Maintenance of granuloma formation in pulmonary sarcoidosis by T lymphocytes within the lung

Human immunodeficiency virus-associated pulmonary sarcoidosis in a Japanese man as a manifestation of immune reconstitution inflammatory syndrome

Asymptomatic pulmonary sarcoidosis can develop after starting antiretroviral therapy. The decision on whether to treat sarcoidosis with corticosteroids should be based on the disease severity.

Mechanisms of Granulomatous Lung Disease from Inhaled Beryllium: The Role of Antigenicity in Granuloma Formation

Granulomatous lung disease is a debilitating and sometimes fatal condition encountered in humans, for which the cellular and molecular mechanisms are poorly understood. Two patterns of granulomatous lung disease are recognized; foreign-body reactions and immune-mediated granulomas. Beryllium inhalation by humans results, in a small number of exposed individuals, in a chronic, granulomatous, immune-mediated pulmonary disease (chronic beryllium lung disease, CBD). Animal models used to study CBD have demonstrated significant species differences in the pathologic response to beryllium. While rats exposed to beryllium appear to develop a chronic, foreign-body response within the lung, dogs so exposed develop beryllium-specific immune responses within the lung and blood, accompanied by immune granulomas within the lung. At the heart of this difference appears to be the ability of the dog, but not the rat, to immunologically recognize the antigenicity of beryllium. This important difference further underscores the need to understand the mechanistic differences among similar disease syndromes, particularly if therapeutic regimens are to be used.

Differential expression of microRNA and predicted targets in pulmonary sarcoidosis

BACKGROUND

Recent studies show that various inflammatory diseases are regulated at the level of RNA translation by small non-coding RNAs, termed microRNAs (miRNAs). We sought to determine whether sarcoidosis tissues harbor a distinct pattern of miRNA expression and then considered their potential molecular targets.

METHODS AND RESULTS

Genome-wide microarray analysis of miRNA expression in lung tissue and peripheral blood mononuclear cells (PBMCs) was performed and differentially expressed (DE)-miRNAs were then validated by real-time PCR. A distinct pattern of DE-miRNA expression was identified in both lung tissue and PBMCs of sarcoidosis patients. A subgroup of DE-miRNAs common to lung and lymph node tissues were predicted to target transforming growth factor (TGFβ)-regulated pathways. Likewise, the DE-miRNAs identified in PBMCs of sarcoidosis patients were predicted to target the TGFβ-regulated "wingless and integrase-1" (WNT) pathway.

CONCLUSIONS

This study is the first to profile miRNAs in sarcoidosis tissues and to consider their possible roles in disease pathogenesis. Our results suggest that miRNA regulate TGFβ and related WNT pathways in sarcoidosis tissues, pathways previously incriminated in the pathogenesis of sarcoidosis.

Sarcoidosis blood transcriptome reflects lung inflammation and overlaps with tuberculosis

RATIONALE

Sarcoidosis is a granulomatous disease of unknown etiology, although M. tuberculosis may play a role in the pathogenesis. The traditional view holds that inflammation in sarcoidosis is compartmentalized to involved organs.

OBJECTIVES

To determine whether whole blood gene expression signatures reflect inflammatory pathways in the lung in sarcoidosis and whether these signatures overlap with tuberculosis.

METHODS

We analyzed transcriptomic data from blood and lung biopsies in sarcoidosis and compared these profiles with blood transcriptomic data from tuberculosis and other diseases.

MEASUREMENTS AND MAIN RESULTS

Applying machine learning algorithms to blood gene expression data, we built a classifier that distinguished sarcoidosis from health in derivation and validation cohorts (92% sensitivity, 92% specificity). The most discriminative genes were confirmed by quantitative PCR and correlated with disease severity. Transcript profiles significantly induced in blood overlapped with those in lung biopsies and identified shared dominant inflammatory pathways (e.g., Type-I/II interferons). Sarcoidosis and tuberculosis shared more overlap in blood gene expression compared with other diseases using the 86-gene signature reported to be specific for tuberculosis and the sarcoidosis signature presented herein, although reapplication of machine learning algorithms could identify genes specific for sarcoidosis.

CONCLUSIONS

These data indicate that blood transcriptome analysis provides a noninvasive method for identifying inflammatory pathways in sarcoidosis, that these pathways may be leveraged to complement more invasive procedures for diagnosis or assessment of disease severity, and that sarcoidosis and tuberculosis share overlap in gene regulation of specific inflammatory pathways.

Blood monocytes and serum and bone marrow lysozyme in sarcoidosis

Serum lysozyme (LZM) concentrations were correlated to the number of neutrophils and monocytes in patients with sarcoidosis and nongranulomatous diseases. In sarcoidosis patients with an increased activity of serum angiotensin converting enzyme (ACE), a positive correlation was noted between LZM and blood monocytes. In sarcoidosis patients with normal ACE activity, as well as in patients with non-granulomatous diseases, a correlation was found between blood neutrophils and LZM, but not between blood monocytes and LZM. LZM was found in bone marrow plasma and in serum in a ratio of 1.5 to 1. Sarcoidosis patients had 30% higher LZM levels than healthy controls. The concentration of LZM in bone marrow plasma did not correlate to detectable granulomas in bone marrow specimens. The positive correlation between blood monocytes and LZM in patients with clinically active sarcoidosis is possibly due to recruitment of bone marrow monocytes for the granuloma formation.

Indices of inflammatory cell activity and pulmonary function in different stages of sarcoidosis

The present study was carried out to compare radiological and physiological changes in sarcoidosis with biochemical markers for inflammatory cell populations. Of 53 patients with sarcoidosis, 28 had respiratory symptoms and 30 past or present bilateral hilar adenopathy without symptoms. A clinical score based on lung function tests and radiological findings correlated well with elevations of lysozyme and beta2-microglobulin in serum, indicating increased inflammatory cell activity in patients with more severe lung affection. A covariation between beta2-microglobulin and lysozyme was found, suggesting concomitant activation of macrophages and lymphocytes in sarcoidosis. Serum levels of lactoferrin were elevated in patients with a disease of short duration but did not correlate with the severity of the lung affection. The closing volume also seems to be abnormal in the early course of the disease, while elevated lysozyme and beta2-microglobulin levels rather seem to reflect the extent of the pulmonary affection.

