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Correspondence |

Noncaseating Granulomas in Lung: Think Beyond Sarcoidosis FREE TO VIEW

Alkesh Kumar Khurana, MD, DNB, FCCP
Author and Funding Information

From the Department of Pulmonary Medicine, the Government Medical College and Hospital.


Financial/nonfinancial disclosure: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1486. doi:10.1378/chest.09-3017
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To the Editor:

The case report by Papanikolaou and Sharma in a recent issue of CHEST (Dec 2009),1 whereby they reported sarcoidosis concurrently in a patient with rheumatoid arthritis, generates a lot of interest. After going through this report, I would like to raise the following issues which I feel should be addressed.

Having a close look at the high-resolution CT image, it is hard to appreciate the perivascular distribution of nodular opacities in the left lung parenchyma. Also, the absence of bilateral hilar lymph nodes makes the radiologic picture rather incompatible with that of sarcoidosis.

As far as the presence of noncaseating granulomas on histopathologic examination is concerned, Daïen et al2 have recently reported a series of 10 cases of sarcoid-like granulomas in patients treated with Etarnacept (anti-tumor necrosis factor [TNF] therapy). It has been suggested that TNF levels may paradoxically increase on treatment with Etarnacept, occasionally leading to TNF-mediated disease.3 Although the same effect was mentioned by the authors in this discussion, I wonder why the case is being seen as a dual pathology harboring both sarcoidosis and rheumatoid arthritis. In such cases, discontinuation of treatment with anti-TNF therapy has been suggested to help the patient recover from the illness. The delay between onset of treatment and appearance of granulomatosis has been reported to be > 4 years, and it may take up to a year for the clinical and radiologic signs to go into remission after stopping the culprit drug.2 Therefore, in this particular case, the pulmonary involvement should be seen as a side effect of Etarnacept treatment rather than labeling the patient as having sarcoidosis.

Papanikolaou IC, Sharma OP. A 47-year-old woman with rheumatoid arthritis and dyspnea on exertion. Chest. 2009;1366:1694-1697. [CrossRef] [PubMed]
 
Daïen CI, Monnier A, Claudepierre P, et al; Club Rhumatismes et Inflammation (CRI) Club Rhumatismes et Inflammation (CRI) Sarcoid-like granulomatosis in patients treated with tumor necrosis factor blockers: 10 cases. Rheumatology (Oxford). 2009;488:883-886. [CrossRef] [PubMed]
 
Sari I, Akar S, Birlik M, Sis B, Onen F, Akkoc N. Anti-tumor necrosis factor-alpha-induced psoriasis. J Rheumatol. 2006;337:1411-1414. [PubMed]
 

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Papanikolaou IC, Sharma OP. A 47-year-old woman with rheumatoid arthritis and dyspnea on exertion. Chest. 2009;1366:1694-1697. [CrossRef] [PubMed]
 
Daïen CI, Monnier A, Claudepierre P, et al; Club Rhumatismes et Inflammation (CRI) Club Rhumatismes et Inflammation (CRI) Sarcoid-like granulomatosis in patients treated with tumor necrosis factor blockers: 10 cases. Rheumatology (Oxford). 2009;488:883-886. [CrossRef] [PubMed]
 
Sari I, Akar S, Birlik M, Sis B, Onen F, Akkoc N. Anti-tumor necrosis factor-alpha-induced psoriasis. J Rheumatol. 2006;337:1411-1414. [PubMed]
 
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