Advertisement

Sarcoidosis

  • Robert P. Baughman
  • Elyse E. Lower

Abstract

Sarcoidosis involves systemic inflammatory disorder with noncaseating granulomatous inflammation in affected organs. It commonly involves the lungs, eyes, skin, joints, lymph nodes, and upper respiratory tract. In the United States, prevalence of sarcoidosis is between 10 and 40 cases/100,000 population. In Sweden, the prevalence is higher, estimated to be between 60 and 80 cases/100,000 population. In the United States, the highest incidence of sarcoido-sis is observed in young African—American women. Löfgren's syndrome, the combination of fever, erythema nodosum, bilateral hilar adenopathy, symmetric polyarthritis, and uveitis, is one mode of acute presentation of sarcoidosis. The Heerfordt syndrome, another acute presentation, consists of fever, granulomatous inflammation of the lacrimal and parotid glands, uveitis, bilateral hilar ade-nopathy, and cranial neuropathies. Ninety percent of patients with sarcoidosis have evidence of pulmonary disease on chest radiography. The most common finding is hilar adenopathy. Ocular involvement is a common complication of sar-coidosis. The usual ocular manifestations are anterior uveitis and pars planitis. However, posterior uveitis and optic neuritis may also occur. Posterior uveitis can remain asymptomatic until it has reached the advanced stages. Thus, screening for oph-thalmologic disease is important for sarcoidosis patients. The diagnosis of sarcoidosis is established by correlation of the clinical presentation, clinical course, histo-pathological findings, and response to therapy. Glucocorticoids remain the cornerstone of therapy for active sarcoidosis.

Keywords

Interstitial Lung Disease Optic Neuritis Cardiac Sarcoidosis Sarcoidosis Patient Pulmonary Sarcoidosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. Baughman RP, Drent M, Kavuru M, et al Infliximab therapy in patients with chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med. 2006a;174(7):795–802CrossRefGoogle Scholar
  2. Baughman RP, Drent M. Role of bronchoalveolar lavage in interstitial lung disease. Clin Chest Med. 2001;22(2):331–41PubMedCrossRefGoogle Scholar
  3. Baughman RP, du Bois RM, Lower EE. Sarcoidosis. Lancet 2003a; 361:1111–8CrossRefGoogle Scholar
  4. Baughman RP, Engel PJ, Meyer CA, et al Pulmonary hypertension in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2006b;23:108–16Google Scholar
  5. Baughman RP, Hurtubise PE. Systemic immune response of patients with active pulmonary sarcoidosis. Clin Exp Immunol. 1985; 61:535–41PubMedGoogle Scholar
  6. Baughman RP, Judson MA, Teirstein A, et al Chronic facial sarcoidosis including lupus pernio: clinical description and proposed scoring systems. Am J Clin Dermatol. 2008;9(3):155–61PubMedCrossRefGoogle Scholar
  7. Baughman RP, Judson MA, Teirstein A, et al Presenting characteristics as predictors of duration of treatment in sarcoidosis. QJM. 2006c;99(5):307–15CrossRefGoogle Scholar
  8. Baughman RP, Judson MA, Teirstein AS, et al Thalidomide for chronic sarcoidosis. Chest 2002;122:227–32PubMedCrossRefGoogle Scholar
  9. Baughman RP, Keeton D, Lower EE. Relationship between interleu-kin-8 and neutrophils in the BAL fluid of sarcoidosis. Sarcoidosis 1994;11:S217–20SGoogle Scholar
  10. Baughman RP, Koehler A, Bejarano PA, et al Role of liver function tests in detecting methotrexate-induced liver damage in sarcoidosis. Arch Intern Med. 2003b;163(5):615–20CrossRefGoogle Scholar