Thyroid uptake of 67Ga-citrate is associated with thyroid autoimmunity and hypothyroidism in patients with sarcoidosis

PURPOSE

To evaluate the association of gallium-67 ((67)Ga)-citrate thyroid uptake with the presence of thyroid disorders in patients with sarcoidosis (S patients).

METHODS

Eighty-four S patients were evaluated by a complete thyroid work-up (neck ultrasound, circulating thyroid hormones and anti-thyroid antibodies, fine-needle aspiration).

RESULTS

In S patients with (67)Ga thyroid uptake (respect those without): serum thyroid-stimulating hormone, the titre of anti-thyroid peroxidase (AbTPO) and/or anti-thyroglobulin antibodies (AbTg), and the prevalence of S patients with hypothyroidism or with positive AbTg or AbTPO was significantly higher; a thyroid hypoechoic pattern was more frequent. The prevalence of thyroid nodules was not significantly different between the two groups. Two cases of papillary thyroid cancer were observed in S patients without (67)Ga thyroid uptake, whilst no case in those with (67)Ga thyroid uptake.

CONCLUSIONS

(67)Ga thyroid uptake is associated with the presence of aggressive autoimmune thyroiditis and hypothyroidism in S patients; thyroid function and ultrasonography should be performed in the presence of (67)Ga thyroid uptake.

Prevalence of hypothyroidism and Graves disease in sarcoidosis

BACKGROUND

The association of sarcoidosis (S) and thyroid autoimmunity has been reported by several studies in a wide range of variability. The aim of our study was to evaluate the prevalence of clinical and subclinical thyroid disorders in patients with S vs gender-matched and age-matched control subjects.

METHODS

Thyroid hormones and antithyroid antibodies, thyroid ultrasonography and fine-needle aspiration were performed in 111 patients with S who had been consecutively referred to the Respiratory Pathophysiology Section of the University of Pisa, and the results were compared to 333 gender-matched and age-matched control subjects from the same geographic area.

RESULTS

The odds ratio for subclinical hypothyroidism for female patients with S vs control subjects was 2.7 (95% confidence interval [CI], 1.3 to 5.9); for anti-thyroid peroxidase antibody titer (AbTPO) positivity, 2.2 (95% CI, 1.2 to 3.9); and for thyroid autoimmunity, 1.9 (95% CI, 1.1 to 3.2). The mean values of thyroid-stimulating hormone and AbTPO were higher in female S patients than in control subjects (p < 0.01). A significantly higher prevalence of clinical hypothyroidism (four patients) and Graves disease (three patients) was observed in female S patients than in control subjects (none; p = 0.005 and 0.0026, respectively). Two cases of papillary thyroid cancer were detected in S patients. No significant difference between S patients and control subjects was detected for free triiodothyronine and thyroxine, antithyroglobulin autoantibodies, thyroid volume and nodularity, and subclinical hyperthyroidism.

CONCLUSIONS

Thyroid function, AbTPO antibodies, and ultrasonography should be tested as part of the clinical profile in female S patients. Subjects who are at high risk (female subjects, those with positive AbTPOs, and those with hypoechoic and small thyroid) should have thyroid function follow-up and appropriate treatment in due course.

Sarcoidosis following HIV infection: evidence for CD4+ lymphocyte dependence

BACKGROUND

The chronic granulomatous inflammation of sarcoidosis has been hypothesized to depend on the CD4+ T-helper lymphocyte. HIV infection, which depletes these cells, has been reported to attenuate the manifestations of sarcoidosis.

STUDY OBJECTIVES

We asked whether the development of symptomatic sarcoidosis in the context of preexisting HIV infection was dependent on the CD4+ lymphocyte count.

DESIGN

We performed a retrospective standardized chart review of all patients who developed granulomatous inflammation following HIV infection at an urban academic referral center.

MEASUREMENTS

We identified seven patients with sarcoidosis within this cohort and compared their CD4+ lymphocyte count to that in a cohort of 16 patients in whom similar granulomatous inflammation was found but who did not have sarcoidosis. We then compared our cases to all reported cases using a systematic literature review.

RESULTS

The CD4+ lymphocyte count was > 200 cells/ microL in all of our patients with HIV infection when they developed subsequent sarcoidosis. In contrast, specific etiologies for granulomatous inflammation were found in all 10 HIV-infected patients who presented with granulomatous inflammation and a CD4+ lymphocyte count of < 200 cells/ microL, with infectious etiologies found in 8 patients. Similarly, there was relative preservation of the CD4+ lymphocyte count in previously reported cases, with 14 of 19 patients (74%) having an absolute CD4+ lymphocyte count of > 200 cells/ microL.

CONCLUSIONS

We conclude that the development of the chronic granulomatous inflammation of sarcoidosis appears to depend on the preservation or restoration of the peripheral CD4+ lymphocyte count and that in most cases the CD4+ lymphocyte count exceeds 200 cells/ microL. Furthermore, alternative specific etiologies of granulomatous inflammation are generally identifiable in HIV-infected patients with peripheral CD4+ lymphocyte counts of < 200 cells/ microL.

Increased expression of IL-12 receptor mRNA in active pulmonary tuberculosis and sarcoidosis

Cytokines have been implicated in the pathophysiology and development of pulmonary diseases such as tuberculosis and sarcoidosis. In particular, the numbers of cells expressing Th1-type cytokines such as IFN-gamma and IL-12 are increased within the lungs of patients with these granulomatous diseases. As a factor promoting the commitment of naive lymphocytes to a Th1-type profile of cytokine expression, IL-12 may be pivotal in the cascade of proinflammatory events within the airways. In this study, we examined the expression of the IL-12 receptor (IL-12R) mRNA in bronchoalveolar lavage (BAL) fluid from patients with active pulmonary tuberculosis (n = 6) and active pulmonary sarcoidosis (n = 6), and from allergic asthmatics (n = 6) and normal control subjects (n = 6). Bronchoscopy with BAL was undertaken, and cell cytospins were examined using the technique of in situ hybridization. There was a significant increase in the numbers of cells expressing mRNA for both beta(1) and beta(2) subunits of the IL-12R in active pulmonary sarcoidosis (p < 0.02, p < 0.01, respectively) and active pulmonary tuberculosis (p < 0.01, p < 0.005, respectively) compared with normal control subjects. In contrast, the allergic asthmatic patients exhibited a significant decrease in the number of IL-12R mRNA-positive cells (both beta(1) and beta(2) subunits (p < 0.01, p < 0.005, respectively), compared with the normal control subjects. These patients did, however, exhibit a significant increase in IL-4R mRNA, which was not evident in those with either tuberculosis or sarcoidosis when compared with normal subjects (p < 0.05). Colocalization studies demonstrated that CD8+ve cells are a principal site for the expression of IL-12R in tuberculosis. In sarcoidosis, IL-12R was expressed both on CD4+ve and CD8+ve cells. The increased expression of receptors for IL-12 in granulomatous diseases such as pulmonary tuberculosis and sarcoidosis provides evidence supporting the commitment of lymphocytes to a Th1-type cytokine profile in vivo.

