Activated alveolar macrophage and lymphocyte alveolitis in extrathoracic sarcoidosis without radiological mediastinopulmonary involvement

Case report: middle-aged woman from Ghana with unsteady gait and enlarging cerebellar mass

RATIONALE

Neurosarcoidosis (NS) is an uncommon manifestation of systemic sarcoidosis, with a propensity for middle-agedwomen. Often discovered only at autopsy, rates of neurologic involvement (5%-10%) reported in the literature underscore a lack of sensitivity and specificity in current diagnostic methods.

PATIENT CONCERNS

Herein, we describe a 53-year-old woman who presented with gait imbalance and distal extremity muscular weakness. She was known to harbor a brain mass (4 years in duration) that was monitored and recently seemed to enlarge.

DIAGNOSIS

A subsequent brain biopsy showed necrotizing granulomatous inflammation suggestive of NS. However, no clinical or radiologic evidence of activity was found in other organs.

INTERVENTIONS AND OUTCOMES

Ultimately, endo and transbronchial biopsies were performed, providing histologic confirmation of systemic sarcoidosis.

LESSONS

This approach is advised in all instances of suspected NS where systemic involvement is in question.

Uterine Sarcoidosis Potentially Associated With Interferon-α Use for Chronic Hepatitis C Infection

BACKGROUND

A regimen including interferon-alpha has become the standard of care in the treatment of chronic hepatitis C over the last decade. One rare adverse effect associated with the use of interferon-alpha is a granulomatous pulmonary reaction.

CASE

A unique case of uterine sarcoidosis associated with the use of interferon-alpha for chronic hepatitis C infection is presented.

CONCLUSION

Gynecologists should be aware of a potential association between interferon-alpha therapy and granulomatous reactions occurring not only in the lung but also in the female genital tract.

Significance of lymphocytosis in bronchoalveolar lavage in suspected ocular sarcoidosis

Ocular sarcoidosis is frequent in Japan, but in many cases the condition remains undiagnosed in patients with suspected ocular sarcoidosis. Bronchoalveolar lavage (BAL) was performed in order to study the clinical implications of lymphocytosis of BAL fluid in such patients with characteristic ocular manifestations. The subjects included in this study were 39 patients with suspected ocular sarcoidosis. The patients were divided into four types based on high-resolution computed tomography (HRCT) findings; no lung involvement (HRCT-0), bilateral hilar lymphadenopathy (BHL) without lung involvement (HRCT-I), lung involvement and BHL (HRCT-II), and lung involvement and no BHL (HRCT-III). Transbronchial lung biopsy (TBLB) and BAL were conducted after examining serum angiotensin-converting enzyme and serum lysozyme values, skin test for purified protein derivative chest radiograph, HRCT, and gallium scintigram. Twenty patients were histologically diagnosed as having sarcoidosis, and 19 patients remained undiagnosed. Granuloma was identified by TBLB in 19 of 20 patients in type HRCT-II but in only one of 19 patients in types HRCT-0 and HRCT-I (p<0.0001). Lymphocytosis in BAL (>15%) was identified in all patients who showed lung field involvement (type HRCT-II) and in 16 of 19 patients without lung field involvement (types HRCT-0 and HRCT-I). There were 10 patients whose only relevant findings were lymphocytosis in BAL. Among these 10 patients, an increased CD4+/CD8+ ratio (>3.5) in BAL was seen in 60%. The authors conclude that high-resolution computed tomography results yield the same degree of diagnostic accuracy as transbronchial lung biopsy in ocular sarcoidosis suspects. However, bronchoalveolar lavage revealed significant lymphocytosis in patients with negative high-resolution computed tomography results. It should be kept in mind that a diagnostic group of patients with sarcoidosis who manifest ocular involvement and lymphocytosis in bronchoalveolar lavage exists.

Sarcoidosis of the eye, orbit, and central nervous system. Role of MR imaging

Sarcoidosis, a systemic disease of unknown cause, frequently involves the eye, orbit, and central nervous system. The MR imaging findings of orbital and optic pathway sarcoidosis may closely resemble several other orbital and intracranial diseases. This article reviews MR imaging findings of sarcoidosis when it involves the eye, orbit, and visual pathways. Careful review of MR findings and other neuroimaging findings and clinical characteristics will reduce the incidence of mistaking optic nerve and chiasmal sarcoidosis for meningioma or glioma.

