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Semin Respir Crit Care Med 2017; 38(04): 437-449
DOI: 10.1055/s-0037-1603766
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pulmonary Sarcoidosis

Martina Bonifazi
1   Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
2   Pulmonary Diseases Unit, Department of Internal Medicine, Azienda Ospedali Riuniti, Ancona, Italy
,
Stefano Gasparini
1   Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
2   Pulmonary Diseases Unit, Department of Internal Medicine, Azienda Ospedali Riuniti, Ancona, Italy
,
Veronica Alfieri
3   Respiratory Disease and Lung Function Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
,
Elisabetta A. Renzoni
4   Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom
› Author Affiliations
Further Information

Publication History

Publication Date:
27 July 2017 (online)

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Abstract

Sarcoidosis is a systemic granulomatous disorder of unknown etiology, with a predilection for the respiratory system, involved in more than 90% of cases, with considerable variability in terms of patterns and prognostic implications. A protean interplay between genetic susceptibility and antigen exposure in selected environmental contexts is likely to define not only the risk for disease but also the different clinical phenotypes. Advances in imaging and functional tests over the past decades have increasingly broadened the awareness of the wide spectrum of features potentially occurring in pulmonary sarcoidosis, while the evolution of diagnostic techniques in interventional pulmonology has increased the possibility of obtaining tissue characterization more easily, by means of ultrasound-guided tools and cryotechnology. However, histological proof is not always needed, as, in selected scenarios with compatible clinical and imaging picture, a confirmatory biopsy is perceived as redundant. The diagnostic workup should be tailored on a case-by-case basis, according to an integrated assessment of clinical features, local resources, and expertise availability. Owing to the heterogeneity of possible clinical scenarios and the paucity of evidence-based data on treatments, a standardized clinical management has yet to be established, and general approach usually reflects expert opinion from accumulated clinical data. Key elements of decision-making process are to assess the baseline severity of disease, to stratify the risk of progression, and to define the goals of treatment.

Keywords

pulmonary sarcoidosis - lung - diagnosis - epidemiology - management

Funding

None.


 