Bronchoalveolar lavage fluid granulomas in a case of severe sarcoidosis

A case of pulmonary sarcoidosis is presented in which cytologic analysis of bronchoalveolar (BAL) fluid showed intact granulomas. The patient had severe alveolar inflammation and probable endobronchial sarcoidosis. Thus the granulomas in the BAL fluid probably reflect a high burden of alveolar wall granulomas and/or the removal of granulomas from proximal inflamed airways. This is the first reported case of granulomas in BAL fluid in sarcoidosis. Although an unusual finding, the recovery of BAL granulomas is not diagnostic for sarcoidosis and cannot substitute for the demonstration of granulomatous inflammation in lung tissue.

Randomized trial of prolonged chloroquine therapy in advanced pulmonary sarcoidosis

Sarcoidosis may cause severe ventilatory impairment requiring corticosteroid treatment. Chloroquine (CQ) can be an effective treatment for lung sarcoidosis with few side effects, but has not been accepted as standard therapy. We investigated the benefits of prolonged CQ therapy in 23 symptomatic patients with biopsy-proven pulmonary sarcoidosis (duration, >/= 2 yr). Patients were initially treated for 6 mo with CQ, 750 mg/d, tapering every 2 mo to 250 mg/d. Eighteen patients were then randomized to either a Maintenance group (CQ, 250 mg/d) or to an Observation group (no CQ). After the initial treatment, significant improvement was observed in symptoms, pulmonary function, angiotensin-converting enzyme, and lung gallium scan. Patients randomized to the Maintenance group showed a slower decline in pulmonary function (FEV1, 51.4 +/- 28.2 ml/yr [Maintenance] versus 196.3 +/- 33.4 ml/yr [Observation], p < 0.02) and had fewer relapses: 2 of 10 patients in the Maintenance group at 29.5 +/- 4.9 mo versus 6 of 8 patients in the Observation group at 15.5 +/- 2.9 mo. Adverse effects were seen mainly during high-CQ dosage. We conclude that CQ should be an important consideration for the treatment and maintenance of chronic pulmonary sarcoidosis.

Sarcoidosis: a pediatric perspective

Childhood sarcoidosis is a rare multisystemic granulomatous disease of unknown etiology. The clinical presentation can vary greatly depending upon the organs involved. Two distinct forms of sarcoidosis exist in children. Older children usually present with a multisystem disease similar to the adult manifestation, with frequent hilar lymphadenopathy and pulmonary infiltration. Early-onset childhood sarcoidosis is a unique form of the disease characterized by the triad of rash, uveitis, and arthritis in patients presenting before age 4 years. The diagnosis of sarcoidosis is confirmed by demonstrating a typical noncaseating granuloma on a biopsy specimen. The current therapy of choice for childhood sarcoidosis with multisystem involvement is corticosteroids. Methotrexate given orally in low doses is effective and safe and has steroid-sparing properties.

Mucosa-associated lymphoid tissue lymphoma coexisting with epithelioid granulomas in the stomach of a patient with systemic sarcoidosis

Malignant lymphoma arising in the stomach of a 23-year-old Japanese man with systemic sarcoidosis is presented. The patient was followed because of systemic sarcoidosis involving the lungs, eyes, and lymph nodes. Biopsy specimens from the stomach were repeated because of recurrent epigastralgia and multiple ulcerations. Some of the specimens revealed epithelioid granulomas with no caseous necrosis, which confirmed gastric involvement of sarcoidosis. Three years after the initial diagnosis, biopsy specimens taken from the stomach were diagnosed as malignant lymphoma of the large cell type. The resected stomach revealed multicentric mucosa-associated type malignant lymphoma of low-grade B cell type, with foci of high-grade transformation coexisting with numerous epithelioid granulomas with no caseous necrosis. Epithelioid granulomas were observed in all the respected lymph nodes, liver, and appendix, which had been obtained at operation, whereas malignant lymphoma was limited to the stomach. Helicobacter pylori (H. pylori) infection was also observed in the stomach. Consequently, the present report is a rare case of coexistence of malignant lymphoma and involvement of sarcoidosis in the stomach. Both H. pylori infection and active sarcoid nodules may play a role in the development of malignant lymphoma, although the exact mechanism remains unclear.

Bronchoalveolar lavage. Still useful in diagnosing sarcoidosis?

BALF parameters, if evaluated as a diagnostic or prognostic tool, should be based on a full understanding of the clinical profiles and course of pulmonary sarcoidosis. The various markers that have been reported so far are unreliable in determining the prognosis, although BALF lymphocytes and CD4/CD8 ratios are still useful for diagnosing sarcoidosis. It is critical to find feasible markers that relate to a change in disease activity and prognosis, because markers of chronicity may be different from those of progressively worsening sarcoidosis.

Immunology of sarcoidosis

Because of its association with cutaneous anergy, sarcoidosis was originally viewed as a defect of cellular immunity. Supporting that misperception were early studies of peripheral blood lymphocytes that found lymphopenia and impaired lymphocyte responses to mitogens and recall antigens. The clue to a vast underlying network of complex hyperactive cellular immune functions was discovered in the paradoxical finding of in vitro spontaneous lymphoblastic transformation and lymphokine production. Subsequently, investigative focus shifted to the activated, proliferating T-helper lymphocytes, the lymphokines of which were found to function in the recruitment and retention of monocytes for granuloma development. T-helper lymphocytes also contributed to the mechanism of hypergammaglobulinemia through their influence on B cells. The most intriguing question about sarcoid immunology is the initiating factor that triggers the T-lymphocyte activation and proliferation in the first place. There is much to suggest that antigen processing and presentation launches the process. Because lymphocyte activation and proliferation antedate granuloma formation at K-S skin test sites and in the lung, we combined the harvesting technique of BAL with the K-S bioassay to show that granulomagenic antigen is being processed by monocyte-macrophages. The finding of autologous monocyte-macrophage granulomagenicity raises the distinct possibility that sarcoidosis is a unique cell-mediated type of autoimmune process. The isolation and identification of the granulomagenic factor is the exciting research frontier ahead.

