This text is written by sarcoidosis patient without medical education and may contain erroneous conclusions based on the citations from PubMed.

More about Marshall's protocol SARCINFO and JOIMR

Alexander Belousov

Marshall's protocol alternative explanation


Anti-inflammatory properties of macrolides

Macrolide antibiotics have anti-inflammatory activity, which likely depends on their ability to prevent the production of proinflammatory mediators and cytokines, and suggest that these agents, can exert therapeutic effects independently of their antibacterial activity [1].

Macrolides have been shown to affect a number of the processes involved in inflammation, including the migration of neutrophils, the oxidative burst in phagocytes and the production of various cytokines, although the precise mechanisms are not clear. Roxithromycin suppressed the oedema produced by injecting carrageenin into the paw with effects almost equal to that seen with the non-steroidal anti-inflammatory drug nimesulide [2].

Azithromycin decreased capacities of the cells to phagocytize Escherichia coli (62% from 27 to 91%) and generate reactive oxygen products (75% from 34 to 26%). These demonstrate that the accumulation of macrolides in neutrophils can suppress the response of phagocytic cells to bacterial pathogens after a therapeutic dose [3].

At concentrations that are physiologically achievable, clarithromycin and azithromycin affected in vitro production of IL-1alpha, IL-1beta, IL-6, IL-10, GM-CSF and TNF-alpha to varying degrees. For azithromycin, the most interesting results were for IL-1alpha (decrease in 100% of individuals) and for TNF-alpha (decrease in 100% of individuals). These results show that both clarithromycin and azithromycin alter cytokine production in human monocytes and thus possess immunomodulatory activity [4].

Incubation of alveolar macrophages with different concentrations of azithromycin or clarithromycin modified IL-8 production: it increased at a drug concentration of 4 mg/L and decreased at concentration of 400 mg/L. This findings suggest that azithromycin and clarithromycin may alter IL-8 production, thus enhancing the clinical effectiveness of these antibiotics. [5].

Amelioration of alveolitis and lung fibrosis after treatment with azithromycin was shown. The activity of NF-kappaB was significantly higher in one-week pulmonary fibrosis model than that in normal control and its level in alveolar macrophage reduced (67.2%) after treatment with azithromycin. The level of protein and mRNA of TNFalpha, TGF-beta in lung tissue and alveolar macrophage was increased in the early stage of pulmonary fibrosis and reduced after treatment with azithromycin. It is suggested that azithromycin might be a therapeutic drug for pulmonary fibrosis in the future. Azithromycin reduced the degree of alveolitis and fibrosis through inhibition of the activity of NF-kappaB and the expression of TNFalpha, TGF-beta mRNA and lowering the level of protein in alveolar macrophage and lung tissue in the early stage of pulmonary fibrosis. This might be one of the mechanisms of azithromycin treatment in pulmonary fibrosis [6].

Macrolides inhibit epithelial cell-mediated neutrophil survival by modulating GM-CSF release [7].

The effect of three macrolide antibiotics, midecamycin acetate, josamycin, and clarithromycin, on human T-cell function was investigated in vitro. Midecamycin acetate and josamycin suppressed the proliferative response of peripheral blood mononuclear cells stimulated by polyclonal T-cell mitogens at concentrations between 1.6 and 8 micrograms/ml. At higher concentrations (40 to 200 micrograms/ml), all these drugs showed a marked inhibitory effect. At concentrations of 1.6 to 40 micrograms/ml, these drugs suppressed interleukin-2 (IL-2) production induced by mitogen-stimulated T cells, but not the expression of IL-2 receptor (CD25), in a dose-dependent manner. Therefore, the suppressive action on T-lymphocyte proliferation seems to be based on the ability of these drugs to inhibit IL-2 production by T cells. The drug also inhibited mixed lymphocyte reaction at the same concentrations. Combined treatment with these macrolides and the known immunosuppressants such as FK506 and cyclosporin A resulted in an increased inhibition of T-cell proliferation. The immunomodulatory properties of the antibiotics may have clinical relevance for modulation of the immune response in transplant patients and in patients with inflammatory diseases [8].

Macrolide treatment inhibits neutrophil infiltration and IL-8 secretion in nasal epithelium in vivo and that these clinical effects depend on a mechanism other than the direct action of macrolide on nasal epithelial cells [9].

Incubation of pulmonary alveolar macrophages with lipopolysaccharide from Escherichia coli and recombinant human interferon-gamma caused release of NO, which was accompanied by induction of type II NOS mRNA. The release of NO was reduced by coincubation of cells with the macrolides erythromycin, clarithromycin and josamycin in a concentration-dependent manner. These macrolides likewise inhibited the induction of type II NOS mRNA, whereas no inhibitory effects were observed with amoxycillin or cefaclor. These results suggest that macrolide antibiotics specifically inhibit type II NO synthase gene expression and consequently reduce NO production by rat pulmonary alveolar macrophages, which might result in attenuation of airway inflammation [10].

