Small Doses Of Steroids Research Articles

Abstract #174 Avascular Necrosis of Femoral Head with Very Small Doses of Steroids

Abstract #174 Avascular Necrosis of Femoral Head with Very Small Doses of Steroids

P.037 Disseminated leptomeningeal hemangioblastoma in a case of Von Hippel Lindau

Background: Leptomeningeal dissemination of hemangioblastomas (HB), whether sporadic or associated with Von Hippel Lindau (VHL), are extremely rare. Very scanty literature is available. Methods: A 36 year old female with VHL and stable pancreatic, adrenal and renal lesions was operated upon 4 years ago for a large symptomatic cervicomedullary cystic and solid tumor. 2 years after surgery the tumour recurred and further removal was unsuccessful due to medullary adhesions. Radiation was given to the posterior fossa area and to several small nodules over the cauda equina resulting in severe pain. Serial follow up imaging revealed diffuse leptomeningeal dissemination increasing in size of the suprasellar region, ambient cistern and Sylvian fissures. Clinically, she has been stable with small dose of steroids and VP shunt insertion for papilledema. Results: Review of the literature consists of 2 series of 7 and 21 patients each with leptomeningeal dissemination involving sporadic HB and VHL associated HB. Leptomeningeal dissemination is estimated at about 4.3%. It is postulated that the tumour starts in the Pia and spreads in an extra medullary fashion throughout the subarachnoid spaces. Conclusions: Long term recurrence has been noted raising the question of aggressive treatment with some drug therapy related to angiogenesis is postulated.

Manic episode induced by steroid (fluorometholone) eye drops in an elderly patient

A 76-year-old man was diagnosed with cataract in both eyes, and surgical intervention was planned. After diagnosis, he showed anxiety and agitation, and frequently became irritable and verbally abusive. One month later, the operation was performed successfully, and administration of fluorometholone eye drops was started. Although the patient was pleased with the improvement of his eyesight, his aggressive behavior escalated, and he used violent and abusive language towards his family and strangers. Two months after the operation, he visited our hospital. He showed hyperthymia and hyperactivity. He was lucid and coherent, and was able to remember his behavior; however, he showed no sign of regret. The Young Mania Rating Scale1 (YMRS) score was 32. A medical work-up, including complete blood cell count, liver, renal and thyroid function tests, vitamin levels, and an examination for infectious diseases, showed no abnormalities. Brain computed tomography (CT) showed mild cortical atrophy appropriate for his age. The Mini-Mental State Examination score was 26; his memory and orientation were within the normal range. To determine its relevance, the fluorometholone eye drop was discontinued, and sodium valproate (200 mg/day) was administered. Seven days later, the patient's behavior improved rapidly. The YMRS score decreased to 7. The serum concentration of valproate was 11.1 μg/mL. Presently (12 months after the first visit to our hospital), he is stable and shows no psychiatric symptoms. Psychiatric symptoms frequently occur as central nervous system-related adverse effects of pharmacotherapy; topical agents, such as eye drops, have also shown adverse psychiatric effects.2 To date, however, adverse psychiatric effects of steroid eye drops have never been reported. In our patient, the serum concentration of valproate was markedly lower than the general level corresponding to acute mania (>94 μg/mL3); therefore, discontinuation of the fluorometholone eye drops was possibly associated with recovery from the manic episode. In a report on a patient with hallucinatory–paranoid state induced by subconjunctival injection of steroids, psychological stress and organic changes of the brain were suggested to induce psychosis upon exposure to a small amount of steroid.4 Similarly, our patient showed extreme anxiety and agitation initially, and his brain CT showed atrophy due to aging. These factors possibly contributed to a predisposition to develop psychiatric symptoms when treated with a small amount of steroid. Thus, when elderly patients with anxiety are treated with even a small dose of steroids, psychiatric symptoms should be carefully monitored.

Natalizumab Associated PML in a Multiple Sclerosis Patient: Excellent Response to Minimal Intervention

We present a case of a woman with natalizumab associated progressive multifocal leukoencephalopathy (PML) who developed an immune reconstitution inflammatory syndrome (IRIS) 9 weeks after natalizumab withdrawal. She responded well to a small dose of steroids intravenously, without plasma exchange, and has returned to her baseline status within one year of her initial symptoms and MRI abnormality.

