The CD4/CD8 ratio in BAL fluid is highly variable in sarcoidosis

Role of Bronchoscopy in Diagnosis of Sarcoidosis

Sarcoidosis is a multisystem inflammatory disorder with unclear etiology and can often pose a diagnostic challenge. A tissue diagnosis is often necessary to illustrate the non-caseating granulomas on histopathology. This review aims to synthesize current evidence related to tissue diagnosis of sarcoidosis using various bronchoscopic techniques. We start by discussing standard bronchoscopic techniques which have remained the cornerstone of diagnostic workup such as bronchoalveolar lavage (BAL), endobronchial biopsy (EBB), conventional transbronchial needle aspiration (cTBNA) and transbronchial lung biopsy (TBLB) followed by newer modalities that incorporate real-time image guidance using endobronchial and endoscopic ultrasound. Although BAL, EBB, and TBLB have been employed as a diagnostic tool for several decades, their sensitivity and diagnostic yield is inferior to ultrasound-based endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). More recently, convincing evidence has also emerged to support the diagnostic accuracy and tissue yield of transbronchial lung cryobiopsy which will also be discussed in this review. These advances in bronchoscopic equipment and techniques over the last 2 decades have made it possible to obtain tissue samples using minimally invasive techniques thus avoiding invasive open lung biopsy and the risks that inherently follow. Up-to-date knowledge of these modalities is imperative for ensuring evidence-based medicine and improving patient-centric outcomes.

Diagnosis of Pulmonary Sarcoidosis

Diagnosis of sarcoidosis depends on a compatible clinical and imaging presentation, histologic finding of non-necrotizing granulomatous inflammation, and exclusion of alternative causes of granulomatous diseases. This study has reviewed the diagnostic algorithms and approaches of sarcoidosis.

Analysis of lymphocyte profile in lymph nodes, bronchoalveolar lavage fluid and peripheral blood in patients with stage II sarcoidosis

OBJECTIVE

To evaluate the lymphocyte profile (LP) in lymph node puncture fluid (LNPF) of mediastinal and hilar lymph nodes, bronchoalveolar lavage fluid (BALF), and peripheral blood (PB) involved in stage 2 sarcoidosis.

METHODS

After selection, 31 patients diagnosed with stage II sarcoidosis were finally included. Patients were further divided into symptomatic (n = 17) and asymptomatic (n = 14) groups according to the presence or absence of respiratory symptoms. The LP in lymph node puncture fluid (LNPF), bronchoalveolar lavage fluid (BALF), and peripheral blood (PB) were evaluated and compared using flow cytometry. The relationship between respiratory symptoms and LP was preliminarily analyzed.

RESULTS

The proportions of T cells and CD4 T cells, and CD4/CD8 ratio in BALF were significantly higher than that of LNPF with PB (all P < 0.05). The proportions of lymphocyte cells, CD8 T cells, NK cells, and CD4/CD8 ratio in LNPF and PB were significantly different (all P < 0.05). There were significant differences in CD4 T cells [72.40 (68.90,75.55) vs.46.30 (38.55,52.50), P = 0.004], CD8 T cells (9.9 ± 3.9 vs. 16.8 ± 6.8, P = 0.002), and CD4/CD8 ratio (7.9 ± 2.8 vs. 3.9 ± 1.5, P < 0.001) in BALF between the symptomatic group and asymptomatic group (all P < 0.05). The T cells (rs = 0.447, P = 0.011), CD4 (rs = 0.572, P = 0.002), and CD4/CD8 ratio (rs = 0.701, P < 0.001) in BALF were positively correlated with respiratory symptoms.

CONCLUSION

The LP in LNPF, BALF and PB were significantly different and the main index correlated with respiratory symptoms was CD4/CD8 ratio in BALF. The difference of LP in BALF and LNPF may help to deeply understand the pathophysiological process and may reflect the different degree of lung and lymph node lesion.

Sarcoid Uveitis: An Intriguing Challenger

The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.

The place of the bronchoalveolar lavage in the diagnosis of interstitial lung disease: a descriptive and qualitative study

BACKGROUND

Interstitial lung disease represents a challenge and consists in more than 200 entities. Their diagnoses are assessed through a multidisciplinary approach including pulmonologists, radiologists, pathologists and biologists. BAL analysis is useful mainly when clinical and radiological findings aren't suggestive of an etiology. Even if, the indication of BAL is consensual, its real place as a diagnostic mean remains non consensual.

AIM

To describe the BAL findings and to analyse the perceptions of the pulmonologists, anaesthesiologists and pathologists implicated in the interpretation of the BAL data, that are related to the presentation and the validity of the results.

METHODS

the authors performed a descriptive study about BAL results during an 8-year-period (2010-2018) and a qualitative study assessing the pulmonologists, anaesthesiologists and pathologists' opinions concerning the different results performed in the same institution. Two questionnaires were conceived with participation of different experts and satisfaction scores were calculated.

RESULTS

2508 BAL were recorded including 1320 women (53%) and 1188 men (47%) with a sex-ratio (H/F) of 0,9. The mean age of the patients was 51 years. The mean response delay was 3.25 days. An accurate diagnosis was retained in 24.3%. It consisted in infection evoked in 13.89% cases. Eosinophilic pneumonia was evoked in 0.35% cases. 15.01% cases presented erythrophagocytosis with a golde score>100 favouring active alveolar haemorrhage with occult alveolar haemorrhage. Lipoproteinosis was diagnosed in 2 cases. Adenocarcinoma was retained in 1.04% cases and lymphoma in 0.16% cases. Langerhans cell histiocytosis was confirmed in 1.51% cases. In the other cases, cellular profile was not specific evoking tuberculosis or sarcoidosis in 316 cases with a CD4/CD8 ratio superior to 1,6 and the diagnoses of tuberculosis or hypersensitivity pneumonia in 202 cases with a CD4/CD8 ratio inferior to 1,2. Concerning the questionnaire-based study, 50 pulmonologists and anaesthesiologists attributed a mean score of 7.96/10 (DS=0.55) concerning the presentation of the results and 9.28/15 (DS=0.77) concerning the quality and validity of the results. On the other hand, the mean satisfaction score rated by pathologists reached 24/40.

CONCLUSION

BAL results could be helpful for the management of interstitial lung disease depending on the experience of pathologists and a good communication between pulmonologists, anaesthesiologists and pathologists.

