Bronchoalveolar Lavage in Sarcoidosis

Marjolein Drent; Khaled Mansour; Catharina Linssen

doi:10.1055/s-2007-991521

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2007; 28(5): 486-495
DOI: 10.1055/s-2007-991521

Bronchoalveolar Lavage in Sarcoidosis

Marjolein Drent¹ , Khaled Mansour¹ , Catharina Linssen²

¹Department of Respiratory Medicine, University Hospital Maastricht, Maastricht, The Netherlands
²Department of Medical Microbiology, Sarcoidosis Management Centre, University Hospital Maastricht, Maastricht, The Netherlands

Abstract

ABSTRACT

There is no single cell type present in bronchoalveolar lavage (BAL) fluid that appears to be predictive for sarcoidosis. However, BAL fluid analysis can be very helpful in the differential diagnosis. A grouping of features, an elevated total cell count, predominantly lymphocytes, together with a nearly normal percentage of eosinophils and polymorphonuclear neutrophils and the absence of plasma cells, distinguish the most likely diagnosis of sarcoidosis from the most common interstitial lung diseases, extrinsic allergic alveolitis (EAA), nonspecific interstitial pneumonia (NSIP), and idiopathic pulmonary fibrosis (IPF). In sarcoidosis the majority of cases have an increased number of lymphocytes and a normal amount of eosinophils and neutrophils. Disease presentation or activity at the time the BAL is performed as well as the smoking status is crucial for interpretation of individual BAL fluid analysis results. In severe cases the number of neutrophils can be increased as well. For an individual case the CD4:CD8 ratio is of less importance because it can be increased, normal, and even decreased. In the follow-up depicting prognosis and response to treatment, BAL fluid analysis has less clinical relevance.

