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To the Editor:

We thank Dr. Specks and his colleagues for their interest in our article. Dr. Specks et al give a sophisticated summary of the literature concerning treatment concepts in sarcoidosis. Six articles are cited describing infliximab therapy in sarcoidosis (1–6), but none of them fulfills all of the criteria described in our case presentation.

We described a female patient with severe sarcoidosis involving the lung and liver, who also had arthritis. Various treatment regimens with azathioprine, methotrexate, cyclophosphamide, and pentoxifylline failed to control the disease. Infliximab therapy induced radiologic remission of the pulmonary and liver involvement and brisk clinical benefit for arthritis. Yee and Pochapin (1) presented an “unusual case of sarcoidosis, manifested by severe protein-losing enteropathy and proximal myopathy.” In another 3 case reports cited by Specks et al (2, 4, 5), patients with cutaneous, pulmonary, and/or brain manifestations, but not widespread multiorgan involvement as in our patient, in whom sarcoidosis was partly refractory, are described. In an additional 2 case reports of treatment of sarcoidosis involving several organs, improvement was observed in only 1 organ (3, 6).

We agree with Dr. Specks on the necessity for standardized clinical trials to study the efficacy of TNFα blockade in sarcoidosis. The indication for infliximab therapy has to be clearly defined. Should TNFα blockade be reserved for therapy-resistant sarcoidosis? Is there a need for adjuvant immunosuppression with conventional drugs such as azathioprine or methotrexate, or additional TNFα blockade with pentoxifylline or thalidomide? However, for patients such as the one described by our group, who are vitally threatened by progressive liver failure, TNFα blockade with infliximab is a promising new treatment modality.

Kai U. Ulbricht MD*, Matthias Stoll MD*, Janine Bierwirth MD*, Torsten Witte MD*, Reinhold E. Schmidt MD*, * Hannover Medical School, Hannover, Germany.