapy with interferon for chronic viral hepatitis C involves mainly by isolated cutaneous lesions or with lung lesions. Systemic forms are very rare. We report an observation. A 50-year-old patient developed a systemic sarcoïdosis two months after the end of treatment for hepatitis C with pegylated interferon and ribavirin with lung, joint and hepatic manifestations. After starting corticosteroid therapy, the evolution was favourable. Induced sarcoïdosis by interferon therapy is rare, treatment necessitates stopping interferon, and sometimes corticosteroid therapy.

Interferon-alpha-induced sarcoidosis in a patient being treated for hepatitis C

PATIENT

Female, 43 FINAL DIAGNOSIS: -

SYMPTOMS

Diarrhea • generalized weakness • headache • lightheadedness • nausea • rash • short of breath • vomiting

MEDICATION

- Clinical Procedure: - Specialty: Pulmonology.

OBJECTIVE

Rare diseae.

BACKGROUND

IFN-alpha-2b in combination with ribavirin is now the standard of care for the treatment of hepatitis C. Sarcoidosis is a chronic multisystem granulomatous disorder characterized by noncaseating granulomas in the involved organs. The pathologic hallmark of sarcoidosis is the presence of noncaseating granulomas in the interstitium that typically involve the lymphatics.

CASE REPORT

A 43-year-old woman presented to our care with 2-week history of nausea, vomiting, diarrhea, shortness of breath, migraine headache, maculopapular rash, generalized weakness, and lightheadedness. She had been treated for hepatitis C with telaprevir, ribavirin, and interferon-alpha-2b for 6 months. Chest radiograph showed bilateral diffuse prominence of bronchovascular markings. CT of the chest revealed bilateral diffuse centrilobular nodules with associated intralobular septal thickening, thickening of the central peribronchovascular interstitium, nodularity of the major fissures, and mediastinal lymphadenopathy. These findings were suspicious for atypical pulmonary sarcoidosis, possibly interferon-induced. The pathology of the mediastinal lymph node biopsy revealed noncaseating granulomatous inflammation consistent with the diagnosis of pulmonary sarcoidosis. Pathology of the skin punch biopsy showed giant-cell granulomatous inflammation without necrosis. The patient was started on prednisone 40 mg daily with a steroid tapering course for 8 weeks.

CONCLUSIONS

The management of IFN-induced sarcoidosis includes the discontinuation of IFN therapy with or without the administration of systemic corticosteroids. With the increasing prevalence of HCV in the United States, it is likely that more IFN-alpha-induced sarcoidosis will be encountered by clinicians.

Two cases of interferon-alpha-induced sarcoidosis Koebnerized along venous drainage lines: new pathogenic insights and review of the literature of interferon-induced sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin commonly affecting the lung, the lymphoid system and the skin. We report here two cases of cutaneous sarcoidosis in two former intravenous drug users following interferon (IFN)-α and ribavirin therapy for chronic hepatitis C. Both patients developed skin sarcoidosis along venous drainage lines of both forearms, coinciding with the areas of prior drug injections. The unique distribution of the skin lesions suggests that tissue damage induced by repeated percutaneous drug injections represents a trigger for the local skin manifestation of sarcoidosis. Interestingly, skin damage was recently found to induce the local expression IFN-α, a well-known trigger of sarcoidosis in predisposed individuals. Here we review the literature on sarcoidosis elicited in the context of IFN-α therapy and propose a new link between the endogenous expression of IFN-α and the induction of disease manifestations in injured skin.

Light on the horizont: biologicals in Behçet uveitis

Relapsing ocular involvement is one of the major manifestations in Behçet disease (BD). When ocular BD is left untreated, it often results in blindness in <5 years. Combining systemic corticosteroids with cyclosporine A and other conventional immune modulating agents has been the only choice for treatment. More recently, the introduction of 'biologics' seems to be an effective therapy in patients affected with BD, especially in those with ocular disease. Our purpose was to survey the current knowledge regarding the biological therapeutic approaches for Behçet uveitis. We focused on the most commonly used biological agents: 'tumor necrosis factor-alpha antagonists' and 'interferon alpha'. We attempted to compare the effectiveness of these two biologicals and tried to balance on the pros and cons of these agents in clinical practice. The impressive efficacy of both approaches in sight-threatening BD argues for their expanding role. Earlier introduction of these agents in the course of disease may prevent irreversible structural damage and may result in improved long-term prognosis.