Transbronchial biopsy vs. bronchoalveolar lavage in interstitial lung disease

PURPOSE OF REVIEW

Interstitial lung diseases (ILDs) are heterogeneous disorders characterized by varying degrees of inflammation and fibrosis in the lung parenchyma. The use of bronchoalveolar lavage (BAL) cellular analysis and transbronchial biopsy with forceps (TBLB) in ILD is often a matter of debate. ILDs have been a diagnostic challenge and require multidisciplinary discussion (MDD) to develop a consensus diagnosis based on clinical, radiologic, laboratory, BAL cellular analysis, and histologic information.

RECENT FINDINGS

The BAL cellular analysis is a commonly performed tool, and some ILDs have distinctive cellular findings. Its use alone is seldom diagnostic and almost always requires clinical, radiologic findings, and or histologic information interpretation. The minimally invasive procedures, such as TBLB, transbronchial cryo-biopsy (TBCB), and invasive procedures, such as surgical lung biopsy (SLB) help obtain a histologic diagnosis.

SUMMARY

This review serves as a resource to assist clinicians to develop effective communication and close collaboration through MDD for accurate selection of diagnostic tools to reach the correct and final diagnosis.

T Lymphocyte Maturation Profile in the EBUS-TBNA Lymph Node Depending on the DLCO Parameter in Patients with Pulmonary Sarcoidosis

Sarcoidosis (SA) is a systemic granulomatous disorder of unknown etiology with lung and mediastinal lymph nodes (LNs) as the main location. T lymphocytes play important role in the formation of granulomas in SA, but still little is known about the role of maturation profile in the development of inflammatory changes. The aim of this study was to determine the CD4+ and CD8+ T cells maturation profile in LNs and in peripheral blood (PB) and its relation to disease severity expressed by diffusing capacity of the lung for carbon monoxide (DLCO). 29 patients with newly pulmonary SA were studied. Flow cytometry was used for cells evaluation in EBUS-TBNA samples. We observed lower median proportion of T lymphocytes, CD4+ T and CD8+ T cells in patients with DLCO< 80% than in patients with normal diffusion (DLCO > 80%). Patients with DLCO < 80% had lower median proportion of effector and higher median proportion of central memory CD4+ and CD8+ T cells than patients with DLCO > 80%. We reported for the first time that LNs CD4+ and CD8+ T cells maturation differs depending on the DLCO value in sarcoidosis. Lymphocytes profiles in LNs may reflect the immune status of patients with SA and can be analysed by flow cytometry of EBUS-TBNA samples.

Distinct Expression of Coinhibitory Molecules on Alveolar T Cells in Patients With Rheumatoid Arthritis-Associated and Idiopathic Inflammatory Myopathy-Associated Interstitial Lung Disease

OBJECTIVE

To identify immunologic factors in the lungs of patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and patients with idiopathic inflammatory myopathy-associated ILD (IIM-ILD) and to examine their pathologic mechanisms.

METHODS

Eleven patients with RA-ILD, 16 with IIM-ILD, 6 with drug-induced ILD (DI-ILD), and 8 healthy controls were enrolled. Peripheral blood (PB) and bronchoalveolar lavage (BAL) fluid were immunophenotyped by flow cytometry. Alveolar macrophages (AMs) were analyzed by coculture assay with PB naive CD4+ T cells from healthy individuals and RNA sequencing.

RESULTS

Several coinhibitory molecules were coexpressed on BAL fluid T cells (CTLA-4, programmed death 1 [PD-1], T cell immunoglobulin and mucin domain-containing protein 3 [TIM-3], and lymphocyte activation gene 3 protein, from most to least), whereas only PD-1 was expressed on PB T cells. CTLA-4+PD-1+CD4+ T cells were characteristic of RA-ILD, whereas CTLA-4+PD-1+TIM-3+CD8+ T cells were characteristic of IIM-ILD. BAL fluid PD-1+CD4+ T cells rarely expressed CXCR5, but their levels correlated with levels of plasmablasts and plasma cells (ρ = 0.57, P = 0.006), indicating that most of them would be considered peripheral helper T cells. In coculture experiments, AMs from patients with RA-ILD and IIM-ILD induced more PD-1 and TIM-3 on T cells (P < 0.05), suggesting that coinhibitory molecule expression on BAL fluid T cells was partly due to AMs. RNA sequencing showed significant down-regulation of PD ligand 1/2 genes in AMs from patients with RA-ILD compared to those with DI-ILD.

CONCLUSION

We have identified differences in coinhibitory molecule expression between patients with RA-ILD and those with IIM-ILD. PD-1 on T cells in RA-ILD and TIM-3 on CD8+ T cells in IIM-ILD might be key factors in the disease process. Evaluation of coinhibitory molecules on BAL fluid T cells could be clinically useful.

Sarcoidosis: Pitfalls and Challenging Mimickers

Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.

Enigmatic Rapidly Enlarging Nasal Mass That Is Not Cancer

Cutaneous blastomycosis is not rare, but progressively enlarging nasal mass as the only presentation with nondiagnostic biopsy results, presence of pulmonary fibrosis, nodules and lymphadenopathy, and urinary sediments, as well as ANA and p-ANCA positivity, can make things more cryptic than expected.

Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases

Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.

Biomarkers in the Diagnosis and Prognosis of Sarcoidosis: Current Use and Future Prospects

Sarcoidosis is a heterogeneous disease in terms of presentation, duration, and severity. Due to this heterogeneity, it is difficult to align treatment decisions. Biomarkers have proved to be useful for the diagnosis and prognosis of many diseases, and over the years, many biomarkers have been proposed to facilitate diagnosis, prognosis, and treatment decisions. Unfortunately, the ideal biomarker for sarcoidosis has not yet been discovered. The most commonly used biomarkers are serum and bronchoalveolar lavage biomarkers, but these lack the necessary specificity and sensitivity. In sarcoidosis, therefore, a combination of these biomarkers is often used to establish a proper diagnosis or detect possible progression. Other potential biomarkers include imaging tools and cell signaling pathways. Fluor-18-deoxyglucose positron emission tomography and high-resolution computed tomography have been proven to be more sensitive for the diagnosis and prognosis of both pulmonary and cardiac sarcoidosis than the serum biomarkers ACE and sIL-2R. There is an upcoming role for exploration of signaling pathways in sarcoidosis pathogenesis. The JAK/STAT and mTOR pathways in particular have been investigated because of their role in granuloma formation. The activation of these signaling pathways also proved to be a specific biomarker for the prognosis of sarcoidosis. Furthermore, both imaging and cell signaling biomarkers also enable patients who might benefit from a particular type of treatment to be distinguished from those who will not. In conclusion, the diagnostic and prognostic path of sarcoidosis involves many different types of existing and new biomarker. Research addressing biomarkers and disease pathology is ongoing in order to find the ideal sensitive and specific biomarker for this disease.

