Sarcoidosis Remission and Aden Protocol
INTRODUCTION Sarcoidosis is a noncaseating granulomatous multi-system disease of unknown etiology that most commonly affects young adults. It affects males and females equally, but females are more likely to show ocular involvement. There is a greater prevalence of sarcoidosis in the southeastern United States, and it is believed to occur more commonly among blacks. A bimodal incidence has been reported. A sub-acute presentation in patients less than 30 years of age is more likely to be self-limited, subsiding within two years. This transient variety is seldom associated with skin lesions. A more chronic form of the disease occurs in older age groups and skin lesions occur in up to 30 of patients. This form is believed to be due to a defect in T-lymphocyte suppressor function, and it frequently presents with hilar adenopathy, lung infiltrations, and more rarely with skin or eye lesions. The incidence of ocular involvement in patients with sarcoidosis is estimated to be 22 and eyelid...
FDCM is distinguished from other specific cardiac diseases and systemic processes resulting in secondary ventricular dilatation and dysfunction 1 eccentric hypertensive cardiomyopathy, ischemic cardiomyopathy, decompensated valvular heart disease, alcoholic cardio-myopathy, and myocarditis. Less common are cardiomyopathies resulting from amyloidosis, sarcoidosis, hemochromatosis and other metabolic disorders, and peripartum cardiomyopathy. Doxorubicin can cause toxic cardiomyopathy.
Peripheral neuropathies Spinal mononeuropathies that can be confused with radiculopathies (e.g., diabetic neuropathy, sarcoid spinal mononeuropathy, paraneoplastic sensory neuropathy, combined system disease-vitamin B12 deficiency, pharmaceutical and industrial toxin neuropathy, ischemic neuropathy)
Secondary hypogonadotrophic hypogonadism may result from systemic conditions including sarcoidosis, tuberculosis as well as following head injury or cranial irradiation. Sheehan's syndrome, the result of profound and prolonged hypotension on the sensitive pituitary gland, enlarged by pregnancy, may also be a cause of hypogonadotrophic hypogonadism in someone with a history of a major obstetric haemorrhage 40 . It is essential to assess the pituitary function fully in all these patients and then instigate the appropriate replacement therapy. Ovulation may be induced with pulsatile subcutaneous GnRH or human menopausal gonadotropins (hMG). The administration of pulsatile GnRH provides the most 'physiological' correction of infertility caused by hypogonadotrophic hypogonadism and will result in unifollicular ovulation, while hMG therapy requires close monitoring to prevent multiple pregnancy. Purified or recombinant FSH preparations are not suitable for women with hypogonadotrophic...
Treatment goals are to reduce the osteoclastic bone resorption, reduce tumor burden, and facilitate renal clearance of calcium. Bisphosphonates have become the standard therapy to reduce bone resorption and decrease hypercalcemia in malignancy. Bisphosphonates may also prevent the progression of bone metastases, particularly in multiple myeloma (36). Glucocorticoids are useful in reducing hypercalcemia of malignancy as well, particularly when it is caused by multiple myeloma or excess 1,25(OH)2D, as in sarcoidosis. Severe hypercalce-mia, as often seen in malignancy, needs to be aggressively treated with intravenous normal saline and a loop diuretic while the patient's cardiovascular status is closely monitored.
Sarcoidosis is a systemic disease that is often diagnosed following evaluation of hilar or mediastinal adenopathy on chest radiograph. In the past, diagnostic studies included blind transbronchial biopsy or more invasive surgical procedures, such as mediastinoscopy. Several studies have recently demonstrated the utility of EUS-FNA in establishing the diagnosis of sarcoid. In a retrospective, descriptive review, of 108 consecutive patients who underwent EUS-FNA of mediastinal nodes for various clinical indications, 6 were found to have cytological evidence of sarcoidosis, with a central hyperechoic strand evident in 4 (25). These preliminary studies suggest that mediastinal lymph nodes in patients with sarcoidosis have specific echocharacteristics, and EUS-FNA can be used for confirmatory tissue diagnosis. of thoracic specialists was asked to decide the course of evaluation if EUS-FNA had not been available and this diagnostic strategy was compared to the actual clinical course of...
All lesions that involve the eyelids or any other region of the body can be thought of as deriving from two basic sources. Those that arrive in the lids from other more remote sources are exogenous lesions. These include metastatic tumors from sites such as the breast or lung. Also included here are infiltrations in the dermis and epidermis of cellular or other materials that secondarily involve eyelid structures. Included here are diseases such as amyloidosis, sarcoidosis, infectious inflammations such as herpes and cellulitis, xanthelamas, acute atopic dermatitis, erythema multiforme, granuloma annulare, and lymphoid and myeloid infiltrates. All exogenous lesions disturb the normal eyelid architechture to some extent, and may be generalized or confined to specific eyelid tissue types.
They are multiple, they may be clustered or form a linear array. Solitary lesions usually occur on the extremities, and multiple lesions may occur on either the trunk or extremities. Pain is commonly reported, and may be precipitated by cold or pressure. The discomfort is described as sharp, burning, or throbbing (7). The differential diagnosis is wide for solitary lesions, and for multiple lesions may include such disparate entities as segmental neurofibromatosis, foreign body granuloma, dermatofibrosar-coma protuberans, and sarcoidosis.
