Involvement Of Upper Respiratory Tract Research Articles

Leprosy mimicking ANCA-associated vasculitis

Vasculitis represents a large group of diseases, classified between primary and secondary. Diagnosis of primary vasculitis is a challenge in medical practice, since there are wide and heterogeneous clinical manifestations, with diagnostic criteria still scarce. Some clinical manifestations are common: constitutional status, myalgia, arthralgia, arthritis, papules, nodules and ulcers. One of the clinical forms is the limited one in which patients with upper respiratory tract involvement often evolve with systemic disease. Most patients have nasal, sinus or ear involvement that may be present weeks or months before other symptoms. Secondary vasculitis can be related to infections, drugs, toxic substances and neoplasms. The virchowian and dimorphic form of leprosy has similar clinical and serological characteristics with rheumatological diseases. As it is an endemic disease in Brazil, there is a description of a wide variety of clinical presentations, so making a differential diagnosis is essential.

Peripheral T-cell lymphoma mimicking granulomatosis with polyangiitis.

Upper respiratory tract involvement is common in patients with granulomatosis with polyangiitis (GPA), but malignancies should be kept in mind in the differential diagnosis. A68-year-old man was referred to rheumatology to investigate for GPA after nasal excisional biopsy. After careful radiologic and pathologic assessment, he was diagnosed with peripheral T‑cell lymphoma, nasal type. This is arare case of T‑cell lymphoma in apatient who was referred as GPA.

The Common Cold and Influenza in Children: To Treat or Not to Treat?

The common cold, which is mostly caused by respiratory viruses and clinically represented by the symptoms of acute respiratory viral infections (ARVI) with mainly upper respiratory tract involvement, is an important problem in pediatric practice. Due to the high prevalence, socio-economic burden, and lack of effective prevention measures (except for influenza and, partially, RSV infection), ARVI require strong medical attention. The purpose of this descriptive literature review was to analyze the current practical approaches to the treatment of ARVI to facilitate the choice of therapy in routine practice. This descriptive overview includes information on the causative agents of ARVI. Special attention is paid to the role of interferon gamma as a cytokine with antiviral and immunomodulatory effects on the pathogenesis of ARVI. Modern approaches to the treatment of ARVI, including antiviral, pathogenesis-directed and symptomatic therapy are presented. The emphasis is on the use of antibody-based drugs in the immunoprophylaxis and immunotherapy of ARVI. The data presented in this review allow us to conclude that a modern, balanced and evidence-based approach to the choice of ARVI treatment in children should be used in clinical practice. The published results of clinical trials and systematic reviews with meta-analyses of ARVI in children allow us to conclude that it is possible and expedient to use broad-spectrum antiviral drugs in complex therapy. This approach can provide an adequate response of the child's immune system to the virus without limiting the clinical possibilities of using only symptomatic therapy.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective.

