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.

Anticoagulation with warfarin compared to novel oral anticoagulants for atrial fibrillation in adults with transthyretin cardiac amyloidosis: comparison of thromboembolic events and major bleeding

BACKGROUND

Atrial fibrillation (AF) is common in patients with transthyretin cardiac amyloidosis (ATTR-CA). The optimal strategy to prevent strokes in patients with ATTR-CA and AF is unknown.

OBJECTIVES

To compare outcomes in patients with ATTR-CA and AF treated with warfarin versus novel oral anticoagulants (NOACs).

METHODS

This study was a retrospective analysis of patients with ATTR-CA stratified by presence or absence of AF and anticoagulation therapy. The primary outcome included a time to event analysis for the combined outcomes of stroke, transient ischaemic attack (TIA), major bleed, or death.

RESULTS

Of 290 patients, 217 patients (74.8%) had AF. Of those with AF (n = 217), 78 (35.9%) patients received warfarin compared with 116 (53.5%) patients who received NOACs. There were 17 thrombotic events, all in those diagnosed with AF compared with none in the patients without AF (p = .01). Over a mean follow-up of 2.4 years (range 0.1-12) there was no difference in primary outcome between those with AF treated with warfarin compared with NOACs (p = .35).

CONCLUSION

Patient with ATTR-CA and AF are at increased risk for stroke compared to patients with ATTR-CA and without AF. Thrombotic events and major bleeds did not differ between those who received warfarin and NOACs.

Diagnosis of Chlamydia pneumoniae in community-acquired pneumonia in children in Chile

The incidence of Chlamydia pneumoniae in community-acquired pneumonia in children was studied prospectively in 112 children aged 1 mo to 14 y. Diagnosis of C. pneumoniae was performed by polymerase chain reaction (PCR) on nasopharyngeal aspirates and serology by the microimmunofluorescence test on a single serum specimen. Three (2.7%) cases of pneumonia due to this agent were diagnosed by both PCR and serology. C. pneumoniae was not found in any of 62 children below 5 y of age. In the age group 5-8 y, only 1/30 (3%) was found positive, and in the age group 9-14 y, C. pneumoniae was diagnosed in 2/20 (10%) children.

CONCLUSION

Although the number of enrolled patients is small, and the diagnostic techniques used may have some limitations, the results of this study suggest that C. pneumoniae.plays a minor role in the aetiology of pneumonia in children less than 9 y of age in our country. However, it should be considered as a potential agent in pneumonia in older children.

Seroprevalence of Chlamydia pneumoniae in Chile

We used microimmunofluorescence to survey the prevalence of antibodies to Chlamydia pneumoniae in 403 serum samples from asymptomatic subjects aged 6 months to 89 y in Santiago, Chile. The results suggest that Chlamydia pneumoniae infection is endemic in Chile, with a seroprevalence of 60% which does not differ by gender.

Ectopic production of pregnancy-specific beta 1-glycoprotein by a nontrophoblastic tumor in vitro

To demonstrate the ectopic production of pregnancy-specific beta 1-glycoprotein (PSbetaG) by a nontrophoblastic tumor, the in vitro secretion of this glycoprotein was evaluated in an hCG-producing ovarian cystadenocarcinoma cell line maintained in long term cell culture. Parallelism was demonstrated between the immunoreactive material present in the tissue culture media and highly purified PSbetaG measured by a sensitive and specific RIA. The immunoreactive material was shown to cochromatograph with purified PSbetaG present in normal term pregnancy serum on a Sephadex G-150 column. The tumor PSbetaG was adsorbed to concanavalin A-Sepharose and eluted with alpha-D-methyl-glucoside in a manner similar to purified PSbetaG. The indirect immunoperoxidase method with anti-PSbetaG sera localized PSbetaG in secretory vesicles and in the endoplasmic reticulum of the tumor cells by light and electron microscopy. The addition of sodium butyrate to the tissue culture media stimulated PSbetaG production in a fashion quantitatively similar to that seen with hCG. The number of PSbetaG-staining intracellular vesicles also increased after exposure to butyrate. These studies provide direct evidence for the ectopic production of PSbetaG by a nontrophoblastic tumor cell line.