FK506 in the treatment of children with nephrotic syndrome of different pathological types

To evaluate the efficacy of FK506 in the treatment of children with nephrotic syndrome of different underlying pathology. 12 patients were treated with FK506 with a dosage of 0.1 - 0.15 mg/kg/d while corticosteroid dose was tapered stepwise. This therapeutic course lasted 3 - 6 months during which the plasma concentration ofFK506 was monitored. 12 children with different pathological types nephrotic syndrome were treated with FK506, including 4 cases of MCN, 6 cases of MsPGN, and 1 case of MPGN and 1 case of FSGS. After 2-month duration, 8 patients got complete remission including 4 cases of MCN and 4 cases of MsPGN and 3 children including 1 case of MsPGN, 1 case of MPGN, and 1 case of FSGS got partial remission. Only 1 child with MsPGN was considered to be a treatment failure. The overall response rate was 91.67% with the plasma concentration of FK506 maintained at 5 approximately 12 ng/ml, and the response time was 10 - 38 days. After 1-month duration, all patients except one experienced a reduction in proteinuria to normal levels or a partial response (50% reduction in protein excretion), significant increase in serum albumin, decrease in serum cholesterol and triglyceride and disappearance of edema. 2 months later, in 11 patients, blood biochemical values had returned to normal levels. The drug was generally well-tolerated. 3 patients had anorexia, nausea, vomiting. 2 patients experienced transient elevated serum creatinine which was reversible after the adjustment of dosage. 3 patients had minor changes in urine NAG. Only 2 of all patients relapsed. FK506 is one of the effective immunosuppressants. In this study, FK506 in combination with a small doses of steroid while decreasing FK506 dosage plays a role in consolidating the curative effect and preventing relapse. In conclusion, FK506 may be effective in the treatment of nephrotic syndrome.

Prognostic Factors in Sudden Sensorineural Hearing Loss: Our Experience and a Review of the Literature

We investigated prognostic factors in sudden sensorineural hearing loss (SSNHL). Our study group consisted of 133 patients with SSNHL who were treated at our department between 1980 and 2000. Eighty-one of them (group B) were treated between 1980 and 1996; they received vasodilators and small doses of steroids. The others (52 patients; group A) were treated between 1997 and 2000; they received vasodilators, steroids at high doses, and hyperbaric oxygen. A multivariate stepwise linear regression was used to identify the prognostic factors that were related to hearing improvement as measured by objective change of gain in the overall average (0.5, 1, 2, 4, 6, 8 kHz), the pure tone average (0.5, 1, 2 kHz), the high tone average (4, 6, 8 kHz), and the pure middle tone average (0.5, 1, 2, 4 kHz). The following factors were included in the analysis: group (method of treatment), age, gender, seasonal occurrence of disease, presence of tinnitus and vestibular symptoms, time delay before first visit, type of initial audiogram, and type of caloric reaction. In group A, an additional analysis was conducted to include the results of certain laboratory tests: blood morphology parameters, erythrocyte sedimentation rate, glucose level, coagulogram, lipidogram, thyroid-stimulating hormone, autoantibodies (antimitochondrial antibodies, smooth muscle antibodies, and anti-brush border antibodies), and immunoglobulins G, A, and M. Values for p of less than .05 were considered significant. Our analysis suggests the presence of the following prognostic factors for SSNHL: method of SSNHL treatment (better results in group A); time delay before the start of treatment (better results when treatment started within 10 days of the first symptoms of SSNHL); and type of caloric reactions (worse results in patients with canal paresis). In group A, the factors for poor prognosis for absolute hearing improvement were as follows: delayed treatment, labyrinth responsiveness disorders, and decreased level of thyroid-stimulating hormone. In group A, better hearing improvement was observed in those patients in whom SSNHL was diagnosed in the spring. A short time delay before starting treatment (within 10 days), treatment with high doses of steroids and hyperbaric oxygen, preserving complete caloric function of the labyrinths, normal function of the thyroid, and seasonal occurrence of the disease in the spring were positive prognostic factors for hearing recovery in SSNHL.

