Ultrastructure of lymphoid interstitial pneumonia: virus-like particles in bronchiolar epithelium of a patient with Sjögren's syndrome

Pulmonary manifestations of primary Sjögren's syndrome

Sjögren's syndrome (SS) is a systemic disease with a predilection for the exocrine glands. It also is considered to be an autoimmune epitheliitis, and, as the respiratory system is lined throughout with epithelial cells, it should not be surprising that patients who have SS may develop pulmonary disease. This article describes these manifestations.

Nodular lymphoid hyperplasia of the lung: a clinicopathologic study of 14 cases

Nodular lymphoid hyperplasia is a controversial entity in which its existence in the lung has been doubted. The current opinion is that most, if not all, such cases represent extranodal marginal zone B-cell lymphomas masquerading as reactive lesions. We found 14 cases of nodular lymphoid hyperplasia in the files of the Pulmonary Department at the Armed Forces Institute of Pathology from 1974 through 1998. All had clinical histories and hematoxylin-eosin slides. In 12 of 14 with paraffin blocks, we applied immunohistochemical antibodies for CD20, CD3, CD43, CD5, bcl-2, bcl-1, CD45RA, and kappa and lambda immunoglobulin light chains. Molecular genetic analysis was performed on paraffin sections in 10 of 14 by the polymerase chain reaction for rearrangements of the immunoglobulin heavy chain gene and the minor and major break-point regions of the chromosomal translocation t (14;18). There were eight women and six men ranging in age from 19 to 80 years (median, 65 yrs). Most lesions (71%) were incidental findings on routine chest x-rays. Most patients (64%) had a single lesion by chest x-ray whereas the remainder had two to three lesions, except for one patient who had "multiple" lesions. There was associated regional lymphadenopathy in five of 14 cases (36%) which, on biopsy, proved to be reactive follicular hyperplasia. The only treatment was surgical excision. Of the seven patients with follow-up information from 8 months to 6 years (mean, 30 mos), none had clinical recurrence and no patient died of disease. The histology and immunophenotype of the lesions were strikingly similar, including abundant reactive germinal centers, intense interfollicular polyclonal plasmacytosis, and a variable degree of interfollicular fibrosis. No case showed a molecular rearrangement of the immunoglobulin heavy chain gene or the minor or major break-point region of the t (14;18). We conclude that nodular lymphoid hyperplasia of the lung, although rare, does exist and deserves its place in the spectrum of reactive pulmonary lesions that ranges from follicular hyperplasia to diffuse hyperplasia of the bronchus-associated lymphoid tissue (lymphoid interstitial pneumonitis).

Pulmonary manifestations of Sjögren's syndrome

Sjögren's syndrome is one of the most common systemic rheumatic diseases. Pulmonary disease is prevalent in Sjögren's syndrome; respiratory manifestations include chronic cough, obstructive airways disease, pulmonary lymphoma, and interstitial lung disease that may progress to severe pulmonary fibrosis.

Primary Sjögren's syndrome

Significant abnormalities in pulmonary function are encountered in about 24% of patients with primary Sjögren's syndrome. The most common cause of dyspnoea is interstitial fibrosis, with a prevalence of around 8%, but a number of other pathologies may be encountered in the lungs of these patients (Table 1). Lymphoproliferative disorders are relatively uncommon, but these apparently benign lesions may harbour malignant potential. Interstitial fibrosis and the lymphoproliferative disorders may be responsive to corticosteroids or cytotoxic agents, and it is therefore important to establish an accurate diagnosis at an early stage. On the basis of our experience we would recommend the investigative strategy outlined below. Patients should be screened for significant lung disease by taking a careful history of respiratory symptoms followed by standard pulmonary function testing (including measurement of carbon monoxide diffusing capacity) and chest radiography. High resolution computed tomography is a non-invasive technique that should prove superior to chest radiography in the detection of early cases of interstitial fibrosis. When the disease is patchy it may be useful in identifying areas of maximal involvement for subsequent biopsy. Bronchoalveolar lavage is a sensitive tool in the non-smoker, but lacks the specificity to command a significant role in the investigation of pulmonary pathology in these patients. One exception to this may be in the investigation of the clonality of lymphocytes which may allow early and specific diagnosis of lymphomatous proliferation. The application of techniques such as the polymerase chain reaction may assist in the investigation of the role of the Epstein-Barr virus in the causation of lymphoproliferative lesions. In most patients with significant symptoms and abnormalities of pulmonary function a tissue diagnosis will be required, either by transbronchial biopsy or by open lung biopsy. Both bronchial and interstitial lung tissue should be obtained where possible. Histological confirmation is probably mandatory when there is a recent history of parotid enlargement, weight loss or the appearance of a monoclonal gammopathy. Advances in our understanding of the mechanisms of the MALT system may provide the key to unlocking some of the mysteries of 'autoimmune' diseases such as Sjögren's syndrome. The response of lymphoproliferative disorders to immunosuppressive therapy provides hope that if the diagnosis of sicca syndrome can be made earlier lymphocyte induced tissue damage may be halted or reversed.