  11. Baughman RP, Lower EE, Bradley DA, et al Etanercept for refractory ocular sarcoidosis: results of a double-blind randomized trial. Chest 2005;128(2):1062–67PubMedCrossRefGoogle Scholar
  12. Baughman RP, Ploysongsang Y, Roberts RD, et al Effects of sarcoid and steroids on angiotensin-converting enzyme. Am Rev Respir Dis. 1983;128:631–3PubMedGoogle Scholar
  13. Baughman RP, Shipley RT, Loudon RG, et al Crackles in interstitial lung disease. Comparison of sarcoidosis and fibrosing alveolitis. Chest 1991;100:96–101PubMedCrossRefGoogle Scholar
  14. Baughman RP, Sparkman BK, Lower EE. Six-minute walk test and health status assessment in sarcoidosis. Chest 2007;132(1):207–13PubMedCrossRefGoogle Scholar
  15. Baughman RP, Teirstein AS, Judson MA, et al Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001;164:1885–9PubMedCrossRefGoogle Scholar
  16. Baughman RP, Winget DB, Bowen EH, et al Predicting respiratory failure in sarcoidosis patients. Sarcoidosis 1997;14:154–8Google Scholar
  17. Biousse V, Trichet C, Bloch-Michel E, et al Multiple sclerosis associated with uveitis in two large clinic-based series. Neurology 1999;52(1):179–81PubMedCrossRefGoogle Scholar
  18. Bourbonnais JM, Samavati L. Clinical predictors of pulmonary hypertension in sarcoidosis. Eur Respir J. 2008;32(2):296–302PubMedCrossRefGoogle Scholar
  19. Bradley DA, Baughman RP, Raymond L, et al Ocular manifestations of sarcoidosis. Sem Resp Crit Care Med. 2002;23:543–8CrossRefGoogle Scholar
  20. Bradley DA, Lower EE, Baughman RP. Diagnosis and management of spinal cord sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2006; 23(1):58–65PubMedGoogle Scholar
  21. Brennan NJ, Crean P, Long JP, et al High prevalence of familial sarcoi-dosis in an Irish population. Thorax 1984;39:14–8PubMedCrossRefGoogle Scholar
  22. Chapelon-Abric C, de ZD, Duhaut P, et al Cardiac sarcoidosis: a retrospective study of 41 cases. Medicine (Baltimore) 2004;83(6):315–34CrossRefGoogle Scholar
  23. Chen L, Gordon LK. Ocular manifestations of multiple sclerosis. Curr Opin Ophthalmol. 2005;16(5):315–20PubMedCrossRefGoogle Scholar
  24. de Vries J, Michielsen H, van Heck GL, et al Measuring fatigue in sar-coidosis: the fatigue assessment scale (FAS). Br J Health Psychol. 2004a;9(Pt 3):279–91CrossRefGoogle Scholar
  25. de Vries J, Rothkrantz-Kos S, Dieijen-Visser MP, et al The relationship between fatigue and clinical parameters in pulmonary sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2004b;21(2):127–36Google Scholar
  26. DeRemee RA, Rohrbach MS. Serum angiotensin-converting enzyme activity in evaluating the clinical course of sarcoidosis. Ann Intern Med. 1980;92(3):361–5PubMedCrossRefGoogle Scholar
  27. Doty JD, Mazur JE, Judson MA. Treatment of corticosteroid-resistant neurosarcoidosis with a short-course cyclophosphamide regimen. Chest 2003;124(5):2023–6PubMedCrossRefGoogle Scholar
  28. Drent M, Jacobs JA, Cobben NA, et al Computer program supporting the diagnostic accuracy of cellular BALF analysis: a new release. Respir Med. 2001;95(10):781–6PubMedCrossRefGoogle Scholar
  29. Drent M, Jacobs JA, de Vries J, et al Does the cellular bronchoalveolar lavage fluid profile reflect the severity of sarcoidosis? Eur Respir J. 1999;13(6):1338–44PubMedCrossRefGoogle Scholar
  30. Fisher KA, Serlin DM, Wilson KC, et al Sarcoidosis-associated pulmonary hypertension: outcome with long-term epoprostenol treatment. Chest 2006;130(5):1481–8PubMedCrossRefGoogle Scholar
