DOCSLIB.ORG

Therapeutic Options for Sarcoidosis: Old And

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Therapeutic Options for Sarcoidosis: Old And REVIEW Postgraduate Course ERS Copenhagen 2005 Therapeutic options for R.P. Baughman sarcoidosis: old and new R.P. Baughman University of Cincinnati Medical Center Holmes, Room 1001 Eden Avenue Albert Sabin Way 45267-0565 Cincinnati OH USA Fax: 1 5135845110 E-mail: [email protected] Educational aims To discuss the role of corticosteroids in treating sarcoidosis. To provide information about when to consider cytotoxic drugs for chronic sarcoidosis. To outline how to monitor the use of cytotoxic drugs. To better understand the differences in response when using anti-tumour necrosis factor agents in treating sarcoidosis Summary This article was modified from The decision to treat a patient with sarcoidosis is dependent on many factors, the most an ERS Postgraduate Course important being whether the patient is symptomatic. Initial systemic therapy for symp- held at the 2005 ERS Congress tomatic sarcoidosis usually includes corticosteroids. However, most symptomatic in Copenhagen. patients will require months to years of therapy. Therefore, alternatives to corticosteroids Original slides, web casts and original material can be found have been studied. This review will give a brief overview of the effect of corticosteroids at www.ersnet.org/elearning and alternative treatments options available. Breathe | June 2006 | Volume 2 | No 4 345 REVIEW Postgraduate Course ERS Copenhagen 2005 The focus of this review will be on sarcoidosis The study by PARAMOTHAYAN and JONES [1] also and its treatment; however, much of this studied diffusing capacity of the lungs for carbon information can be applied to other granuloma- monoxide (DL,CO), although only two trials met tous diseases. For example, some of the treat- their criteria for viable double-blind randomised ment strategies that have been developed for trials. Overall, corticosteroid therapy was favoured sarcoidosis have also been used for hypersensi- over placebo for DL,CO. However, these authors felt tivity pneumonitis. that there was not enough evidence to support an The recommended treatments for sarcoidosis improvement in forced vital capacity. differ from none to a combination of cytotoxic The study by GIBSON et al. [2] is an excellent agents. A major reason for this wide spectrum of example of a clinical trial for sarcoidosis patients, treatment relates to the variation in disease out- since it provides full detail of what actually hap- come. Moreover, treatment options vary because pened to the patients studied. Out of 150 no treatment can cure the disease, but rather just patients who were observed for 6 months, 33 control the symptoms. Finally, the preference of experienced a deterioration in their health requir- the patient and treating physician have an influ- ing clinical treatment, and 58 got better without ence. All of these reasons impact on any decisions the need for any form of therapy (although their regarding drug usage and duration of therapy. chest radiography remained abnormal) and they were not randomised into the trial. Patients were randomised to selective thera- Sarcoidosis and py or were immediately prescribed steroids. If they started to deteriorate after 6 months of corticosteroids observation they were tested. Six out of 31 Over the past 10 years, therapy for sarcoidosis patients actually deteriorated and were placed has evolved and corticosteroids are no longer the on steroids. Patients were treated for 18 months only available treatment option. and, on follow-up 5 years later, there was a sig- Early literature suggested that cortico- nificant improvement in the vital capacity and a steroids were effective for sarcoidosis, but the difference in the dyspnoea score. However, it results from these published clinical trials were should be noted that an element of bias was limited, as placebo could not be used for the introduced into the study as the sickest patients most ill patients for obvious ethical reasons. in the placebo group were also treated. Subsequently, it has been shown that the use of The same effect was also seen in a study systemic coricosteroid therapy is linked to chron- examining budesonide [3], where a large num- ic sarcoidosis. ber of stage 1, 2 and 3 patients were treated. The The first question that should be considered most important results were found in patients is whether corticosteroids are helpful in sar- with stage 2 and 3 disease, i.e. those with pul- coidosis. In the 1950s, several small anecdotal monary infiltrates. After 18 months (comprising trials revealed beneficial effects of these drugs in 3 months of prednisolone and 15 months of sarcoidosis patients who were dying from their budesonide), there was a significant improve- disease. In 2002, a meta-analysis on the use of ment in the steroid group, but no change in the corticosteroids in sarcoidosis patients clearly placebo group, which persisted at the 5-year fol- demonstrated an improvement on chest radiog- low-up. It could be argued that this is the best raphy