KEYWORDS

BAL - differential diagnosis - sarcoidosis

Full Text

References

REFERENCES

1 Baughman R P, Lower E E, du Bois R M. Sarcoidosis. Lancet. 2003; 361 1111-1118
2 Hunninghake G W, Costabel U, Ando M et al.. ATS/ERS/WASOG statement on sarcoidosis. American Thoracic Society/European Respiratory Society/World Association of Sarcoidosis and other Granulomatous Disorders. Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16 149-173
3 Costabel U. Sarcoidosis: clinical update. Eur Respir J Suppl. 2001; 32 56s-68s
4 Hunninghake G W, Crystal R G. Pulmonary sarcoidosis: a disorder mediated by excess helper T-lymphocyte activity at sites of disease activity. N Engl J Med. 1981; 305 429-434
5 Semenzato G, Bortoli E, Brunetta C et al.. Immunology and pathophysiology. Eur Respir Mon. 2005; 32 49-64
6 Baughman R P, Drent M. Role of bronchoalveolar lavage in interstitial lung disease. Clin Chest Med. 2001; 22 331-341
7 Costabel U, Guzman J. Bronchoalveolar lavage in interstitial lung disease. Curr Opin Pulm Med. 2001; 7 255-261
8 Moller D R. Treatment of sarcoidosis-from a basic science point of view. J Intern Med. 2003; 253 31-40
9 Ziegenhagen M W, Rothe M E, Zissel G et al.. Exaggerated TNFalpha release of alveolar macrophages in corticosteroid resistant sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2002; 19 185-190
10 Wahlstrom J, Katchar K, Wigzell H et al.. Analysis of intracellular cytokines in CD4 + and CD8 + lung and blood T cells in sarcoidosis. Am J Respir Crit Care Med. 2001; 163 115-121
11 Baughman R P, Strohofer S A, Buchsbaum J et al.. Release of tumor necrosis factor by alveolar macrophages of patients with sarcoidosis. J Lab Clin Med. 1990; 115 36-42
12 Planck A, Eklund A, Grunewald J. Inflammatory BAL-fluid and serum parameters in HLA DR17 positive vs. DR17 negative patients with pulmonary sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2001; 18 64-69
13 Grunewald J, Eklund A, Olerup O. Human leukocyte antigen class I alleles and the disease course in sarcoidosis patients. Am J Respir Crit Care Med. 2004; 169 696-702
14 Drent M, Grutters J C, Mulder P G et al.. Is the different T helper cell activity in sarcoidosis and extrinsic allergic alveolitis also reflected by the cellular bronchoalveolar lavage fluid profile?. Sarcoidosis Vasc Diffuse Lung Dis. 1997; 14 31-38
15 Reynolds H Y. Use of bronchoalveolar lavage in humans: past necessity and future imperative. Lung. 2000; 178 271-293
16 Yeager Jr H, Williams M C, Beekman J F et al.. Sarcoidosis: analysis of cells obtained by bronchial lavage. Am Rev Respir Dis. 1977; 116 951-954
17 Thomas P D, Hunninghake G W. Current concepts of the pathogenesis of sarcoidosis. Am Rev Respir Dis. 1987; 135 747-760
18 Rottoli P, Magi B, Cianti R et al.. Carbonylated proteins in bronchoalveolar lavage of patients with sarcoidosis, pulmonary fibrosis associated with systemic sclerosis and idiopathic pulmonary fibrosis. Proteomics. 2005; 5 2612-2618
19 Psathakis K, Papatheodorou G, Plataki M et al.. 8-Isoprostane, a marker of oxidative stress, is increased in the expired breath condensate of patients with pulmonary sarcoidosis. Chest. 2004; 125 1005-1011
20 Rottoli P, Magi B, Perari M G et al.. Cytokine profile and proteome analysis in bronchoalveolar lavage of patients with sarcoidosis, pulmonary fibrosis associated with systemic sclerosis and idiopathic pulmonary fibrosis. Proteomics. 2005; 5 1423-1430
21 Drent M, Jacobs J A, Cobben N A et al.. Computer program supporting the diagnostic accuracy of cellular BALF analysis: a new release. Respir Med. 2001; 95 781-786
22 Winterbauer R H, Lammert J, Selland M et al.. Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis. Chest. 1993; 104 352-361
23 Pesci A, Bertorelli G, Gabrielli M et al.. Mast cells in fibrotic lung disorders. Chest. 1993; 103 989-996
24 Drent M, Jacobs J A, de Vries J et al.. Does the cellular bronchoalveolar lavage fluid profile reflect the severity of sarcoidosis?. Eur Respir J. 1999; 13 1338-1344
25 Drent M, van Nierop M A, Gerritsen F A et al.. A computer program using BALF-analysis results as a diagnostic tool in interstitial lung diseases. Am J Respir Crit Care Med. 1996; 153 736-741
26 Costabel U. CD4/CD8 ratios in bronchoalveolar lavage fluid: of value for diagnosing sarcoidosis?. Eur Respir J. 1997; 10 2699-2700
27 Kantrow S P, Meyer K C, Kidd P et al.. The CD4/CD8 ratio in BAL fluid is highly variable in sarcoidosis. Eur Respir J. 1997; 10 2716-2721
28 Welker L, Jorres R A, Costabel U et al.. Predictive value of BAL cell differentials in the diagnosis of interstitial lung diseases. Eur Respir J. 2004; 24 1000-1006
29 Schnabel A, Reuter M, Gloeckner K et al.. Bronchoalveolar lavage cell profiles in Wegener's granulomatosis. Respir Med. 1999; 93 498-506
30 Cordier J F. Pulmonary vasculitis. Eur Respir Mon. 2000; 14 226-243