Clarithromycin modified inflammation by suppressing IL-8 production and that clarithromycin may affect the expression of other genes through AP-1 and NF-kappa B. In addition to treatment of airway diseases, the anti-inflammatory effect of macrolides may be beneficial for the treatment of other inflammatory diseases such as chronic gastritis caused by H. pylori [11].

Azithromycin-induced polymorphonuclear leucocyte apoptosis may be detected in the absence of any effect on PMN function, and the pro-apoptotic properties of azithromycin are inhibited in the presence of S. pneumoniae [12].

Low-dose administration of azithromycin in patients with mild asthma might reduce the severity of bronchial hyperresponsiveness [13].

These membrane-stabilizing interactions of macrolides with neutrophils may counteract the proinflammatory, prooxidative activity of several bioactive lipids, lysophosphatidylcholine (LPC), platelet-activating factor (PAF) and lyso-PAF (LPAF), which have been implicated in the pathogenesis of bronchial asthma [14].

Transport to an infected site of azithromycin by phagocyte cells

Sustained high tissue levels of azithromycin have been demonstrated clinically and in basic research. There has been particular interest in the phagocyte delivery system of azithromycin to the site of infection. The mechanism is characterized by the intake of azithromycin by phagocytic cells which release the antibiotic at the site of infection [16].

Azithromycin reaches high concentrations in phagocytic and other host cells, suggesting that they may transport this agent to specific sites of infection. When azithromycin was given during a period of little or no inflammation, there was marginal difference between concentrations found in infected or non-infected sites (bulla, disc, lung). However, when the compound was given during a period of inflammation, considerably higher drug concentrations were found in infected sites than in non-infected sites at 5-24 h after dosing (0.38-0.44 mg/c compared with 0.07-0.14 mg/L of bulla wash; 1.01-1.75 micrograms compared with < or = 0.01-0.03 microgram at the disc site; 1.72-5.28 mg/kg compared with 0.7-1.53 mg/kg of lung). When the observation periods were extended to include 48, 56 or 96 h after dosing, the ratio of azithromycin infection site concentration: serum concentration steadily increased with time in all model systems (middle ear, implanted disc and pneumonia), reflecting the maintenance of concentrations at the sites of infection, while serum concentrations declined. Bioassay of cell pellets and supernatants, obtained from pooled bulla washes of gerbils treated with azithromycin during a period of inflammation, revealed that cellular components accounted for about 75% of the azithromycin detected. These data show that increased azithromycin concentrations occur at sites of localized infection. This correlates with the presence of inflammation and is associated with the cellular components of the inflammatory response. Therefore, phagocytes may be important vehicles for delivering azithromycin to and sustaining azithromycin concentrations at sites of infection [17].

Side effects of macrolides

Macrolide antibiotics are known to have a different proarrhythmic potential in the presence of comparable QT prolongation in the surface ECG. Because the extent of QT prolongation has been used as a surrogate marker for cardiotoxicity, we aimed to study the different electrophysiological effects of the macrolide antibiotics erythromycin, clarithromycin, and azithromycin in a previously developed experimental model of proarrhythmia. Erythromycin and clarithromycin led to early afterdepolarizations (EADs) and torsade de pointes (TdP) after lowering of potassium concentration. Erythromycin and clarithromycin changed the monophasic action potential (MAP) configuration to a triangular pattern, whereas azithromycin caused a rectangular pattern of MAP prolongation. In 13 additional hearts, 150 microM azithromycin was administered after previous treatment with 300 microM erythromycin and suppressed TdP provoked by erythromycin. Macrolide antibiotics lead to similar prolongation of repolarization but show a different proarrhythmic potential (erythromycin > clarithromycin > azithromycin) [18].

Tachycardia may developed shortly after administration of roxithromycin (Rulid). Immediate-type hypersensitivity was confirmed by positive prick test reactions to roxithromycin and the chemically closely related macrolides erythromycin and clarithromycin [20].

Another known side effects of macrolides are cutaneous reactions [21, 24], antibiotic-induced vasculitis (Churg-Strauss syndrome) [22], transient deafness [18*].

Explanation of Azithromycin action in sarcoidosis

Azithromycin have anti-inflammatory properties. At absence of inflammation its concentration in tissue is distributed approximately regular, but at inflammation the immune cells binding azithromycin and transport them to site of inflammation. Concentration of azithromycin is proportionate the activity of inflammation. Therefore, an increased azithromycin concentrations occur at sites of sarcoid inflammation, but not in health tissue. Then azithromycin downregulate sarcoid inflammation and its concentration in sarcoid tissue is decreased.