  • References

  • 1 Ramachandraiah V, Aronow W, Chandy D. Pulmonary sarcoidosis: an update. Postgrad Med 2017; 129 (01) 149-158
    CrossrefPubMedGoogle Scholar
  • 2 Kouranos V, Hansell DM, Sharma R, Wells AU. Advances in imaging of cardiopulmonary involvement in sarcoidosis. Curr Opin Pulm Med 2015; 21 (05) 538-545
    PubMedGoogle Scholar
  • 3 Mirsaeidi M, Machado RF, Schraufnagel D, Sweiss NJ, Baughman RP. Racial difference in sarcoidosis mortality in the United States. Chest 2015; 147 (02) 438-449
    CrossrefPubMedGoogle Scholar
  • 4 Cozier YC. Assessing the worldwide epidemiology of sarcoidosis: challenges and future directions. Eur Respir J 2016; 48 (06) 1545-1548
    CrossrefPubMedGoogle Scholar
  • 5 Liang NC, Truong KT, Afshar K. Key management considerations in sarcoidosis from the American Thoracic Society 2016 Conference. J Thorac Dis 2016; 8 (Suppl. 07) S569-S572
    CrossrefPubMedGoogle Scholar
  • 6 Kouranos V, Jacob J, Wells AU. Severe sarcoidosis. Clin Chest Med 2015; 36 (04) 715-726
    PubMedGoogle Scholar
  • 7 Baughman RP, Lower EE, Gibson K. Pulmonary manifestations of sarcoidosis. Presse Med 2012; 41 (6, Pt 2): e289-e302
    CrossrefPubMedGoogle Scholar
  • 8 Judson MA. Strategies for identifying pulmonary sarcoidosis patients at risk for severe or chronic disease. Expert Rev Respir Med 2017; 11 (02) 111-118
    CrossrefPubMedGoogle Scholar
  • 9 Walsh SL, Wells AU, Sverzellati N. , et al. An integrated clinicoradiological staging system for pulmonary sarcoidosis: a case-cohort study. Lancet Respir Med 2014; 2 (02) 123-130
    CrossrefPubMedGoogle Scholar
  • 10 Arkema EV, Grunewald J, Kullberg S, Eklund A, Askling J. Sarcoidosis incidence and prevalence: a nationwide register-based assessment in Sweden. Eur Respir J 2016; 48 (06) 1690-1699
    CrossrefPubMedGoogle Scholar
  • 11 Ungprasert P, Carmona EM, Utz JP, Ryu JH, Crowson CS, Matteson EL. Epidemiology of sarcoidosis 1946-2013: a population-based study. Mayo Clin Proc 2016; 91 (02) 183-188
    CrossrefPubMedGoogle Scholar
  • 12 Dumas O, Abramovitz L, Wiley AS, Cozier YC, Camargo Jr CA. Epidemiology of sarcoidosis in a prospective cohort study of U.S. women. Ann Am Thorac Soc 2016; 13 (01) 67-71
    CrossrefPubMedGoogle Scholar
  • 13 Ungprasert P, Crowson CS, Matteson EL. Seasonal variation in incidence of sarcoidosis: a population-based study, 1976-2013. Thorax 2016; thoraxjnl-2016-209032
    PubMedGoogle Scholar
  • 14 Sawahata M, Sugiyama Y. An epidemiological perspective of the pathology and etiology of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2016; 33 (02) 112-116
    PubMedGoogle Scholar
  • 15 Sawahata M, Sugiyama Y, Nakamura Y. , et al. Age-related and historical changes in the clinical characteristics of sarcoidosis in Japan. Respir Med 2015; 109 (02) 272-278
    CrossrefPubMedGoogle Scholar
  • 16 Sawahata M, Sugiyama Y, Nakamura Y. , et al. Age-related differences in chest radiographic staging of sarcoidosis in Japan. Eur Respir J 2014; 43 (06) 1810-1812
    CrossrefPubMedGoogle Scholar
  • 17 Fingerlin TE, Hamzeh N, Maier LA. Genetics of sarcoidosis. Clin Chest Med 2015; 36 (04) 569-584
    PubMedGoogle Scholar
  • 18 Sato H, Woodhead FA, Ahmad T. , et al. Sarcoidosis HLA class II genotyping distinguishes differences of clinical phenotype across ethnic groups. Hum Mol Genet 2010; 19 (20) 4100-4111
    CrossrefPubMedGoogle Scholar
