Molecular analysis of sarcoidosis lymph nodes for microorganisms: a case–control study with clinical correlates

Robinson, Lary A; Smith, Prudence; SenGupta, Dhruba J; Prentice, Jennifer L; Sandin, Ramon L

Symptomatic sarcoidosis is usually treated with various anti-inflammatory and immunosuppressive agents such as corticosteroids, methotrexate and TNF-inhibitors 21 The similarities in immunologic abnormalities and treatment to another debilitating granulomatous disease, Crohn's disease, are striking. 22 Granulomatous ileitis (Crohn's) has been suspected by many investigators to be the result of a chronic infection with the obligate intracellular microorganism Mycobacterium avium subspecies paratuberculosis (MAP), that is known to cause a granulomatous ileitis in cattle and other ruminants called Johne's disease. 23 Although the classical treatment of Crohn's disease has been with immunosuppressive agents just like with sarcoidosis, many recent studies suggest a much more effective treatment with less side effects may be a triple antibiotic regimen geared toward the putative triggering agent MAP. [24] [25] [26] In fact, many in the field suspect that this intracellular organism (MAP) that resides in the macrophage impairs the normal autophagy that would usually eradicate the organism. 24 Agents that enhance autophagy such as 16α-bromoepiandersterone, 27, 28 currently in human trials, may prove effective along with antibiotics in Crohn's disease. 24 Can some antibacterial/anti-mycobacterial regimen such as that used in Crohn's disease alter the natural history of sarcoidosis in chronically symptomatic patients? Sixty years ago a number of small trials using classical anti-tuberculous drugs (isoniazide, streptomycin, or cortisone) were published with discouraging results. 29 However, atypical mycobacteria (rather than M. tuberculosis) that are more likely to be one of the etiologic agents in sarcoidosis, are almost all resistant to the standard anti-tuberculosis agents such as isoniazid. [30] [31] [32] [33] [34] [35] And if other organisms such as Proprionibacterium acnes or perhaps cell-wall deficient (L-forms) bacteria trigger and perpetuate sarcoidosis in some individuals, then the standard anti-tuberculous drugs would also be ineffective.