Possible explanation of the increased Jarisch-Herxheimer reaction when Azithromycin added in second phase of Marshall’s protocol

Because Azithromycin accumulation occur in the site of sarcoid inflammation, this situation is analogous Azithromycin overdosing at a healthy individuals. The power of toxic effects is proportional organ involvement by sarcoidosis. Cardiotoxicity of Azithromycin can produce heart rhythm irregularities. The Jarisch-Herxheimer reaction is decrease when anti-inflammatory action of Azithromycin downregulate sarcoid inflammation and Azithromycin concentration (and Azithromycin's toxic effects) in sarcoid tissue is decreased also.

The spectrum of side effects of Azithromycin in patients with sarcoidosis and in individuals without sarcoidosis, is similar. The frequency of side effects in patients with sarcoidosis is much higher because a higher concentration of Azithromycin, which is created in inflammated tissue.

Thus, increased Jarisch-Herxheimer reaction in second phase of Marshall’s protocol is only indicator of presence of superhigh concentration of Azithromycin in inflammated tissue and is proportionate organ involvement by sarcoidosis.

Possible explanation of angiotensin II receptor blockers action

Cell adhesion molecules and the immune system

Cellular interactions are controlled by complex mechanisms which come into play at the receptors on the cell surface (adhesion molecules: selectins, integrins, superfamily of immunoglobulins), the soluble cell mediators (cytokines) and the components of the tissue matrix (fibronectin, collagen, etc.). Disturbance of one of these systems may induce a pathological condition. The physiological state of the individual therefore depends on the balance of all these components. In the development of inflammation, adhesion molecules play an essential role in the localisation of the inflammatory response. At this level, the vascular endothelium, a governing barrier for the exchanges between blood and the tissues, plays an active part in regulation of the transcapillary permeability, control of proliferation of haematopoietic cells and the phases of the inflammatory response. After they have marginated, the active cells migrate by diapedesis towards the site of inflammation by creation of chemotactic signals as the adhesion between the cells is insufficient to induce their migration. The adherence phenomena depend on a process that is strictly controlled by the cytokines and enable intervention of cell-cell reactions and cell-protein recognition of the extra-cellular matrix. Cytokines play a key role in control of the expression and/or avidity of membrane receptors for ligand(s). An appropriate and rapid response of the circulating cells depends on coordination of the train of events that regulate the functional expression of the adhesion molecules. Use of specific antibodies that prevent cell adherence opens very important therapeutic possibilities because a single blockage of cell adhesion can have an immediate direct impact on development of the inflammatory response [25].

Cellular adhesion molecules in sarcoidosis

The serum levels of soluble ICAM-land L-, E-, and P-selectin were significantly elevated in patients with sarcoidosis compared with healthy volunteers. A significant correlation was observed between serum soluble L-selectin levels and the number of lymphocytes in the bronchoalveolar lavage fluid of patients with sarcoidosis. Although higher levels of serum soluble adhesion molecules were present in accordance with the clinical stage of sarcoidosis, the differences were not statistically significant. There was a significant correlation between serum ACE and soluble ICAM-1 or VCAM-1 levels [26].

Median circulating E-selectin levels in sarcoidosis patients were nearly three times those of the controls [27].

In sarcoidosis patients, particularly in those with active disease, an increase of the expressions of beta1-integrins was accompanied by elevated concentrations in BAL fluid of soluble VCAM-1. In serum, the levels of E-selectin and ICAM-1 were significantly higher in patients with active disease than in those with inactive disease and controls [28].

Serum and BALF soluble form of ICAM-1 (sICAM-1) levels in sarcoidosis were significantly higher than those in control. Serum sICAM-1 levels correlated with serum soluble interleukin-2 receptor levels (a marker of T-lymphocyte activation) but not with serum angiotensin-converting enzyme levels. sICAM-1 levels in BALF correlated significantly with the percentage of lymphocytes in BALF. Some patients were examined twice during follow-up periods. In patients in whom the chest radiograph improved, serum and BALF sICAM-1 levels decreased. However, in patients in whom the radiograph worsened, sICAM-1 levels increased [29].

Increased ICAM-1 surface expression on alveolar macrophages reflects disease activity in the pulmonary compartment. Considering the significance of adhesion molecules during antigen presentation and lymphocyte activation, ICAM-1 expression on alveolar macrophages may have an important role in the immune process of pulmonary sarcoidosis [30].

Anti-inflammatory properties of Angiotensin II receptor blockers

AII1R antagonism in an animal model of hypertensive heart disease reduces cardiac monocyte chemoattractant protein-1 (MCP-1) expression in the myocardium that results in reduced macrophage recruitment [31].