  31. Fouchier SM, Moller GM, Van Santen-Hoeufft M, et al [Successful treatment with infliximab of a patient with refractory sarcoidosis]. Ned Tijdschr Geneeskd. 2004;148(49):2446–50PubMedGoogle Scholar
  32. Garwood S, Judson MA, Silvestri G, et al Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis. Chest 2007;132(4):1298–304PubMedCrossRefGoogle Scholar
  33. Gibson GJ, Prescott RJ, Muers MF, et al British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment. Thorax 1996;51(3):238–47PubMedCrossRefGoogle Scholar
  34. Gorham ED, Garland CF, Garland FC, et al Trends and occupational associations in incidence of hospitalized pulmonary sarcoidosis and other lung diseases in Navy personnel: a 27-year historical prospective study, 1975–2001. Chest 2004;126(5):1431–8PubMedCrossRefGoogle Scholar
  35. Gottlieb JE, Israel HL, Steiner RM, et al Outcome in sarcoidosis. The relationship of relapse to corticosteroid therapy. Chest 1997;111(3): 623–31PubMedCrossRefGoogle Scholar
  36. Gronhagen-Riska C, Selroos O, Niemisto M. Angiotensin converting enzyme. V. Serum levels as monitors of disease activity in corticos-teroid-treated sarcoidosis. Eur J Respir Dis. 1980;61(2):113–22Google Scholar
  37. Grunewald J, Eklund A. Sex-specific manifestations of Löfgren's syndrome. Am J Respir Crit Care Med. 2007;175(1):40–4PubMedCrossRefGoogle Scholar
  38. Handa T, Nagai S, Miki S, et al Incidence of pulmonary hypertension and its clinical relevance in patients with sarcoidosis. Chest 2006;129(5):1246–52PubMedCrossRefGoogle Scholar
  39. Honeybourne D. Ethnic differences in the clinical features of sarcoido-sis in South-East London. Br J Dis Chest. 1980;74:63–9PubMedCrossRefGoogle Scholar
  40. Hosada Y. Consensus conference: epidemiology of sarcoidosis. Sarcoidosis 1994;11:17–21Google Scholar
  41. Hunninghake GW, Costabel U, Ando M, et al ATS/ERS/WASOG statement on sarcoidosis. American Thoracic Society/European Respiratory Society/World Association of Sarcoidosis and other Granulomatous Disorders. Sarcoidosis Vasc Diffuse Lung Dis. 1999;16:149–73PubMedGoogle Scholar
  42. Hunninghake GW, Gilbert S, Pueringer R, et al Outcome of the treatment for sarcoidosis. Am J Respir Crit Care Med. 1994;149(4 Pt 1):893–8PubMedCrossRefGoogle Scholar
  43. James DG. Epidemiology of sarcoidosis. Sarcoidosis 1992;9:79–87PubMedGoogle Scholar
  44. Judson MA, Baughman RP, Thompson BW, et al Two year prognosis of sarcoidosis: the ACCESS experience. Sarcoidosis Vasc Diffuse Lung Dis. 2003;20(3):204–11PubMedGoogle Scholar
  45. Judson MA. Hepatc, splenic, and gastrointestinal involvement with sar-coidosis. Sem Resp Crit Care Med. 2002;23:529–43CrossRefGoogle Scholar
  46. Karfis EA, Roustanis E, Beis J, et al Video-assisted cervical mediasti-noscopy: our seven-year experience. Interact Cardiovasc Thorac Surg. 2008;7:1015–8PubMedCrossRefGoogle Scholar
  47. Keller AZ. Hospital, age, racial, occupational, geographical, clinical and survivorship characteristics in the epidemiology of sarcoidosis. Am J Epidemiol. 1971;94:222–30PubMedGoogle Scholar
  48. Kennedy MP, Jimenez CA, Mhatre AD, et al Clinical implications of granulomatous inflammation detected by endobronchial ultrasound transbronchial needle aspiration in patients with suspected cancer recurrence in the mediastinum. J Cardiothorac Surg. 2008;3(8):8PubMedCrossRefGoogle Scholar