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

Clinical features of 19 cases of lower respiratory papillomatosis

Objective: To explore the clinical characteristics and prognosis of lower respiratory papilloma(LRP)and therefore to improve clinical diagnosis and treatment. Methods: We performed a retrospective analysis of patients who were diagnosed with LRP in our department from October 2008 to October 2020. Results: Nineteen patients were enrolled and 12 were male and 7 were female. The average age of the 7 adult patients was (41.3±17.5)years and that of the 12 pediatric patients was (5.5±3.5)years. Ten (83.3%)of the pediatric patients showed disease onset at an age of less than 5 years. The main symptoms were cough and sputum production (13/19), dyspnea (15/19), hoarseness (10/19) and signs of stridor or wheezing (7/19). Chest CT examination was performed in 9 patients, which showed nodules or masses (9/9), cystic thin-walled cavity (4/9), obstructive pneumonia (2/9), atelectasis (2/9), and spicule sign (1/9). The upper respiratory tract was affected in all the pediatric patients (12/12) and 3/7 of the adult patients. Eighteen cases (18/19) were diagnosed by bronchoscopy, 1 (1/9) by thoracoscopy. Eighteen cases (18/19) showed mulberry-like and papillary lesions under bronchoscopy. All the cases were histologically confirmed as squamous cell papilloma, with 17 cases(17/19)showing tissue HPV6/11(+), 2 negative (2/19). The positive rate of HPV6 was 36.8%, ant that of HPV11 was 21.1%, while the double positive rate of HPV6/11 was 31.6%, and HPV16/18 were negative in all the 19 cases. Isolated respiratory papillomatosis was found in 4 cases (4/19), and multiple papillomatosis in 15 cases (15/19). Seventeen cases (17/19) underwent endoscopic interventional therapy, and the result showed that 15 cases relapsed, and 2 cases had no recurrence. One patient was treated with thoracoscopic lobectomy, and died 4 months after surgery. One patient gave up treatment. Conclusions: LRP is a rare clinical disease with a chronic course, and isolated LRP is even rarer. Young patients often suffer from upper respiratory tract involvement, and the main symptoms are cough, sputum production, dyspnea and hoarseness. CT scanning showed nodules and masses, cystic thin-walled cavities or signs of airway obstruction. Bronchoscopy often demonstrates papillary lesions. The diagnosis depends on pathology, with squamous cell papilloma being the most common, and most tests are positive for HPV6/11. It is suggested that the incidence is associated with low-risk HPV infection. Endoscopic resection is the main treatment, which is prone to relapse. The treatment should take into account the pathological changes of upper respiratory tract, and the etiological treatment of HPV should be stressed.

Upper respiratory tract manifestations in patients with ANCA-associated vasculitides and their association with the presence and type of ANCA

Aim of the work – to compare the frequency of upper respiratory tract (URT) involvement in patients with ANCAassociated vasculitides (AAV), to reveal its main clinical and radiological patterns and to estimate their association with the serological profile (ANCA presence and type).Material and methods. This retrospective study evaluated 369 patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The enrolled patients were diagnosed with AAV according to the ACR criteria, CHCC classification (2012) and EMA algorithm. Patients with URT manifestations underwent standard ENT assessment and X-ray/CT. Serum ANCA levels were measured by ELISA.Results. URT involvement was diagnosed in 280 (75.9%) patients with AAV. It was significantly more common amongthe patients with GPA (86.4%) and EGPA (85.5%) compared with the MPA group (29.2%) (p<0.001).URT manifestations mainly appeared as sinusitis (77.2% – GPA; 33.3% – MPA; 70.8% – EGPA) and rhinitis with crusting (87.8%, 72.2% and 16.9% respectively).Proteinase 3 ANCA positive patients had a significantly higher incidence of bone destructive URT lesions, including sinuses wall destruction (p<0.001) and saddle nose deformity (p=0.016), compared with myeloperoxidase-ANCA-positive patients. Similar results were obtained in the GPA group separately.Localized disease with isolated URT involvement was observed in 41.3% cases of ANCA negative GPA (p<0.001).Conclusion. The frequency and patterns of upper respiratory tract manifestations depend both on the nosologic form of AAV and type of ANCA. Localized forms of URT involvement can be observed in patients with GPA and are closely associated with absence of ANCA, which determines the need for especially high suspicion level.

Post-COVID-19 syndrome: morpho-functional abnormalities of the heart and arrhythmias

