Bronchoalveolar lavage in a patient with recurrence of sarcoidosis after lung transplantation

End-stage pulmonary disease due to sarcoidosis rarely leads to lung transplantation. Once a patient has undergone lung transplantation, sarcoidosis often recurs in the lung allograft. In this case report we show, for the first time, the utility of bronchoalveolar lavage fluid in diagnosing the recurrence of sarcoidosis in the transplanted allograft.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause affecting young and middle-aged adults. Patients commonly present with bilateral hilar lymphadenopathy, pulmonary infiltrates, and ocular and skin lesions. The heart, liver,spleen, salivary glands, muscles,bones, kidneys, and central nervous system also may be involved. Diagnosis is based on clinicoradiologic findings plus histologic evidence of noncaseating epithelioid granulomas, and exclusion of other granulomatous diseases. Prognosis correlates with mode of onset, host characteristics, initial clinical course, and extent of disease. The optimal management of sarcoidosis has not been well defined. Although corticosteroids remain the mainstay of treatment, there is little evidence for the optimal initiation, dosage, or duration of therapy. Topical steroids maybe considered for treatment of anterior uveitis and skin lesions. Systemic steroids are indicated for treatment of cardiac, nervous system, severe ocular, and symptomatic or progressive pulmonary involvement. There is little evidence for the efficacy of inhaled steroids. Cytotoxic agents and immunomodulators usually are reserved for treatment of complex or refractory disease. Of these agents, methotrexate is used more frequently because of its safety profile and possible steroid-sparing effects. Antimalarial agents are used frequently for skin lesions, and they have limited success in the treatment of pulmonary disease. Lung and cardiac transplantation is reserved for end-stage disease. Monitoring for symptoms of drug toxicity is essential, and prevention of osteoporosis must be addressed in patients taking long-term oral corticosteroids. It is not known if current therapy alters disease progression.

BAL cytokine profile in different interstitial lung diseases: a focus on systemic sclerosis

BACKGROUND AND AIM

Fibrosing alveolitis develops in up to 80% of systemic sclerosis patients (SSc) but progression to end stage fibrosis occurs in about 15% of cases. Mechanisms leading to the process remain mostly unknown. We compared cytokine profiles of broncho-alveolar lavage fluids (BAL-f) from patients with SSc associated interstitial lung disease (SSc-ILD) (n. 34), idiopathic pulmonary fibrosis (IPF) (n. 13), stage II sarcoidosis (n. 14) and 9 controls.

METHODS

Interleukin (IL) 8, monocyte chemoattractant protein 1 (MCP-1), gamma-interferon (IFN-gamma), IL12, IL18 and IL10 and transforming growth factor-beta (TGF-beta) were assessed by ELISA in concentrated BAL-f.

RESULTS

Levels of IL8 and MCP-1 were significantly elevated in SSc-ILD and in IPF as compared with controls (Mann Whitney test p < 0.05), while MCP-1 values were significantly lower in SSc-ILD than in IPF. A significant correlation between neutrophils and IL8 levels (p = 0.047), as well as between eosinophils and MCP-1 levels (p = 0.004) was also observed. IFN-gamma levels were slightly higher than normal only in sarcoidosis (p = 0.06), whereas IL12 levels increased both in sarcoidosis and SSc-ILD (p < 0.05). No differences were found in IL18 and TGF-beta levels. Finally, IL10 levels were higher in SSc-ILD and sarcoidosis than in controls and IPF (p < 0.05).

CONCLUSION

BAL-f cytokine profile differentiates ILD associated with SSc from IPF. The lower expression of MCP-1 and the higher expression of the anti-fibrotic IL12 and the anti-inflammatory IL10, observed both in sarcoidosis and in SSc-ILD, could account for the better prognosis of these ILDs. Further longitudinal studies are required to confirm whether a different cytokine phenotype may be considered predictive of clinical outcome in SSc-ILD.