Coexistence of diffuse panbronchiolitis and sarcoidosis revealed during splenectomy: a case report

Background

Sarcoidosis is a systemic granulomatous disease caused by CD4+ cell-dominant inflammation. Meanwhile, diffuse panbronchiolitis is a chronic inflammatory respiratory disease predominantly caused by CD8+ lymphocytes and neutrophils. Herein, we report a rare case of sarcoidosis in which the clinical presentation had become evident as diffuse panbronchiolitis after splenectomy for sarcoidosis.

Case presentation

A 23-year-old Japanese woman was referred to our hospital due to splenomegaly of unknown etiology. Upon admission, chest computed tomography scan revealed centrilobular and randomly distributed small nodules in both lungs. Bronchoalveolar lavage revealed a high proportion of lymphocytes and a decreased CD4/CD8 ratio. However, the biopsy specimens obtained from both the liver and lungs revealed noncaseating epithelioid granulomas, which confirmed the diagnosis of sarcoidosis. The patient underwent splenectomy due to progressive cytopenia and high risk of splenic rupture. After the surgery, the condition of the patient was consistently good for 3 months. Then, she gradually developed productive cough and dyspnea. Both sinus and chest computed tomography scan revealed chronic paranasal sinusitis and deterioration of centrilobular nodules in both lung fields, respectively. The second bronchoalveolar lavage revealed a high proportion of neutrophils, and the bronchoalveolar lavage fluid tested positive for Hemophilus influenzae. The titer of cold agglutinin was elevated, thereby confirming the diagnosis of diffuse panbronchiolitis. On the basis of the clinical and radiological findings, the condition of the patient improved with low-dose macrolide therapy for 3 months.

Conclusions

The coexistence of sarcoidosis and diffuse panbronchiolitis has not been previously reported, and the hidden profiles of diffuse panbronchiolitis may have been revealed by splenectomy.

Role of Bronchoscopic Techniques in the Diagnosis of Thoracic Sarcoidosis

The diagnosis of sarcoidosis relies on clinical and radiological presentation, evidence of non-caseating granulomas in histopathology and exclusion of alternative causes of granulomatous inflammation. Currently, a proper diagnosis, with a high level of confidence, is considered as key to the appropriate diagnosis and management of the disease. In this sense, this review aims to provide a brief overview on the role of bronchoscopy in the diagnosis of thoracic sarcoidosis, incorporating newer techniques to establish, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), transesophageal ultrasound-guided needle aspiration with the use of an echo bronchoscope (EUS-B-FNA) and transbronchial lung cryobiopsy (TBLC). Most of the literature reports the diagnostic superiority of endosonographic techniques, such as EBUS-TBNA alone or in combination with EUS-FNA, over conventional bronchoscopic modalities in diagnosing Scadding stages I and II of the disease. Moreover, TBLC may be considered a useful and safe diagnostic tool for thoracic sarcoidosis, overcoming some limitations of transbronchial lung biopsy (TBLB), avoiding more invasive modalities and being complementary to endosonographic procedures such as EBUS-TBNA.

Retrospective Study of Factors Potentially Influencing Occurrence of Cough in Slovak Patients with Sarcoidosis

Introduction

Sarcoidosis is a multisystem granulomatous disease of unknown aetiology, commonly involving the lungs.  Cough is a frequent and troublesome symptom of sarcoidosis that reduces patients' quality of life.

Aim

Retrospective analysis of different factors—smoking history, Scadding stage, results of lung function testing, calcium metabolism, endobronchial finding, CD4+/CD8+ T-cell ratio in bronchoalveolar lavage fluid (BALF), and other sarcoidosis symptoms in relationship to presence/absence of cough in sarcoidosis patients.

Methods

We retrospectively studied sarcoidosis patients diagnosed at the Clinic of Pneumology and Phthisiology of Martin University Hospital between 1998 and 2018. Patients with a history of cough-relevant comorbidities were excluded from the study. GraphPad Prism 7.0 software was used to perform statistical analysis.

Results

101 sarcoidosis patients were included to the study: 65 patients reporting from cough and 36 without cough. The cough was slightly more frequent in nonsmokers (p=0.166) and in women (p=0.688). Cough was associated with dyspnoea (p=0.0007), fever (p=0.0324), and chest pain (p=0.0206) and did not associate with arthralgia (p=0.317) and erythema nodosum (p=0.505). Patients with cough had significantly a lower average value of calciuria (p=0.0014) and lower MEF25 (p=0.0304), MEF50 (p=0.0061), FEV1 (p=0.0025), and FVC (p=0.0025) in % of predicted values, and more often positive endobronchial finding (p=0.0206), compared to patients without cough. Calcemia, FEV1/FVC, DLCO, and CD4+/CD8+ T-cell ratio in BALF and occurrence of cough did not differ between different stages of the disease.

Conclusions

We found significant differences between sarcoidosis patients with/without cough regarding symptoms, results of lung function tests, endobronchial finding, and calcium metabolism. Further research is needed to understand the etiopathogenesis of cough in sarcoidosis patients.

Noncaseating granulomatous diseases in germ cell cancer patients-A single-center experience

OBJECTIVES

In patients with testicular Germ Cell Tumors (GCT) noncaseating granulomatous diseases such as Sarcoid Like Lesions (SLL) or Sarcoidosis can mimic metastasis due to hilar or mediastinal lymphadenopathy. Due to the clinical and prognostic impact, exclusion of malignant diseases is mandatory.

MATERIAL AND METHODS

Retrospectively, data from 636 GCT patients, who were seen in the course of tumor surveillance/follow-up were collected. Focus was put on the detection of tumor relapse vs. noncaseating granulomatous reactions. For the differential diagnosis of thoracic lymphadenopathy or pulmonary infiltrates either bronchoscopy (e.g., endobronchial ultrasound-guided transbronchial needle aspiration, endobronchial ultrasound-guided transbronchial needle aspiration) or thoracic surgery was performed. Both GCT patients with either tumor relapse or coexisting SLL were compared to GCT patients without SLL and tumor relapse.