Aim. To study the myocardial morpho-functional abnormalities, the incidence and nature of cardiac arrhythmias in patients 3 months after the coronavirus disease 2019 (COVID-19).Material and methods. The study included 77 patients (mean age, 35,9 years) treated for coronavirus infection, which underwent echocardiography and 24-hour Holter monitoring 3 months after COVID-19. The patients were divided into 3 groups: group 1 — 31 patients with upper respiratory tract involvement; group 2 — 27 patients with bilateral pneumonia (CT grade 1, 2), 3 — 19 patients with severe pneumonia (CT grade 3, 4). Statistical processing was carried out using Statistica 10.0.Results. According to echocardiography, the peak tricuspid late diastolic velocity and isovolumetric contraction time in all groups increased (P<0,001). The tricuspid and mitral Em/Am ratio decreased depending on the disease severity. In group 3, the right ventricular and atrial size increased (P<0,001). The pulmonary artery systolic pressure, left atrial volume in patients of the 2nd and 3rd groups was higher than in the control one (P<0,001). In group 1 and 2 patients, the regional strain in basal and basal/middle segments decreased, respectively, while, in group 3, not only regional but also global left ventricular (LV) strain decreased (P<0,001). In all groups, cardiac arrhythmias and pericardial effusion were found. The relationship was established between coronavirus activity and the structural and functional myocardial parameters (P<0,001).Conclusion. Cardiovascular injury 3 months after COVID-19 was found in 71%, 93%, and 95% of patients with mild, moderate and severe course. In mild course patients, a decrease in regional myocardial strain in LV basal segments, signs of past pericarditis, and various cardiac arrhythmias were noted. In patients of moderate severity, these changes were more pronounced and were accompanied by an additional decrease in regional strain in LV middle segments, impaired right ventricular diastole and increased pulmonary artery pressure. In severe patients, in addition to the above changes, dilatation of the right heart and inferior vena cava was recorded, as well as LV diastolic and global systolic function decreased.

Frequency and outcome of olfactory impairment and sinonasal involvement in hospitalized patients with COVID-19.

BackgroundOlfactory dysfunction has shown to accompany COVID-19. There are varying data regarding the exact frequency in the various study population. The outcome of the olfactory impairment is also not clearly defined.ObjectiveTo find the frequency of olfactory impairment and its outcome in hospitalized patients with positive swab test for COVID-19.MethodsThis is a prospective descriptive study of 100 hospitalized COVID-19 patients, randomly sampled, from February to March 2020. Demographics, comorbidities, and laboratory findings were analyzed according to the olfactory loss or sinonasal symptoms. The olfactory impairment and sinonasal symptoms were evaluated by 9 Likert scale questions asked from the patients.ResultsNinety-two patients completed the follow-up (means 20.1 (± 7.42) days). Twenty-two (23.91%) patients complained of olfactory loss and in 6 (6.52%) patients olfactory loss was the first symptom of the disease. The olfactory loss was reported to be completely resolved in all but one patient. Thirty-nine (42.39%) patients had notable sinonasal symptoms while rhinorrhea was the first symptom in 3 (3.26%). Fifteen patients (16.3%) had a taste impairment. Patients with sinonasal symptoms had a lower age (p = 0.01). There was no significant relation between olfactory loss and sinonasal symptoms (p = 0.07).ConclusionsSudden olfactory dysfunction and sinonasal symptoms have a considerable prevalence in patients with COVID-19. No significant association was noted between the sinonasal symptoms and the olfactory loss, which may suggest that other mechanisms beyond upper respiratory tract involvement are responsible for the olfactory loss.

COVID-19 in Children: Initial Characterization of the Pediatric Disease.

* Abbreviation: COVID-19 — : coronavirus disease of 2019 The impact of the coronavirus disease of 2019 (COVID-19), which is caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2,1 has been widespread, with >500 000 cases diagnosed in >170 countries since the virus was identified in January 2020.2 The preliminary data have been focused on severe respiratory manifestations, which are seen predominantly in adults, with scant initial data on the burden of COVID-19 in children.3 We, therefore, read with interest the findings of Dong et al,4 who reported in this issue of Pediatrics a series of >2000 children with suspected or confirmed COVID-19. The authors found that 4% of virologically confirmed cases had asymptomatic infection, and this rate almost certainly understates the true rate of asymptomatic infection because many children who are asymptomatic are unlikely to be tested. Among children who were symptomatic, 5% had dyspnea or hypoxemia (a substantially lower percentage than what has been reported for adults3), and 0.6% progressed to acute respiratory distress syndrome or multiorgan system dysfunction (a rate that is also lower than that seen in adults). Preschool-aged children and infants were more likely than older children to have severe clinical manifestations. There are several salient points … Address correspondence to Andrea T. Cruz, MD, MPH, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin St, Suite A2210, Houston, TX 77030. E-mail: acruz{at}bcm.edu

Granulomatosis with polyangiitis: Special focus on suggestive imaging findings in head and neck involvement