Membrane and Capillary Blood Components of Diffusion Capacity of the Lung for Carbon Monoxide in Pulmonary Sarcoidosis

BACKGROUND

Resting pulmonary diffusing capacity of the lung for carbon monoxide (DLCO) is known to be the best predictor of arterial desaturation during exercise in patients with sarcoidosis. However, the relative contribution of each of the two components of DLCO-alveolar membrane diffusing capacity (Dm) and pulmonary capillary blood volume (Vc)-remains unclear.

STUDY OBJECTIVES

To evaluate which component is responsible for the decrease of resting DLCO in patients with sarcoidosis, and to determine which resting pulmonary function test, including Dm and Vc, is the best predictor of gas exchange abnormalities during submaximal exercise.

DESIGN

Prospective analysis of patients referred to our department of respiratory medicine.

PATIENTS

Twenty four patients with pulmonary sarcoidosis were separated into two groups according to chest radiographic findings: group 1, stages 2 and 3 (n = 15); group 2, stage 4 (n = 9). All the patients completed pulmonary function tests (flows, volumes, single-breath DLCO, transfer coefficient [Ka], Dm, Vc) and submaximal exercise (two steady-state levels of mild and moderate exercise corresponding respectively to a target oxygen consumption of approximately 10 to 15 mL/min/kg).

RESULTS

DLCO was reduced in the two groups (group 1, 63 +/- 16% of predicted; group 2, 64 +/- 16% of predicted). Dm was severely decreased (group 1, 58 +/- 24% of predicted; group 2, 51 +/- 15% of predicted), whereas Vc was unchanged or only mildly decreased (group 1, 81 +/- 18% of predicted; group 2, 85 +/- 28% of predicted). Whatever the group of patients and the exercise level, Dm and DLCO were the strongest predictors (p < 0.001) of gas exchange abnormalities. Ka or volumes were weak predictors, and Vc or flows were not related with exercise gas exchange.

CONCLUSIONS

This study demonstrates that a decrease in Dm mostly accounts for resting DLCO reduction, and that Dm as well as DLCO are highly predictive of gas exchange abnormalities at exercise in patients with sarcoidosis.

[A case of pulmonary sarcoidosis with usual interstitial pneumonia-like lesions distributed predominantly in the lower lung fields]

In 2000, in a 75-year-old man, nodular and reticular opacities were detected in both lower lung fields. He was admitted to our hospital for further examination of these abnormal shadows. Bronchoscopic examination revealed pulmonary sarcoidosis. Prednisolone was prescribed because cardiac sarcoidosis was diagnosed as a clinical complication. In April 2002, the patient visited our hospital for dyspnea on effort. Chest radiography and computed tomography showed nodular and reticular opacities in the right upper lobe, and video-assisted thoracoscopic surgery was performed on the basis of a histological diagnosis. The histological findings of the biopsied specimens revealed a lesion of the type seen in usual interstitial pneumonia, whereas non-caseous granulomas were not detected. His symptoms and chest radiographic findings improved and stabilized with prednisolone and azathioprine. In the present case of pulmonary sarcoidosis, the reticular and nodular opacities predominantly distributed in both lower lung fields, and the histological findings obtained by video-assisted thoracoscopic surgery showed a usual interstitial pneumonia-like lesion. These findings may assist in the understanding of the process of development of pulmonary sarcoidosis.

Sarcoidosis and tuberculosis: epidemiological similarities and dissimilarities. A review of a series of studies in a Japanese work population (1941-1996) and the general population (1959-1984)

AIM

The aim of this review is to discuss the epidemiological relationship between sarcoidosis and tuberculosis.

METHODS

We have used a series of health surveillance data in a Japanese work population of 460,000 employees including 70,000 working in Tokyo (1941-1996) and the data from a nation-wide sarcoidosis survey in the general population (1959-1991). The work population was annually x-rayed and tuberculin tested. The data of primary tuberculosis were obtained from a 17 year cohort study of tuberculin positive converters and primary pulmonary sarcoidosis data from the registry of the disease (1952-1996) in the same work population. Hilar lymphadenopathy (HL) was observed as a common marker of the two diseases.