as compared with the use of placebo [1]. data to support treating patients with 3 months However, despite improvement on chest radiog- of systemic steroids, followed by 15 months of raphy, corticosteroid use may not improve inhaled steroids. The data look even more patient health (see Case summary). impressive when the DL,CO is considered. Case summary A patient who had been referred to the current author reported weight gain as a result of taking corticosteroids. The patient had initially been prescribed 20 mg prednisone q.d. (figure 1) but when the dose was reduced to 10 mg q.d. (figure 2) due to the side-effects, the patient's condition deteriorated. This was evident from chest comput- ed tomography, which revealed an increase of infiltrates in various parts of the lung. However, the patient was asymptomatic, with the exception of weight gain and diabetes. Subsequently, the patient was tapered off steroids, has not been taking steroids for 2 years and has had no clinical relapse. Even with abnormal chest radiography, the medical team are quite comfortable monitoring the patient, since his vital capacity has always been >85%. Thus, the decision to give corticosteroid therapy should not be purely based on the results of chest radiography. 346 Breathe | June 2006 | Volume 2 | No 4 Postgraduate Course ERS Copenhagen 2005 REVIEW Figure 1 Indications for Chest radiograph of patient who was initially prescribed 20 mg corticosteroid therapy prednisone. The American Thoracic Society/World Associ- ation for Sarcoidosis and Other Granulomatous Disorders/European Respiratory Society state- ment [4] has considered the absolute indications for corticosteroid therapy. These indications are presented in table 1. Utility of Figure 2 corticosteroids Chest radiograph of patient when Patients with pulmonary radiographic stage 1 the dose was reduced to 10 mg. disease, with or without erythema nodosum, and with normal lung function do not require treat- ment with corticosteroids (grade A recommen- dation). Symptomatic patients with stage 2–3 pul- monary lesions and an impaired lung function respond to treatment with oral corticosteroids (grade A). Patients with newly detected disease respond better than patients who have had sar- coidosis for >2 years (grade A). It is unknown for how long treatment has to be continued and benefit has only been demonstrated with bude- what markers should be used in the decision sonide. making for tapering the dose during treatment Another concern is how much to prescribe and when to stop treatment. when there no dose response is observed. Inhaled corticosteroids have been recom- Recommendations have ranged 30–40 mg, but mended for treating symptoms such as cough, this is a grade U recommendation, meaning that patients with airway obstruction and bronchial there has been no consensus about the starting hyperresponsiveness; however, this has never dose. been supported by any clinical trials and, thus, is Extrapulmonary disease is also a difficult a grade D recommendation. area, since there are no sufficient data to support Conversely, it has been shown that after the use of corticosteroids, although they are induction with oral prednisone, using inhaled commonly used. Hence, it is recommended that budesonide is an alternative for treating a the patients should have organ failure or some patient with sarcoidosis, which is a grade B rec- of the other absolute indications, but this is a ommendation. It is important to realise that this grade D recommendation. Table 1 Indications for Timing of corticos- corticosteroid therapy Absolute Relative teroid treatment Neurological Symptomatic pulmonary For a long time, there has been the philosophy Cardiac disease that therapy once initiated should not be Hypercalcaemia Arthritis stopped, especially in patients with a diagnosis Ocular Hepatic of >2 years [5]. However, it is now clear that (when topical therapy SIRS has failed) there are a group of patients who are not neces- Other life- or organ- sarily going to relapse, although it is still unclear threatening disease how to identify these patients. In a study conducted in Philadelphia, GOTTLIEB et al. [6] examined a mostly African- SIRS: systemic inflammatory response system. American population. Although there was no Breathe | June 2006 | Volume 2 | No 4 347 REVIEW Postgraduate Course ERS Copenhagen 2005 specific protocol, patients were treated in a stan- Antimicrobials dardised fashion. When therapy was discontin- In the literature, there is almost as much data ued, patients were followed-up for at least 2 regarding antimalarials as there is for predisone years. The frequency with which steroids were for the treatment for sarcoidosis. The response rate used was recorded and also whether the patients to antimalarials is much greater in cutaneous dis- relapsed. From the initial 340 patients, one third ease as compared with pulmonary disease. did not require therapy in the first 6 months. The use of chloroquine has been effective for Interestingly, only nine out of the 118 actually some forms of sarcoidosis, mostly skin (grade B). needed therapy in the long term.