Increased inflammatory cytokines and new collagen formation in cutaneous tuberculosis and sarcoidosis

BACKGROUND

Interactions between mononuclear cells, vascular endothelium, fibroblasts, and cytokines during the inflammatory reaction within a granuloma have the potential to contribute to the progression to fibrosis.

METHODS

Biopsy specimens of six tuberculous and eight sarcoidosis skin lesions were examined by immunohistochemistry to seek evidence for the presence of inflammatory and fibrotic reactions in human granulomatous disease. Additionally, to understand how a T cell mediated delayed type hypersensitivity reaction--a component of chronic granulomatous inflammation--could progress to fibrosis, the human in vivo model of the cutaneous tuberculin Heaf reaction to purified protein derivative (PPD) was studied in a group of 48 subjects.

RESULTS

Granulomas from tuberculous and sarcoidosis skin biopsy specimens were seen to contain cells with marked staining by antibodies to fibronectin, transforming growth factor beta (pan TGF-beta), and type 1 procollagen (PCP-1). Accentuated staining of extracellular matrix was seen both in the granulomas and in the peri-granulomatous regions. Less prominent staining was observed using antibodies against interleukin 1 beta (IL-1 beta) and alpha-smooth muscle actin (alpha-SMA). Biopsies of Heaf reactions revealed cells staining for IL-1 beta, tumour necrosis factor alpha (TNF-alpha), platelet derived growth factor B (PDGF-B), and fibronectin which were detected as early as day 1 and persisted throughout the 14 day study period. Cells staining for PCP-1 increased to greatest abundance at day 14. All these cytokines were present in low abundance in biopsy specimens from sites inoculated with saline only.

CONCLUSIONS

Evidence is provided that granulomas in tuberculosis and sarcoidosis behave as active centres of fibrogenesis. Using the Heaf model, the temporal relationship between the early appearance of cytokines and the later increase in the collagen precursor PCP-1 linked the immune mediated chronic inflammatory response with subsequent fibrosis and suggested that the tuberculin Heaf reaction will serve as a model for studying the early events of granuloma formation in patients with tuberculosis and sarcoidosis.

TCR expression and clonality analysis in pulmonary sarcoidosis

Pulmonary sarcoidosis is a granulomatous disease characterized by the accumulation of activated T cells in the lower respiratory tract. To evaluate the hypothesis that sarcoidosis is characterized by a selective activation and expansion of a limited repertoire of T cell receptor (TCR)-specific T cells, we analyzed TCRAV and TCRBV gene expression in bronchoalveolar lavage (BAL) T cells from sarcoidosis patients and, for comparison, from patients with other pulmonary diseases where lymphocyte accumulation is not observed. Increased expression of TCRAV9 and TCRAV14 in BAL T cells was observed in sarcoidosis patients compared to these controls. To ascertain whether the accumulation of AV9 and AV14 expressing BAL T cells in sarcoidosis was the result of clonal expansion, the lengths of the CDR3 regions in AV9 and AV14 transcripts were determined. Some individual patient samples showed evidence of oligoclonality. However, in most cases, the data were consistent with the presence of many different clones. These data suggest that the bulk of BAL T cells in sarcoid patients are either nonspecifically recruited or are responding to a complex mixture of antigens.

Messages and handshakes: cellular interactions in pulmonary fibrosis

A better understanding of early cellular events following pulmonary injury may permit the identification of those patterns of response which are destined to progress to fibrosis. Interactions between inflammatory, fibroblastic and epithelial cells appear to play crucial roles in fibrogenesis. Intercellular communication may be via "messages" delivered by soluble mediators or "handshakes" at sites of cell-to-cell contact. In this review, we question the validity of some prevailing concepts about the importance of growth factor secretion by alveolar macrophages; examine the possible role of activated T-lymphocytes in regulating macrophage production of mediators; and hypothesise that whereas fibroblast proliferation may primarily be stimulated by macrophage-derived cytokines, accumulation of collagen may be regulated by growth factors expressed by injured alveolar epithelial cells.

Clonal analysis of lung and blood T cells in patients with sarcoidosis

BACKGROUND

Sarcoidosis is a disease characterised by clinical "anergy" to delayed type hypersensitivity antigens and the formation of non-caseating granulomas, which frequently manifests in the lungs as a T lymphocyte/mononuclear cell alveolitis. Although there is an increased proportion of T cells in bronchoalveolar lavage (BAL) samples from these patients, and these T cells often show evidence of activation and spontaneous secretion of cytokines such as interleukin 2 (IL-2) and interferon gamma (IFN gamma)--a pattern similar to delayed type hypersensitivity reactions--it is unclear whether both cytokines are produced by the majority of T cells derived from the lungs of patients with sarcoidosis or whether unique subpopulations of T cells produce each cytokine. In this study the properties of T cells cloned from BAL fluid samples of patients with sarcoidosis have been analysed.

METHODS

T cells were cloned by limiting dilution using IL-2, phytohaemagglutinin, and irradiated feeder cells. Cloning efficiencies were compared and phytohaemagglutinin induced clonal production of IL-2, IFN gamma, and IL-4 was determined by bioassay (IL-2 and IFN gamma) or ELISA (IL-4).

RESULTS

T cells derived from the BAL fluid of patients with sarcoidosis cloned less efficiently than those from blood of the same individuals. Lung derived clones (CD4+ or CD8+) produced IFN gamma more frequently and to a higher titre than blood derived clones, whereas IL-2 production by CD4+ clones derived from BAL fluid was less than that from blood derived clones. Interestingly, IL-4 production by clones from both sites was similar. Analysis of the co-production of IL-2, IFN gamma, and IL-4 by these BAL fluid clones did not demonstrate a predominant "Th1"-like population which has been suggested to underlie delayed type hypersensitivity reactions.