A granuloma is a microscopic aggregate containing varying proportions of activated macrophages (epithelioid cells), multinucleated giant cells resulting from fusion of epithelioid cells, and other mononuclear leukocytes (lymphocytes, plasma cells, monocytes, and macrophages). Foreign body granulomas are reactions to relatively inert particles and typically have multinucleated giant cells, macrophages, and usually only small numbers of epithelioid cells. Immune or allergic granulomas are a response to insoluble particles that can induce a cell-mediated immune response they may result from foreign substances such as zirconium, beryllium, or dyes used for tattoos, or microbes such as Mycobacterium tuberculosis and fungi. Immune allergic granulomas typically contain abundant epithelioid cells and variable numbers of multinucleated giant cells. Other descriptors used for granulomas are sarcoidal, tuberculoid, and palisading. Sarcoidal granulomas, also termed naked granulomas, have...
The next most common causes of secondary adrenocortical insufficiency are tumors of the pituitary and or hypothalmic region (most commonm after surgical and radiation treatment to the pituitary) as well as lymphocytic hypophysitis, sarcoidosis, and histocytosis. In these cases, ACTH is rarely the only pituitary hormone deficiency. Patients may present with either symptoms suggestive of a
Diffuse unilateral subacute neuroretinitis (DUSN) 8 is caused by an unidentified species of nematodes that may wander in the subreti-nal space for 4 years or longer and cause progressive ocular damage. DUSN is characterized by early visual loss, vitritis, papillitis, retinal vasculitis, and recurrent crops of evanescent, grayish white outer retinal lesions that may develop in one eye of an otherwise healthy individual. At a late stage, there is severely reduced vision, optic atrophy, retinal vessel narrowing, and diffuse RPE degeneration. The appearance of the fundus can resemble that in several other diseases at different stages, such as optic neuritis, sarcoidosis, MEWDS, unilateral optic atrophy, unilateral retinitis pigmentosa, among others. Ancylostoma caninum, a hookworm of dogs, is a common cause of DUSN.
Hypothesis supported by increased cellular and humoral immune responses observed in HAM TSP patients. In addition to ATLL and HAM TSP, HTLV-1 infection has been associated with many other disorders believed to be caused by immune-system dysfunction. These include uveitis (61), HTLV-1-associated arthropathy (62), Sjogren syndrome (63), infective dermatitis (64), polymyositis (65), lymphadenitis (66), chronic respiratory disease (67), acute myeloid leukemia (68), and conditions such as systemic sarcoidosis as well as increased susceptibility to Strongyloides stercoralis infection (69). However, the direct role of HTLV-1 in the development of these conditions remains controversial.
Sarcoidosis and Other Granulomatous Diseases Hypercalcemia occurs in about 10 of patients with sarcoidosis, and hypercalciuria is about three times more frequent (41). Kidney stones develop in about 10 of patients and are usually pure calcium oxalate stones (42). Pulmonary macrophages from affected individuals contain 25(OH)D 1-a-hydroxylase activity that is not readily inhibited by calcium or 1,25(OH)2D. Glucocorticoids suppress the 1-a-hydroxylase activity and provide effective treatment for both the disease and this complication of it.
Effective treatment for hypercalcemia, particularly if caused by multiple myeloma, lymphoma, sarcoidosis, or intoxication with vitamin D or vitamin A. Other available antiresorptive agents are the bisphosphonate etidronate and gallium nitrate. They are less effective than pamidronate and are therefore in little use at present.
Other options available for managing mild hypercalcemia in patients with asymptomatic primary hyperparathyroidism include estrogen therapy in postmenopausal women, oral phosphate therapy and the use of bisphosphonates. Other causes of mild hypercalcemia, besides primary hyperparathyroidism, are approached best by dealing directly with the underlying etiology. For example, the hypercalcemia of hyperthyroidism is best handled by treating the hyperthyroidism. The hypercalcemia of granulomatous diseases such as sarcoid and tuberculosis is best handled by treating the disorder itself.
Glucocorticoids can be effective in patients with hematological malignancies, and with hypercalcemias associated with vitamin D excess or sensitivity. Myeloma, lymphoma, sarcoidosis, and other granulomatous diseases are conditions for which glucocorticoids might be particularly effective. In these disorders glucocorticoids inhibit production of various osteoclast-activating factors including calcitriol 7 . In general, patients with nonhematological malignancies and primary hyperparathyroidism do not respond. A dosage of 200-300 mg of hydrocortisone iv or prednisone 50 mg po is given daily for 5-7 days. pathic hypercalciuria denotes the urinary excretion of Ca above normal levels for which there is no readily apparent cause, such as hypercalcemia, sarcoidosis, excessive vitamin D ingestion, glucocorticoid excess, thyrotoxicosis, or immobilization. Reasonable upper limits for 24-hr urinary Ca excretion on an ab lib diet are 250 mg per day in women, 300 mg per day in men, or 4 mg kg day...
Lash loss is also associated with infiltrative lesions such as sarcoidosis, lymphoma, and cutaneous neoplasms. Inflammatory processes including severe blepharitis can cause lashes to fall out, and chronic infections with the mite Demodex folliculorum, found in 10 to 15 of normal individuals, can also be associated with madarosis. Loss of lashes and facial hair has been reported as a complication of botulinum toxin for oromandibular dystonia, but this is exceedingly uncommon. Iodine plaque brachytherapy and external beam irradiation for choroidal tumors is a known cause of madarosis. Loss of lashes is a common finding in leprosy and ichthyosis. In some cases the loss of lashes can be factitious or idiopathic.
Probably is delayed hypersensitivity reaction to a variety of antigens most common associations with streptococcal infections in children and sarcoidosis in adults other associations include tuberculosis, myco-plasma pneumonia, leprosy, coccidioid-omycosis, North American blastomycosis, histoplasmosis, inflammatory bowel disease, pregnancy, and Behcet's disease associated medications include oral contraceptives and sulfonamides
|Sarcoidosis Remission and Aden Protocol|
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