Load more

Recommended publications
  • Crohn's Disease-Associated Interstitial Lung Disease Mimicking Sarcoidosis
    Case report SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2016; 33; 288-291 © Mattioli 1885 Crohn’s disease-associated interstitial lung disease mimicking sarcoidosis: a case report and review of the literature Choua Thao1, A Amir Lagstein2, T Tadashi Allen3, Huseyin Erhan Dincer4, Hyun Joo Kim4 1Department of Internal Medicine, University of Nevada School of Medicine Las Vegas, Las Vegas, NV; 2Department of Pathology, Univer- sity of Michigan, Ann Arbor, MI; 3Department of Radiology, University of Minnesota, Minneapolis, MN; 4 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN Abstract. Respiratory involvement in Crohn’s disease (CD) is a rare manifestation known to involve the large and small airways, lung parenchyma, and pleura. The clinical presentation is nonspecific, and diagnostic tests can mimic other pulmonary diseases, posing a diagnostic challenge and delay in treatment. We report a case of a 60-year-old female with a history of CD and psoriatic arthritis who presented with dyspnea, fever, and cough with abnormal radiological findings. Diagnostic testing revealed an elevated CD4:CD8 ratio in the bronchoal- veolar lavage fluid, and cryoprobe lung biopsy results showed non-necrotizing granulomatous inflammation. We describe here the second reported case of pulmonary involvement mimicking sarcoidosis in Crohn’s disease and a review of the literature on the approaches to making a diagnosis of CD-associated interstitial lung disease. (Sarcoidosis Vasc Diffuse Lung Dis 2016; 33: 288-291) Key words: interstitial lung disease, Crohns disease, sarcoidosis, cryoprobe lung biopsy Introduction Moreover, certain diagnostic tests such as bronchoal- veolar lavage (BAL) cell analysis and tissue biopsy Pulmonary involvement in Crohn’s disease (CD) results may mimic other granulomatous lung diseas- is relatively rare and can be difficult to diagnose.
    [Show full text]
  • Neurosarcoidosis
    CHAPTER 11 Neurosarcoidosis E. Hoitsma*,#, O.P. Sharma} *Dept of Neurology and #Sarcoidosis Management Centre, University Hospital Maastricht, Maastricht, The Netherlands, and }Dept of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Correspondence: O.P. Sharma, Room 11-900, LACzUSC Medical Center, 1200 North State Street, Los Angeles, CA 90033, USA. Fax: 1 3232262728; E-mail: [email protected] Sarcoidosis is an inflammatory multisystemic disorder. Its cause is not known. The disease may involve any part of the nervous system. The incidence of clinical involvement of the nervous system in a sarcoidosis population is estimated to be y5–15% [1, 2]. However, the incidence of subclinical neurosarcoidosis may be much higher [3, 4]. Necropsy studies suggest that ante mortem diagnosis is made in only 50% of patients with nervous system involvement [5]. As neurosarcoidosis may manifest itself in many different ways, diagnosis may be complicated [2, 3, 6–10]. It may appear in an acute explosive fashion or as a slow chronic illness. Furthermore, any part of the nervous system can be attacked by sarcoidosis, but the cranial nerves, hypothalamus and pituitary gland are more commonly involved [1]. Sarcoid granulomas can affect the meninges, parenchyma of the brain, hypothalamus, brainstem, subependymal layer of the ventricular system, choroid plexuses and peripheral nerves, and also the blood vessels supplying the nervous structures [11, 12]. One-third of neurosarcoidosis patients show multiple neurological lesions. If neurological syndromes develop in a patient with biopsy- proven active systemic sarcoidosis, the diagnosis is usually easy. However, without biopsy evidence of sarcoidosis at other sites, nervous system sarcoidosis remains a difficult diagnosis [13].