Addition angiotensin-converting enzyme inhibitor (ACEI) temocapril to angiotensin II type 1 receptor blocker (ARB) olmesartan were associated with greater decreases in reactive oxygen species (ROS) generation, macrophage infiltration, and gene expression of transforming growth factor (TGF)-beta(1) and interleukin (IL)-1beta, but not with changes in gene expression of monocyte chemoattractant protein (MCP)-1 and tumor necrosis factor (TNF)-alpha [32].

ARB Candesartan reduced the levels of C-reactive protein and oxidative stress and inflammation in hypertensive patients independently of its effects on blood pressure. This may provide useful information for determining therapeutic strategies to minimize tissue injury by inflammation and oxidative stress in hypertensive patients [33].

ARB Valsartan at a modest dose exerts a profound and rapid ROS and inflammation-suppressive effect that may be relevant to its potential beneficial effects in atherosclerosis, diabetes, and congestive cardiac failure. In contrast, quinapril and simvastatin produced no similar effect over the period of 1 wk. Our observations may also have implications to clinical situations in which a rapid antiinflammatory effect is required [34].

ARB CS-866 reduced lipid deposition along with the suppression of serum macrophage-colony stimulating factor, transforming growth factor-beta 1 and intracellular adhesion molecule-1, and the improvement of vascular functions, suggesting that ARB has multiple mechanisms for reducing lipid deposition [35].

Valsartan at a dose, which did not influence systolic blood pressure, attenuated the expression of MCP-1, TNF-alpha, IL-6, IL-1beta, and infiltration of leukocytes and macrophages in the injured arteries. These results suggest that the stimulation of the AT(2) receptor after AT(1) blockade is important in the improvement of the inflammatory vascular injury [36].

Irbesartan reduced soluble VCAM-1 levels by 36%; soluble TNF-alpha levels were reduced by 54% and superoxide level decreased by 52%. Maximal suppression of inflammatory markers by irbesartan therapy in patients with CAD was seen at 12 weeks [37].

Influense angiotensin II receptor blockers to cellular adhesion molecules

Angiotensin II induces significant leukocyte rolling, adhesion, and emigration, which may contribute not only to hypertension but also to the onset and progression of the vascular damage. Losartan or AT(2) (PD123,319) receptor antagonists significantly reduced this Angiotensin II-induced responses [38].

Candesartan decreased the stress-induced expression of TNF-alpha and that of the adhesion protein ICAM-1 in arterial endothelium, decreased the neutrophil infiltration in the gastric mucosa, and decreased the gastric content of PGE2. AT1 receptor blockers prevent stress-induced ulcerations by a combination of gastric blood flow protection, decreased sympathoadrenal activation, and anti-inflammatory effects (with reduction in TNF-alpha and ICAM-1 expression leading to reduced neutrophil infiltration) while maintaining the protective glucocorticoid effects and PGE2 release [40].

Interesting, that intravenous methylprednisolone may inhibit inflammatory cell recruitment to active MS lesions by effects on leukocyte or endothelial cell adhesion molecule expression [41].

Possible explanation of ARBs action

Angiotensin II receptor blockers can influence lymphocyte transport to involved tissue. ARBs may reduce expression of adhesion molecules, inhibit inflammatory cell recruitment to the site of sarcoid inflammation and inhibit secretion proinflammatory cytokines. ARBs downregulate azithromycin (and possible minocycline) transport by phagocytes and decrease Jarisch-Herxheimer reaction.


Immunomodulatory properties of minocycline

Minocycline is a semisynthetic second-generation tetracycline that exerts antiinflammatory effects that are completely separate from its antimicrobial action. Minocycline may represent a prototype of an antiinflammatory compound that provides protection against ischemic stroke and has a clinically relevant therapeutic window [42].

Minocycline exerted an inhibitory effect on tumor necrosis factor alpha (TNF-alpha) and gamma interferon production by stimulated T cells, whereas the production of interleukin 6 (IL-6) remained unaffected. The effect of minocycline on TNF-alpha mRNA synthesis by T cells was shown to be stimulus specific. T cells stimulated by a Ca2+-independent mode exhibited a decrease in TNF-alpha mRNA in the presence of minocycline, whereas the TNF-alpha mRNA level remained unaffected by minocycline when cells were stimulated in a Ca2+-dependent manner. In contrast to the effect on T cells, addition of minocycline to lipopolysaccharide-stimulated monocytes led to a dose-dependent increase in TNF-alpha and IL-6 production which was paralleled by an enhancement of TNF-alpha mRNA synthesis. These results indicate that minocycline exerts differential effects on the regulation of cytokine production by T cells and monocytes that are partly reflected at the mRNA level. Given the pleiotropic effects of minocycline, it is suggested that the immunostimulatory effect on monocytes might counteract its beneficial properties in the treatment of several forms of chronic inflammation [43].