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.

Photon emission of phagocytes in relation to stress and disease

Phagocytes, the first-line cells of the body's defence mechanisms against invading pathogens, kill microorganisms by means of lysosomal degradative enzymes and highly toxic reactive oxygen intermediates. The reactive oxygen compounds are produced, in a process called the 'respiratory burst', by the NADPH oxidase complex in plasma membranes, and by myeloperoxidase in phagolysosomes after degranulation. These processes generate electronically excited states which, on relaxation, emit photons, giving rise to phagocyte chemiluminescence (CL). This paper describes the conditions for the measurement of CL, and reviews the activity of phagocytes from individuals undergoing stress or disease. The capability of phagocytes to emit photons reflects remarkably well the pathophysiological state of the host. In many cases even the magnitude of the stress, the presence of a pathogen in the body, or the activity of the disease can be estimated. Physiological changes, e.g. in the reproductive cycle, can also be predicted.

Subclinical alveolitis in immunologic systemic disorders

Subclinical alveolitis is a frequent finding in immunologic systemic disorders. However the significance of subclinical alveolar inflammation does not seem to be univocal and varies according to the disease. The fact that pulmonary involvement is rare during the course of extrathoracic granulomatosis like Crohn's disease or primary cirrhosis and that subclinical alveolitis is frequent suggests that alveolar inflammation may be the expression in the lung of a systemic immune disorder. In contrast subclinical alveolitis in collagen-vascular diseases, particularly progressive systemic sclerosis, is frequently associated with abnormalities of lung parenchyma as assessed by CT scan supporting the hypothesis that subclinical alveolitis is associated with development of ILD. Close follow-up of these patients is needed to better determine whether subclinical alveolitis precedes ILD and whether early detection of subclinical alveolitis in immunologic systemic disorders may identify those patients that are at risk for the development of ILD in the future.

Are there characteristic alterations in lung tissue associated with Crohn's disease?

Two male patients aged 12 and 31 years suffered from Crohn's disease for more than six years and were treated with Cortison for more than four years. Surgical excision of parts of the terminal ileum was performed in both patients. They suffered from pulmonary symptoms as dyspnoea, shortness of breath and ventilation disturbances two years after operation. Wedge biopsies of the lungs revealed the following histomorphological findings: 1. Granulomatous interstitial lymphocyte infiltrates 2. Acute alveolitis with severe dysplasia of pneumocytes 3. Moderate interstitial fibrosis. Immunohistology performed in one case showed predominantly lambda chains expressed by lymphocytes associated with IgA and IgM. IgG was missing, furthermore kappa chains could not be detected. Macrophages contained endogenous lectins (sugar receptors) for fucose, maltose, and N-acetyl-D-glucosamine (glcNAc). No receptors specific for mannose, lactose, and heparin could be found. Pneumocytes did not bind the neoglycoproteins but were found to express HLA-DR receptors detectable by the monoclonal antibody LN 3 in dysplastic pneumocytes only. The histomorphological and immunohistochemical findings suggest that the analyzed alterations of lung tissue are related to the underlying disease of enteritis regionalis.

From subclinical alveolitis to granulomatosis. Sequential evaluation of pulmonary involvement in extrathoracic sarcoidosis

Follow-up of patients with subclinical inflammatory alveolitis associated with systemic diseases may represent the best opportunity to study the mechanisms responsible for the development of interstitial lung disease. We report a seven-year sequential pulmonary evaluation of one patient with clinically isolated gastric sarcoidosis, treated by gastrectomy, without evidence of clinical, radiologic or functional lung impairment and with chronic subclinical lymphocyte alveolitis. Five years later, she developed an overt interstitial lung disease characterized by fine crackles, diffuse parenchymal opacities and impaired diffusing capacity, preceded by an expansion of polymorphonuclear neutrophils in the lower respiratory tract, raising the hypothesis that these cells may be implicated in the pathogenesis of pulmonary derangement in sarcoidosis. This observation illustrates the importance of pulmonary follow-up of unaffected patients with systemic diseases and with subclinical inflammatory alveolitis, and the potential predictive value of neutrophil alveolitis in the pulmonary outcome of these patients.