    [Show full text]
  • Differential Diagnosis of Granulomatous Lung Disease: Clues and Pitfalls
    SERIES PATHOLOGY FOR THE CLINICIAN Differential diagnosis of granulomatous lung disease: clues and pitfalls Shinichiro Ohshimo1, Josune Guzman2, Ulrich Costabel3 and Francesco Bonella3 Number 4 in the Series “Pathology for the clinician” Edited by Peter Dorfmüller and Alberto Cavazza Affiliations: 1Dept of Emergency and Critical Care Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan. 2General and Experimental Pathology, Ruhr-University Bochum, Bochum, Germany. 3Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany. Correspondence: Francesco Bonella, Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University of Duisburg-Essen, Tueschener Weg 40, 45239 Essen, Germany. E-mail: [email protected] @ERSpublications A multidisciplinary approach is crucial for the accurate differential diagnosis of granulomatous lung diseases http://ow.ly/FxsP30cebtf Cite this article as: Ohshimo S, Guzman J, Costabel U, et al. Differential diagnosis of granulomatous lung disease: clues and pitfalls. Eur Respir Rev 2017; 26: 170012 [https://doi.org/10.1183/16000617.0012-2017]. ABSTRACT Granulomatous lung diseases are a heterogeneous group of disorders that have a wide spectrum of pathologies with variable clinical manifestations and outcomes. Precise clinical evaluation, laboratory testing, pulmonary function testing, radiological imaging including high-resolution computed tomography and often histopathological assessment contribute to make
    [Show full text]
  • Sarcoidosis: Causes, Diagnosis, Clinical Features, and Treatments
    Journal of Clinical Medicine Review Sarcoidosis: Causes, Diagnosis, Clinical Features, and Treatments 1, 2, 3, 1 2,4, Rashi Jain y , Dhananjay Yadav y , Nidhi Puranik y, Randeep Guleria and Jun-O Jin * 1 Department of Pulmonary Critical Care and Sleep Medicine, AIIMS, New Delhi 110029, India; [email protected] (R.J.); [email protected] (R.G.) 2 Department of Medical Biotechnology, Yeungnam University, Gyeongsan 712-749, Korea; [email protected] 3 Department of Biological Science, Bharathiar University, Coimbatore, Tamil Nadu-641046, India; [email protected] 4 Shanghai Public Health Clinical Center & Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai 201508, China * Correspondence: [email protected]; Tel.: +82-53-810-3033; Fax: +82-53-810-4769 These authors contributed equally to this work. y Received: 5 March 2020; Accepted: 8 April 2020; Published: 10 April 2020 Abstract: Sarcoidosis is a multisystem granulomatous disease with nonspecific clinical manifestations that commonly affects the pulmonary system and other organs including the eyes, skin, liver, spleen, and lymph nodes. Sarcoidosis usually presents with persistent dry cough, eye and skin manifestations, weight loss, fatigue, night sweats, and erythema nodosum. Sarcoidosis is not influenced by sex or age, although it is more common in adults (< 50 years) of African-American or Scandinavians decent. Diagnosis can be difficult because of nonspecific symptoms and can only be verified following histopathological examination. Various
    [Show full text]
  • Colon Sarcoidosis Responds to Methotrexate
    y & R ar esp on ir m a l to u r y Shigemitsu et al., J Pulm Respir Med 2013, 3:3 P f M o e l Journal of Pulmonary & Respiratory d a i DOI: 10.4172/2161-105X.1000148 n c r i n u e o J ISSN: 2161-105X Medicine Case Report Open Access Colon Sarcoidosis Responds to Methotrexate: A Case Report with Review of Literature Hidenobu Shigemitsu, Samer Saleh, Om P Sharma and Kamyar Afshar* Division of Pulmonary and Critical Care, University of Southern California, Keck School of Medicine, USA Abstract Sarcoidosis is a systemic disease with a 90% predilection for the lungs, but any organ can be involved. Sarcoidosis of the colon is rare. When this organ system is involved, it can be a feature of systemic disease or in isolated cases. Gastrointestinal sarcoid can resemble a broad spectrum of other disease processes, thus it is important for health care providers to be familiar with the various GI manifestations. Patients can have symptoms of fever, nausea, vomiting, unintentional weight loss, diarrhea, hematachezia, and severe abdominal pain. We report a case of sarcoidosis of the colon that responded to methotrexate and a MEDLINE search of 22 reported cases of colon sarcoid based on a compatible history and the demonstration of non-caseating granulomas. We describe the clinical manifestations of symptomatic colon sarcoid in relation to the endoscopic findings. Elevated serum ACE level, presence of CARD 15 mutations, and certain intestinal and extra-intestinal clinical features are helpful in differentiating between colon sarcoidosis and Crohn’s regional ileitis.