RESULTS

1) Sarcoidosis HL was not detected in the work population until tuberculosis HL decreased. 2) BHL was rare in primary tuberculosis, but occurred in 95.5% of sarcoidosis subjects. 3) In both diseases, HL resolved in a few years, though accompanying extra-pulmonary involvements delayed the resolution of sarcoidosis BHL. 4) The grade of tuberculin sensitivity prior to sarcoidosis was not a risk factor for developing sarcoidosis. 5) Several well-documented sarcoidosis cases remained tuberculin-negative before and at the time of diagnosis of the disease and after resolution of pulmonary involvement. 6) Age-specific incidence curves showed a mono-modal curve in tuberculosis and a bimodal curve in sarcoidosis. 7) Tuberculosis prevalence was higher in the South of Japan, while sarcoidosis was higher in the North.

CONCLUSIONS

These epidemiological dissimilarities do not support a tuberculosis etiology of sarcoidosis.

Cutaneous and pulmonary sarcoidosis in a Hong Kong Chinese woman with silicone breast prostheses

Sarcoidosis is rarely reported in Hong Kong. We report cutaneous and pulmonary sarcoidosis in a 54-year-old Chinese woman, who presented with papular lesions over the face and neck. She had silicone breast augmentation surgery 4 years earlier. Skin biopsy revealed granulomatous inflammation and anti-tuberculosis treatment was started empirically but stopped 2 months later owing to a poor response. A right supraclavicular lymph node was aspirated and revealed granulomatous inflammation. The CXR was normal initially but subsequently showed diffuse reticulonodular opacities and a small right-sided pleural effusion. High-resolution CT of the thorax showed mediastinal lymphadenopathy and diffuse perilymphatic nodular opacities consistent with sarcoidosis. Sputum mycobacterial culture was negative. Fibreoptic bronchoscopy showed no endobronchial lesion but the transbronchial biopsy showed granulomatous inflammation with no evidence of infection, malignancy or foreign body. Pulmonary function tests were normal except for impairment of transfer factor. One year later, most of the cutaneous lesions had healed spontaneously. The CXR showed partial improvement of the right pleural opacification but little change in the lung field. The features of sarcoidosis and its association with silicone are reviewed.

Spinal Neurosarcoidosis Mimicking an Idiopathic Inflammatory Demyelinating Syndrome

BACKGROUND

Intramedullary neurosarcoidosis may be the first and only manifestation of the disease and may mimic an idiopathic inflammatory demyelinating syndrome both clinically and on neuroimaging results.

METHODS AND RESULTS

Two patients who were seen initially with a relapsing-remitting neurologic course and a cervical intramedullary lesion on magnetic resonance imaging findings are reported. Both proved to have neurosarcoidosis. A computed axial tomographic scan of the chest showed hilar adenopathy, which provided a clue to the diagnosis.

CONCLUSIONS

Symptoms due to an intramedullary cervical lesion can be the first manifestation of neurosarcoidosis. The clinical course can mimic a demyelinating illness. A high index of suspicion and a search for sarcoidosis at extraneural sites are required for an early diagnosis. Steroid treatment is associated with a favorable outcome.

Characterization of p40 and IL-10 in the BALF of patients with pulmonary sarcoidosis

This study investigated cytokine protein levels (interleukin-12 p70 [IL-12p70], p40, and IL-10) in bronchoalveolar lavage fluid (BALF) from patients with pulmonary sarcoidosis (n = 59), healthy control subjects (n = 17), and patients with idiopathic pulmonary fibrosis (IPF) (n = 30). The relationship between cytokine levels and clinical course of sarcoidosis was also examined. Overall, p40 was far more abundant than IL-12p70. p40 levels (pg/ml, mean +/- SEM) were significantly higher in the BALF from patients with sarcoidosis (2.97 +/- 3.69) than in IPF patients (0.83 +/- 1.57) and healthy subjects (0.78 +/- 1.00). Size exclusion chromatography indicated that p40 detected in BALF from sarcoidosis patients corresponded to p40 monomers or (p40)(2) homodimers. Further, p40 levels were associated with (paralleled) the clinical course of sarcoidosis, with the highest levels detected in BALF from patients with persistent disease. Higher p40 levels were also found in the BALF from sarcoid patients who required corticosteroid treatment compared with patients with spontaneous regression (3.51 +/- 3.83 vs. 2.01 +/- 3.43, p = 0.03). IL-10 concentrations paralleled p40 changes. No similar association was found for IL-12p70 levels. In conclusion, this report shows that the BALF from patients with sarcoidosis contains elevated levels of p40, (p40)(2), and IL-10 protein but not of IL-12p70. The present data also suggest that BALF p40 concentrations may be indicative of the sarcoidosis clinical course.

