Diagnosis and Management of Sarcoidosis.

Sarcoidosis is a systemic disease of unknown etiology characterized by the presence of noncaseating granulomas in any organ, most commonly the lungs and intrathoracic lymph nodes. A diagnosis of sarcoidosis should be suspected in any young or middle-aged adult presenting with unexplained cough, shortness of breath, or constitutional symptoms, especially among blacks or Scandinavians. Diagnosis relies on three criteria: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings, such as infections or malignancy. An early and accurate diagnosis of sarcoidosis remains challenging, because initial presentations may vary, many patients are asymptomatic, and there is no single reliable diagnostic test. Prognosis is variable and depends on epidemiologic factors, mode of onset, initial clinical course, and specific organ involvement. The optimal treatment for sarcoidosis remains unclear, but corticosteroid therapy has been the mainstay of therapy for those with significantly symptomatic or progressive pulmonary disease or serious extrapulmonary disease. Refractory or complex cases may require immunosuppressive therapy. Despite aggressive treatment, some patients may develop life-threatening pulmonary, cardiac, or neurologic complications from severe, progressive disease. End-stage disease may ultimately require lung or heart transplantation for eligible patients.

The risk and outcomes of pneumonia in patients on inhaled corticosteroids.

Corticosteroids are frequently prescribed anti-inflammatory medications. Inhaled corticosteroids (ICS) are indicated for Chronic Obstructive Pulmonary Disease (COPD) and asthma. ICS are associated with a decrease in exacerbations and improved quality of life in COPD, however multiple studies have linked the chronic use of ICSs with an increased risk of developing pneumonia, though the effect on mortality is unclear. We review the association of ICS with the risk of pneumonia and the implications on clinical outcomes.

Pneumonia: an arrhythmogenic disease?

BACKGROUND: Recent studies suggest that there is an increase in cardiovascular disease after pneumonia; however, there is little information on cardiac arrhythmias after pneumonia. The aims of this study were to assess the incidence of, and examine risk factors for, cardiac arrhythmias after hospitalization for pneumonia. METHODS: We conducted a national cohort study using Department of Veterans Affairs administrative data including patients aged ≥65 years hospitalized with pneumonia in fiscal years 2002-2007, receiving antibiotics within 48 hours of admission, having no prior diagnosis of a cardiac arrhythmia, and having at least 1 year of Veterans Affairs care. We included only the first pneumonia-related hospitalization, and follow-up was for the 90 days after admission. Cardiac arrhythmias included atrial fibrillation, ventricular tachycardia/fibrillation, cardiac arrest, and symptomatic bradycardia. We used a multilevel regression model, adjusting for hospital of admission, to examine risk factors for cardiac arrhythmias. RESULTS: We identified 32,689 patients who met the inclusion criteria. Of these, 3919 (12%) had a new diagnosis of cardiac arrhythmia within 90 days of admission. Variables significantly associated with increased risk of cardiac arrhythmia included increasing age, history of congestive heart failure, and a need for mechanical ventilation or vasopressors. Beta-blocker use was associated with a decreased incidence of events. CONCLUSION: An important number of patients have new cardiac arrhythmia during and after hospitalization for pneumonia. Additional research is needed to determine whether use of cardioprotective medications will improve outcomes for patients hospitalized with pneumonia. At-risk patients hospitalized with pneumonia should be monitored for cardiac arrhythmias during the hospitalization.