    [Show full text]
  • Allergic Bronchopulmonary Aspergillosis: Diagnostic and Treatment Challenges
    y & Re ar sp Leonardi et al., J Pulm Respir Med 2016, 6:4 on ir m a l to u r P y DOI: 10.4172/2161-105X.1000361 f M o e Journal of l d a i n c r i n u e o J ISSN: 2161-105X Pulmonary & Respiratory Medicine Review Article Open Access Allergic Bronchopulmonary Aspergillosis: Diagnostic and Treatment Challenges Lucia Leonardi*, Bianca Laura Cinicola, Rossella Laitano and Marzia Duse Department of Pediatrics and Child Neuropsychiatry, Division of Allergy and Clinical Immunology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy Abstract Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder, occurring mostly in asthmatic and cystic fibrosis patients, caused by an abnormal T-helper 2 lymphocyte response of the host to Aspergillus fumigatus antigens. ABPA diagnosis is defined by clinical, laboratory and radiological criteria including active asthma, immediate skin reactivity to A. fumigatus antigens, total serum IgE levels>1000 IU/mL, fleeting pulmonary parenchymal opacities and central bronchiectases that represent an irreversible complication of ABPA. Despite advances in our understanding of the role of the allergic response in the pathophysiology of ABPA, pathogenesis of the disease is still not completely clear. In addition, the absence of consensus regarding its prevalence, diagnostic criteria and staging limits the possibility of diagnosing the disease at early stages. This may delay the administration of a therapy that can potentially prevent permanent lung damage. Long-term management is still poorly studied. Present primary therapies, based on clinical experience, are not yet standardized. These consist in oral corticosteroids, which control acute symptoms by mitigating the allergic inflammatory response, azoles and, more recently, anti-IgE antibodies.
    [Show full text]
  • Allergic Bronchopulmonary Aspergillosis
    Allergic Bronchopulmonary Aspergillosis Karen Patterson1 and Mary E. Strek1 1Department of Medicine, Section of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, Illinois Allergic bronchopulmonary aspergillosis (ABPA) is a complex clinical type of pulmonary disease that may develop in response to entity that results from an allergic immune response to Aspergillus aspergillus exposure (6) (Table 1). ABPA, one of the many fumigatus, most often occurring in a patient with asthma or cystic forms of aspergillus disease, results from a hyperreactive im- fibrosis. Sensitization to aspergillus in the allergic host leads to mune response to A. fumigatus without tissue invasion. activation of T helper 2 lymphocytes, which play a key role in ABPA occurs almost exclusively in patients with asthma or recruiting eosinophils and other inflammatory mediators. ABPA is CF who have concomitant atopy. The precise incidence of defined by a constellation of clinical, laboratory, and radiographic ABPA in patients with asthma and CF is not known but it is criteria that include active asthma, serum eosinophilia, an elevated not high. Approximately 2% of patients with asthma and 1 to total IgE level, fleeting pulmonary parenchymal opacities, bronchi- 15% of patients with CF develop ABPA (2, 4). Although the ectasis, and evidence for sensitization to Aspergillus fumigatus by incidence of ABPA has been shown to increase in some areas of skin testing. Specific diagnostic criteria exist and have evolved over the world during months when total mold counts are high, the past several decades. Staging can be helpful to distinguish active disease from remission or end-stage bronchiectasis with ABPA occurs year round, and the incidence has not been progressive destruction of lung parenchyma and loss of lung definitively shown to correlate with total ambient aspergillus function.
    [Show full text]
  • The Pathomechanism of Lung Fibrosis and Sarcoidosis
    The pathomechanism of lung fibrosis and sarcoidosis Dr. Manuela Funke-Chambour Inselspital Universitätsklinik für Pneumologie Freiburgstrasse 4 3010 Bern SWITZERLAND [email protected] AIMS Understanding the pathomechanism of IPF Apprehend the change of paragdigm if IPF pathogenesis from predominant inflammation to impaired wound repair in IPF Understanding the pathomechanism of granulomatous disease potentially leading to fibrosis SUMMARY Idiopathic pulmonary fibrosis (IPF) was considered longtime a defect in immune response. Over years patients were treated with triple immunosuppression. A model of impaired wound repair has replaced this paradigm. More importantly, the PANTHER study comparing azathioprine, prednisone and N- acetylcysteine against placebo revealed that mortality under this treatment was increased. Understanding the exact pathomechanism of disease is crucial in order to develop treatment strategies. Tremendous progress has been made in understanding the mechanisms of pathogenesis of IPF. On the microscopic level a distinct histopathological pattern is observed in IPF. The typical heterogeneous distribution of fibrotic areas with fibroblast accumulation (so-called fibroblats foci) is called usual interstitial pneumonia (UIP), which is not exclusively found in IPF, but also other fibrotic lung diseases (e.g. rheumatoid arthritis). On the cellular level, initial injury by undetermined agents (so-called hit e.g. by gastric reflux, environmental substances, smoking, infection) induces epithelial cell apoptosis. Apoptosis of epithelial cells leads to interrupted alveolar structures and prompt vascular leak. Fibrin is released and accumulates in the alveolar space. The coagulation cascades are activated. Released cytokines and activated coagulation induce further wound repair mechanisms, which are exaggerated in lungs of IPF patients possibly due to genetic differences and/or multiple hits.