New Approaches in the Management of Septic Shock

In fact sepsis remains a major cause of death in hospitalized patients. More than 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increase in the frequency of sepsis is anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro and anti-inflammatory mediators, activation of inflammatory cells, disruption of coagulation, endothelial activation with injury, vasodilatation, and vascular hyporesponsiveness to vasoactive mediators that cause cardiac dysfunction, and cellular dysoxia. Despite the massive research effort over the past two decades to identify innovative therapies, current management of severe sepsis includes eradication of infection through source control and microbial therapy, aggressive and targeted shock resuscitation with fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, and compulsive supportive care to manage organ dysfunction and to avoid complications. Novel therapeutic strategies include use of activated protein C (an endogenous protein that inhibits thrombosis and inflammation while promoting fibrinolysis), small doses of steroids (methylprednisolone) for long period, limiting the tidal volume in Acute Lung Injury / Acute Respiratory Distress Syndrome, an early goal-directed therapy, and a tight control of glycemia with insulin treatment even in non-diabetic patients. It has been demonstrated, in clinical trials, that these strategies can improve survival of septic patients.

Steroid Therapy For Idiopathic Retroperitoneal Fibrosis: Dose And Duration

Idiopathic retroperitoneal fibrosis is an uncommon disease of unknown etiology that may involve the ureters and other retroperitoneal structures. Surgical ureterolysis as well as medical treatment with steroids have been used to treat these patients. However, there is no agreement as to the dose and duration of steroid. We adopted a regimen of long-term steroid use in this prospective study. We treated 12 patients with idiopathic retroperitoneal fibrosis with a regimen of steroids during a 10-year period. Tissue diagnosis was established by biopsy of all lesions and ureteral obstruction was managed with insertion of a nephrostomy tube or a ureteral stent. The initial dose of prednisolone was 60 mg. on alternate days for 2 months and was tapered during the following 2 months to a daily dose of 5 mg. The total duration of prednisolone use was 2 years. Of the 12 patients 11 who completed this treatment regimen have been followed for a duration of 26 to 132 months (median 63.1) after discontinuation of treatment. Good response in the form of relief of symptoms and regression of the mass occurred in 9 cases and there were 2 failures. In 1 case the retroperitoneal mass did not regress and surgical ureterolysis was required. In the 2nd case symptoms recurred after discontinuation of steroid and a further small dose of steroids was required. Function deteriorated in 1 of 19 functioning renal units. No steroid related serious side effects developed. This regimen of steroid may be used as the primary mode of treatment for the majority of patients with idiopathic retroperitoneal fibrosis with minimal complications. Patients with idiopathic retroperitoneal fibrosis should be followed periodically for the rest of their lives.

Patterns of remission in pemphigus vulgaris

Background: The incidence of remissions in pemphigus is unclear because these are usually reported at a single point in the evolution of the disease. Thus it is uncertain whether treatment simply suppresses the manifestations of the disease and consequently must be continuously administered, or induces complete and long-lasting remissions that permit therapy to be discontinued. Objective: To answer this question, we investigated the incidence of remission in a long-term longitudinal study. Methods: The induction of complete and long-lasting remissions (lesion free with no systemic therapy for at least 6 months) was studied in 40 patients with pemphigus vulgaris treated conventionally and followed up for an average of 7.7 years by the same investigator. Results: Five (5%) of the patients died of the disease. Complete and long-lasting remissions were induced in 25%, 50%, and 75% of patients 2, 5, and 10 years, respectively, after diagnosis. Most of the remaining patients were in partial remission or had mild disease controlled with a small dose of steroids. The course of the disease followed different patterns, with some patients rapidly entering complete and long-lasting remissions, whereas others never entered into a complete remission. The induction of complete remission was related to the initial severity and extent of disease and to early response to treatment. Conclusion: It is possible to eventually induce complete and durable remissions in most patients with pemphigus that permit systemic therapy to be safely discontinued without a flare in disease activity. The proportion of patients in whom this can be achieved increases steadily with time, and therapy can be discontinued in approximately 75% of patients after 10 years. (J Am Acad Dermatol 2000;42:422-7.)

Laparoscopic splenectomy for immune thrombocytopenic purpura--long-term result of 40 laparoscopic splenectomies.