  • 19 Wennerström A, Pietinalho A, Vauhkonen H. , et al; Finnish Sarcoidosis Study Group. HLA-DRB1 allele frequencies and C4 copy number variation in Finnish sarcoidosis patients and associations with disease prognosis. Hum Immunol 2012; 73 (01) 93-100
    PubMedGoogle Scholar
  • 20 Iannuzzi MC, Maliarik MJ, Poisson LM, Rybicki BA. Sarcoidosis susceptibility and resistance HLA-DQB1 alleles in African Americans. Am J Respir Crit Care Med 2003; 167 (09) 1225-1231
    CrossrefPubMedGoogle Scholar
  • 21 Spagnolo P, Renzoni EA, Wells AU. , et al. C-C chemokine receptor 5 gene variants in relation to lung disease in sarcoidosis. Am J Respir Crit Care Med 2005; 172 (06) 721-728
    CrossrefPubMedGoogle Scholar
  • 22 Wijnen PA, Nelemans PJ, Verschakelen JA, Bekers O, Voorter CE, Drent M. The role of tumor necrosis factor alpha G-308A polymorphisms in the course of pulmonary sarcoidosis. Tissue Antigens 2010; 75 (03) 262-268
    CrossrefPubMedGoogle Scholar
  • 23 Wijnen PA, Cremers JP, Nelemans PJ. , et al. Association of the TNF-α G-308A polymorphism with TNF-inhibitor response in sarcoidosis. Eur Respir J 2014; 43 (06) 1730-1739
    CrossrefPubMedGoogle Scholar
  • 24 Sato H, Williams HR, Spagnolo P. , et al. CARD15/NOD2 polymorphisms are associated with severe pulmonary sarcoidosis. Eur Respir J 2010; 35 (02) 324-330
    CrossrefPubMedGoogle Scholar
  • 25 Veltkamp M, van Moorsel CH, Rijkers GT, Ruven HJ, Grutters JC. Genetic variation in the Toll-like receptor gene cluster (TLR10-TLR1-TLR6) influences disease course in sarcoidosis. Tissue Antigens 2012; 79 (01) 25-32
    CrossrefPubMedGoogle Scholar
  • 26 Fischer A, Ellinghaus D, Nutsua M. , et al; GenPhenReSa Consortium. Identification of immune-relevant factors conferring sarcoidosis genetic risk. Am J Respir Crit Care Med 2015; 192 (06) 727-736
    CrossrefPubMedGoogle Scholar
  • 27 Fischer A, Nothnagel M, Franke A. , et al. Association of inflammatory bowel disease risk loci with sarcoidosis, and its acute and chronic subphenotypes. Eur Respir J 2011; 37 (03) 610-616
    CrossrefPubMedGoogle Scholar
  • 28 Heron M, van Moorsel CH, Grutters JC. , et al. Genetic variation in GREM1 is a risk factor for fibrosis in pulmonary sarcoidosis. Tissue Antigens 2011; 77 (02) 112-117
    CrossrefPubMedGoogle Scholar
  • 29 Kruit A, Grutters JC, Ruven HJ. , et al. Transforming growth factor-beta gene polymorphisms in sarcoidosis patients with and without fibrosis. Chest 2006; 129 (06) 1584-1591
    CrossrefPubMedGoogle Scholar
  • 30 Mostard RL, Verschakelen JA, van Kroonenburgh MJ. , et al. Severity of pulmonary involvement and (18)F-FDG PET activity in sarcoidosis. Respir Med 2013; 107 (03) 439-447
    CrossrefPubMedGoogle Scholar
  • 31 Adams H, Keijsers RG, Korenromp IH, Grutters JC. FDG PET for gauging of sarcoid disease activity. Semin Respir Crit Care Med 2014; 35 (03) 352-361
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Lockstone HE, Sanderson S, Kulakova N. , et al. Gene set analysis of lung samples provides insight into pathogenesis of progressive, fibrotic pulmonary sarcoidosis. Am J Respir Crit Care Med 2010; 181 (12) 1367-1375
    CrossrefPubMedGoogle Scholar
  • 33 Wynn TA, Ramalingam TR. Mechanisms of fibrosis: therapeutic translation for fibrotic disease. Nat Med 2012; 18 (07) 1028-1040
    CrossrefPubMedGoogle Scholar
  • 34 Pechkovsky DV, Prasse A, Kollert F. , et al. Alternatively activated alveolar macrophages in pulmonary fibrosis-mediator production and intracellular signal transduction. Clin Immunol 2010; 137 (01) 89-101