    [Show full text]
  • Update in the Study of Granulomatosis with Polyangiitis (Wegener's
    Rev Chil Radiol 2019; 25(1): 26-34. Update in the study of Granulomatosis with polyangiitis (Wegener’s granulomatosis) David Ladrón de Guevara1,*, Felipe Cerda2, María Ángela Carreño3, Antonio Piottante4, Patricia Bitar1. 1. Department of Radiology, Clínica Las Condes, Santiago, Chile. 2. Radiology Scholarship, Universidad de Chile, Santiago, Chile. 3. Department of Internal Medicine, Rheumatology Unit, Clínica Las Condes, Santiago, Chile. 4. Department of Pathological Anatomy, Clínica Las Condes, Santiago, Chile. Actualización en el estudio de Granulomatosis con poliangeitis (Granulomatosis de Wegener) Resumen: La granulomatosis con poliangeítis (GPA) es una vasculitis sistémica de pequeño vaso, que afecta más frecuentemente el tracto respiratorio y el riñón. Sus criterios diagnósticos se basan en la clínica, exámenes de laboratorio, imágenes e histología. El 90% son ANCA (anticuerpos anticitoplasma de neu- trófilos) positivos. La histología muestra inflamación granulomatosa, necrosis y vasculitis. Los exámenes de imagen son de vital importancia en su estudio inicial y seguimiento, correspondiendo principalmente a técnicas tomográficas. La tomografía Computada (TC) es el método de elección para la evaluación de vía aérea superior y pulmón, con alta sensibilidad en afectación de cavidades nasal/paranasales, árbol bronquial y pulmón. La Resonancia Magnética está indicada en compromiso del sistema nervioso cen- tral y corazón. El PET/CT presenta alta sensibilidad en enfermedad tóraco-abdominal, es de utilidad en detectar lesiones no visibles con otras técnicas, y en control de tratamiento. El compromiso renal, de alta ocurrencia en GPA, presenta escasa traducción en las imágenes y es frecuentemente indetectable con imágenes, aunque el PET/CT puede ser positivo en casos de glomerulonefritis acentuada. La radiología simple no debe ser utilizada en el estudio de GPA dado su bajo rendimiento diagnóstico.
    [Show full text]
  • Concurrent Allergic Bronchopulmonary Aspergillosis and Aspergilloma: Is It a More Severe Form of the Disease?
    Eur Respir Rev 2010; 19: 118, 261–263 DOI: 10.1183/09059180.00009010 CopyrightßERS 2010 EDITORIAL Concurrent allergic bronchopulmonary aspergillosis and aspergilloma: is it a more severe form of the disease? A. Shah he mould Aspergillus, a genus of spore forming fungi, lung diseases in which aspergilloma formation has been affects the respiratory system in more ways than one. reported include sarcoidosis [15], hydatidosis [16], pneumato- T The clinical spectrum of Aspergillus involvement of the coele caused by Pneumocystis pneumonia [17], bronchiectasis, lungs ranges from various hypersensitivity manifestations to emphysematous bullae, and sites of prior lobectomies or invasive disease which can be fatal. The inhaled spores hardly pneumonectomies. The time required for the development of affect healthy persons but in asthmatic subjects these spores fungal balls ranges from a few months to more than 10 yrs [18]. are trapped in the viscid secretions found in the airways. Repeated inhalation of Aspergillus antigens triggers allergic The clinical categories of Aspergillus-related respiratory disor- reactions in atopic individuals, which may manifest as ders, for reasons unknown, usually remain mutually exclusive. Aspergillus-induced asthma, allergic bronchopulmonary asper- In spite of similar immunopathological responses, concomitant gillosis (ABPA) and allergic Aspergillus sinusitis (AAS) [1]. occurrence of ABPA and AAS is infrequently reported [19–22]. Saprobic colonisation of airways, cavities and necrotic tissue In this issue of the European Respiratory Review,MONTANI et al. leads to the development of aspergillomas. [23] describe a 50-yr-old female with concomitant ABPA and aspergilloma. Even though chronic lung damage appears to Although ABPA is predominantly a disease of asthmatics, only provide a favourable milieu for aspergilloma formation, the a few asthmatics actually suffer from it.