The T cells, when activated via the T cell receptor (TCR)/CD3 complex, were suppressed functionally by minocycline, resulting in a dose-dependent inhibition of T cell proliferation and reduction in production of IL-2, interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha (TNF-alpha). Besides an inhibition of IL-2 production, minocycline exerted its effect on T cell proliferation by induction of a decreased IL-2 responsiveness. We showed that the chelating capacity of minocycline plays a crucial role in the inhibitory effect on T cell function, since the inhibitory effect on T cell proliferation could be annulled by addition of exogenous Ca2+. However, minocycline did not markedly influence the typical TCR/CD3-induced intracellular Ca2+ mobilization. Taken together, the results clearly indicate that minocycline has immunomodulating effects on human T cells [44].

The effect of antimicrobial agents on polymorphonuclear (PMN) chemotaxis was investigated. No significant effect was obtained in vitro with penicillins, cephems, macrolides, aminoglycosides or quinolones by the agarose plate method. However, chemotaxis was inhibited at 100 micrograms/ml or less of minocycline and doxycycline. The inhibitory effect on chemotaxis is considered to be due to chelation of Ca-ions by minocycline or doxycycline. The chelation reduced the concentrations of Ca-ions in the PMNs. The chemotactic index of minocycline increased when CaCl2 or A23187 were given in combination. Our findings indicate that a small number of the short lamellipodia were observed in PMNs preincubated with minocycline or doxycycline and these two agents affected the movement of PMNs morphologically [45].

The relative antioxidant efficacy, in vitro, of several antibiotics was examined by studying their effects on the generation of reactive oxygen species (ROS) using zymosan-stimulated polymorphonuclear leukocytes (PMNL) and the cell-free, xanthine-xanthine oxidase system. The antioxidant effect of these antibiotics does not stem from their capability to scavenge ROS, but originates rather from their effect on PMNL cell function directly with resultant anti-inflammatory effects on the inflammatory processes [46].

Antiapoptotic properties of minocycline

Minocycline reduced tubular cell apoptosis 24 hours after ischemia as determined by TUNEL staining and nuclear morphology. It also decreased cytochrome c release into the cytoplasm and reduced upregulation of p53 and Bax after ischemia. The minocycline - treated group showed a significant reduction in tubular injury and cast formation. In addition, minocycline reduced the number of infiltrating leukocytes, decreased leukocyte chemotaxis both in vitro and ex vivo and downregulated the expression of ICAM-1 [47].

Minocycline significantly reduced necrotic and apoptotic cell death, both in neonatal and adult myocytes [48].

Minocycline treatment prevents the formation of activated caspase-3, a known effector of apoptosis, as well as the appearance of a calpain cleaved substrate, a marker of excitotoxic/necrotic cell death. Minocycline or a related neuroprotective tetracycline may be a candidate to consider in human clinical trials to protect the developing brain against hypoxic-ischemic-induced damage [49].

Minocycline delays disease progression, inhibits caspase-1 and caspase-3 mRNA upregulation, and decreases inducible nitric oxide synthetase activity in a Huntington disease model [50].

Minocycline suppressed the release of cytochrome c from mitochondria both in vivo and in vitro and significantly decreased the number of TUNEL-positive cells. These findings suggest that heat stress of testes triggers the release of cytochrome c from mitochondria in spermatogenic cells, leading to the activation of an apoptotic pathway [51].

Transport of minocycline

The interaction between human erythrocyte lysates and antibiotics was studied, and the effect of intracellular components on the activity and binding of the drugs was determined. Lysates inhibited antibacterial activity of penicillin G, dicloxacillin, tetracycline, and minocycline to about the same extent as did human plasma. Dicloxacillin activity was the most inhibited, followed by the activities of penicillin G, minocycline and tetracycline. All four antibiotics bound to human hemoglobin, as determined by gel filtration methods. Heme-free globin was also effective in binding the antibiotics. In addition, minocycline and tetracycline were bound to another erythrocytic protein, which, on the basis of electrophoretic mobility, molecular size, and localization, has been identified as carbonic anhydrase. Experiments with pure preparations of carbonic anhydrase revealed that the C isozyme is the major binder of the tetracyclines and that zinc is required for binding. Tetracyclines did not inhibit enzymatic activity of carbonic anhydrase [52].