[Idiopathic gingival hyperplasia]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei Gingivahyperplasie besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Sarkoidose im Allgemeinen und speziell bei Beteiligung der Gingiva eingegangen.

[Bilateral lacrimal gland inflammation in a 42-year-old entrepreneur]

Eine Tränendrüsenschwellung als Erstmanifestation einer Sarkoidose tritt in weniger als 1% der Fälle auf. Im Rahmen dieser Systemerkrankung werden die verschiedenen Augenabschnitte und die Adnexe unterschiedlich isoliert oder kombiniert betroffen. Unser Fallbericht zeigt, dass die Diagnostik bei einer Tränendrüsenschwellung schwierig sein kann und dass eine konklusive Diagnose eventuell erst im weiteren Krankheitsverlauf einer Multisystemerkrankung gestellt werden kann.

FUO due to sarcoidosis-lymphoma syndrome

This is a patient who presented as a fever of unknown origin (FUO) due to sarcoidosis-lymphoma syndrome. In favor of sarcoidosis was an elevated angiotensin-converting enzyme level, hypercalciuria, and bilateral hilar adenopathy on chest x-ray and chest CT. CT-guided biopsy of a hilar node revealed B-cell lymphoma. The differential diagnosis of sarcoidosis versus lymphoma and sarcoidosis-lymphoma syndrome as a cause of fever of unknown origin is discussed in this article.

The Yield of Endobronchial Biopsy in Pulmonary Sarcoidosis: Connection between Spirometric Impairment and Lymphocyte Subpopulations in Bronchoalveolar Lavage Fluid

BACKGROUND

Sarcoidosis is a multi-organ granulomatous disorder of undetermined aetiology with 90% of patients exhibiting some degree of pulmonary involvement. Transbronchial biopsy and endobronchial biopsy (EBB) with a fiber-optic bronchoscope, which demonstrate giant or epithelial cells of granuloma formation, have been established as standard methods for histological confirmation of sarcoidosis.

OBJECTIVES

The analysis of EBB and bronchoalveolar lavage (BAL) specimens was used to assess the frequency of positive EBB findings in patients with pulmonary sarcoidosis. The influence of spirometric abnormalities and BAL findings on EBB-based diagnosis was also evaluated.

METHODS

The examined group of patients comprised 60 subjects mean age 39.4 +/- 9.65 years). The results of pulmonary function tests, EBB and BAL were analysed.

RESULTS

EBB was performed on 52 patients. Positive histological results were found in 40% of subjects; 12 of them were affected by spirometry impairment. All patients with restriction and almost half of the subjects with obstruction disorders had positive EBB findings. In the BAL fluid, the percentage of CD3+ and CD4+ cells was significantly lower and the percentage of CD19+ and CD8+ lymphocytes was significantly higher in patients with positive biopsies in comparison with the subjects with negative EBB findings.

CONCLUSIONS

Positive biopsies are related to the intensity of abnormalities in the pulmonary function tests and BAL, and may reflect an advanced stage of sarcoidosis.

Pulmonary sarcoidosis: new genetic clues and ongoing treatment controversies

The wide-ranging, multisystemic manifestations of sarcoidosis can make diagnosis and management difficult. Corticosteroid treatment is effective, but the optimal time to start, the dose, and the duration of treatment are controversial. We are just beginning to understand the genetic basis of sarcoidosis.