Objective: Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease with frequent upper respiratory tract involvement. Early diagnosis is crucial for early initiation of effective treatment, which improves outcome. Imaging plays an important role for confirming clinically suspected cases. The aim of our study is to reveal the frequencies of imaging findings previously defined as suggestive for GPA (i.e. osseous erosions or destructions, neoosteogenesis, subglottic stenosis) and to investigate frequency and characteristics of previously under-recognized nasopharyngeal involvement in GPA.
 Materials and Methods: We retrospectively examined paranasal, nasopharynx/neck, temporal CTs (n=51) and MRIs (n=14) of 48 patients with GPA. The evaluated imaging findings include mucosal ulcerations in nasal cavity, sinonasal and temporal opacifications/inflammatory signal changes, presence and locations of osseous erosions and neoosteogenesis, periantral soft tissue infiltration, septal perforation, presence and characteristics of nasopharyngeal involvement, and subglottic stenosis. Descriptive statistics were presented as mean ± SD; categorical variables were presented as count and percentage.
 Results: Forty patients (87%) had sinonasal and fourteen (29%) patients had tympanic cavity±mastoid opacifications. Three patients (23%) had signal and diffusion characteristics suggesting a sinonasal granulomatous inflammation. Mucosal ulcerations were detected in 32% of patients. Osseous erosions/destruction (40%) was common in disease onset and frequently affected mid-line sinonasal structures. Neoosteogenesis of paranasal sinuses (21%) was more common in follow-up studies and invariably affected maxillary sinuses. Septal perforation (6%), periantral infiltration (4%) and subglottic stenosis (10%) were relatively infrequent findings. Nasopharyngeal involvement (23%) was not infrequent; predominantly presented with wall thickening, ulcerations, low T2-weigted signal changes and restricted diffusion in MRI.
 Conclusion: Sinonasal osseous erosion/destruction is a relatively common and highly suggestive finding especially when co-existent with nasal mucosal ulcerations, neoosteogenesis and nasopharyngeal thickening in a suspected case. Nasopharyngeal involvement is not infrequent and imaging could overlap with other entities such as nasopharyngeal cancer, lymphoma or sarcoma.

A clinical threat in patients with granulomatosis polyangiitis in remission: Subglottic stenosis

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing granulomatous disease that involves small- and medium-sized arteries and affects the main respiratory tracts and kidneys. Upper respiratory tract involvement usually occurs in 90% of patients, who most frequently present with symptoms of chronic sinusitis. Subglottic stenosis (SS) is a rare and severe complication that is usually observed in approximately 15% of patients. Here we present a case of SS in a patient with limited form of GPA during remission.

Epidemiology and clinical characteristics of sarcoidosis: an update from a population-based cohort study from Olmsted County, Minnesota.

Information about the epidemiology, clinical manifestations and comorbidities of sarcoidosis among Caucasians is relatively scarce. This review focuses primarily on the data from a recently published Caucasianpredominant population-based cohort from Olmsted County, Minnesota. Overall, the incidence rate was 10.0 per 100,000 population, which suggested that sarcoidosis is less common in Caucasians than in Blacks, but is more common in Caucasians than in Asians. Intrathoracic involvement was seen in the vast majority of patients, but less than half have respiratory symptoms. The most common extra-thoracic manifestations were skin rash followed by arthralgia, ophthalmologic involvement, hepatic involvement, splenomegaly, renal involvement, neurological involvement, extra-thoracic lymphadenopathy, exocrine gland involvement, upper respiratory tract involvement and cardiac involvement. Compared to sex and age-matched subjects, patients with sarcoidosis suffer from increased rates of cardiovascular disease, venous thromboembolism and hospitalized infection.

Histopathological Classification and Renal Outcome in Patients with Antineutrophil Cytoplasmic Antibodies-associated Renal Vasculitis: A Study of 186 Patients and Metaanalysis.