  49. Klatskin G, Yesner R. Hepatic manifestations of sarcoidosis and other granulomatous diseases. Yale J Biol Med. 1950;51:207–48Google Scholar
  50. Koonitz CH, Joyner LR, Nelson RA. Transbronchial lung biopsy via the fiberoptic bronchoscope in sarcoidosis. Ann Intern Med. 1976; 85(1):64–6PubMedCrossRefGoogle Scholar
  51. Lieberman J, Nosal A, Schlessner A, et al Serum angiotensin-convert-ing enzyme for diagnosis and therapeutic evaluation of sarcoidosis. Am Rev Respir Dis. 1979;120(2):329–35PubMedGoogle Scholar
  52. Lieberman J. Elevation of serum angiotensin converting enzyme (ACE) level in sarcoidosis. Am J Med. 1975;59:365–72PubMedCrossRefGoogle Scholar
  53. Loddenkemper R, Kloppenborg A, Schoenfeld N, et al Clinical findings in 715 patients with newly detected pulmonary sarcoidosis — results of a cooperative study in former West Germany and Switzerland. WATL Study Group. Wissenschaftliche Arbeitsgemeinschaft fur die Therapie von Lungenkrankheitan. Sarcoidosis Vasc Diffuse Lung Dis. 1998;15(2):178–82PubMedGoogle Scholar
  54. Lower EE, Broderick JP, Brott TG, et al Diagnosis and management of neurologic sarcoidosis. Arch Intern Med. 1997;157:1864–8PubMedCrossRefGoogle Scholar
  55. Lower EE, Harman S, Baughman RP. Double-blind, randomized trial of dexmethylphenidate hydrochloride for the treatment of sarcoidosis-associated fatigue. Chest 2008;133(5):1189–95PubMedCrossRefGoogle Scholar
  56. Lower EE, Weiss KL. Neurosarcoidosis. Clin Chest Med. 2008; 29(3):475–92PubMedCrossRefGoogle Scholar
  57. Lynch JP, Standiford TJ, Rolfe MW, et al Neutrophilic alveolitis in idio-pathic pulmonary fibrosis. The role of interleukin-8. Am Rev Respir Dis. 1992;145(6):1433–9PubMedCrossRefGoogle Scholar
  58. Mana J, Marcoval J. Erythema nodosum. Clin Dermatol. 2007;25(3): 288–94PubMedCrossRefGoogle Scholar
  59. Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol. 2007;25(3):295–302PubMedCrossRefGoogle Scholar
  60. Mechanic LJ, Dikman S, Cunningham RC. Granulomatous disease in common variable immunodeficiency. Ann Intern Med. 1997;127(8 Pt 1):613–7PubMedCrossRefGoogle Scholar
  61. Mehta D, Lubitz SA, Frankel Z, et al Cardiac involvement in patients with sarcoidosis: diagnostic and prognostic value of outpatient testing. Chest 2008;133(6):1426–35PubMedCrossRefGoogle Scholar
  62. Mezaki T, Chinushi M, Washizuka T, et al Discrepancy between induc-ibility of ventricular tachycardia and activity of cardiac sarcoidosis. Requirement of defibrillator implantation for the inactive stage of cardiac sarcoidosis. Intern Med. 2001;40(8):731–5PubMedCrossRefGoogle Scholar
  63. Milman N, Burton CM, Iversen M, et al Pulmonary hypertension in end-stage pulmonary sarcoidosis: therapeutic effect of sildenafil? J Heart Lung Transplant. 2008;27(3):329–34PubMedCrossRefGoogle Scholar
  64. Neville E, Walker AN, James DG. Prognostic factors predicting the outcome of sarcoidosis: an analysis of 818 patients. Q J Med. 1983; 208:525–33Google Scholar
  65. Niimi H, Kang EY, Kwong JS, et al CT of chronic infiltrative lung disease: prevalence of mediastinal lymphadenopathy. J Comput Assist Tomogr. 1996;20(2):305–8PubMedCrossRefGoogle Scholar
  66. Ohara K, Judson MA, Baughman RP. Clinical aspects of ocular sarcoi-dosis. In: Drent M, Costabel U, editors. Sarcoidosis. Wakefiled, UK: The Charlesworth Group; 2005. p.188–209Google Scholar