    CrossrefPubMedGoogle Scholar
  • 35 Patterson KC, Hogarth K, Husain AN, Sperling AI, Niewold TB. The clinical and immunologic features of pulmonary fibrosis in sarcoidosis. Transl Res 2012; 160 (05) 321-331
    CrossrefPubMedGoogle Scholar
  • 36 Miyara M, Amoura Z, Parizot C. , et al. The immune paradox of sarcoidosis and regulatory T cells. J Exp Med 2006; 203 (02) 359-370
    CrossrefPubMedGoogle Scholar
  • 37 Chen ES, Song Z, Willett MH. , et al. Serum amyloid A regulates granulomatous inflammation in sarcoidosis through Toll-like receptor-2. Am J Respir Crit Care Med 2010; 181 (04) 360-373
    CrossrefPubMedGoogle Scholar
  • 38 Cinetto F, Agostini C. Advances in understanding the immunopathology of sarcoidosis and implications on therapy. Expert Rev Clin Immunol 2016; 12 (09) 973-988
    CrossrefPubMedGoogle Scholar
  • 39 Kobayashi J, Kitamura S. Serum KL-6 for the evaluation of active pneumonitis in pulmonary sarcoidosis. Chest 1996; 109 (05) 1276-1282
    CrossrefPubMedGoogle Scholar
  • 40 Miyoshi S, Hamada H, Kadowaki T. , et al. Comparative evaluation of serum markers in pulmonary sarcoidosis. Chest 2010; 137 (06) 1391-1397
    CrossrefPubMedGoogle Scholar
  • 41 Janssen R, Sato H, Grutters JC. , et al. Study of Clara cell 16, KL-6, and surfactant protein-D in serum as disease markers in pulmonary sarcoidosis. Chest 2003; 124 (06) 2119-2125
    CrossrefPubMedGoogle Scholar
  • 42 Honda K, Okada F, Ando Y. , et al. Comparison of pulmonary thin section CT findings and serum KL-6 levels in patients with sarcoidosis. Br J Radiol 2011; 84 (999) 229-235
    CrossrefPubMedGoogle Scholar
  • 43 Xu X, Chen H, Zhu X. , et al. S100A9 promotes human lung fibroblast cells activation through receptor for advanced glycation end-product-mediated extracellular-regulated kinase 1/2, mitogen-activated protein-kinase and nuclear factor-κB-dependent pathways. Clin Exp Immunol 2013; 173 (03) 523-535
    CrossrefPubMedGoogle Scholar
  • 44 Korthagen NM, Nagtegaal MM, van Moorsel CH, Kazemier KM, van den Bosch JM, Grutters JC. MRP14 is elevated in the bronchoalveolar lavage fluid of fibrosing interstitial lung diseases. Clin Exp Immunol 2010; 161 (02) 342-347
    PubMedGoogle Scholar
  • 45 Polychronopoulos VS, Prakash UB. Airway involvement in sarcoidosis. Chest 2009; 136 (05) 1371-1380
    CrossrefPubMedGoogle Scholar
  • 46 Carmona EM, Kalra S, Ryu JH. Pulmonary sarcoidosis: diagnosis and treatment. Mayo Clin Proc 2016; 91 (07) 946-954
    CrossrefPubMedGoogle Scholar
  • 47 Nunes H, Uzunhan Y, Gille T, Lamberto C, Valeyre D, Brillet PY. Imaging of sarcoidosis of the airways and lung parenchyma and correlation with lung function. Eur Respir J 2012; 40 (03) 750-765
    CrossrefPubMedGoogle Scholar
  • 48 Bonham CA, Strek ME, Patterson KC. From granuloma to fibrosis: sarcoidosis associated pulmonary fibrosis. Curr Opin Pulm Med 2016; 22 (05) 484-491
    CrossrefPubMedGoogle Scholar
  • 49 Martusewicz-Boros MM, Boros WP, Wiatr E, Wesolowski S, Roszkowski-Sliz K. Bronchial hyperreactivity in sarcoidosis patients: correlation with airflow limitation indices. Sarcoidosis Vasc Diffuse Lung Dis 2012; 29 (02) 99-106
    PubMedGoogle Scholar
  • 50 Boros PW, Enright PL, Quanjer PH, Borsboom GJ, Wesolowski SP, Hyatt RE. Impaired lung compliance and DL,CO but no restrictive ventilatory defect in sarcoidosis. Eur Respir J 2010; 36 (06) 1315-1322
    CrossrefPubMedGoogle Scholar
  • 51 Baughman RP. Sarcoidosis-associated pulmonary hypertension. Semin Respir Crit Care Med 2017; 38 (04) XX-XX
