Re: Sunlight

[Guest guest]

Hi Connie,

I see that you are a proponent of Sarcinfo.

The Marshall Protocol is not one that we support here at this site. If people choose to look up other sites--please do so with your searches using "sarcoidosis, neurosarcoidosis or some combination of sarcoidosis and bone involvement" etc.

This is an article that one of the MD's on our site was able to have her specialist put together.

The Significance of Calcium and Vitamin D in Sarcoidosis

Norman T. Soskel, MD, FACP, FCCP

Sarcoidosis Center

Memphis, Tennessee

Calcium metabolism in patients with sarcoidosis has been studied since the first intriguing reports by Harrell, et al in 1939 demonstrated elevated serum levels of calcium (hypercalcemia) in those patients. Even more common is hypercalciuria (elevated calcium in the urine). Exposure to sunlight is believed to contribute to this by way of vitamin D metabolism and is counteracted with therapy by avoiding sunlight as well as corticosteroid ingestion. Newer data suggests immunological functions of vitamin D with respect to granuloma formation. The exact significance of these will be discussed in this communication. A detailed scientific discussion is beyond the scope and intent of this article. The major purpose is to discuss in terms most people can appreciate, the way in which calcium is handled by the body in normal individuals and in people with sarcoidosis, what health concerns result and how and when they are treated.

A certain amount of scientific/medical jargon is required but this will be kept to a minimum.

Calcium and Vitamin D Metabolism

Calcium is taken in orally and is absorbed in the gastrointestinal tract. It is excreted through the kidneys into the urine. Additional calcium can be reclaimed from the bones. This process is regulated by vitamin D and parathyroid hormone, among other factors. Vitamin D enhances absorption in the GI tract but not excretion in the kidneys. The latter is determined by calcium fluxes from the gut and bone. Vitamin D is produced in the skin as a result of exposure to ultraviolet B rays from sunlight in the form of a precursor that is inactive. It spontaneously converts to vitamin D3 which is initially inert. In order to become biologically active it must undergo addition of two chemicals called hydroxyl groups. The first is attached in the liver forming 25 hydroxyvitamin D3. The second is added in the kidney to form 1,25 dihydroxy-vitamin D3 or 1,25(OH)2-D3 which is the active form of the hormone, sometimes referred to as calcitriol. A major finding was that the macrophages (cells) can convert the inactive to the active form of vitamin D in the granulomas of sarcoidosis.

Hypercalcemia and Hypercalciuria in Sarcoidosis

While it is true that hypercalciuria is three times more common than hypercalcemia in sarcoidosis, several important discoveries aid our understanding of the uniqueness of the findings in that disease. The site of overproduction of calcitriol is extrarenal. Alveolar macrophages (cells in the lungs) make calcitriol in sarcoidosis, specifically the macrophages in the granulomas themselves. Another important observation is the fact that hypercalcemia can occur in other granulomatous diseases. Hypercalciuria may occur without hypercalcemia, but the reverse is not true; that is, hypercalcemia is always associated with hypercalciuria. Hypercalcemia, if extreme, can cause severe health problems, however, this rarely occurs even in the worst cases of sarcoidosis. Development of kidney stones can occur, especially with hypercalciuria, and, if left unchecked, could lead to kidney damage and even kidney failure. But, again, this is very uncommon and can be avoided by monitoring very simple parameters such as serum and urine calcium levels and paying attention to flank pain and other symptoms of kidney stones.

Additional Effects of Vitamin D in Sarcoidosis

Recently it has been demonstrated that calcitriol affects the immune system in a manner that favors granuloma formation. Various immune cells have receptors for vitamin D. When vitamin D binds to these receptors, lymphocytes (a type of white blood cell) proliferate, immunoglobulin (antibody) production increases and monocytes/macrophages differentiate into the types of cells that form granulomas. One reference demonstrates that calcitriol stimulates macrophages in the granulomas to make angiotensin converting enzyme (ACE) which has been used as a marker for sarcoidosis for many years. In turn, ACE may stimulate macrophages to perform many of their protective functions. Overall this suggests that calcitriol may favor mechanisms that protect against invasion by foreign bodies. However, the data could also be interpreted as being detrimental or even just neutral to the whole process. Clear-cut ramifications of these findings awaits further study as it is too premature to formulate conclusions at this time. Clinical trials involving patients (not only cells in culture) need to be performed.