Pulmonary hypertension and human immunodeficiency virus infection. Two reports and a review of the literature

Pulmonary hypertension may be primary (idiopathic) or secondary. While the etiologies for secondary pulmonary hypertension are diverse, infection with the human immunodeficiency virus (HIV) has not been included. To date there have been 16 reported cases of pulmonary hypertension in the HIV-infected population. Plexogenic arteriopathy was the most common pathologic finding. We report two HIV-infected patients who were concomitantly found to have pulmonary hypertension with plexogenic arteriopathy. One patient had lymphocytic interstitial pneumonitis, an entity not previously associated with pulmonary hypertension. We review the 16 previous cases of pulmonary hypertension and HIV infection and discuss this association.

Pulmonary lymphoma in Sjögren's syndrome

Sjögren's syndrome (SS) is an immunologic disease characterized by progressive destruction of the exocrine glands that causes mucosal and conjunctival dryness. In addition to the common pulmonary complications of diffuse interstitial lung disease, airways obstruction, desiccation of the upper respiratory tract, localized parenchymal nodules, recurrent tracheobronchitis, bronchiectasis, interstitial pneumonitis, and pleural effusion, patients with SS have a high risk of developing non-Hodgkin's lymphoma that may affect the lungs. Among 50 patients with SS and associated lymphoma, 10 had pulmonary involvement by lymphoma. The mean age of these 10 patients was 59.7 years, and 8 were women. The mean duration of SS was 7.2 years, and the mean interval between the onset of SS and lymphoma was 5.4 years. Cough and slowly progressive dyspnea were the most common pulmonary symptoms, and chest roentgenographic findings varied. Lung biopsies revealed a spectrum of low-to high-grade lymphomas, and high-grade lymphomas were associated with increased mortality. Of the 10 patients, 4 died from 8 to 48 months after lymphoma was diagnosed. We conclude that pulmonary involvement is common in patients with lymphoma associated with SS; thus, lymphoma should be considered in the differential diagnosis of pulmonary lesions in patients with SS.

Viruses and salivary gland disease: are there associations?

Viruses can cause sialadenitis and may be associated with other diseases of salivary glands, particularly immunologically mediated and neoplastic lesions. The evidence that such an association with Sjögren's syndrome is causal is reviewed here and shown to be fairly tenuous at present.

Sjögren's syndrome: clinical and laboratory features, immunopathogenesis, and management

Sjögren's syndrome may be accompanied by local oral problems such as dry mouth, rampant caries, candidosis, or sialadenitis, but it is a systemic autoimmune disorder with wide repercussions, including a small premalignant potential. This article reviews the clinical and immunopathogenic features, as well as the etiology, of Sjögren's syndrome and discusses the diagnosis and management of oral complications.

Benign lymphoid disorders of the lung, with a theory regarding their development

The authors review the clinical, radiographic, and pathologic features of the benign pulmonary lymphoid disorders. The essential role of immunopathologic techniques in distinguishing pulmonary lymphoid hyperplasias from malignant lymphoma is stressed. A theory regarding the development of pulmonary lymphoid hyperplasia is proposed as a basis for understanding these disorders. The authors suggest that lymphoid hyperplasia is a basic inflammatory response of the lung.