Defining the clinical outcome status (COS) in sarcoidosis: results of WASOG Task Force

The clinical outcome of sarcoidosis is quite variable. Several scoring systems have been used to assess the level of disease and clinical outcome. The definition of clinical phenotypes has become an important goal as genetic studies have identified distinct genotypes associated with different clinical phenotypes. In addition, treatment strategies have been developed for patients with resolving versus non resolving disease. A task force was established by the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) to define clinical phenotypes of the disease based on the clinical outcome status (COS). The committee chose to examine patients five years after diagnosis to determine the COS. Several features of the disease were incorporated into the final nine categories of the disease. These included the current or past need for systemic therapy, the resolution of the disease, and current status of the condition. Sarcoidosis patients who were African American or older were likely to have a higher COS, indicating more chronic disease. The COS may be useful in future studies of sarcoidosis.

Presenting characteristics as predictors of duration of treatment in sarcoidosis

BACKGROUND

Some sarcoidosis patients never need therapy, but many still require therapy more than 2 years after initial diagnosis.

AIM

To determine what features at initial presentation are associated with treatment 2 years later.

METHODS

Patients with biopsy-confirmed sarcoidosis enrolled in the ACCESS (A Case Control Etiologic Study of Sarcoidosis) study were initially evaluated within 6 months of diagnosis. Pulmonary function, chest X-ray and dyspnoea score were measured, and systemic therapy for the sarcoidosis recorded. Organ involvement was assessed using a standardized instrument. A subset (n = 215) were seen 18-24 months later for follow-up, and these patients constitute our study group.

RESULTS

Ten patients had only received therapy before the first visit, with no further therapy, and were excluded from analysis. Of the remaining 205, 95 were not on therapy at the initial visit and 75 (79%) of these were never treated during follow-up. Of the 110 initially on therapy, 52 (47%) remained on therapy at follow-up. Other initial features associated with continued therapy were the level of dyspnoea and predicted vital capacity. On logistic regression, only dyspnoea and therapy at initial visit remained significant. Patients on systemic therapy at initial evaluation were more likely to be on therapy at follow-up (OR 3.6, p = 0.003). Neither ethnicity nor gender independently predicted therapy at follow-up.

DISCUSSION

This study group represents a sample of newly diagnosed sarcoidosis patients. However, this is a referral population, and there was no set protocol for treatment. Use of systemic therapy within the first 6 months after diagnosis appears to be strongly associated with continued use of therapy 2 years later.

Lung transplantation in interstitial lung disease

Interstitial lung disease is a heterogeneous group of illnesses, some of which may progress to a fibrosing stage and cause respiratory failure. For selected candidates, lung transplantation is the ultimate therapeutic option. We review data on lung transplantation for various interstitial lung diseases. We address indications, procedures, and outcomes for patients undergoing transplantation. Unique issues affecting morbidity, mortality, and recurrence of disease are discussed. We review the literature of transplantation for specific interstitial lung diseases and the outcomes of transplantation for interstitial lung diseases. Candidates with idiopathic pulmonary fibrosis experience high mortality on the waiting list, but derive significant survival benefit from lung transplantation. Recurrence is reported for several interstitial lung diseases after lung transplantation. Survival with lung transplantation for interstitial lung diseases is comparable with that attained in recipients with other indications. Lung transplantation is a well-tolerated, effective therapy for respiratory failure in interstitial lung disease.

Functional integrity of T, B, and natural killer cells in homosexual subjects with prodromata and in patients with AIDS

We have examined the numbers of the total T (T11+) cells, T-helper (T4+) cells, T-suppressor (T8+) cells, NK cells (Leu7+), and the functional integrity of T, B, and NK cells in healthy male heterosexuals and compared the data to those obtained from AIDS patients and male homosexuals at risk. The absolute number of total T (T11+) and T-helper (T4+) cell populations were significantly reduced among most of the asymptomatic homosexual males and even more decreased in the AIDS patients. By contrast, the absolute numbers of T-suppressor cells (T8) remained virtually unaltered in the three study populations. The absolute numbers of circulating natural killer cells were similar in the controls and the homosexual subjects, but significantly reduced in the AIDS patients. Proliferative responses to T-cell mitogen (PHA) and T-cell dependent B-cell mitogen (PWM) were severely impaired in prodromal subjects and more so in the AIDS group. Response to PWM was unrelated to the total number of T-suppressor cells, but was associated with a significant decrease in T-helper cell number. Furthermore, all AIDS patients exhibited a significantly depressed NK-cell activity that could not be normalized by addition of alpha IFN or IL-2 and in most cases correlated with the reduced absolute number of NK (Leu7+) cells as well as T-helper cells (T4) and T4/T8 ratios. Three distinctive subgroups with normal (N-NK), significantly heightened (H-NK), and markedly lowered (L-NK) NK activity could be readily identified among the homosexual male population at risk. The N-NK and L-NK groups displayed marginal to no response to in vitro treatment with alpha IFN and interleukin-2. The NK-cell activity, however, in the H-NK group was moderately to strongly inhibited by inclusion of the two immunomodifiers.

Pulmonary tumorlets in cases of "tuberculoma" of the lung with malignant cells in brush biopsy

Two cases of pulmonary nodules associated with Mycobacterium intracellulare infection were initially interpreted as carcinomas of the lung after brush cytology specimens were reported to contain malignant epithelial cells. In both instances, the cells observed in the cytology specimens exhibited marked cytologic atypia. These cells were identical to those present in tumorlets adjacent to the granulomatous lesion. Tumorlets may thus represent a source of false-positive cytologic findings or constitute a type of microscopic neoplasms of the lung.