    PubMedGoogle Scholar
  • 52 Harrison BD, Shaylor JM, Stokes TC, Wilkes AR. Airflow limitation in sarcoidosis--a study of pulmonary function in 107 patients with newly diagnosed disease. Respir Med 1991; 85 (01) 59-64
    PubMedGoogle Scholar
  • 53 Lamberto C, Saumon G, Loiseau P, Battesti JP, Georges R. Respiratory function in recent pulmonary sarcoidosis with special reference to small airways. Bull Eur Physiopathol Respir 1985; 21 (04) 309-315
    PubMedGoogle Scholar
  • 54 Burgel PR, Bourdin A, Chanez P. , et al. Update on the roles of distal airways in COPD. Eur Respir Rev 2011; 20 (119) 7-22
    CrossrefPubMedGoogle Scholar
  • 55 Goldman MD, Saadeh C, Ross D. Clinical applications of forced oscillation to assess peripheral airway function. Respir Physiol Neurobiol 2005; 148 (1-2): 179-194
    CrossrefPubMedGoogle Scholar
  • 56 Renzoni E, Karagiannis K, Bikov A. , et al. Impulse oscillometry is more tightly linked to symptoms and quality of life than conventional lung function measures in pulmonary sarcoidosis. Am J Respir Crit Care Med 2014; 189: A4078
    PubMedGoogle Scholar
  • 57 Tanizawa K, Handa T, Nagai S. , et al. Comprehensive evaluation of airway involvement in pulmonary sarcoidosis. ERJ Open Res 2017; 3 (01) 00105-02016
    PubMedGoogle Scholar
  • 58 Gasparini S, Bonifazi M. Cryobiopsy for interstitial lung diseases. J Bronchology Interv Pulmonol 2016; 23 (01) 4-6
    CrossrefPubMedGoogle Scholar
  • 59 Agarwal R, Aggarwal AN, Gupta D. Efficacy and safety of conventional transbronchial needle aspiration in sarcoidosis: a systematic review and meta-analysis. Respir Care 2013; 58 (04) 683-693
    PubMedGoogle Scholar
  • 60 Vorselaars AD, Crommelin HA, Deneer VH. , et al. Effectiveness of infliximab in refractory FDG PET-positive sarcoidosis. Eur Respir J 2015; 46 (01) 175-185
    CrossrefPubMedGoogle Scholar
  • 61 Cremers JP, Van Kroonenburgh MJ, Mostard RL. , et al. Extent of disease activity assessed by 18F-FDG PET/CT in a Dutch sarcoidosis population. Sarcoidosis Vasc Diffuse Lung Dis 2014; 31 (01) 37-45
    PubMedGoogle Scholar
  • 62 Culver DA. Diagnosing sarcoidosis. Curr Opin Pulm Med 2015; 21 (05) 499-509
    PubMedGoogle Scholar
  • 63 Nagai S, Izumi T. Bronchoalveolar lavage. Still useful in diagnosing sarcoidosis?. Clin Chest Med 1997; 18 (04) 787-797
    CrossrefPubMedGoogle Scholar
  • 64 Shen Y, Pang C, Wu Y. , et al. Diagnostic performance of bronchoalveolar lavage fluid CD4/CD8 ratio for sarcoidosis: a meta-analysis. EBioMedicine 2016; 8: 302-308
    CrossrefPubMedGoogle Scholar
  • 65 Mondoni M, Radovanovic D, Valenti V, Patella V, Santus P. Bronchoscopy in sarcoidosis: union is strength. Minerva Med 2015; 106 (02) (Suppl. 02) 1-7
    PubMedGoogle Scholar
  • 66 Kocoń P, Szlubowski A, Kużdżał J. , et al. Endosonography-guided needle aspiration in the diagnosis of sarcoidosis - randomized study. Pol Arch Med Wewn 2017; 127 (03) 154-162
    PubMedGoogle Scholar
  • 67 Li K, Jiang S. A randomized controlled study of conventional TBNA versus EBUS-TBNA for diagnosis of suspected stage I and II sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2014; 31 (03) 211-218
    PubMedGoogle Scholar
  • 68 Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest 2014; 146 (03) 547-556
    CrossrefPubMedGoogle Scholar
  • 69 Gasparini S. It is time for this ‘ROSE’ to flower. Respiration 2005; 72 (02) 129-131
    CrossrefPubMedGoogle Scholar