RESULTS

Twenty-nine patients suffered from suspected tumor relapse. Whereas thoracic relapses were suspected in 15 patients on chest computed tomography, thoracic relapse was confirmed in 5 cases by open surgery. In 2 cases open surgery yielded reactive lymphadenitis, and in 8 cases SLL was diagnosed either via EBUS-TBNA (n = 7) or thoracoscopic wedge resection plus lymphadenectomy (n = 1). With focus on overall survival, no relevant difference was found between all tested subgroups (P = 0.265; logrank test).

CONCLUSIONS

In GCT patients, the coexistence of noncaseating granulomatous disease is common. Minimal invasive bronchoscopic techniques can serve for the cytopathologic exclusion of malignant thoracic manifestations. In our monocenter patient group the coexistence of SLL did not have any prognostic impact on overall survival.

Selenium Rescues Aflatoxin B1-Inhibited T Cell Subsets and Cytokine Levels in Cecal Tonsil of Chickens

Cecal tonsil is the largest peripheral lymphoid organ of the gut-associated lymphoid tissue executing immune function. To evaluate the protective effect of selenium (Se) on the cecal tonsil of chicken exposed to aflatoxin B₁ (AFB₁), 144 1-day-old healthy Cobb chickens were randomly divided into four groups, and fed with basal diet (control group), 0.6 mg/kg AFB₁ (AFB₁ group), 0.4 mg/kg Se supplement (+Se group), and 0.6 mg/kg AFB₁ + 0.4 mg/kg Se supplement (AFB₁ + Se group) for 21 days, respectively. The results showed that AFB₁ significantly decreased the percentages of CD3⁺, CD3⁺CD4⁺, CD3⁺CD8⁺ T cells, and the CD4⁺/CD8⁺ ratio, and suppressed the expressions of IL-2, IL-4, TNF-α, and IFN-γ mRNA in the cecal tonsil. However, Selenium (Se) supplied in the diets restored the percentages of T cell subsets, the CD4⁺/CD8⁺ ratio, and mRNA expressions of cytokines in the AFB₁ group to be close to those in the control group, and did not exhibit obvious toxicity to the cecal tonsil. These results indicated that Se exerted protective effect against AFB₁ on the functions of cecal tonsil, and also partially uncovered a new role of Se that could protect cecal tonsil of chickens from immunotoxicity of AFB₁.

Multisystemic sarcoidosis-important lessons learnt from one of the great imitators

We report a case of a woman who was admitted with a suspicion of metastatic malignancy of unknown primary origin. A few months prior to her admission, she presented to a rheumatologist with acute anterior uveitis, psoriasiform rashes and polyarthritis. A diagnosis of psoriatic arthropathy was made and she was treated accordingly. Soon after she presented with persistent back and right upper quadrant abdominal pain for which she had a CT scan done with evidence of hilar lymphadenopathy, liver hypodensities and lytic-sclerotic bone lesions. She was referred to our hospital for further investigations and management. After re-exploring her clinical presentation and further investigations (including a liver biopsy), a diagnosis of multisystemic sarcoidosis with ocular, reticuloendothelial, hepatic and skeletal involvement was made. The patient was started on systemic glucocorticoids and second line immunosuppressants and demonstrated significant clinical improvement with resolution of her liver granulomata on imaging and improvement in her back pain. The case illustrates the importance of a thorough clinical assessment, review of investigations and an open mind in the evaluation of a patient.

Bronchoscopic modalities to diagnose sarcoidosis

PURPOSE OF REVIEW

Several studies have investigated different bronchoscopic techniques to obtain tissue diagnosis in patients with suspected sarcoidosis when the diagnosis cannot be based on clinicoradiographic findings alone. In this review, we will describe the most recent and relevant evidence from different bronchoscopic modalities to diagnose sarcoidosis.

RECENT FINDINGS

Despite multiple available bronchoscopic modalities to procure tissue samples to diagnose sarcoidosis, the vast majority of evidence favors endobronchial ultrasound transbronchial needle aspiration to diagnose Scadding stages 1 and 2 sarcoidosis. Transbronchial lung cryobiopsy is a new technique that is mainly used to aid in the diagnosis of undifferentiated interstitial lung disease; however, we will discuss its potential use in sarcoidosis.

SUMMARY

This review illustrates the limited information about the different bronchoscopic techniques to aid in the diagnosis of pulmonary sarcoidosis. However, it demonstrates that the combination of available bronchoscopic techniques increases the diagnostic yield for suspected sarcoidosis.

Interstitial lung disease: the diagnostic role of bronchoscopy

Interstitial lung diseases (ILDs) form one of the most fascinating fields in pulmonary medicine. They also pose one of the greatest challenges for accurate diagnosis and proper treatment. Even within the recommended and warranted multidisciplinary approach, differentiating between one disease and another may lead to frustration, especially when proper lung tissue is not available for adequate pathological review. A surgical lung biopsy (SLB) might render enough tissue for histopathology, but this could come at the expense of high morbidity and even mortality, as in the case of usual interstitial pneumonia (UIP). Could bronchoscopy and its various techniques offer a safer and higher yield alternative? Since the very late 19th century, efforts have been made to better examine the airways, obtain tissue and treat various conditions. This resulted in the successive emergence of bronchoalveolar lavage (BAL), endobronchial and transbronchial forceps biopsies, until recently when transbronchial cryobiopsy surfaced as a nascent technique with much promise. The use of endobronchial ultrasound revolutionized the diagnosis and staging of lung cancer, while adding to the yield of other conditions such as sarcoidosis. Ongoing research, efforts and studies have continuously scrutinized the roles of various techniques in the approach to ILDs. For example, BAL seems to serve mostly to eliminate infection as an etiology or a complicating factor in the acute worsening of a fibrotic lung disease, while a predominant cellular component might be diagnostic, such as eosinophilia in eosinophilic lung disease, or lymphocytosis in hypersensitivity pneumonitis (HP). On the other hand, endobronchial biopsy's (EBB) role appears limited to sarcoidosis. As for transbronchial biopsy by forceps, the small sample size and related artifact appear to be limiting factors in making an accurate diagnosis. Recently, however, the use of cryotherapy via employing a cryoprobe in obtaining transbronchial lung biopsies is unfolding into a refined interventional method which might transform indefinitely our approach to the pathological diagnosis of the various ILDs.

