BRONCHOALVEOLAR LAVAGE: Still Useful in Diagnosing Sarcoidosis?
Section snippets
USEFULNESS OF BRONCHOALVEOLAR LAVAGE IN DISCRIMINATING DISEASE PRESENTATION
Because combined information about cell recovery, cell differentials, and the ratio of CD4 to CD8 T cells can be obtained from the BAL procedure and BAL fluid cells (BALF cells) are considered to reflect pathophysiologic processes in the lungs of patients with diffuse interstitial lung diseases such as sarcoidosis, BAL could offer useful clues for differential diagnosis.16, 36
Although it is impossible to detect a specific cell such as epithelioid cells using BAL, a characteristic finding of
BALF CELL PATTERNS AND DIFFERENTIAL DIAGNOSIS
Based on our experience, performing BAL procedures on 400 healthy subjects and 1600 cases with diffuse interstitial lung diseases, BALF cell findings can be divided into four patterns—healthy pattern, sarcoidosis pattern, bronchiolitis obliterans with organizing pneumonia (BOOP) pattern, and usual interstitial pneumonia (UIP) pattern.
FACTORS THAT AFFECT ACCURACY OF DIAGNOSIS
Factors that affect accuracy of diagnosis in patients with sarcoidosis can be summarized as follows:
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Disease activity is one of the critical factors. The majority of patients with pulmonary sarcoidosis are asymptomatic, especially when lesions such as BHL are detected by mass survey. In that condition, various levels of disease activity can be found by BAL at the time of initial examination. Overall clinical evaluation and the use of biopsy to obtain a definite hallmark of granuloma are
DIFFERENTIAL DIAGNOSIS BETWEEN SARCOIDOSIS AND OTHER INTERSTITIAL LUNG DISEASES
Sarcoidosis is a systemic immune-mediated disease and its mode of onset is chronic and insidious except in cases with febrile onset or erythema nodosum. Without typical BHL and cutaneous manifestations, it occasionally is difficult to diagnose sarcoidosis correctly. Especially when only parenchymal interstitial shadows are seen on chest radiograph at the time of initial examination, we are concerned about making a diagnosis. Other additional findings such as elevated serum ACE activity are not
DIAGNOSTIC VALUE OF BALF CELL FINDINGS WITH REGARD TO DISEASE ACTIVITY AND PROGNOSIS
How to determine the disease activity or prognostic factors in patients with sarcoidosis has long been a matter of controversy. The current consensus of the disease activity was proposed as a result of the WASOG meeting in Los Angeles in 1993. Disease activity is considered to be as follows6:
Activity means that something is still acting or working, is causing motion or change, is still evolving, has not come to rest. In sarcoidosis, the term activity implies that the disease is undergoing
SUMMARY AND CONCLUSION
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
ACKNOWLEDGMENT
We would like to thank Om P. Sharma, MD, for reviewing our manuscript and giving useful advice. We thank M. Kitaichi, MD, for diagnosing lung biopsy specimens. We also thank T. Mikuniya, PhD, N. Satake, MD, T. Mio, MD, M. Shigematsu, for helping with BAL procedures. We thank F. Tanioka, MD and M. Yamada for preparing BALF cell specimens and M. Kurozumi for counting BALF cell differentials. We thank Simon Johnson for checking linguistic problems.
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Cited by (0)
Address reprint requests to Sonoko Nagai, MD, Pulmonary Medicine and Clinical Immunology, Chest Disease Research Institute, Kyoto University, Kyoto, Japan
This work was supported by a Grant-in-Aid for Medical Science Research (No. 06670610) from the Ministry of Education, Japan, and by a Grant from the Smoking Research Foundation in Japan.
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From the Chest Disease Research Institute, Kyoto University, Kyoto, Japan