Bronchoalveolar Lavage Cell Populations in the Diagnosis of Sarcoidosis

doi:10.1378/chest.104.2.352

Chest

Volume 104, Issue 2, August 1993, Pages 352-361

https://doi.org/10.1378/chest.104.2.352 Get rights and content

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 noneaseating 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 ELD 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.

Conclusion

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.

Section snippets

Study Population

Between February 1, 1984, and February 1, 1989, fiberoptic bronchoscopy (FOB) was performed by members of the Section of Pulmonary and Critical Care Medicine on 2,692 patients, 592 of whom had bronchoalveolar lavage (BAL). The indications for BAL were usually the evaluation of diffuse or focal pulmonary infiltrates on a chest roentgenogram. In rare instances, BAL was performed on patients with normal chest x-ray films but suspected cryptic interstitial lung disease (ILD). Bronchoalveolar lavage

Diseases With Bronchoalveolar Lavage Fluid Lymphocytosis

One hundred thirty-eight (23.3 percent) of 592 BALF specimens obtained over the 5-year period contained 16 percent or more lymphocytes as determined by the differential cell count. Ten patients with BALF lymphocytosis were excluded from further analysis. These included seven patients with AIDS, one patient who had coexisting sarcoidosis and squamous cell carcinoma of the lung, one patient with a clinical presentation and BALF results consistent with sarcoidosis but no biopsy confirmation of the

Discussion

In 1981, Crystal and colleagues⁹ stated that “other than sarcoidosis, the only lung disorders known to be associated with increased proportions of lymphocytes in lavage are hypersensitivity pneumonitis, tuberculosis, and lymphoma involving the lung parenchyma.” Four years later, Chretien and colleagues¹⁵ expanded the list to include tuberculosis and other pulmonary infections, malignancy, asthma, and pneumoconiosis. The current study further expands the list of diseases associated with

ACKNOWLEDGMENT

Joni Noges provided technical assistance.

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: Manuscript received July 27; revision accepted December 17.

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Chest

Clinical InvestigationBronchoalveolar Lavage Cell Populations in the Diagnosis of Sarcoidosis

Study design

Methods

Results

Conclusion

Section snippets

Study Population

Diseases With Bronchoalveolar Lavage Fluid Lymphocytosis

Discussion

ACKNOWLEDGMENT

Non-granulomatous interstitial pneumonitis in sarcoidosis: relationship to the development of epithelialoid granulomas

Chest

Sarcoidosis: 1. From the pathologists vantage point

Pathol Annu

Sarcoidosis: analysis of cells obtained by bronchial lavage

Am Rev Respir Dis

Bronchoalveolar lavage in interstitial lung disease

Ann Intern Med

Localization of the immune response in sarcoidosis

Am Rev Respir Dis

Bronchoalveolar cell populations in acute sarcoidosis: observations in smoking and nonsmoking patients

J Lab Clin Med

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

N Engl J Med

Pulmonary sarcoidosis: a disorder mediated by excess helper T-lymphocyte activity at sites of disease activity

N Engl J Med

Pulmonary sarcoidosis: a disease characterized and perpetuated by activated T-lymphocytes

Ann Intern Med

Interstitial lung disease

Disease-A-Month

Azathioprine combined with prednisone in the treatment of idiopathic pulmonary fibrosis: a prospective double-blind, randomized, placebo-controlled clinical trial

Am Rev Respir Dis

Clinical Investigation
Bronchoalveolar Lavage Cell Populations in the Diagnosis of Sarcoidosis