Lymphocyte subpopulations in bronchoalveolar lavage in Sjögren's syndrome. Evidence for an expansion of cytotoxic/suppressor subset in patients with alveolar neutrophilia

We initiated this study to determine the cellular composition and T-lymphocyte subpopulations of fluid from bronchoalveolar lavage from 15 patients with primary Sjögren's syndrome (1SS), six patients with secondary Sjögren's syndrome associated with primary biliary cirrhosis (2SS-PBC), eight patients with secondary Sjögren's syndrome associated with collagen-vascular diseases (2SS-CVD), and 12 normal subjects. All were nonsmokers who were free of clinical pulmonary symptoms and had normal findings on chest roentgenograms. Lymphocyte subsets were identified by mouse monoclonal antibodies that were specific for T-cells, helper/inducer, and suppressor/cytotoxic (namely, OKT3, OKT4, and OKT8). Patients with 1SS, patients with 2SS-PBC, and patients with 2SS-CVD had a significantly increased percentage of lymphocytes in fluid from bronchoalveolar lavage (respectively, 21.6 +/- 3.7 percent, 24.3 +/- 6.1 percent, and 25.6 +/- 3.9 percent) compared with the normal value of control subjects (9.9 +/- 1.5 percent). In addition, two of the 15 patients with 1SS and five of the eight patients with 2SS-CVD demonstrated an increased percentage of alveolar neutrophils. The predominant T-cell subset in patients with 1SS was T4+, and the mean T4:T8 ratio was normal. The percentage of T4+ cells was increased in patients with 2 SS-PBC, resulting in an increased T4:T8 ratio. In contrast, patients with 2 SS-CVD demonstrated a markedly increased percentage of T8+ cells, reflected by a shift in the T4:T8 ratio which was inverted. Patients with Sjögren's syndrome and with neutrophilia on bronchoalveolar lavage had a marked expansion of the T8+ lymphocyte subpopulation, where as patients with Sjögren's syndrome and with pure lymphocytosis on bronchoalveolar lavage showed predominantly T4+ cells. In addition, we found a strong positive correlation between the number of neutrophils and the number of T8+ cells in bronchoalveolar lavage from patients with Sjögren's syndrome (r = 0.74; p less than 0.05). Until the functional activities of OKT4+ and OKT8+ cells are better defined, the role that these cells play in the pathogenesis of pulmonary disease in Sjögren's syndrome remains unclear.

Primary biliary cirrhosis. Subclinical inflammatory alveolitis in patients with normal chest roentgenograms

To determine whether a subclinical inflammatory alveolitis is associated with primary biliary cirrhosis (PBC), we compared the numbers and types of cells recovered by bronchoalveolar lavage from 12 patients with PBC, ten healthy control subjects, and nine patients with alcoholic cirrhosis (AC). All were free of clinical pulmonary symptoms and had normal findings on chest roentgenograms. Total BAL cell count did not differ among patients with PBC (mean 9.6 X 10(4) cells/ml), patients with AC (mean 14.8 X 10(4) cells/ml), and control subjects (mean 9.9 X 10(4) cells/ml). Patients with PBC but not patients with AC had an increased proportion of lymphocytes in bronchoalveolar lavage fluid (respectively 22.4 percent +/- 5.2 and 11.6 percent +/- 2.52 compared with the normal value of 9.9 percent +/- 1.5 p less than 0.05). In the same way, alveolar lymphocytosis of the lower respiratory tract from PBC patients predominantly comprised T4+ (helper/inducer) T-lymphocyte subset in patients showing an increased alveolar lymphocytosis. Alveolar macrophages from PBC patients showed a dramatic increased chemiluminescence response before and after stimulation by phorbol-myristate-acetate, regardless of the intensity of alveolar lymphocytosis. Thus, our data demonstrated that subclinical alveolar inflammation comprising T-lymphocytes and activated alveolar macrophages mimicking sarcoid alveolitis is present in a high proportion of patients with PBC.