31 Drent M, Jacobs J A, Wagenaar S S. Bronchoalveolar lavage. In: Olivieri D, du Bois RM Interstital Lung Diseases. Eur Respir Mon 2000 14: 64-78
32 Baughman R P, Drent M, Kavuru M et al.. Infliximab therapy in patients with chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med. 2006; 174 795-802
33 Carr P L, Singer D E, Goldenheim P et al.. Noninvasive testing of asymptomatic bilateral hilar adenopathy. J Gen Intern Med. 1990; 5 138-146
34 Zompi S, Couderc L J, Cadranel J et al.. Clonality analysis of alveolar B lymphocytes contributes to the diagnostic strategy in clinical suspicion of pulmonary lymphoma. Blood. 2004; 103 3208-3215
35 Poletti V, Romagna M, Gasponi A et al.. Bronchoalveolar lavage in the diagnosis of low-grade, MALT type, B-cell lymphoma in the lung. Monaldi Arch Chest Dis. 1995; 50 191-194
36 Poletti V, Romagna M, Allen K A et al.. Bronchoalveolar lavage in the diagnosis of disseminated lung tumors. Acta Cytol. 1995; 39 472-477
37 Wisecarver J, Ness M J, Rennard S I et al.. Bronchoalveolar lavage in the assessment of pulmonary Hodgkin's disease. Acta Cytol. 1989; 33 527-532
38 Drent M, Wagenaar S S, Mulder P H et al.. Bronchoalveolar lavage fluid profiles in sarcoidosis, tuberculosis, and non-Hodgkin's and Hodgkin's disease: an evaluation of differences. Chest. 1994; 105 514-519
39 Drent M, van Velzen Blad H, Diamant M et al.. Differential diagnostic value of plasma cells in bronchoalveolar lavage fluid. Chest. 1993; 103 1720-1724
40 Drent M, Peters F P, Jacobs J A et al.. Pulmonary infiltration associated with myelodysplasia. Ann Oncol. 1997; 8 905-909
41 Bagatin E, Pereira C A, Afiune J B. Granulomatous diseases of occupational etiology [in Portuguese]. J Bras Pneumol. 2006; 32(Suppl) S69-S84
42 Newman L S. Aetiologies of sarcoidosis. Eur Respir Mon. 2005; 10 23-48
43 Newman L S. Beryllium disease and sarcoidosis: clinical and laboratory links. Sarcoidosis. 1995; 12 7-19
44 Sawyer R T, Parsons C E, Fontenot A P et al.. Beryllium-induced tumor necrosis factor-alpha production by CD4 + T cells is mediated by HLA-DP. Am J Respir Cell Mol Biol. 2004; 31 122-130
45 Muller-Quernheim J, Gaede K I, Fireman E et al.. Diagnoses of chronic beryllium disease within cohorts of sarcoidosis patients. Eur Respir J. 2006; 27 1190-1195
46 Drent M, Bomans P H, Van Suylen R J et al.. Association of man-made mineral fibre exposure and sarcoidlike granulomas. Respir Med. 2000; 94 815-820
47 Klimczak A, Langfort R, Zych J et al.. Granulomatous lung lesions after occupational exposure to glass fibers [in Polish]. Pneumonol Alergol Pol. 2000; 68 273-278
48 Newman L S. Metals that cause sarcoidosis. Semin Respir Infect. 1998; 13 212-220
49 Werfel U, Schneider J, Rodelsperger K et al.. Sarcoid granulomatosis after zirconium exposure with multiple organ involvement. Eur Respir J. 1998; 12 750
50 Hull M J, Abraham J L. Aluminum welding fume-induced pneumoconiosis. Hum Pathol. 2002; 33 819-825
51 Drent M, van Velzen Blad H, Diamant M et al.. Relationship between presentation of sarcoidosis and T lymphocyte profile: a study in bronchoalveolar lavage fluid. Chest. 1993; 104 795-800
52 Grunewald J, Eklund A. Sex-specific manifestations of Lofgren's syndrome. Am J Respir Crit Care Med. 2007; 175 40-44
53 Costabel U, Teschler H. Biochemical changes in sarcoidosis. Clin Chest Med. 1997; 18 827-842
54 Takahashi T, Azuma A, Abe S et al.. Significance of lymphocytosis in bronchoalveolar lavage in suspected ocular sarcoidosis. Eur Respir J. 2001; 18 515-521
55 Camus P, Colby T V. The lung in inflammatory bowel disease. Eur Respir J. 2000; 15 5-10
56 Blackmon G M, Raghu G. Pulmonary sarcoidosis: a mimic of respiratory infection. Semin Respir Infect. 1995; 10 176-186
57 Bongartz T, Sutton A J, Sweeting M J et al.. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA. 2006; 295 2275-2285
58 Baughman R P, Lynch J P. Difficult treatment issues in sarcoidosis. J Intern Med. 2003; 253 41-45
59 Baughman R P, Lower E E. Therapy for sarcoidosis. Eur Respir Mon. 2005; 32 301-315
60 Baughman R P, Lower E E. Fungal infections as a complication of therapy for sarcoidosis. QJM. 2005; 98 451-456
61 Schilstra A, Rottoli P, Jacobs J A, van Suylen R J, Galluzzi P, Drent M. Case studies to explore the pitfalls in the diagnosis of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2006; 23 135-140
62 Riemer H, Hainz R, Stain C et al.. Severe pulmonary hypertension reversed by antibiotics in a patient with Whipple's disease. Thorax. 1997; 52 1014-1015
63 Peschard S, Brinkane A, Bergheul S et al.. Whipple disease associated with pulmonary arterial hypertension: Jarisch-Herxheimer reaction after antibiotic therapy [in French]. Presse Med. 2001; 30 1549-1551

Marjolein DrentM.D. Ph.D.

Sarcoidosis Management Centre, Department of Respiratory Medicine, University Hospital Maastricht

P.O. Box 5800, 6202 AZ Maastricht, The Netherlands

Email: m.drent@lung.azm.nl