Laparoscopic surgery has recently extended its indications and it has also become an acceptable surgical approach for splenectomy. In the last five years, we have performed 40 laparoscopic splenectomies for immune thrombocytopenic purpura. Thirty-five patients were female and 5 patients were male. The mean age was 34, varying from 17 to 56. After learning to perform laparoscopic splenectomy with five ports, we are now usually using three or four ports in a right lateral kidney position. There was no case of conversion to exploratory laparotomy. The mean hospital stay was 7 days. There was no perioperative mortality; but in 2 cases we had postoperative subphrenic abscesses which were successfully managed by catheter drainage. Since undergoing laparoscopic splenectomy, 28 patients (70%) were weaned effectively from their steroid medications. Eight patients (20%) have been on small doses of steroid, and 4 patients (10%) have been on the same doses of steroid with no response. The patient group with rapidly increasing platelet count after splenectomy showed a statistically significant relation with the complete response group (p < 0.001). Laparoscopic splenectomy is a safe and reasonable operative procedure for patients with immune thrombocytopenic purpura.

A CASE OF GASTRIC CANCER ASSOCIATED WITH IDIOPATHIC THROMBOCYTOPENIC PURPURA

The patient was 67-year-old female. A diagnosis of ITP had been made 13 years ago previously, and her platelet count had been maintained well with small doses of steroids. We performed distal gastrectomy to treat early gastric cancer, but preserved the spleen. After the operation, the platelet count gradually increased and steroid therapy was no longer required. The results suggested that it is particularly important to select the most appropriate treatment according the stage of the cancer and ITP, instead of routinely performing splenectomy in the gastric cancer combined with ITP.

The interrelationships between nonapeptide and steroid hormones secretion by bovine granulosa cells in vitro

The effects of adding oxytocin (OT) and arginine-vasopressin (AVP) on progesterone and estradiol-17β secretion by bovine granulosa cells in culture were studied. The influence of these steroids on OT and AVP release was also evaluated. OT (1, 10, 100 or 1000 mIU/Ml) stimulates both progesterone and estradiol output. Small doses (10 pM/ml) of exogenous progesterone or estradiol stimulated a surge in OT, while the intermediate doses (100 or 1000 pM/ml) had no influence, and large doses (10,000 pM/ml) inhibited OT secretion by granulosa cells. Thus, a potential regulatory loop between OT and steroid hormone release by granulosa cells was demonstrated. Stimulation of a surge in steroids by OT, activation of OT release by small doses of steroids and inhibition of OT secretion by excess steroids may suggest the existence of a feedback mechanism regulating these hormones production. Addition of AVP (1, 10, 100 or 1000 pM/ml) inhibited progesterone and stimulated a surge in estradiol, while steroid hormones did not induce AVP release. These data suggest the regulation of ovarian steroidogenesis by AVP, feedback influences are less likely.

Clinical Analysis of Isolated Angiitis of the Central Nervous System

Isolated angiitis of the central nervous system may occur more frequently, and with a more favorable outcome, than has previously been described. During the past 10 years, we diagnosed this condition in 11 patients ranging in age from 23 to 38 years whose initial presenting symptoms included severe headache, transient focal neurologic deficits, or seizures. The diagnosis was established in all cases by characteristic angiographic findings. All patients were initially treated with high-dose steroids; one patient later required the addition of an immunosuppressive agent. All patients responded initially to the steroids, and 10 were in clinical remission while receiving either a small dose of steroids or no medication after a mean follow-up of 33 months. One patient died 9 months after diagnosis, presumably of an intracerebral hemorrhage. This experience suggests that the diagnosis of isolated angiitis of the central nervous system should be considered in any young person complaining of persistent headache, transient focal neurologic deficits, or seizures. Angiography usually yields characteristic diagnostic findings. Treatment should consist of high-dose steroids, with the addition of immunosuppressive agents only in cases where steroids are ineffective.

Clinical and serological spectrum of systemic lupus erythematosus in greek children

In the present study 19 Greek Caucasian children with systemic lupus erythematosus (SLE), onset before the age of 16, were followed up for 1-12 years (mean 5.6 yrs.). Diagnosis was determined early in 14 patients and delayed by 2 to 6 years in 5. The clinical manifestations and laboratory findings did not differ significantly from those reported in adults with lupus. The major organ system involvement at onset and early course were skin and joints (80%) followed by kidneys (42%). During the course of the disease 26% of the children developed central nervous system (CNS) involvement. All the patients were treated with steroids and/or cytotoxic drugs in severe uncontrolled progressive disease. At the mean 5.6 years follow-up most patients were in remission on small doses of steroids; one patient still presents signs of active lupus nephritis and one patient died from sepsis. All the patients with CNS involvement recovered without permanent CNS residue.