Systemic fluoroquinolones and tetracyclines can attain higher levels in gingival fluid than in blood. We hypothesized that gingival fibroblasts take up and accumulate these agents, thereby enhancing their redistribution to the gingiva. Using fluorescence to monitor transport activity, we characterized the accumulation of fluoroquinolones and tetracyclines in cultured human gingival fibroblast monolayers. Both were transported in a concentrative, temperature-dependent, and saturable manner. Fibroblasts transported ciprofloxacin and minocycline with K(m) values of 200 and 108 micro g/mL, respectively, at maximum velocities of 4.62 and 14.2 ng/min/ micro g cell protein, respectively. For both agents, transport was most efficient at pH 7.2 and less efficient at pH 6.2 and 8.2. At steady state, the cellular/extracellular concentration ratio was > 8 for ciprofloxacin and > 60 for minocycline. Thus, gingival fibroblasts possess active transporters that could potentially contribute to the relatively high levels these agents attain in gingival fluid [53].

Side effects of minocycline

Hypersensitivity pneumonitis can developed after exposure of minocycline but not to amoxicillin. Bronchoalveolar lavages showed a transient rise of eosinophils and neutrophils and a persistent alveolar lymphocytosis. Alveolar lymphocytes consisted predominantly of CD8+ but also CD4+ cells. Two CD8+ lymphocyte subsets were identified: CD8+ D44+ cytotoxic T cells that increased rapidly after the drug was resumed and CD8+ CD57+ suppressor T cells that predominated 11 days after the drug's withdrawal. In-vitro assays showed the presence of a lymphocyte-mediated specific cytotoxicity against minocycline-bearing alveolar macrophages. These results support the hypothesis of a central role of T lymphocytes in the pathogenesis of drug-related hypersensitivity pneumonitis [54].

The antibiotic minocycline, which is used in the treatment of acne, has been associated with various pulmonary complications such as pulmonary lupus and hypersensitivity pneumonitis. Report a particularly severe case of minocycline-related pulmonary toxicity that was characterized by a relapsing form of hypersensitivity eosinophilic pneumonia complicated by acute respiratory failure [55].

Minocycline, a semisynthetic tetracycline, is often used to treat acne and rheumatoid arthritis. It has been considered an unlikely drug to be associated with systemic lupus erythematosus; however, many cases of drug-induced lupus related to minocycline have been reported. Some of those reports included pulmonary lupus, but none of the patients described developed respiratory distress. We describe a patient treated with minocycline for 2 years who presented with progressive dyspnea, severe hypoxia, and pulmonary infiltrates necessitating hospitalization and oxygen supplementation [56].

A 17-year-old female patient who had been taking oral minocycline (50 mg twice daily) for 3 weeks for acne developed an eruption that progressed to an exfoliative dermatitis. This illness was also characterized by fever, lymphadenopathy, pharyngitis, a leukemoid reaction, lymphocytosis, eosinophilia, hepatitis, and noncardiogenic pulmonary edema. Dramatic improvement followed institution of corticosteroid therapy. Studies for infectious and collagen vascular diseases were negative. This severe illness was likely caused by minocycline, and we speculate that minocycline may have acted as a superantigen, causing lymphocyte over-activation and massive cytokine release [57].

Reported the case of a woman who presented with dyspnoea whilst taking minocycline for acne. Imaging features of bilateral patchy alveolar opacities suggested a diagnosis of bronchiolitis obliterans organizing pneumonia, which was confirmed by lung biopsy. The patient improved, partially, after stopping minocycline, and then completely on treatment with corticosteroids, without relapse when these where stopped 8 weeks later [58].

A case of drug-induced immune hemolytic anemia is described. A 2 year old boy exhibited sudden anemia and hemoglobinuria after administration of minocycline (MINO). The specific immunoglobulin G antibody against MINO was demonstrated in the patient's serum by western blotting. This is a rare example where anti-minocycline immune complex-mediated hemolysis was responsible for an intravascular hemolytic process [59].

Reported two cases of drug-induced vasculitis subsequent to long-term minocycline therapy. Early recognition of ANCA-positive vasculitis is essential during long-term minocycline treatment, because cessation of the drug can result in complete resolution [60].

Minocycline can induce drug-induced lupus. The treatment was complicated by rash and serological signs of lupus (antinuclear antibodies and anti-DNA antibodies) [61].

Minocycline can induce autoimmune hepatitis [62-64].

Prolonged treatment with minocycline for acne vulgaris has been associated with the development of arthralgia, arthritis, and other autoimmune phenomena. Increased titers of perinuclear ANCA (p-ANCA) were detected in all seven patients; five patients had fluorescent antinuclear antibodies, two had antihistone autoantibodies and one had anticardiolipin antibodies. Antigenic characterization of p-ANCA disclosed antibodies to bactericidal permeability increasing protein in one patient, to elastase in three patients, and to cathepsin G in five patients. Symptoms resolved in five patients upon discontinuation of minocycline; the other two patients were treated with corticosteroids and also achieved remissions. Minocycline-induced autoimmune syndrome is characterized by reversible polyarthralgia or arthritis, morning stiffness, fever, frequent skin involvement, occasional chronic active hepatitis, and increased titers of p-ANCA with various minor p-ANCA-related antigens [65].