  67. Ohira H, Tsujino I, Ishimaru S, et al Myocardial imaging with 18F-fluoro-2-deoxyglucose positron emission tomography and magnetic resonance imaging in sarcoidosis. Eur J Nucl Med Mol Imaging. 2008;35(5):933–41PubMedCrossRefGoogle Scholar
  68. Padilla ML, Schilero GJ, Teirstein AS. Sarcoidosis and transplantation. Sarcoidosis 1997;14:16–22Google Scholar
  69. Park JE, Beal I, Dilworth JP, et al The HRCT appearances of granu-lomatous pulmonary disease in common variable immune deficiency. Eur J Radiol. 2005;54(3):359–64PubMedCrossRefGoogle Scholar
  70. Pastores SM, Naidich DP, Aranda CP, et al Intrathoracic adenopathy associated with pulmonary tuberculosis in patients with human immunodeficiency virus infection. Chest 1993;103(5):1433–7PubMedCrossRefGoogle Scholar
  71. Pietinalho A, Ohmichi M, Lofroos AB, et al The prognosis of sarcoido-sis in Finland and Hokkaido, Japan. A comparative five-year study of biopsy-proven cases. Sarcoidosis Vasc Diffuse Lung Dis. 2000; 17:158–66PubMedGoogle Scholar
  72. Pietinalho A, Tukiainen P, Haahtela T, et al Oral prednisolone followed by inhaled budesonide in newly diagnosed pulmonary sarcoidosis: a double-blind, placebo-controlled, multicenter study. Chest 1999; 116:424–31PubMedCrossRefGoogle Scholar
  73. Prieto JF, Dios E, Gutierrez JM, et al Pars planitis: epidemiology, treatment, and association with multiple sclerosis. Ocul Immunol Inflamm. 2001;9(2):93–102PubMedCrossRefGoogle Scholar
  74. Pujol RM, Nadal C, Taberner R, et al Cutaneous granulomatous lesions in common variable immunodeficiency: complete resolution after intravenous immunoglobulins. Dermatology 1999;198(2):156–8PubMedCrossRefGoogle Scholar
  75. Rahman I, Sadiq SA. Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol. 2007;52(2):121–44PubMedCrossRefGoogle Scholar
  76. Rizzato G, Fraioli P, Montemurro L. Nephrolithiasis as a presenting feature of chronic sarcoidosis. Thorax 1995;50(5):555–9PubMedCrossRefGoogle Scholar
  77. Rizzato G, Pezzano A, Sala G, et al Right heart impairment in sarcoido-sis: haemodynamic and echocardiographic study. Eur J Respir Dis. 1983;64(2):121–8PubMedGoogle Scholar
  78. Rose AS, Tielker MA, Knox KS. Hepatic, ocular, and cutaneous sarcoi-dosis. Clin Chest Med. 2008;29(3):509–24PubMedCrossRefGoogle Scholar
  79. Rybicki BA, Iannuzzi MC, Frederick MM, et al Familial aggregation of sarcoidosis: a case-control etiologic study of sarcoidosis (ACCESS). Am J Respir Crit Care Med. 2001a;164:2085–91CrossRefGoogle Scholar
  80. Rybicki BA, Iannuzzi MC. Epidemiology of sarcoidosis: recent advances and future prospects. Semin Respir Crit Care Med. 2007;28(1):22–35PubMedCrossRefGoogle Scholar
  81. Rybicki BA, Kirkey KL, Major M, et al Familial risk ratio of sarcoido-sis in African—American sibs and parents. Am J Epidemiol. 2001b;153(2):188–93CrossRefGoogle Scholar
  82. Rybicki BA, Major M, Popovich J Jr, et al Racial differences in sarcoi-dosis incidence: a five year study in a health maintenance organization. Am J Epid. 1997;145:234–41CrossRefGoogle Scholar
  83. Sakowitz AJ, Sakowitz BH. Bilateral hilar lymphadenopathy: an uncommon manifestation of adult tuberculosis. Chest 1977; 71(3):421–3PubMedCrossRefGoogle Scholar
  84. Sato H, Grutters JC, Pantelidis P, et al HLA-DQB1*0201: a marker for good prognosis in British and Dutch patients with sarcoidosis. Am J Respir Cell Mol Biol. 2002;27(4):406–12PubMedCrossRefGoogle Scholar
  85. Scadding JG. Prognosis of intrathoracic sarcoidosis in England. Br Med J. 1961;4:1165–72CrossRefGoogle Scholar
