La Revue du praticien
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Sarcoidosis treatment suppresses the granulomatous process and its clinical, functional and radiographic consequences but it is not etiological. Only a minority of patients necessitate systemic therapy. This is definitely required in severe extra-respiratory sarcoidosis including cardiac, neurological, renal, ocular involvement not responding to topical therapy and malignant hypercalcemia. ⋯ One of the following sparing agents can be associated with steroids when the threshold level to control the disease is high: hydroxychloroquine, methotrexate or azathioprine. An alternative option to corticosteroids is proposed in case of contra-indication or cortico-resistant sarcoidosis; methotrexate is then the treatment of choice. Although other drugs are only occasionnally needed, the available therapeutical range is wide (thalidomide, infliximab, cyclophosphamide, leflunomide...).
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Severe forms of pulmonary sarcoidosis are not frequent and include stage IV pulmonary involvement and specific complications of intrathoracic sarcoidosis. Pulmonary hypertension may be due to granulomatous involvement of vessels and/or extrinsic compression of pulmonary arteries by enlarged lymph nodes. ⋯ Mycetomas may develop in cystic spaces and be responsible for severe haemoptysis. A better knowledge of these patterns is associated with a better management of severe sarcoidosis.
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Cushing's syndrome results from inappropriate exposure to excessive endogenous glucocorticoids. Untreated, it has an important morbidity and a significant mortality. The syndrome remains a challenge to diagnose and manage. Here, we propose algorithms for the diagnosis of Cushing's syndrome and its cause, and review pathogenesis, clinical features, and treatment.
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Aspergillosis, due to moulds belonging to the genus Aspergillus, occurs in patients with residual lung cavities. The clinical manifestations are determined by the host immune response, ranging from a local inflammatory response to the systemic dissemination. ⋯ The chest X-ray reveals a round mass with a radio-lucent crescent of air. The antifungal treatments are successful.