Renal vasculitis is one of the most common manifestations of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) and renal histology is a key predictor of the outcome. A new histopathologic classification was proposed and validated, but the results are still debated. We performed a retrospective analysis to validate the histopathologic classification and performed a metaanalysis to evaluate its predictive value. There were 186 patients with ANCA-associated renal vasculitis diagnosed at Ruijin Hospital who were enrolled in the retrospective study. The metaanalysis considered the data for 1601 patients. In our retrospective study, patients with focal class had the best renal outcome while patients with mixed class had the worst (p < 0.001). Metaanalysis showed that patients with focal class had better renal outcome than did those with crescentic class [risk ratio (RR) 0.23, 95% CI 0.16-0.34, p < 0.00001], with no evidence of heterogeneity (I2 = 0%, p = 0.96). Patients with crescentic class had better renal outcome than did those with sclerotic class (RR 0.52, 95% CI 0.41-0.64, p < 0.00001), with no evidence of heterogeneity (I2 = 2%, p = 0.43). We did not find statistical significance regarding renal outcome between mixed and crescentic classes (RR 1.14, 95% CI 0.91-1.43, p = 0.27), with no evidence of heterogeneity (I2 = 23%, p = 0.19). The retrospective study showed that lung and upper respiratory tract involvement were the most common extrarenal manifestations. We demonstrated the clinical utility of histopathologic classification in determining renal outcome in patients with AAV. Metaanalysis showed that patients with focal class had the best outcome while sclerotic class had the worst.

Viral respiratory infections in a nursing home: a six-month prospective study.

BackgroundThe knowledge on viral respiratory infections in nursing home (NH) residents and their caregivers is limited. The purpose of the present study was to assess and compare the incidence of acute respiratory infections (ARI) in nursing home (NH) residents and staff, to identify viruses involved in ARI and to correlate viral etiology with clinical manifestations of ARI.MethodsThe prospective surveillance study was accomplished in a medium-sized NH in Slovenia (central Europe). Ninety NH residents and 42 NH staff were included. Nasopharyngeal swabs were collected from all participants at enrollment (December 5th, 2011) and at the end of the study (May 31st, 2012), and from each participant that developed ARI within this timeframe. Molecular detection of 15 respiratory viruses in nasopharyngeal swab samples was performed.ResultsThe weekly incidence rate of ARI in NH residents and NH staff correlated; however, it was higher in staff members than in residents (5.9 versus 3.8/1,000 person-days, P = 0.03), and was 2.5 (95 % CI: 1.36–4.72) times greater in residents without dementia than in residents with dementia. Staff members typically presented with upper respiratory tract involvement, whereas in residents lower respiratory tract infections predominated. Respiratory viruses were detected in 55/100 ARI episodes. In residents, influenza A virus, respiratory syncytial virus, and human metapneumovirus were detected most commonly, whereas in NH staff rhinovirus and influenza A virus prevailed. 38/100 ARI episodes (30/56 in residents, 8/44 in staff) belonged to one of three outbreaks (caused by human metapneumovirus, influenza A virus and respiratory syncytial virus, respectively). NH residents had higher chances for virus positivity within outbreak than HN staff (OR = 7.4, 95 % CI: 1.73–31.48, P < 0.01).ConclusionsARI are common among NH residents and staff, and viruses were detected in a majority of the episodes of ARI. Many ARI episodes among NH residents were outbreak cases and could be considered preventable.Trial registrationThe study was registered on the 1th of December 2011 at ClinicalTrials (NCT01486160).

Granulomatous polyangitis (Wegener granulomatosis): Clinical findings and results of long-term follow-up.

To evaluate long-term outcome of patients with granulomatous polyangitis (GPA) followed up in a tertiary university hospital. We reviewed medical records of 22 patients with GPA diagnosis confirmed by tissue biopsies between 2004 and 2014. The mean time from the onset of symptoms to diagnosis was 7.8 ± 12.3 months [interquartile range (IR)= 4.0]. The most commonly involved organs were the upper respiratory tract (URT) (72.7%), lower respiratory tract (81.8%) and kidneys (72.7%). URT involvement indicated good prognosis (p= 0.046). Survival in the patients with and without URT involvement was 124.6 ± 6.9 months and 59.7 ± 22.9 months, respectively. End-stage renal failure (ESRF) requiring dilaysis and cardiac involvement were associated with mortality (p= 0.022 and p= 0.026, respectively). Of the 12 dialysis-dependent patients at diagnosis, 11 survived > 3 months and seven regained renal function permanently. Dialysis dependency was significantly lower in patients who received plasmapheresis (p= 0.047). Overall mortality rate was 18% (4/22). Mean survival was 55.9 ± 42.8 months (IR= 84.0). Diagnosis of GPA may be delayed by the nonspecific nature of its symptoms. URT involvement was associated with good prognosis, whereas cardiac involvement and ESRF requiring dialysis were associated with poor outcome. Plasmapheresis may increase the rate of renal recovery in the patients with ESRF requiring dialysis.