Diversity of Human and Macaque Airway Immune Cells at Baseline and during Tuberculosis Infection

Immune cells of the distal airways serve as "first responders" of host immunity to the airborne pathogen Mycobacterium tuberculosis (Mtb). Mtb infection of cynomolgus macaques recapitulates the range of human outcomes from clinically silent latent tuberculosis infection (LTBI) to active tuberculosis of various degrees of severity. To further advance the application of this model to human studies, we compared profiles of bronchoalveolar lavage (BAL) cells of humans and cynomolgus macaques before and after Mtb infection. A simple gating strategy effectively defined BAL T-cell and phagocyte populations in both species. BAL from Mtb-naive humans and macaques showed similar differential cell counts. BAL T cells of macaques were composed of fewer CD4⁺cells but more CD8⁺ and CD4⁺CD8⁺ double-positive cells than were BAL T cells of humans. The most common mononuclear phagocyte population in BAL of both species displayed coexpression of HLA-DR, CD206, CD11b, and CD11c; however, multiple phagocyte subsets displaying only some of these markers were observed as well. Macaques with LTBI displayed a marked BAL lymphocytosis that was not observed in humans with LTBI. In macaques, the prevalence of specific mononuclear phagocyte subsets in baseline BAL correlated with ultimate outcomes of Mtb infection (i.e., LTBI versus active disease). Overall, these findings demonstrate the comparability of studies of pulmonary immunity to Mtb in humans and macaques. They also indicate a previously undescribed complexity of airway mononuclear phagocyte populations that suggests further lines of investigation relevant to understanding the mechanisms of both protection from and susceptibility to the development of active tuberculosis within the lung.

Pulmonary tuberculosis followed by sarcoidosis in an HIV-infected patient: A case report and a simplified diagnostic flowchart for diagnosis and treatment of sarcoidosis

The diagnosis of sarcoidosis in a patient living with HIV infection is an uncommon event and a challenge for clinicians. Clinical manifestations are variable and fluctuating depending to adherence to ARV therapy and to the level of CD4 count. We analyze here one chronic case in which sarcoidosis appeared clinically two years after pulmonary tuberculosis. The course of the disease was influenced and prolonged by frequent interruptions of antiretroviral therapy. Moreover the diagnosis and the decision to treat have been delayed by the need of exclusion of other pathologies, principally tuberculosis reactivation/reinfection, other mycobacterial diseases, hematologic malignancies. We propose a simplified flowchart for diagnosis and follow up of sarcoidosis, which may also be applied to patients with HIV infection. Diagnosis of latent tuberculosis infection (LTBI) may be difficult in these patients, because the immunological paradox of sarcoidosis. For this reason, following exclusion of active tuberculosis, we advise to submit all sarcoidosis patients to IPT (isoniazid preventive therapy), when immunosuppressive therapy is started.

Diagnostic Performance of Bronchoalveolar Lavage Fluid CD4/CD8 Ratio for Sarcoidosis: A Meta-analysis

BACKGROUND

The usefulness of bronchoalveolar lavage fluid (BALF) CD4/CD8 ratio for diagnosing sarcoidosis has been reported in many studies with variable results. Therefore, we performed a meta-analysis to estimate the overall diagnostic accuracy of BALF CD4/CD8 ratio based on the bulk of published evidence.

METHODS

Studies published prior to June 2015 and indexed in PubMed, OVID, Web of Science, Scopus and other databases were evaluated for inclusion. Data on sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were pooled from included studies. Summary receiver operating characteristic (SROC) curves were used to summarize overall test performance. Deeks's funnel plot was used to detect publication bias.

RESULTS

Sixteen publications with 1885 subjects met our inclusion criteria and were included in this meta-analysis. Summary estimates of the diagnostic performance of the BALF CD4/CD8 ratio were as follows: sensitivity, 0.70 (95%CI 0.64-0.75); specificity, 0.83 (95%CI 0.78-0.86); PLR, 4.04 (95%CI 3.13-5.20); NLR, 0.36 (95%CI 0.30-0.44); and DOR, 11.17 (95%CI 7.31-17.07). The area under the SROC curve was 0.84 (95%CI 0.81-0.87). There was no evidence of publication bias.

CONCLUSION

Measuring the BALF CD4/CD8 ratio may assist in the diagnosis of sarcoidosis when interpreted in parallel with other diagnostic factors.

The Diagnosis of Sarcoidosis

Sarcoidosis is a diagnosis of exclusion; there exists neither a pathognomonic clinical feature nor a perfect diagnostic test. Missed diagnosis and overdiagnosis are common. A careful history and physical examination look for "footprints" of sarcoidosis or features suggesting alternative diagnoses. Some presentations are classic and do not require tissue confirmation. A tissue biopsy should be performed if doubt exists. Sampling intrathoracic disease by transbronchial or ultrasound-guided biopsy of mediastinal lymph nodes provide high diagnostic yield with low complication rates. Even with tissue confirmation, diagnosis is never secure and follow-up is required to be fully confident of the diagnosis.

A diagnostic predicament: activated sarcoidosis or pulmonary histoplasmosis. A case report

We report a case of a 41-year-old man presenting with persisting fevers over 2 weeks. The patient had spent 4 weeks in Central America. He was in control of a stable stage II sarcoidosis. Laboratory and various microbiological tests as well as chest radiography led to no diagnosis. Activated sarcoidosis was hypothesized as the most likely diagnosis. However, we considered an infectious process as a differential diagnosis, in detail, the travel history imposed histoplasmosis. Chest-CT documented localized interstitial consolidations. Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy was performed. Results of BAL fluid, biopsy, distinct sarcoidosis serum markers and a borderline positive histoplasmosis-serology yielded in a diagnostic dilemma as no distinct diagnosis was drawable. After the patient was already started on a prednisolone trial, the final diagnosis - pulmonary histoplasmosis - could be achieved via positive culture and PCR out of the BAL fluid. This case shows the difficult differentiation between an acute exacerbation of a chronic pulmonary disease and a concomitant infection, which was especially aggravated in this case as the histoplasmosis masqueraded an acute picture of sarcoidosis.