  • 70 Bonifazi M, Sediari M, Ferretti M. , et al. The role of the pulmonologist in rapid on-site cytologic evaluation of transbronchial needle aspiration: a prospective study. Chest 2014; 145 (01) 60-65
    CrossrefPubMedGoogle Scholar
  • 71 Plit ML, Havryk AP, Hodgson A. , et al. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J 2013; 42 (05) 1302-1308
    CrossrefPubMedGoogle Scholar
  • 72 Raghu G, Collard HR, Egan JJ. , et al; ATS/ERS/JRS/ALAT Committee on Idiopathic Pulmonary Fibrosis. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011; 183 (06) 788-824
    CrossrefPubMedGoogle Scholar
  • 73 Tomassetti S, Wells AU, Costabel U. , et al. Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2016; 193 (07) 745-752
    CrossrefPubMedGoogle Scholar
  • 74 Ravaglia C, Bonifazi M, Wells AU. , et al. Safety and diagnostic yield of transbronchial lung cryobiopsy in diffuse parenchymal lung diseases: a comparative study versus video-assisted thoracoscopic lung biopsy and a systematic review of the literature. Respiration 2016; 91 (03) 215-227
    CrossrefPubMedGoogle Scholar
  • 75 Chopra A, Judson MA. How are cancer and connective tissue diseases related to sarcoidosis?. Curr Opin Pulm Med 2015; 21 (05) 517-524
    PubMedGoogle Scholar
  • 76 Cohen PR, Kurzrock R. Sarcoidosis and malignancy. Clin Dermatol 2007; 25 (03) 326-333
    CrossrefPubMedGoogle Scholar
  • 77 Bonifazi M, Bravi F, Gasparini S. , et al. Sarcoidosis and cancer risk: systematic review and meta-analysis of observational studies. Chest 2015; 147 (03) 778-791
    CrossrefPubMedGoogle Scholar
  • 78 Newman LS, Rose CS, Bresnitz EA. , et al; ACCESS Research Group. A case control etiologic study of sarcoidosis: environmental and occupational risk factors. Am J Respir Crit Care Med 2004; 170 (12) 1324-1330
    CrossrefPubMedGoogle Scholar
  • 79 Valeyre D, Soler P, Clerici C. , et al. Smoking and pulmonary sarcoidosis: effect of cigarette smoking on prevalence, clinical manifestations, alveolitis, and evolution of the disease. Thorax 1988; 43 (07) 516-524
    CrossrefPubMedGoogle Scholar
  • 80 Denning DW, Pleuvry A, Cole DC. Global burden of chronic pulmonary aspergillosis complicating sarcoidosis. Eur Respir J 2013; 41 (03) 621-626
    CrossrefPubMedGoogle Scholar
  • 81 Denning DW, Cadranel J, Beigelman-Aubry C. , et al; European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016; 47 (01) 45-68
    CrossrefPubMedGoogle Scholar
  • 82 Desai SR, Hedayati V, Patel K, Hansell DM. Chronic aspergillosis of the lungs: unravelling the terminology and radiology. Eur Radiol 2015; 25 (10) 3100-3107
    CrossrefPubMedGoogle Scholar
  • 83 Stevens DA, Kan VL, Judson MA. , et al; Infectious Diseases Society of America. Practice guidelines for diseases caused by Aspergillus . Clin Infect Dis 2000; 30 (04) 696-709
    CrossrefPubMedGoogle Scholar
  • 84 Keir G, Wells AU. Assessing pulmonary disease and response to therapy: which test?. Semin Respir Crit Care Med 2010; 31 (04) 409-418
    Article in Thieme ConnectPubMedGoogle Scholar
  • 85 Nam HS, Jeon K, Um SW. , et al. Clinical characteristics and treatment outcomes of chronic necrotizing pulmonary aspergillosis: a review of 43 cases. Int J Infect Dis 2010; 14 (06) e479-e482
    PubMedGoogle Scholar
  • 86 Drent M, Cremers JP, Jansen TL, Baughman RP. Practical eminence and experience-based recommendations for use of TNF-α inhibitors in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2014; 31 (02) 91-107
    PubMedGoogle Scholar