Therapy and Other Recommendations

Not everyone with sarcoidosis needs therapy. Furthermore, not everyone with hypercalcemia or hypercalciuria needs therapy. The magnitude of elevations of calcium levels as well as the duration of elevation will determine the need for therapy. Frequently, elevations are transient and require no therapy. Chronic elevations might need to be treated. Prednisone (a corticosteroid) is usually the drug of choice since it can reduce production of calcitriol fairly quickly. Usually the effect on lowering serum calcium is noticeable within 3-5 days. The effect on urinary calcium occurs shortly thereafter, about 7-10 days. This short duration of therapy usually minimizes the side effects, but, if the side effects are unbearable, chloroquine or hydroxychloroquine can be used. Ketoconazole has been used but with variable results, and most physicians do not use it for this purpose. Dietary restriction of calcium is needed but not total elimination of calcium from the diet. The same can be said for sunlight; it is not necessary to totally avoid sunlight, just to minimize excessive exposure.

Summary

Hypercalcemia and hypercalciuria occur in a minority of patients with sarcoidosis. Usually the consequences are minimal, but, if left unchecked, could lead to kidney stones and even kidney failure. Mechanisms suggest a broader role for vitamin D than just hormonal, and may include various immunologic regulatory functions. While these functions are intermediary and not causal, suppression of some of them by corticosteroids or other immunosuppressive medications could play a role in controlling some of the manifestations of sarcoidosis. More accurate and more clinically oriented studies are required before further implications can be made at this time. In addition to medication, simple measures may be of benefit in a subgroup of patients. These include refraining from overindulgence in exposure to sunlight and ingestion of calcium and vitamin D. However, total abstinence from these substances is not usually required or recommended.

References

1. Harrell GT and Fisher S. Blood chemical changes in Boeck’s sarcoid, with particular reference to protein, calcium and phosphatase values. J. Clin Invest 18:687-693, 1939.

2. Scadding G. Sarcoidosis. Eyre and Spottiswoode, London., 1967, pp. 193, 338, 340, 341, 346, 347, 348, 349, 352, 353, 354, 509.

3. Barbour GL, Coburn JW, Slatopolosky E. Hypercalcemia in an anephric patient with sarcoidosis.

Evidence for extrarenal generation of 1,25-dihydroxyvitamin D. N Engl J Med 305:440-443, 1981.

4. JS, Sharma OP, Gacad MA, et al: Metabolism of 25-hydroxyvitamin D3 by cultured pulmonary macrophages in sarcoidosis. J Clin Invest 72:1856-1860, 1983.

5. Selroos OBN: Biochemical markers in sarcoidosis. Crit Rev Clin Lab Sci 24:185-216, 1986.

6. Nishimua M, Hara A, Nojima H, Mashimo M, Hori Y. Possible role of the hormonal form of vitamin D3 in the granuloma-associated angiotensin-converting enzyme activity. Sarcoidosis 1991 8:101-4.

7. Basile JN, Liel Y, Shary J, et al: Increased calcium intake does not suppress circulating 1,25-dihydroxyvitamin D in normocalcemic patients with sarcoidosis. J Clin Invest 91:1396-1398, 1993.

8. Sharma OP. Vitamin D, Calcium, and Sarcoidosis. Chest 109:535-539, 1996.

9. Costabel U, Teschler H. Biochemical Changes in Sarcoidosis. Clinics in Chest Medicine 18:827-842, 1997.

Reprinted by permission. Norman T. Soskel, MD http://www.sarcoidcenter.com The above questions are taken from Dr. Soskel’s site linking the online book entitled "Sarcoidosis" by Dr. Sharma.Ed. Note: A patient should consult with his or her personal physician before changing or considering any medical treatments or health related changes.

The important points are this.

If you have high calcium levels--do not take a supplement and Vit. D. the amounts you get from your diet should suffice.

If you find that sunlight is bothering your eyes--get into the Ophthalmologist-- your eyes should not be light sensitive! This is a sign of Iritis and Uveitis--and left untreated can cause glaucoma-- and loss of vision.

If you find that spending the day in the sun is bothersome-- use sunscreen, and cover those arms-- use long sleeve lightweight clothing so that you don't end up with heat exhaustion.

The heat and dehydration is more detrimental to your energy level, than is the sunlight.

You do not have to stay inside a dark house-- or out the sunshine. But do realize that MOST of our medication comes with a warning to use caution when out in the sun. (Dr. Sharma explained that the medication and sunlight reaction was more the culprit than is the sarc Vit D issue.)

Connie,

I know you are new to our group. Unfortunately, The Marshall Protocol people have come into the group in the past-- and every new member that comes in was getting a n email that stated they needed to sign up for his protocol. That is not allowed in Yahoo Groups Terms of Agreement, and is not tolerated. Any member from that group that comes into our group and tries to promote their site will be banned immediately.

I do hope you stick around-- we are over 370+ people strong-- and many of us have had this disease for many years-- and have done a tremendous amount of "reading." We have had these debates time and again-- and have some success with getting this disease to a manageable state.

Sincerely,

Tracie

NS Co-owner/moderator