The patient had been treated with oral minocycline therapy for adult facial acne for 12 years when she began to develop bilateral blue-gray discoloration of the sclera as well as of the teeth, hard palate, ears, nail beds, and skin [66]

Reported the unusual case developing black discoloration of breast milk 3 weeks after commencing oral minocycline therapy for acne vulgaris. Histochemical analysis of the breast milk revealed the presence of pigment particles within macrophages with iron staining characteristics [67].

Minocycline can induce interstitial nephritis [68] and Sweet's syndrome [69, 70].

Possible explanation of Minocycline action in Marshall’s protocol

Autoimmune side effects of Minocycline shows that this drug make a deep effect to immune system.

Minocycline have lymphocyte-mediated specific cytotoxicity against minocycline-bearing alveolar macrophages and can produce alveolar lymphocytosis with predominantly of CD8+. As in sarcoidosis occur alveolitis with predominance CD4+ and increased CD4+/CD8+ ratio, Minocycline can decrease CD4+/CD8+, that is a target of sarcoidosis therapy.

Fact, that fibroblasts binding and transport minocycline allow to hope, that minocycline can influence for collagen synthesis and prevent fibrosis.

Antiapoptotic properties of minocycline may protect pneumocyte from inflammatory damage.

Minocycline have chelating properties and may binding metals, that cause sarcoidosis [71].

Possible explanation of Minocycline-associated Jarisch-Herxheimer reaction

Ability of Minocycline to produce reversible side effects (hypersensitivity pneumonitis, drug-induced vasculitis, drug-induced lupus, drug-induced immune hemolytic anemia, fever, lymphadenopathy, pharyngitis, eosinophilia, hepatitis, acute respiratory failure), probably, is connected with conflict of cascades Th1 and Th2 cytokines. The power of this effects is proportional organ involvement by sarcoidosis. Increased azithromycin concentrations may occur in fibrotic changes.


All drugs used in the Marshall’s protocol have immunomodulatory activity.

Clue of Marshall’s protocol is Minocycline which produce alveolar lymphocytosis with predominantly of CD8+. As in sarcoidosis occur alveolitis with predominance CD4+ and increased CD4+/CD8+ ratio, Minocycline can decrease CD4+/CD8+, that is a target of sarcoidosis therapy.

Azithromycin have anti-inflammatory properties and produce increased concentrations at sites of sarcoid inflammation. Azithromycin downregulate sarcoid inflammation and its concentration and side effects in sarcoid tissue is decreased.

Angiotensin II receptor blockers can influence lymphocyte transport to involved tissue. ARBs may reduce expression of adhesion molecules, inhibit inflammatory cell recruitment to the site of sarcoid inflammation and inhibit secretion proinflammatory cytokines. ARBs downregulate azithromycin (and possible minocycline) transport by phagocytes and decrease Jarisch-Herxheimer reaction.

Because adrenal gland is one of the major target organs of angiotensin II, ARBs may suppress angiotensin II-induced aldosterone secretion and hyperkalaemia.

Thus, the properties of drugs used in the Marshall’s protocol do not require artificial introduction cell wall deficient bacteria to pathogenesis of sarcoidosis as a target for antibiotic treatment and CWD toxines to explanation of Jarisch-Herxheimer reaction.

Benefit feature of Marshall’s protocol is the choice of drugs, which is selective (in contrast with hormonal drugs) transported to the sites of inflammation, make high concentration proportional to activity of an inflammation with absence of serious system side effects and low concentration in healthy tissue. Negative feature of Marshall’s protocol is toxic side effects of antibiotics (Jarisch-Herxheimer reaction), which act to involved organs, frequently with remodelling architecture and functional insufficiency, that can create life-threatening condition.

Marshall’s protocol can be useful in patients with sarcoidosis and opportunistic infections after long corticosteroid therapy. For this group of patients monotherapy by antibiotics can be enough. For other groups of patients, the benefits of such therapy should be appreciated in randomised double blind study.

Questions about MP in Russian Sarcoidosis Patients Forum

Questions about possible mechanism of antibiotics and ARBs action in sarcoidosis

1. Whether there is a transport of minocycline by phagocytes and superhigh concentration of minocycline in inflammated tissue proportionate of organ involvement by sarcoidosis?

2. Whether will mean the binding of azithromycin (and presumably minocycline) by phagocytes, that antibiotics have homology with antigene, which presumably caused expansion of specific sarcoid Ò-cells? Whether this binding changes activity of Ò-cells and their ability to produce cytokines?