Clinical usefulness of bronchoalveolar lavage cellular analysis and lymphocyte subsets in diffuse interstitial lung diseases

BACKGROUND

Diffuse interstitial lung diseases (DILDs) form a part of a heterogeneous group of respiratory diseases. Bronchoalveolar lavage (BAL) analysis has been used for differential diagnosis of DILDs, but their clinical usefulness is controversial. The aim of this study was to investigate the clinical usefulness of BAL cellular analysis with lymphocyte subsets for the differential diagnosis of DILDs.

METHODS

A total of 69 patients diagnosed with DILDs were enrolled. Basic demographic data, BAL cellular analysis with lymphocyte subsets, histology, and high resolution computed tomogram (HRCT) findings were analyzed and compared as per disease subgroup.

RESULTS

Significant differences were found between groups in the proportion of neutrophils (P=0.0178), eosinophils (P=0.0003), T cells (P=0.0305), CD4 cells (P=0.0002), CD8 cells (P<0.0001), and CD4/CD8 ratio (P<0.0001). These findings were characteristic features of eosinophilic pneumonia and sarcoidosis. Other parameters were not significantly different between groups. At the cut-off value of 2.16 for sarcoidosis, CD4/CD8 ratio showed sensitivity of 91.7% (95% CI, 61.5-98.6%) and specificity of 84.2% (95% CI, 72.1-92.5%).

CONCLUSIONS

Routine analysis of BAL lymphocyte subset may not provide any additional benefit for differential diagnosis of DILDs, except for conditions where BAL is specifically indicated, such as eosinophilic pneumonia or sarcoidosis.

Chitotriosidase in the Pathogenesis of Inflammation, Interstitial Lung Diseases and COPD

As a member of 18 glycosyl hydrolase (GH) family, chitotriosidase (Chitinase 1, CHIT1) is a true chitinase mainly expressed in the differentiated and polarized macrophages. CHIT1 is an innate immune mediator that digests the cell walls of chitin-containing eukaryotic pathogens, such as fungi. However, CHIT1 is dysregulated in granulomatous and fibrotic interstitial lung diseases characterized by inflammation and tissue remodeling. These include tuberclosis, sarcoidosis, idiopathic pulmonary fibrosis, scleroderma-associated interstitial lung diseases (SSc-ILD), and chronic obstructive lung diseases (COPD). CHIT1 serum concentration correlates with the progression or the severity of these diseases, suggesting a potential use of CHIT1 as a biomarker or a therapeutic target. Recent studies with genetically modified mice demonstrate that CHIT1 enhances TGF-β1 receptor expression and signaling, suggesting a role in initiating or amplifying the response to organ injury and repair. This additional CHIT1 activity is independent of its enzymatic activity. These studies suggest that CHIT1 serves a bridging function; it is both an innate immune mediator and a regulator of tissue remodeling. This review will focus on recent data linking CHIT1 to the pathogenesis of inflammation, interstitial lung disease, and COPD.

Cutaneous sarcoidosis: an intriguing model of immune dysregulation

Sarcoidosis is a systemic granulomatous disease characterized by the presence of non-caseating granulomas. Its etiology remains obscure. A plausible hypothesis suggests that a complex interplay of host factors, infectious processes, and non-infectious environmental factors, matched with a susceptible genetic background, results in a pathway that leads to systemic granulomatous inflammation. Although presentations of sarcoidosis vary enormously, multi-organ involvement is a common feature. Cutaneous involvement occurs in about 25% of patients with protean manifestations and variable prognoses. Skin manifestations are divided into specific lesions with histopathologically evident non-caseating granulomas and nonspecific lesions arising from a reactive process that does not form granulomas. A peculiar form of cutaneous sarcoidosis is represented by sarcoidal lesions at sites of trauma that has caused scarring. The pathogenesis of scar sarcoidosis remains unknown. Scar sarcoidosis is also associated with herpes zoster infection, surgery, and tattooing. Such heterogeneous events, along with those at the sites of chronic lymphedema, thermal burns, radiation dermatitis, and vaccinations, occur on areas of vulnerable skin labeled "immunocompromised districts". Numerous options are available for the treatment of cutaneous sarcoidosis. Although corticosteroids remain the treatment of choice for initial systemic therapy, other nonsteroidal agents have proven effective and therefore useful for long-term management. Tumor necrosis factor-α antagonists such as infliximab may have a role in the treatment of cutaneous sarcoidosis, especially in refractory cases that are resistant to standard regimens. Elucidation of the relationship of sarcoidal granulomas with malignancy and immunity may facilitate a better understanding of some pathomechanisms operating in neoplastic and immunity-related disorders.

Relationship between the ratios of CD4/CD8 T-lymphocytes in the bronchoalveolar lavage fluid and lymph nodes in patients with sarcoidosis

BACKGROUND

Evaluating the ratio of CD4/CD8 T-lymphocytes in the bronchoalveolar lavage fluid (BALF) is important for understanding the clinical and pathological conditions of patients with sarcoidosis. However, few studies have thus far demonstrated the usefulness of evaluating the relationship between the ratios of CD4/CD8 T-lymphocytes in the mediastinal lymph nodes and BALF. This study aimed to investigate and identify the relationships between CD4/CD8 T-lymphocyte ratio in the mediastinal lymph nodes and BALF in patients with sarcoidosis.

METHODS

Thirty-three consecutive patients with sarcoidosis with enlarged mediastinal and/or hilar lymphadenopathy were enrolled in the study, and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and bronchoalveolar lavage (BAL) were simultaneously performed. The CD4/CD8 T-lymphocyte ratios in the mediastinal lymph nodes and BALF were evaluated using immunohistochemistry and flow cytometry, respectively.

RESULTS

The interobserver variability in the CD4/CD8 ratio in the mediastinal lymph nodes as determined by immunostaining was low, and the pathological and cytological profiles of T-lymphocytes in the mediastinal and/or hilar lymph nodes and BALF were correlated in patients with sarcoidosis. Additionally, the CD4/CD8 T-lymphocyte ratios in BALF were significantly higher than those in the mediastinal lymph nodes. Importantly, non-caseating granulomas were detected at a high rate by using EBUS-TBNA.

CONCLUSIONS

Performing EBUS-TBNA in patients with sarcoidosis allows correct diagnosis as well as the estimation of the ratio of CD4/CD8 T-lymphocytes in BALF.