Evaluation of IL-8 nasal lavage levels and the effects of nasal involvement on disease severity in patients with stable chronic obstructive pulmonary disease.

Interleukin 8 (IL-8) is used to evaluate the severity of inflammation in the airways. The aim of this study was to evaluate patients with chronic obstructive pulmonary disease (COPD) for the presence of upper respiratory tract involvement by questioning patients regarding nasal symptoms and by measuring levels of IL-8 in nasal lavage material. A total of 47 COPD patients and 23 healthy controls were enrolled in this study. Pulmonary function tests were performed for all participants who were asked to complete a Sinonasal Outcome Test-20 (SNOT-20) questionnaire on the same day, as a measure of quality of life. Median IL-8 level in nasal lavage specimens of COPD patients with stable disease was higher than that of healthy controls. An increase in cigarette pack-years was significantly associated with an increase in nasal IL-8 levels. Similarly, IL-8 levels correlated positively with stage of COPD. A significant link between number of visits to the emergency department and stage of disease was observed. Patients with COPD had a significantly higher mean SNOT-20 severity score compared to healthy controls. Proper management of sinonasal disease may help to decrease the number of COPD attacks and consequently improve quality of life.

SAT0165 Clinical and Laboratory Characteristics of Polyarteritis Nodosa (PAN) vs Other Systemic Necrotizing Vasculitis (SNV): Retrospective Study of 192 Patients in the North and Central Regions of Ukraine

BackgroundRecent clinical studies indicated that there is a geographical difference in the incidence of SNV and anti-neutrophil cytoplasmic antibodies (ANCA) pattern between Asian and Caucasian (1). Therefore we cannot exclude...

THU0217 Nailfold videocapillaroscopy in patients with granulomatosis with polyangiitis (wegener’s): An observational study

BackgroundNailfold videocapillaroscopy (NFC), allows for the detection of changes in microcirculation characteristic of connective tissue diseases. Sistemic Sclerosis (SSc) is one of the diseases most recognized as presenting alterations in...

Granulomatosis polyangiitis associated with meningeal involvement: response to rituximab therapy after failure of cyclophosphamide

Wegener's granulomatosis or granulomatosis polyangiitis associated (GPA) is a granulomatous inflammation of the upper and lower respiratory tracts associated with necrotising vasculitis of small and medium-sized blood vessels and, frequently, necrotising glomerulonephritis. We describe the case of a 37 year old female patient presenting with upper respiratory tract involvement, chronic rhinosinusitis with green secretions, and bilateral hypoacusia. Ten months later, she suffered occipital headache and two episodes of lipothymia associated with nausea, photophobia, faintness with visual blurring. Magnetic resonance imaging (MRI) revealed aseptic meningitis. The patient was treated with steroids and cyclophosphamide without any effect on the neurological symptoms which, however, greatly improved after subsequent treatment with rituximab as confirmed by means of cerebral MRI. Rituximab is an optimal means of treating cyclophosphamide-resistant patients with GPA associated with meningeal involvement.

Wegener granulomatosis: type of presentation and initial treatment in a series of 23 cases

Granulomatosis with poliangeitis (Wegener) is a necrotizing granulomatous vasculitis characterized by damage in the respiratory tract, kidney, skin, nervous system ... The onset of the disease is usually indolent, with nonspecific symptoms. The most frequent initial clinical presentation is the upper respiratory tract involvement (90%). The presence of pulmonary infiltrates is 70% and bilateral and cavitary nodules in about 60%.