CONCLUSIONS

The reduced cloning efficiency of T cells from the lung compared with the blood in sarcoidosis is consistent with, although probably more pronounced than, previous observations in normal lungs and shows that T cell hyporesponsiveness is not overcome in the lungs of patients with sarcoidosis. Furthermore, major differences exist between the cytokine producing potential of T cells derived from the lung and the blood in sarcoidosis, and these parallel the differences in the properties of blood and lung T cells seen in healthy individuals.

Recurrence of sarcoidosis in pulmonary allograft recipients

Lung transplantation is a potentially curative therapy for the end-stage pulmonary sequelae of sarcoidosis. We reviewed the course of five lung allograft recipients with underlying sarcoidosis (S) at the University of Pittsburgh Medical Center and compared them with a control group (C) of 44 contemporaneous transplant recipients with other respiratory diseases. Sarcoid granulomata have developed in the allografts of 4 S, although these lesions have not yet been demonstrated to result in clinically significant abnormalities. In comparison with C, sarcoidosis patients had significantly greater mean grades of acute rejection during the first 3 months after transplantation (2.1 +/- 0.3 versus 1.6 +/- 0.1, S and C, respectively, p < 0.042) and larger proportions of lung biopsies showing more than mild acute rejection (40 versus 18%, p < 0.012) and lymphocytic bronchitis (30 versus 13%, p = 0.02), as well as a greater percentage of polymorphonuclear leukocytes in BAL returns (34.9 +/- 5.4 versus 19.0 +/- 1.6, p < 0.01). The two groups did not differ, however, in frequency of obliterative bronchiolitis, survival, or pulmonary function. We conclude that lung transplant recipients with underlying sarcoidosis are very likely to develop recurrent disease in the allograft and have more severe acute rejection responses, especially in the first weeks after transplantation. Pulmonary transplantation appears to be an efficacious therapy for end-stage sarcoidosis, but the long-term sequelae of the increased acute rejection and recurrent sarcoidosis in the allograft remain to be determined.

Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis

STUDY DESIGN

Between February 1, 1984, and February 1, 1989, fiberoptic bronchoscopy was performed on 2,692 patients, 592 of whom had bronchoalveolar lavage (BAL). One hundred twenty-eight patients with 16 percent or more lymphocytes in BAL fluid (BALF) were selected for further study. The group included 27 patients with sarcoidosis, 28 with nonsarcoidosis interstitial lung disease (ILD), 22 with lung infection (organism isolated), 31 with inflammation (presumed infection, no organism isolated), 14 with neoplasm, and 6 with bronchial hyperreactivity.

METHODS

The percentages of lymphocytes, B lymphocytes, and T lymphocytes, the CD4/CD8 ratio and the percentages of neutrophils and eosinophils were analyzed individually and in combination for discrimination between the sarcoidosis and nonsarcoidosis patients and compared with the diagnostic accuracy of multiple noncaseating granuloma (MNG) on a simultaneous transbronchial biopsy (Tbbx).

RESULTS

Neither the percentages of lymphocytes, T lymphocytes, or B lymphocytes discriminated sarcoidosis from nonsarcoidosis patients. Sarcoidosis patients had higher CD4/CD8 ratios, fewer neutrophils, and 1 percent or less eosinophils in the BAL cell populations. An analysis of CD4/CD8 ratios, and percentages of neutrophils and eosinophils individually revealed that a CD4/CD8 ratio of 4:1 or greater had a positive predictive value of 94 percent in distinguishing sarcoidosis from other ILD but a sensitivity of only 59 percent. The positive predictive value of CD4/CD8 ratio of 4:1 or greater fell to 50 percent in separating sarcoidosis from all other diseases. A CD4/CD8 ratio of less than 1:1 has a 100 percent negative predictive value to exclude the diagnosis of sarcoidosis. Finding 1 percent or less neutrophils in BAL had an 80 percent positive predictive value in distinguishing sarcoidosis from nonsarcoidosis ILD and 51 percent for distinguishing sarcoidosis from all other disease groups. The CD4/CD8 ratio and the percentages of neutrophils and eosinophils also were combined and analyzed for the diagnosis of sarcoidosis.

CONCLUSIONS

Results showed a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils has essentially the same specificity and positive predictive value as MNG on Tbbx in distinguishing sarcoidosis from nonsarcoidosis disease. The combination of finding MNG in a Tbbx specimen plus a BALF CD4/CD8 ratio of 4:1 or greater had a 100 percent positive predictive value in separating sarcoidosis from other ILD and an 81 percent value in separating sarcoidosis from all other disease. Finding MNG in a Tbbx specimen plus a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils had a 93 percent positive predictive value in distinguishing sarcoidosis from both nonsarcoidosis ILD and all other diseases.

Relative release of interleukin-1 beta and interleukin-1 receptor antagonist by alveolar macrophages. A study in asbestos-induced lung disease, sarcoidosis, and idiopathic pulmonary fibrosis

We examined the influence of untreated interstitial lung disease (ILD) on the in vitro release of interleukin-1 beta (IL-1 beta) and interleukin-1 receptor antagonist (IL-Ira) from alveolar macrophages (AM); AM were harvested from normal volunteers, ILD patients, and patients with asbestos-related pleural disease but no ILD. AM were cultured for 24 h and assays for IL-1 beta and IL-1ra were done using sensitive and specific enzyme-linked immunosorbent assay. A greater amount of IL-1 beta was detected in AM supernatants from asbestosis, sarcoidosis, and IPF patients than in those from normal subjects. The IL-1 beta:IL-1ra ratio (IL-1 beta activity index [IL-1AI]) was significantly lower in supernatants of normal macrophages compared with macrophage supernatants from individuals with ILD. The IL-1AI correlated with bronchoalveolar lavage cellularity, a marker of disease activity. Current smoking was associated with lower IL-1 beta and IL-1ra release in ILD. The IL-1AI is a convenient method for comparison of IL-1 beta activity between patient populations.