A novel alternative to environmental monitoring to detect workers at risk for beryllium exposure-related health effects

The purpose of this study was to describe a methodology for surveillance and monitoring of beryllium exposure using biological monitoring to complement environmental monitoring. Eighty-three Israeli dental technicians (mean age 41.6 ± 1.36 years) and 80 American nuclear machining workers (54.9 ± 1.21 years) were enrolled. Biological monitoring was carried out by analyzing particle size (laser technique) and shape (image analysis) in 131/163 (80.3%) induced sputum samples (Dipa Analyser, Donner Tech, Or Aquiva, Israel). Environmental monitoring was carried out only in the United States (Sioutas impactor, SKC, Inc., Eighty Four, Pa.). Pulmonary function testing performance and induced sputum retrieval were done by conventional methods. Sixty-three Israeli workers and 37 American workers were followed up for at least 2 years. Biological monitoring by induced sputum indicated that a >92% accumulation of <5 μm particles correlated significantly to a positive beryllium lymphocyte proliferation test result (OR 3.8, 95% CI 1.2-11.4, p = 0.015) among all participants. Environmental monitoring showed that beryllium particles were <1 μm, and this small fraction (0.1-1 μ) was significantly more highly accumulated in nuclear machining workers compared to dental technicians. The small fractions positively correlated with induced sputum macrophages (r = 0.21 p = 0.01) and negatively correlated with diffusion lung carbon monoxide single breath (DLCO-SB r = 0.180 p = 0.04) in all subjects. Years of exposure were positively correlated to the number of accumulated particles 2-3 μ in diameter (r = 0.2, p = 0.02) and negatively correlated to forced expiratory volume in one second/forced vital capacity findings (r = -0.18, p = 0.02). DLCO was decreased in both groups after two years of monitoring. Biological monitoring is more informative than environmental monitoring in the surveillance and monitoring of workers in beryllium industries. Induced sputum is a feasible and promising biomonitoring method that should be included in the surveillance of exposed workers.

Activated CD8(+) T cells and NKT cells in BAL fluid improve diagnostic accuracy in sarcoidosis

PURPOSE

The clinical diagnosis of pulmonary sarcoidosis is based on the presence of noncaseating granulomas in an appropriate clinical setting with either bilateral hilar adenopathy and/or parenchymal infiltrates. Lymphocytosis with an increased CD4/CD8 T cell ratio in bronchoalveolar lavage fluid is supportive. We evaluated the diagnostic accuracy of a predictive binary logistic regression model in sarcoidosis based on sex, age, and bronchoalveolar lavage fluid cell profile with and without the inclusion of HLA-DR(+) CD8(+) T cells and natural killer T-cell fractions.

METHODS

A retrospective analysis of differential cell counts and lymphocyte phenotypes by flow cytometry in bronchoalveolar lavage was performed in 183 patients investigated for possible diffuse parenchymal lung disease. A logistic regression model with age, sex, lymphocyte fraction, eosinophils, and CD4/CD8 ratio in bronchoalveolar lavage fluid (basic model) was compared with a final model, which also included fractions of HLA-DR(+) CD8(+) T cells and natural killer T cells. Diagnostic accuracy of the two models was assessed by receiver operating characteristic (ROC) curves.

RESULTS

The area under the ROC curve for the basic and final model was 0.898 [95 % confidence interval (CI) 0.852-0.945] and 0.937 (95 % CI 0.902-0.972), respectively, p = 0.008.

CONCLUSIONS

Assessment of HLA-DR(+) CD8(+) T cell and natural killer T-cell fractions may improve diagnostic accuracy and further strengthen the importance of bronchoalveolar lavage in the diagnostic workup of sarcoidosis.

Usefulness of endobronchial ultrasound-guided transbronchial needle aspiration for diagnosis of sarcoidosis

PURPOSE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate and minimally invasive technique used routinely for investigation of mediastinal and hilar lymphadenopathy. However, few studies have addressed its role in comparison to the traditional diagnostic approaches of transbronchial lung biopsy (TBLB), endobronchial biopsy (EBB), and bronchoalveolar lavage (BAL) in the diagnosis of sarcoidosis. We evaluated the usefulness of EBUS-TBNA in the diagnosis of sarcoidosis compared to TBLB, EBB, and BAL.

MATERIALS AND METHODS

Consecutive patients with suspected sarcoidosis (stage I and II) on chest radiography and chest computed tomography were included. All 33 patients underwent EBUS-TBNA, TBLB, EBB, and BAL during the same session between July 2009 and June 2011. EBUS-TBNA was performed at 71 lymph node stations.

RESULTS

Twenty-nine of 33 patients, were diagnosed with histologically proven sarcoidosis; two patients were compatible with a clinical diagnosis of sarcoidosis during follow-up; and two patients were diagnosed with metastatic carcinoma and reactive lymphadenopathy, respectively. Among 29 patients with histologically proven sarcoidosis in combination with EBUS-TBNA, TBLB, and EBB, only EBUS-TBNA and TBLB revealed noncaseating granuloma in 18 patients and one patient, respectively. The overall diagnostic sensitivities of EBUS-TBNA, TBLB, EBB, and BAL (CD4/CD8 ≥3.5) were 90%, 35%, 6%, and 71%, respectively (p<0.001). The combined diagnostic sensitivity of EBUS-TBNA, TBLB, and EBB was 94%.

CONCLUSION

EBUS-TBNA was the most sensitive method for diagnosing stage I and II sarcoidosis compared with conventional bronchoscopic procedures. EBUS-TBNA should be considered first for the histopathologic diagnosis of stage I and II sarcoidosis.

Algorithmic approach by endobronchial ultrasound-guided transbronchial needle aspiration for isolated intrathoracic lymphadenopathy: a study in a tuberculosis-endemic country

BACKGROUND/PURPOSE

Isolated intrathoracic lymphadenopathy (IT-LAP) is clinically challenging because of the difficult anatomic location and wide range of associated diseases, including tuberculosis (TB). Although sampling via endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histopathology is a major development, there is still room for improvement. This study aimed to investigate an algorithmic approach driven by EBUS-TBNA and conventional bronchoscopy to streamline the management of IT-LAP.

METHODS

Eighty-three prospectively enrolled patients with IT-LAP were subjected to an EBUS-TBNA diagnostic panel test (histopathology, cytology, and microbiology) and underwent conventional bronchoscopy for bronchoalveolar lavage. The results were structured into an algorithmic approach to direct patient treatment, workup, or follow-up.