Immunosuppressant therapy of inflammatory bowel disease. Pharmacologic and clinical aspects.

The history of immunosuppressant drug use, both azathioprine (Aza) and 6-mercaptopurine (6-MP), in inflammatory bowel disease (IBD) over the past 20 years is briefly reviewed. The two drugs appear identical in their pharmacologic and biologic effects. Azathioprine is converted to 6-MP while in the body. Conflicting reports on the effectiveness of Aza have been published. The major National Cooperative Crohn's Disease Study (NCCDS) has found no advantage in Aza over placebo. In contrast, 6-MP was found to be effective in a large randomized trial. The shortcomings of the NCCDS reports are discussed with possible explanations for their negative findings. Our own studies, dating from 1968, are reviewed with 38 patients having been treated for up to 18 years, always in combination with small doses of steroids. Our results with Aza are similar to those of Present and Korelitz with 6-MP; about 70% of previously intractable patients improved substantially. Both Aza and 6-MP bring about healing and closure of most fistulas. Side effects can be serious but are usually manageable and, to some extent, preventable by appropriate dosage schedules. Since Aza has been approved for another benign, presumably autoimmune disease--rheumatoid arthritis--and because of its extensive use in other autoimmune diseases, we prefer to use Aza in selected patients with Crohn's disease who have failed to respond to more conventional modes of therapy. The use of immunosuppressants in ulcerative colitis is less clearly indicated.

CIRCULATING IMMUNE COMPLEXES AND PROPHYLACTIC EFFECTS OF STEROIDS IN ANAPHYLACTOID PURPURA NEPHRITIS OF CHILDREN

Circulating immune complexes(IC) were measured in anaphylactoid purpura(AP) with or without renal involvement of children. IC were measured by 4% polyethlene glycol precipitated method. IC levels of IgG, IgA and IgE in AP were higher than in control and moreover these IC levels in cases with renal involvement were higher than in cases without renal involvement except IC of IgM. The frequency of complicated purpura nephritis in 98 cases of AP (1976-1979) treated with prednisolone(1-2mg/kg/day) was compared with that in 104 cases of AP(1963-1971) treated with small doses of steroid or without steroids. According to the data, the frequency in both groups showed the significant difference; 18.4% in the former group and 35.6% in the latter group. It may suggest that sufficient steroid therapy during the initial stage in AP shows prophylactic effect on complicated nephritis.

Monocyte cellular function in asthmatic patients on alternate-day steroid therapy

Monocyte cellular function in 15 asthmatics on alternate-day steroid therapy (mean dose of prednisone, 45.4 ± 17.45 mg qod) was studied at 8 a.m. and noon after receiving an 8 a.m. steroid dose and at 8 a.m. the following day, and was contrasted to function in 16 healthy controls. Monocyte chemotaxis, bacterial killing and phagocytosis, and oil phagocytosis were not significantly altered by the steroid dose. On the other hand, all the patients experienced monocytopenia, lymphopenia, and neutrophilia 4 hr following the administration of steroid. The lack of functional impairment on this clinically relevant steroid regimen is consistent with the lack of serious infections seen in patients on such regimens. This study re-enforces the need to differentiate the effect of even small doses of steroid on circulating cell populations from direct effects on cell function which occur only with very high or frequent steroid dose regimens.