Peripolesis in alveolar sarcoidosis

We observed that in bronchoalveolar lavages (BAL) of patients with active sarcoidosis (SARC) a mononuclear cell infiltrate is present that often contains clusters consisting of lymphocytes adhering to a macrophage. In order to investigate what kind of cellular interactions are involved in such a process, cell suspensions obtained from BAL of patients with SARC or extrinsic allergic alveolitis (EAA) were cultured for 1 to 2 days, during which time lapse cinematography was applied. We were able to show that such clusters consist of lymphocytes gathered around a macrophage. This is known as peripolesis. Peripolesis, as observed in our BAL, could last for some minutes or for some hours during which time a number of lymphocytes were moving around a single alveolar macrophage, without losing contact with the macrophage. Short interactions were mostly observed in EAA, whereas SARC was characterized by long periods of lymphocyte-macrophage cooperation. We also found a correlation between the time-dependent peripolesis t > 30 min/t < 30 min and the CD4/CD8 ratio. Although the precise mechanisms of peripolesis are not well understood, some interactions between lymphocytes and macrophages have now become more comprehensive.

Clonal expansion of lung V delta 1+ T cells in pulmonary sarcoidosis

Sarcoidosis is a multisystem disease of unknown etiology characterized by the presence of noncaseating granulomas in involved tissues. To investigate a potential role for gamma/delta T cells in the pathogenesis of pulmonary sarcoidosis, we studied lung and blood T cells from patients for preferential expression of particular gamma/delta T cell receptors. An abnormally high percentage of gamma/delta cells was found in the blood of some patients. However, the increased percentage did not reflect an increase in absolute number, and appeared to be secondary to a decrease in T cells expressing alpha/beta receptors. Furthermore, as in normals, the circulating gamma/delta cells in patients predominantly expressed V gamma 9/V delta 2 receptors, a subset that was not enriched at the site of disease. In contrast, in the lung, an increased percentage of gamma/delta cells expressing V delta 1 was found in a subset of patients. Importantly, these cells demonstrated evidence of prior activation by selectively expanding in vitro in the presence of interleukin 2. Furthermore, an analysis of junctional region sequences revealed their clonal nature. These clonal expansions of V delta 1+ cells in pulmonary sarcoidosis provide evidence for a disease process that involves specific recognition of a local antigen by T cells, and contributes new information regarding the nature of the as yet undefined antigenic stimulus.

Soluble interleukin 2 receptors in patients with sarcoidosis. Possible origin

We determined levels of soluble interleukin 2 receptors (IL-2R) in patients with sarcoidosis and further examined their origin. Thirty-nine patients with sarcoidosis and 18 healthy control subjects were studied. Soluble IL-2R levels in serum were significantly higher (p < 0.01) in sarcoidosis than in control subjects. In sarcoidosis, levels of soluble IL-2R in serum were significantly higher (p < 0.05) in patients with active disease than those with inactive disease and were significantly (p < 0.01) correlated with serum angiotensin-converting enzyme (ACE) levels. IL-2R expression on monocytes and alveolar macrophages (AMs) was significantly (p < 0.01) increased in patients with sarcoidosis as compared with control subjects. Soluble IL-2R levels in the supernatants of cultured monocytes and AMs were higher in patients with sarcoidosis than in control subjects. Those of cultured T lymphocytes obtained from peripheral blood and bronchoalveolar lavage fluid were detected in some patients with sarcoidosis, while undetected in control subjects. Furthermore, soluble IL-2R in serum was significantly correlated with soluble IL-2R in the supernatants of cultured monocytes and AMs (p < 0.01 and p < 0.05, respectively). These results demonstrate that soluble IL-2R in serum is a useful index of the disease activity of sarcoidosis and is mainly derived from monocytes and AMs.

Scintigraphy with J001 macrophage targeting glycolipopeptide. A new approach for sarcoidosis imaging

Scintigraphy with radiolabeled J001 as a ligand for macrophage targeting is a new approach for sarcoidosis imaging. J001 is a fully characterized acylated peptido-poly (1,3) galactoside isolated from Klebsiella membrane proteoglycans and able to bind electively recruited macrophages. Its physiochemical properties allow rapid absorption by the respiratory tract when this agent, labeled by 99m technetium, is administered as an aerosol. Images are obtained within 3 to 5 h after inhalation. In the present study, we determined the ability of J001 scintigraphy to localize areas of sarcoidosis involvement in 22 patients compared with gallium scanning in ten of them. Nineteen patients underwent bronchoalveolar lavage (BAL) and serum angiotensin-converting enzyme (ACE) assay. J001 scintigraphy was also performed on a control group of six patients with extrathoracic melanoma, in whom J001 scintigraphy was used to evaluate the cutaneous extent of the tumor and the lymph node involvement. In this control group, no fixation appeared in the thoracic area. In the sarcoidosis group, 18 positive results were observed. One stage 0 patient had a mediastinal fixation. Five of the six stage 1 patients had a fixation located in the mediastinum, the lungs, and the wrists. Five of the six stage 2 patients had positive foci located in the mediastinum or the lung areas and in the myocardium in one of them. Six of the nine stage 3 patients had positive J001 scintigraphy occurring in the lungs and/or the mediastinum. One patient had a fixation on the main bronchi. J001 scintigraphy and gallium scanning, performed in ten patients, were positive in seven of them. There were discrepancies between the BAL results and J001 scintigraphy, as well as between the ACE results and J001 scintigraphy. In conclusion, 99mTc-J001 scintigraphy appears to be a sensitive and rapid technique for the imaging of thoracic sarcoidosis at the three stages of the disease.

An ultrastructural and cytochemical study of the pulmonary lesions and multinucleate giant cells in porcine dermatosis vegetans

The pulmonary lesions and multinucleate giant cell formations in porcine dermatosis vegetans were studied ultrastructurally and cytochemically in seven affected pigs that ranged from one to 120 days of age. At birth, no pulmonary lesions were observed. By seven days of age, there was a moderate infiltration of monocytes/macrophages in the alveoli and interstitium. These changes progressed, and by two weeks of age there was pronounced infiltration of macrophages and lymphocytes in the alveoli. Close apposition of macrophages and lymphocytes was observed, and cellular contact was demonstrated. By three to four weeks of age, small aggregates with epithelioid cells, macrophages, and lymphocytes resembling granulomas were present. In an older pig, aged four months, the inflammatory changes waned. Large macrophages, and large and small multinucleate cells shared common morphological characteristics of cytoplasm endowed with organelles, primary and secondary lysosomes, Golgi profiles, and granular endoplasmic reticulum. Cytochemically, macrophages and MGCs were positive for acid phosphatase. The present study showed that the initial pulmonary changes share morphological characteristics with a granulomatous inflammatory response, and evolve into small granulomas with macrophages, epithelioid cells and lymphocytes. Morphologically, these changes share characteristics with epithelioid cell granulomas. Macrophages and MGCs share common ultrastructural traits, and are positive for acid phosphatase. MGCs seem to evolve in the course of the granulomatous inflammatory response and are probably of monocyte/macrophage origin.

