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Journal of Occupational & Environmental Medicine:
doi: 10.1097/JOM.0b013e31823cbf1e
Letters to the Editor

Sarcoidosis and World Trade Center Disaster

Reich, Jerome Mark MD

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Earle A Chiles Research Institute, Portland, Ore

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To the Editor:

Several findings weaken the authors’ conclusion that a causal relationship exists between World Trade Center Disaster (WTC) exposure and the development of sarcoidosis.1

1. Dose-response: Assuming causation, one would expect inhalation of airborne, pulverized material from the disaster explosions, the highest systemic dose, to generate the greatest likelihood of developing sarcoidosis. The authors reported a sarcoidosis odds ratio of 1 between those exposed and unexposed to the dust cloud (Table 4).

2. Exposure-disease interval: The interval between immunogenic exposure and inception of granulomatous diseases, for example, tuberculosis and histoplasmosis, is measured in weeks to a few months. A similar interval is occasionally identified in persons in whom inception is definable (acute onset sarcoidosis), who, fortuitously, have had a recent, normal, presymptomatic chest radiograph. Evolution of a positive Kveim response requires 6 to 8 weeks. Ascribing the evolution of sarcoidosis up to 5-year postexposure (Table 2) implies a latency of immunological response inconsistent with the natural history of infectious granulomatous disorders and our circumscribed knowledge of the time course of sarcoidosis. In addition, were WTC exposure a cause of sarcoidosis, one would expect a secular incidence decline over time-since-exposure. Constant incidence for years following the exposure (Table 2) renders a causal connection less plausible. Might it not represent the background incidence of radiographically detectable sarcoidosis (the majority of screen-identified cases are clinically inevident) in the surveilled, working-age cohort?

Jerome Mark Reich, MD

Earle A Chiles Research Institute

Portland, Ore

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1. Jordan HT, Stellman SD, Prezant D, Teirstein A, Osahan SS, Cone JE. Sarcoidosis diagnosed after September 11, 2001 among adults exposed to the World Trade Center disaster. J Occup Environ Med. 2011;53:963–974.

©2012The American College of Occupational and Environmental Medicine


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