Angio-immunoblastic lymphadenopathy: Diagnosis and clinical course

The clinical and pathologic findings in 24 patients with “angioimmunoblastic lymphadenopathy with dysprotehiemia” (AILD) are presented. The patients' ages ranged from 44 to 80 years, with a median age of 68 years. The disease has an acute onset. In many respects, the clinical presentation is suggestive of malignant lymphoma. Generalized lymphadenopathy was always present. Hepatomegaly was found in 20 patients, splenomegaly in 17, constitutional symptoms in 20 and skin rashes in nine. Twenty patients had anemia, with positive Coombs' tests in eight of 14 tested. Polyclonal hypergammaglobulinemia was found in 17 of 22 patients. Two patterns of evolution were recognizable: (1) long survival (24 to 67 months) without treatment or after the administration of intensive combination chemotherapy; and (2) rapid progression (one to 19 months) regardless of the treatment given. Sixteen patients died; postmortem examination in 10 cases showed the cause of death to be attributable to severe infection in eight patients, to renal disease in one and to cardiovascular disease in one. No evidence of malignant lymphoma was seen in any of these autopsies. Histologically, the disease is systemic, with specific lesions in the lymph nodes. The spleen, liver, bone marrow, skin and lung are also involved, but the changes are less characteristic than in the lymph nodes. In the patients in whom sequential biopsies were performed, a trend toward restoration of the nodal architecture was observed. AILD is a clinical-pathologic entity in a spectrum of yet to be defined immune reactions. The clinical, laboratory and pathologic manifestations of AILD are consistent with an autoimmune disorder, in which a deficiency of the T-cell regulatory functions probably predisposes to an abnormal proliferative and autoaggressive reaction of the B-cell system. Surgical staging procedures do not appear to be indicated. Intensive cytotoxic treatment may be hazardous in some patients, precipitating their death, but long survival after such therapy has been observed in others. Supportive therapy and small doses of steroids appear to be a safer therapeutic approach.

Polymyalgia rheumatica and giant cell arteritis

Summary The cardinal features for the diagnosis of polymyalgia rheumatica are as follows: o 1. Age . Patients are at least 55 years of age and usually older than 60. 2. Symptoms . Patients complain of proximal, symmetric muscle aching and stiffness without weakness, often accompanied by constitutional symptoms, such as fatigue or fever. 3. Physical examination . The musculoskeletal system usually is within normal limits despite severe symptoms. 4. Laboratory . There is a striking elevation of the ESR. A mild anemia may be present. 5. Therapeutic response . Treatment with small doses of steroids, such as prednisone, 10 mg daily for 4 days, produces a rapid, dramatic, subjective improvement and eventual fall in the ESR. 6. Exclusions . Other diseases causing myalgia should be excluded, such as infection, rheumatoid arthritis, systemic lupus erythematosus, malignancy or polymyositis. 7. Self-limited disease . Disease activity manifested by symptoms and elevation of the ESR should remit after about 2 years. Many patients with polymalgia rheumatica apparently have underlying giant cell arteritis. Every patients should be investigated carefully for other manifestations of giant cell arteritis as follows: o 1. Symptoms . Temporal or other headache, any ocular symptoms or extremity claudication may result from other vessel involvement. 2. Signs . The temporal arteries should be examined carefully for thickening, tenderness, nodularity and diminished or absent pulsations. The patient should be examined for any arterial bruits. 3. Biopsy . Temporal artery biopsy seldom is necessary diagnostically and usually will not alter therapy, since a negative biopsy cannot exclude the diagnosis. Indications for biopsy are fever of unknown origin or equivocal diagnosis because of psychogenic or other factors. Guidelines for management are: o 1. Initial treatment . Patients with polymyalgia rheumatica can be started on low doses of prednisone, e.g., 10 mg daily, with gradual increase in dose if necessary to control symptoms and the ESR. Patients with manifestations of temporal or ophthalmic arteritis probably are treated more safely by higher initial doses, such as prednisone, 40–60 mg daily, with gradual reduction to lower maintenance doses. 2. Follow-up . Maintenance steroids should be the lowest dose that will render the patient essentially symptom-free and keep the ESR within normal limits. Exacerbations of myalgias or constitutional symptoms, the appearance of symptoms or signs of temporal or ophthalmic arteritis or rises in the ESR call for increased steroid doses. After 6 months, periods of stability should lead to attempts to taper and eventually to discontinue steroids, as the disease has run its course. The ESR must be monitored carefully. The most important point is that polymyalgia rheumatica is a treatable disease that can be missed easily. Recognition and treatment of this illness in an older patient who has been prematurely incapacitated can produce complete amelioration of symptoms and perhaps save him from visual loss or other serious complications of giant cell arteritis. Few other rheumatic or any other diseases can be so gratifying to treat.

Bronchial stenosis due to sarcoidosis

Summary A case of sarcoidosis with persistent stenosis and subsequent collapse of the right upper lobe in a woman of twenty-nine is described. The unusual features of the case are the mildness of symptoms, and the absence of intercurrent infection despite evidence of gross bronchial stenosis which is usually associated with a bad prognosis. The response to small doses of steroids with absence of relapse after three years is noteworthy.