Monocyte heterogeneity in angiotensin-converting enzyme induction mediated by autologous T lymphocytes

The ability of monocyte subpopulations to be induced selectively by T lymphocytes to synthesize enhanced levels of angiotensin-converting enzyme (ACE) was examined using an in vitro model employing normal peripheral blood monocytes and T lymphocytes. Separation of monocytes into subpopulations on the basis of buoyant density indicated no difference in the ability of the resulting monocyte subpopulations to produce basal levels of ACE when cultured in the absence of T lymphocytes. However, the subpopulations differed significantly in their ability to synthesize enhanced levels of ACE in response to the presence of autologous T lymphocytes; low-density monocytes were induced by T lymphocytes to synthesize three-fold more ACE than were high-density monocytes. Surface antigen labelling using MoAbs demonstrated that the low-density monocyte subpopulations also had a significantly higher percentage of Leu-M2+ monocytes compared with the high-density monocyte subpopulations. When monocytes were separated on the basis of the presence of the Leu-M2 antigen using an immune rosetting technique, T lymphocytes were able to induce significantly elevated levels of ACE in the Leu-M2+ enriched monocyte subpopulation but were unable to induce ACE beyond basal levels in the Leu-M2(+)-depleted monocyte subpopulation. These results demonstrate that monocytes are heterogeneous with respect to their ability to be induced by T lymphocytes to synthesize ACE. This raises the possibility that selective accumulation of a monocyte subpopulation in the granulomatous inflammation of sarcoidosis may be one of the factors required for elevated ACE synthesis in the resulting granuloma epithelioid cells.

Hashimoto's thyroiditis with granulomas: A unifying immunological etiology?

Two cases of granulomatous inflammation of the thyroid gland associated with Hashimoto's thyroiditis are presented. In neither case is there an obvious cause of granuloma formation, the only accompanying abnormality being rheumatoid arthritis in one of the patients. Autoimmune thyroid disease has been reported in association with sarcoidosis as well as rheumatoid arthritis, diseases in which cellular immunity is activated. Immune mechanisms alone are capable of initiating and amplifying granulomatous inflammation. In this report, we suggest that the granulomas in both cases may have their origin in immunological malfunction, the same immunological malfunction responsible for Hashimoto's thyroiditis.

Bronchoalveolar lavage in alcoholic liver cirrhosis. T-lymphocyte subsets and immunoglobulin concentrations

The purpose of this study was to determine the phenotype profiles of immune effector cells and the concentrations of immunoglobulins in the lower respiratory tract of non-smoking patients with alcoholic liver cirrhosis (ALC). Nine nonsmoking patients with liver biopsy-proved ALC (grade B or C cirrhosis in Child's classification), free of clinical pulmonary symptoms, and with normal chest roentgenogram were included in the study. The control group included 12 healthy nonsmokers. Each patient had fiberoptic bronchoscopy with bronchoalveolar lavage (BAL). The number of T cells and of lymphocyte subpopulations was determined by immunofluorescence studies using monoclonal antibodies that were specific for CD3, CD4, and CD8 markers. Patients with ALC exhibited a dramatically increased percentage of CD8+ cells in BAL that induced a low CD4/CD8 ratio (0.96 +/- 0.15 vs 1.8 +/- 0.12 in healthy controls). Further characterization of lymphocyte subsets' dual immunofluorescence analysis demonstrated that most of the CD8+ alveolar lymphocytes had a phenotype of cytotoxic cells (CD8+ CD11b-; 48 percent +/- 13 in ALC vs 10 percent +/- 5 in controls). ALC was associated with an appreciable alveolar-capillary "leak" as demonstrated by a significant increase in BAL fluid albumin. In addition, the concentrations of immunoglobulins in BAL fluid were significantly greater in ALC than in controls. However, the relative (to albumin) coefficient of excretion of IgG, A, and M in and alpha 2-macroglobulin BAL fluid was not significantly different between controls and ALC. Our results indicate that increased proportions of CB8+ and especially of CD8+ CD11b- cells are a common feature in the lower respiratory tract of nonsmoking patients with ALC. These changes may be of potential functional importance in the regulation of the local pulmonary immune response in ALC.

Prognostic value of bronchoalveolar lavage lymphocyte count in recently diagnosed pulmonary sarcoidosis

We prospectively looked at the prognostic value of bronchoalveolar lavage (BAL) lymphocyte count in 98 patients with recently diagnosed (less than 4 months) untreated sarcoidosis. These 50 men and 48 women (mean age, 37.4) were followed up for a period of 6 to 60 months (mean, 25.6), and were clinically evaluated every three to six months with repeated chest roentgenograms and pulmonary function tests. Twenty-four patients required steroid treatment during the study period. The proportion of treated patients was not significantly higher in the group presenting a BAL lymphocyte count less than or equal to 30 percent at diagnosis than in the group with fewer lymphocytes (31.9 and 17.7 percent of total group respectively, p = 0.10). No significant change in TLC, FRC, FVC, FEV1 or DLCO was found at follow-up between the groups with or without an initial high lymphocyte count. In the treated group, BAL lymphocyte percent weakly correlated with the improvement of FEV1 and FVC while on steroid treatment (mean duration: 3.5 months): r = 0.41, p = 0.031 and r = 0.36, p = 0.05 respectively; no correlation was found with lung volumes and DCO. We conclude that BAL lymphocyte count at the time of diagnosis is not a helpful predictor of lung function deterioration in recently diagnosed sarcoidosis and is not very useful in predicting response to treatment.