  86. Shorr AF, Helman DL, Davies DB, et al Pulmonary hypertension in advanced sarcoidosis: epidemiology and clinical characteristics. Eur Respir J. 2005;25(5):783–8PubMedCrossRefGoogle Scholar
  87. Skold CM, Larsen FF, Rasmussen E, et al Determination of cardiac involvement in sarcoidosis by magnetic resonance imaging and Doppler echocardiography. J Intern Med. 2002;252(5): 465–71PubMedCrossRefGoogle Scholar
  88. Smith KJ, Skelton H. Common variable immunodeficiency treated with a recombinant human IgG, tumour necrosis factor-alpha receptor fusion protein. Br J Dermatol. 2001;144(3):597–600PubMedCrossRefGoogle Scholar
  89. Sollberger M, Fluri F, Baumann T, et al Successful treatment of steroid-refractory neurosarcoidosis with infliximab. J Neurol. 2004; 251(6):760–1PubMedCrossRefGoogle Scholar
  90. Sulica R, Teirstein AS, Kakarla S, et al Distinctive clinical, radiographic, and functional characteristics of patients with sarcoidosis-related pulmonary hypertension. Chest 2005;128(3):1483–9PubMedCrossRefGoogle Scholar
  91. Sullivan FM, Swan IR, Donnan PT, et al Early treatment with predniso-lone or acyclovir in Bell's palsy. N Engl J Med. 2007;357(16): 1598–607PubMedCrossRefGoogle Scholar
  92. Suzuki T, Kanda T, Kubota S, et al Holter monitoring as a noninvasive indicator of cardiac involvement in sarcoidosis. Chest 1994;106(4): 1021–4PubMedCrossRefGoogle Scholar
  93. Thatayatikom A, Thatayatikom S, White AJ. Infliximab treatment for severe granulomatous disease in common variable immunodeficiency: a case report and review of the literature. Ann Allergy Asthma Immunol. 2005;95(3):293–300PubMedCrossRefGoogle Scholar
  94. Tomita H, Ina Y, Sugiura Y, et al Polymorphism in the angiotensin-converting enzyme (ACE) gene and sarcoidosis. Am J Respir Crit Care Med. 1997;156(1):255–9PubMedCrossRefGoogle Scholar
  95. Tomlinson JR, Sahn SA. Aspergilloma in sarcoid and tuberculosis. Chest 1987;92(3):505–8PubMedCrossRefGoogle Scholar
  96. Vagal AS, Shipley R, Meyer CA. Radiological manifestations of sarcoi-dosis. Clin Dermatol. 2007;25(3):312–25PubMedCrossRefGoogle Scholar
  97. Wagner MT, Marion SD, Judson MA. The effects of fatigue and treatment with methylphenidate on sustained attention in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2005;22(3):235PubMedGoogle Scholar
  98. Warshauer DM, Dumbleton SA, Molina PL, et al Abdominal CT findings in sarcoidosis: radiologic and clinical correlation. Radiology 1994;192(1):93–8PubMedGoogle Scholar
  99. Welker L, Jorres RA, Costabel U, et al Predictive value of BAL cell differentials in the diagnosis of interstitial lung diseases. Eur Respir J. 2004;24(6):1000–6PubMedCrossRefGoogle Scholar
  100. Winget D, O'Brien GM, Lower EE, et al Bell's palsy as an unrecognized presentation for sarcoidosis. Sarcoidosis 1994;11:S368–70Google Scholar
  101. Winterbauer RH, Belic N, Moores KD. A clinical intepretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78:65–71PubMedCrossRefGoogle Scholar
  102. Wong M, Yasufuku K, Nakajima T, et al Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J. 2007; 29(6):1182–6PubMedCrossRefGoogle Scholar
  103. Zajicek JP, Scolding NJ, Foster O, et al Central nervous system sarcoi-dosis — diagnosis and management. QJM. 1999;92(2):103–17PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  • Robert P. Baughman
    • 1
  • Elyse E. Lower
    • 1
  1. 1.University of Cincinnati, Internal Medicine, 1001 HomlesCincinnatiUSA

Personalised recommendations