Pharmacotherapeutic management of pulmonary sarcoidosis

Corticosteroids are the mainstay of treatment for sarcoidosis. Although the indications for medical therapy of sarcoidosis are controversial, standard therapy for symptomatic, progressive disease consists of corticosteroids. The British Thoracic Society concluded, with respect to systemic corticosteroids for the treatment of sarcoidosis, that some patients required no treatment, some required prednisone for control of symptoms, and others, with persistent disease, appeared to benefit from long-term corticosteroid therapy. Inhaled budesonide can be an effective treatment for lung sarcoidosis, with few adverse effects, when used in combination with oral systemic corticosteroids such as deflazacort administered in a tapered regimen for 6 months. A randomized controlled trial has also demonstrated the efficacy of 3 months of treatment with oral prednisolone in a tapered regimen followed by inhaled budesonide for 15 months in patients with early stage pulmonary sarcoidosis.Alternative drugs are required in chronic resistant sarcoidosis and/or in conditions where systemic corticosteroids are contraindicated. Immunosuppressive agents (chlorambucil, cyclophosphamide, methotrexate, cyclosporine, azathioprine), anticytokine agents (thalidomide, pentoxifylline), antimalarials (chloroquine, hydroxychloroquine), melatonin and monoclonal antibody (infliximab) have been used in such situations. Chlorambucil and cyclophosphamide have been used in anecdotal cases of pulmonary sarcoidosis as corticosteroid-sparing agents. However, their toxicity and neoplastic potential recommend prudence in patient selection. A comparison between combination therapy with cyclosporine and prednisone and prednisone alone has shown an increased prevalence of serious adverse effects with combined therapy with no between-group differences in treatment efficacy. The cost and toxicity of cyclosporine limit its use to patients in whom its efficacy has been proven. In patients with chronic or refractory disease, methotrexate, usually administered once a week as a single oral dose for at least 2 years, has resulted in a significant improvement in respiratory function, chest radiographs and extrapulmonary manifestations. In most patients, this treatment enabled discontinuation of corticosteroids. Azathioprine may be effective as a corticosteroid-sparing agent in the long-term treatment of sarcoidosis. The combination of prednisolone and azathioprine over a period of 2 years has induced long-lasting remission in patients with resistant sarcoidosis. Thalidomide at low doses is effective in selected cases of sarcoidosis with cutaneous and mild pulmonary involvement. Pentoxifylline alone or combined with low doses of corticosteroids has achieved significant improvement in respiratory function in patients with pulmonary sarcoidosis. Chloroquine and hydroxychloroquine have been shown to have a specific effect in cutaneous manifestations, neurological involvement and hypercalcemia associated with sarcoidosis. Infliximab has yielded good results in patients with chronic resistant pulmonary and extrapulmonary sarcoidosis resistant to corticosteroid and cytotoxic therapy. The effectiveness of melatonin in cutaneous and pulmonary sarcoidosis has also been confirmed in a single center.

Diagnostic relevance of Langerin detection in cells from bronchoalveolar lavage of patients with pulmonary Langerhans cell histiocytosis, sarcoidosis and idiopathic pulmonary fibrosis

The diagnosis of pulmonary Langerhans cell histiocytosis might be refined by demonstrating reliability of a new cell marker, i.e., Langerin (CD207), used on bronchoalveolar lavage fluid. For this purpose, we collected material from patients with this disease and also with sarcoidosis and idiopathic pulmonary fibrosis as controls. In addition to the immunocytochemical detection of Langerin, we examined the expression profiles of CD1a and the macrophage tandem-repeat mannose receptor (CD206). To test accessibility of Langerin, a C-type lectin, for mannosides, we employed reverse lectin histochemistry using mannose-containing neoglycoproteins. The analysis revealed a significantly increased percentage of CD1a- and Langerin-positive cells in pulmonary Langerhans cell histiocytosis in comparison with both other studied diseases. No expression of the 175-kDa mannose-binding lectin (CD206) in Langerhans cells was observed. Evidently, binding sites on the cells were not accessible for the mannose-containing neoglycoligand. These results provide evidence for the usefulness of Langerin-directed immuno- and glycohistochemical monitoring of bronchoalveolar lavage fluid in the diagnosis of pulmonary Langerhans cell histiocytosis.