Macrophage chemotactic factor partially purified from granulomatous inflammation

Pathophysiological roles of macrophage chemotactic factor (MCF) in granulomatous inflammation were investigated. MCF was extracted in 10 mM phosphate-buffered saline, pH 7.4, from experimentally produced epithelioid cell granulomas in the liver and skin of mice. MCF activity reached a peak in the lesions prior to the time when granulomatous inflammation became maximal. MCF was then purified from 10-week-old hepatic granulomas and 2-week-old skin lesions by gel filtration, ion exchange column chromatography, and HPLC gel filtration. MCF from either liver or skin had a molecular weight about 650 kDa. MCF from hepatic granulomas was coupled to Affi-Gel beads and transplanted subcutaneously into naive mice. In vivo macrophage chemotaxis was observed around the beads and the cells formed a sheet, but organization of macrophages into granulomas did not occur with the MCF-active fractions. Macrophage chemotaxis alone is insufficient to elicit granulomatous inflammation.

Comparison of the T lymphocyte-dependent induction of angiotensin-converting enzyme and leucine aminopeptidase in cultured human monocytes

The T lymphocyte-mediated induction of angiotensin-converting enzyme (ACE) in cultured autologous peripheral blood monocytes has been proposed as a model system for the investigation of the in vivo induction of ACE in the monocyte-derived granuloma epithelioid cells of some granulomatous diseases such as sarcoidosis. The studies described here were designed to evaluate the specificity of the model system by comparing the parameters for induction of ACE with those for the induction of another monocyte metallo-ecto-peptidase, leucine aminopeptidase (LAP). The concentration of LAP in freshly isolated monocytes was 0.09 mU/10(6) monocytes (s.e.m. 0.04) and increased to a maximal value of 0.19 mU/10(6) monocytes (s.e.m. 0.32) after 3 days when monocytes were cultured alone. ACE was not detectable in freshly isolated monocytes. However, after 6 days of culture, monocytes contained 0.22 mU ACE/10(6) monocytes (s.e.m. 0.04). Comparison of the levels of ACE and LAP induced during culture of monocytes alone indicated that the induction of these two enzymes were correlated. The induction of both enzymes was further enhanced by the presence of T lymphocytes in a dose-dependent manner. At 4 x 10(6) T lymphocytes per culture, ACE levels increased to 1.81 mU/10(6) monocytes (s.e.m. 0.24) and LAP levels to 1.03 mU/10(6) monocytes (s.e.m. 0.35). The enhancement of ACE activity required autologous lymphocytes, while heterologous T lymphocytes were equally effective in inducing LAP. Comparison of the levels of ACE and LAP induced during coculture of autologous T lymphocytes and monocytes from 21 independent donors, demonstrated no correlation between the induction of ACE and LAP. These data indicate that, although T lymphocytes also enhance the induction of LAP, the underlying mechanism must differ from that of ACE induction.

Characteristics and clinical significance of the lymphocytic alveolitis in interstitial lung disorders

Although the mechanisms responsible for lung damage and respiratory function deterioration for each type of alveolitis are not entirely known, with the opportunity to study the cells present in the lower respiratory tract, their functions and the mediators released in different conditions, we will be able to better understand the link between the inflammatory process, the acute tissue damage, the progression of the disease and the pulmonary scarring. This knowledge will be helpful in a better management of patients with interstitial lung diseases modulated by immunologic mechanisms.

Antigen-presenting capacity in patients with sarcoidosis

Antigen-presenting capacity by monocytes and AMs was determined in 13 patients with sarcoidosis and nine healthy control subjects, using PPD as the antigen. The patients and healthy control subjects all had positive PPD skin tests. Monocytes from both the control subjects and the patients with sarcoidosis exhibited antigen-presenting capacity to autologous peripheral T-lymphocytes, without any significant difference between the two groups. The AMs from patients, but not control subjects, demonstrated antigen-presenting capacity to autologous peripheral T-lymphocytes. Antigen-presenting capacity by monocytes and AMs to lung T-lymphocytes was lower than to peripheral T-lymphocytes, but not significantly. Antigen-presenting capacity was not significantly different between patients with sarcoidosis who had positive and negative PPD skin tests. The mechanism of enhanced antigen-presenting capacity by AMs in sarcoidosis is uncertain at present, but no significant difference was observed in DR antigen expression on AMs between controls and patients with sarcoidosis, and the addition of exogenous IL-1 or IFN-gamma did not induce antigen-presenting capacity by AMs in controls, suggesting that neither increased DR antigen expression on AMs nor increased release of IL-1 or IFN-gamma from AMs is responsible. Thus, these results suggest that T-lymphocyte activation in sarcoidosis may in part be attributable to an enhanced antigen-presenting capacity by AMs.

Diversity in junctional sequences associated with the common human V gamma 9 and V delta 2 gene segments in normal blood and lung compared with the limited diversity in a granulomatous disease

The T cell receptor (TCR) junctional regions (N regions) of the common human V gamma 9 and V delta 2 gene segments were sequenced from the blood and lung of normal individuals (195 transcripts) and a group of individuals with sarcoidosis (220 transcripts), a granulomatous disease in which increased numbers of V gamma 9+ gamma/delta + T cells are often observed. In normal individuals, the vast majority (86%) of blood V gamma 9 transcripts used the J gamma P gene segment. In contrast to this restriction of J region usage, there was a large diversity of the junctional region, with less than 20% of blood V gamma 9 junctional regions showing identical sequences for any one normal individual. For the blood V delta 2 transcripts in normal individuals, there was restriction of J region usage, with 93% using J delta 1. The junctional regions were even more diverse than for V gamma 9, with a unique sequence observed in each transcript examined. Compared with blood, sequences from the normal lung showed a small increase in identical junctional regions, particularly in one individual where 46% of V gamma 9 transcripts examined were identical, suggesting a response of some gamma/delta T cells to antigens found in the lung in the normal state. In marked contrast to normals, some individuals with sarcoidosis had large numbers of V gamma 9 transcripts, as well as V delta 2 transcripts, sharing identical sequences. For V gamma 9 blood transcripts, two individuals showed 84 and 56% of junctional region sequences to be identical, respectively. Similarly, blood V delta 2 transcripts showed 43, 33, and 25% identical junctional region sequences in three individuals. In the sarcoid patient with the most striking over-representation of blood V gamma 9 junctional sequences, lung V gamma 9 transcripts showed increased (67%) use of the same junctional region sequence as in blood. This limited diversity of TCR junctional regions among some individuals with sarcoidosis suggests a response from specific stimuli, possibly antigenic, and that gamma/delta T cells may play a specific role in granuloma formation in sarcoidosis, as has been suggested in other granulomatous diseases.