3. Whether will mean an inefficiency of the MP even at one patient, that at this patient the trigger was another and for binding with specific sarcoid Ò-cells can be required other drug, not necessary antibiotics.

4. It is possible to synthesize a drug having binding site with specific sarcoid Ò-cells, but without (or minimal) other properties, including antibacterial? May this drug change activity of Ò-cells and their ability to produce cytokines with minimal side effects?

5. Whether exist competition ARBs with minocycline and azithromycin in binding with specific sarcoid Ò-cells? In other words, whether ARB influence only to leukocyte-endothelial interaction (barrier function) or as well as the antibiotics have homology with antigene, which presumably caused expansion of specific sarcoid Ò-cells?

5. It is necessary to compare cell count in BAL (total number of cells, % neutrophils, lymphocytes; eosinophils; macrophages), BAL CD4/CD8 ratio, cytokine profile before MP application and (1) MINO only, (2) MINO+ARBs, (3) MINO+Z+ARBs.

6. If general problem in sarcoidosis is CWD endotoxins, plasmapheresis and enterosorbents may be useful.

7. Extracorporal antibiotic therapy may be more safe than MINO+Z per os.

Questions about CWD with Trevor Marshall comments

1. How to explain the Kveim test if sarcoidosis have mycobacterial pathogenesis? May Kveim–Siltzbach reagent contain CWD? Can active component of Kveim–Siltzbach reagent be disappeared and produce the Kveim reaction after application Marshall protocol? Can patient be infected CWD after Kveim test?

Trevor Marshall: Many studies have shown sarcoidosis apparently caused by BCG (Bacille of Calmette-Guerin). I think the Mycobacterium bovis is probably a direct pathogen for individuals who are pre-disposed to develop sarcoid inflammation. The Kveim reagent is obtained from ground-up spleens of patients who have died from sarcoidosis. I would be very surprised if Kveim test does not transfer some of the bacterial pathogens into the patient. Most physicians in the USA do not use this test because of safety concerns. Twenty years ago in Australia the same safety concerns were well known. But I haven't seen any published studies linking Kveim reagent with people developing Sarcoidosis.

2. Whether was the reason of increase sarcoidosis incidence rate is wide use of antibiotics. As is known, the L-forms can be received at action of antibiotics, which ability to delete peptidoglycan from cell wall of bacteria.

Trevor Marshall: I think partly the use of antibiotics, and partly also the supplementation in the West of food with Vitamin D and Folic Acid, especially baby food. Also the rising use of injected vaccines. I have seen no studies to back up this opinion of mine.

3. CWD is artefact of sarcoid inflammation? Antibacterial components, such as lysozyme in BAL patients with sarcoidosis also may delete peptidoglycan from cell wall of bacteria and produce CWD. After successful treatment and decrease inflammation CWD may revert to commom acid-fast rod forms.

Trevor Marshall: No, the same treatment protocol works just as well in other Th1 diseases beside sarcoidosis, including CFIDS and Chronic-Lyme and Rheumatoid Arthritis (current patient sample size about 25 each CFIDS and Chronic Lyme, just 3 in RA so far).

4. Increase of sarcoidosis incidence rate is consequence of wide application of vaccination? The possible reasons is (1) using of alive vaccines, (2) preparation of the ''weakened'' vaccines (Salk vaccine, Sabin vaccine, BCG vaccine, MMR vaccine, TAB vaccine and others) with help of antibiotics, bacteria can revert to CWD and back. This method can produce CWD and CWD with multidrug resistance. Need to find CWD in vaccines used at obligatory vaccination in USA.

Trevor Marshall: Any vaccine has risks of carrying CWD which depend on its manufacturing process. Biologicals (like Remicade) also carry risks. CWD bacteria are sometime only 0.01-0.025 microns in diameter and the filters used in vaccine manufacturing are 10 times more coarse

5. Blood and tissue donor. Need to develop the CWD test presence, to prevent the recipient infection.

Trevor Marshall: Sarcoidosis patients are not allowed to give blood by the USA Red Cross. They are allowed to give organ transplants, and Dr Moller noted that during transplants involving patients with sarcodiosis, patients who receive a donor organ from a sarcoidosis patients develop the disease, and clean organs transplanted into sarc patients become infected.(see full text of this paper: )

6. Pregnancy. Can CWD penetrate through placental barrier? Is necessary prenatal therapy? Early diagnostics of sarcoidosis is necessary as sarcoidosis usually develop later, that the first pregnancy.

Trevor Marshall: Our paper being translated by Dr Vizel includes citations to several studies showing mycoplasma being transmitted from mother to child.

7. Check presence CWD in insulin, antibiotics and other drug.

Trevor Marshall: Nobody has done this yet, according to my information.In my opinion, there is a similar risk of contamination for the reasons in my answer 4.



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