Corticosteroid treatment in pulmonary sarcoidosis: do serial lavage lymphocyte counts, serum angiotensin converting enzyme measurements, and gallium-67 scans help management?

Abstract

Thirty two patients with persisting pulmonary sarcoidosis fulfilling defined criteria for treatment were managed according to a standard clinical protocol. In this an attempt was made to achieve and maintain maximal radiographic and physiological improvement with individually titrated doses of corticosteroids. Lavage cell counts, serum angiotensin converting enzyme (SACE) determinations, and gallium-67 scans were planned at standard intervals but were not used in management decisions. The study analysed serial measurements in relation to changes in the clinical measurements. Twelve patients' radiographs showed complete clearing, seven cleared partially, and 13 had partial clearing with evidence of fibrosis. There was no predictive value in the initial lavage lymphocyte counts or the SACE or gallium measurements. Notably, in seven patients, substantial radiographic improvement was observed when the initial lavage lymphocyte counts were normal. Higher initial lavage neutrophil counts (p < 002), higher initial radiographic profusion scores (p < 002), and lower vital capacity (p < 001) and carbon monoxide transfer factor (p < 005) were related to incomplete clearing. A repeat study of the patients when their radiograph had cleared maximally showed that the levels of lavage lymphocytes, SACE, and gallium tended to fall, but frequently remained raised even in the presence of a normal radiograph or vital capacity or both. On the other hand, however, most of the patients with a normal lavage lymphocyte count showed persisting abnormality of the radiograph, lung function measurements, SACE, and gallium scan (or of at least one of these indices). The interrelationships between changes in clinical indices (radiograph, vital capacity, and transfer factor) and in lavage lymphocyte counts, SACE, and gallium scans showed that concordance was fairly poor in each comparison; lavage lymphocytes showed a greater major discordance than did the other pairs of measurements. Symptom free patients with normal or stable radiographic appearances have been followed for many months and have shown no clinical deterioration despite abnormal lavage lymphocyte counts, SACE, and gallium scans. Radiographic relapse; within the criteria defined, was seen in only four patients during the study; this was reflected in the gallium counts in three and in SACE and lavage lymphocyte counts measurements in two.It is concluded that serial lavage lymphocyte counts, serum angiotensin converting enzyme measurements, and gallium-67 scans are not consistently more sensitive methods by which to monitor patients with sarcoidosis during treatment than are serial measurements of high quality radiographs and results of standard lung function tests.

Systemic oxidative stress in patients with pulmonary sarcoidosis

“…Although lack of serial measurements (before and after therapy administration) limits definite conclusions this finding suggests a reduction of oxidative stress under the influence of systemic corticosteroids. This is in accordance to the already known immunomodulatory role of corticosteroids and their ability to suppress inflammation by activating anti-inflammatory genes or by disabling inflammatory genes [23]. The complex interactions between inflammation and redox-related pathways which have already been described might also explain the lower systemic oxidative stress in patients receiving corticosteroids.…”

Corticosteroids in sarcoidosis: friend or foe?

“…Many studies have shown quite conclusively that steroids can improve chest radiographic features and lung function measurements, and these include some of those studies which conclude that there was no long-term benefit on disease outcome (but see below) [59][60][61][62][63][64]. ODLUM and FITZGERALD [62] studied six patients who had been untreated for a period of 6.8±2.4 yrs and whose disease was demonstrated to be progressing.…”

“…TURNER-WARWICK et al [64] treated 32 patients with a standard treatment which was then titrated to maintain maximum improvement. Results showed that chest radiographs improved in all 32 and were not related to the initial BAL lymphocytes count.…”

Bronchoalveolar lavage immunoglobulin A and G and antiproteases correlate with changes in diffusion indices during the natural course of pulmonary sarcoidosis

“…Since the cells recovered in bronchoalveolar lavage (BAL) fluid reflect the alveolitis [3], the analysis of BAL cell populations, especially lymphocyte count and T-cell subsets, has largely been used to define prognostic markers [4][5][6][7][8][9][10][11][12][13][14][15][16]. Some investigators reported that a high BAL lymphocyte count was associated with a higher risk of pulmonary function deterioration [4,9] and with a better response to steroid therapy [7], whilst others found that the helper to suppressor T-cell ratio (T4/T8) was more reliable [5,8].…”