    [Show full text]
  • Immunohistochemical Detection of Potential Microbial Antigens in Granulomas in the Diagnosis of Sarcoidosis
    Journal of Clinical Medicine Review Immunohistochemical Detection of Potential Microbial Antigens in Granulomas in the Diagnosis of Sarcoidosis Tetsuo Yamaguchi 1,2, Ulrich Costabel 3, Andrew McDowell 4 , Josune Guzman 5, Keisuke Uchida 1, Kenichi Ohashi 1 and Yoshinobu Eishi 1,* 1 Department of Human Pathology, Graduate School and Faculty of Medicine, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; [email protected] (T.Y.); [email protected] (K.U.); [email protected] (K.O.) 2 Department of Pulmonology, Shinjuku Tsurukame Clinic, Tokyo 151-0053, Japan 3 Department of Pneumology, Ruhrlandklinik, Medical Faculty, University of Duisburg-Essen, 45239 Essen, Germany; [email protected] 4 Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine BT52 1SA, UK; [email protected] 5 Department of General and Experimental Pathology, Ruhr University, 44801 Bochum, Germany; [email protected] * Correspondence: [email protected]; Tel.: +81-90-3332-0948 Abstract: Sarcoidosis may have more than a single causative agent, including infectious and non- infectious agents. Among the potential infectious causes of sarcoidosis, Mycobacterium tuberculosis and Propionibacterium acnes are the most likely microorganisms. Potential latent infection by both microorganisms complicates the findings of molecular and immunologic studies. Immune responses to potential infectious agents of sarcoidosis should be considered together with the microorganisms Citation: Yamaguchi, T.; Costabel, U.; detected in sarcoid granulomas, because immunologic reactivities to infectious agents reflect current McDowell, A.; Guzman, J.; Uchida, K.; Ohashi, K.; Eishi, Y. and past infection, including latent infection unrelated to the cause of the granuloma formation.
    [Show full text]
  • Steroid Sparing Therapy in Sarcoidosis
    Sarcoidosis Case Robert P. Baughman Interstitial Lung Disease and Sarcoidosis Clinic University of Cincinnati, USA © WASOG: educational material Sarcoidosis Case • patient is a Caucasian male • age 46 was diagnosed with sarcoidosis – positive mediastinoscopy • skin lesions on arms and back • no pulmonary symptoms Question 1: Would you treat this patient? 1. yes because he has lung involvement 2. yes because he has skin disease 3. no because he is not short of breath 4. no because his skin lesions are not on his face 5. I would let the patient decide Question 2: Which systemic therapy would you initiate? 1. none 2. prednisone 3. hydroxychloroquine 4. methotrexate 5. infliximab Symptoms none single organ multi-organ observe treat topically prednisone, 20-40 mg qd Extensive skin: Hydroxychloroquine no response response no response taper to <10mg qd yes: no: continue regimend treat with MTX response: no response: taper off prednisone consider other agents Antimalarials in sarcoidosis Davies D. Br J Dis Chest 1963; 57:30-6.; Hirsch JG. Am Rev Respir Dis 1961; 84:52; Jones E, et al. J Am Acad Dermatol 1990; 23:487; Morse SI, et al. Am J Med 1961; 779. Siltzbach LE, Teirstein AS. Acta Med Scand 1964; 425:302S. Treatment course •for two years skin did well with hydroxychloroquine and topical steroids •presents in 2004 with worsening skin lesions despite hydroxychloroquine •has no pulmonary symptoms, although still has thoracic sarcoidosis Sarcoidosis Case: 2004 Question 3: Which systemic therapy would you initiate? 1. stop all therapy 2. prednisone
    [Show full text]