The cause(s) of sarcoidosis is unknown. Mycobacterium spp. are suspected in Europe and Propionibacterium spp. are suspected in Japan. The present international collaboration evaluated the possible etiological links between sarcoidosis and the suspected bacterial species. Formalin-fixed and paraffin-embedded sections of biopsy samples of lymph nodes, one from each of 108 patients with sarcoidosis and 65 patients with tuberculosis, together with 86 control samples, were collected from two institutes in Japan and three institutes in Italy, Germany, and England. Genomes of Propionibacterium acnes, Propionibacterium granulosum, Mycobacterium tuberculosis, Mycobacterium avium subsp. paratuberculosis, and Escherichia coli (as the control) were counted by quantitative real-time PCR. Either P. acnes or P. granulosum was found in all but two of the sarcoid samples. M. avium subsp. paratuberculosis was found in no sarcoid sample. M. tuberculosis was found in 0 to 9% of the sarcoid samples but in 65 to 100% of the tuberculosis samples. In sarcoid lymph nodes, the total numbers of genomes of P. acnes or P. granulosum were far more than those of M. tuberculosis. P. acnes or P. granulosum was found in 0 to 60% of the tuberculosis and control samples, but the total numbers of genomes of P. acnes or P. granulosum in such samples were less than those in sarcoid samples. Propionibacterium spp. are more likely than Mycobacteria spp. to be involved in the etiology of sarcoidosis, not only in Japanese but also in European patients with sarcoidosis.

historical evidence2 that showed exacerbations of hypercalcaemia or hypercalciuria during the summer when the skin is exposed to more ultraviolet light. More recently it was recognised that serum levels of 1,25-dihydroxyvitamin D3 were raised in some patients with sarcoidosis with hypercalciuria and/or hypercalcaemia.34 An extrarenal overproduction of vitamin D was first reported in a hypercalcaemic, anephric male patient with sarcoidosis in 1981.5 The source of this overproduction was found to be in the pulmonary macrophages of patients with acute sarcoidosis.6 It is suggested that excess vitamin D may result in increased intestinal calcium absorption and consequent hypercalcaemia, hypercalciuria, and renal calculi.In studies in which hypercalcaemia is defined as a blood calcium level above 11 mg/dl (0 11 kg/m3) in more than 50 patients the proportion with hypercalcaemia ranged from 3-8% to 35-4%.7 In 243 patients studied in Philadelphia whose records were surveyed retrospectively, however, it was only 2-9%,' and of 137 patients studied prospectively only two had levels above 11 mg/dl which persisted, although nine others had isolated measurements at this level.7Hypercalciuria is found more frequently; when defined as an excretion of more than 200 mg daily on an intake of 400 mg it occurred in 36 (62%) of 58 patients with sarcoidosis and in 7-5% of normal subjects.8 Taking an upper limit of urinary calcium excretion rate of 300 mg/24 hours, it was found in 77 (40%) of 192 patients in London.9 Using urinary excretion rates of >300 mg/day in men or >250 mg/day in women, about 2-5% ofhealthy adults exhibit hypercalciuria.10

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E Ef ff fi ic ca ac cy y o of f a a t th hr re ee e d da ay y c co ou ur rs se e o of f a az zi it th hr ro om my yc ci in n i in n m mo od de er ra at te el ly y s se ev ve er re e c co om mm mu un ni it ty y--a ac cq qu ui ir re ed d p pn ne eu um mo on ni ia a The aetiology of pneumonia was identified in 18 patients by serology (nine Mycoplasma pneumoniae, four Chlamydia pneumoniae, five Legionella pneumophila; one patient with chlamydial infection also had Klebsiella pneumoniae bacteraemia). A presumptive aetiological diagnosis was obtained with sputum culture in three other patients (one Haemophilus influenzae, two Haemophilus parainfluenzae), all strains were sole isolates with 10 8 Colony forming units (CFU), and with Gram stain in one patient with Streptococcus pneumoniae. All patients in the azithromycin group (one after a second 3 day course), and all but two (of those available for evaluation) of the clarithromycin group were cured. Defervescence occurred after 2.6±1.6 days, and chest roentgenogram cleared after 8.9±3.3 days, with no difference between the two groups. Tolerance was good, and there were no withdrawals from therapy.Azithromycin, as well as clarithromycin, may be a good first choice approach for the treatment of low to moderately severe community-acquired pneumonia, but a 3 day course of azithromycin may increase patient compliance.

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