RESULTS

The diagnostic yields of EBUS-TBNA based on histopathology were similar for each disease entity: 77.8% for malignancy, 70.0% for TB, 75.0% for sarcoidosis, 80.0% for anthracosis, and 70.0% for lymphoid hyperplasia (p = 0.96). The incidence of malignancy was 10.8% for total IT-LAP patients, and 12.0% and 33.7% for patients with TB and sarcoidosis, respectively. Thirty-five (42.2%) patients were symptomatic. The leading diagnosis was sarcoidosis (60%), followed by TB (20%), malignancy (11.4%), lymphoid hyperplasia (5.7%), and anthracosis (2.9%). By logistic regression analysis, granulomatous disease (odds ratio: 13.45; 95% confidence interval: 4.45-40.67, p < 0.001) was an independent predictor of symptoms. Seven (8.4%) and three (3.6%) IT-LAP patients diagnosed active TB and suggestive of TB with household contact history, respectively, were all placed on anti-TB treatment.

CONCLUSION

The algorithmic approach streamlines patient management. It enables early detection of malignancy, correctly places nonmalignant patients on an appropriate treatment regimen, and particularly identifies candidates at high risk of TB reactivation for anti-TB chemoprophylaxis.

An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease

BACKGROUND

The clinical utility of bronchoalveolar lavage fluid (BAL) cell analysis for the diagnosis and management of patients with interstitial lung disease (ILD) has been a subject of debate and controversy. The American Thoracic Society (ATS) sponsored a committee of international experts to examine all relevant literature on BAL in ILD and provide recommendations concerning the use of BAL in the diagnosis and management of patients with suspected ILD.

PURPOSE

To provide recommendations for (1) the performance and processing of BAL and (2) the interpretation of BAL nucleated immune cell patterns and other BAL characteristics in patients with suspected ILD.

METHODS

A pragmatic systematic review was performed to identify unique citations related to BAL in patients with ILD that were published between 1970 and 2006. The search was updated during the guideline development process to include published literature through March 2011. This is the evidence upon which the committee's conclusions and recommendations are based.

RESULTS

Recommendations for the performance and processing of BAL, as well as the interpretation of BAL findings, were formulated by the committee.

CONCLUSIONS

When used in conjunction with comprehensive clinical information and adequate thoracic imaging such as high-resolution computed tomography of the thorax, BAL cell patterns and other characteristics frequently provide useful information for the diagnostic evaluation of patients with suspected ILD.

Respiratory Tract and Mediastinum

Normal cytology, abnormal and atypical cells, non-cellular components, and infectious cell changes are largely described together with benign, malignant, and neuroendocrine lesions regarding exfoliative and aspiration cytology of the lung. A separate section broadly addresses diagnostic findings and differential diagnoses in bronchoalveolar washings.

The section ‘Fine needle aspiration biopsy of mediastinal disorders’ covers in particular biopsy techniques, accuracy of liquid-based cytology, and the complex lesions of the thymus gland. Cytodiagnostic algorithms of the major benign and malignant pulmonary and mediastinal lesions and their respective differential diagnoses are additionally presented in synoptic setups.

Effect of dietary vanadium on cecal tonsil T cell subsets and IL-2 contents in broilers

The purpose of this 42-day study was to investigate the effects of dietary excess vanadium on intestinal immune function by histopathological observation of cecal tonsil and changes of the cecal tonsil T cell subsets by method of flow cytometry. Four hundred twenty 1-day-old avian broilers were divided into six groups and fed on a corn-soybean basal diet as control diet or the same diet amended to contain 5, 15, 30, 45, and 60 mg/kg vanadium supplied as ammonium metavanadate. In comparison with those of control group, lymphocytes in the lymphatic nodule of cecal tonsil were apparently decreased in 45 and 60 mg/kg groups. The percentage of CD(3)(+) T cells was decreased (p < 0.05) in 45 mg/kg group at 28 and 42 days of age and significantly decreased (p < 0.01) in 60 mg/kg group at 28 and 42 days of age. The percentages of CD(3)(+)CD(4)(+) and CD(3)(+)CD(8)(+) T cells were markedly decreased (p < 0.05 or p < 0.01) in 60 mg/kg group from 14 to 28 days of age and were decreased (p < 0.05) in 45 mg/kg group at 28 and 42 days of age. However, changes of the CD(4)(+)/CD(8)(+) ratio were not significant. Meanwhile, the cecal tonsil interleukin-2 (IL-2) contents were decreased (p < 0.05 or p < 0.01) in 45 and 60 mg/kg groups from 14 to 42 days of age. It was concluded that dietary vanadium in excess of 30 mg/kg reduced the percentages of cecal tonsil T cells subsets and IL-2 contents, and caused cecal tonsil lesions, which impaired cecal tonsil function and impacted the local mucosal immune function of the intestines in broilers.

Neuro-ophthalmic sarcoidosis

PURPOSE OF REVIEW

Almost 100 years after its original description, sarcoidosis remains an enigmatic disease with unclear etiology and capricious symptomology, as well as a diagnostic challenge. This review coalesces current literature on the neuro-ophthalmic manifestations of sarcoidosis and discusses the epidemiology, etiology, clinical presentation, diagnosis, and management of this disease.

RECENT FINDINGS

Recent investigations strongly identify a genetic component as well as a host of candidate antigenic triggers. Certain human leukocyte antigen polymorphisms may influence not only the susceptibility of individuals to sarcoidosis but also the course of the disease. Diagnostic advances include the finding of two additional potential biomarkers of sarcoidosis as well as the use of positron emission tomography technology in localization of disease sites for biopsy. In addition to the concomitant and alternative use of immunosuppressive agents to steroid therapy, disease remission in refractory neuro-ophthalmic sarcoidosis with tumor necrosis factor alpha inhibitors has also been reported.

SUMMARY

Sarcoidosis can affect any part of the visual system; the most common neuro-ophthalmic presentation is optic neuropathy. Diagnosing the disease is problematic as the clinical presentation is nonspecific which may be associated with many other pathologies and no diagnostic finding is pathognomonic. In recent years, progress has been made in identifying new biomarkers and developing imaging techniques. Although corticosteroids remain the mainstay of therapy, many new pharmacological agents have been added to the treatment arsenal.

Human lung immunity against Mycobacterium tuberculosis: insights into pathogenesis and protection

The study of human pulmonary immunity against Mycobacterium tuberculosis (M.tb) provides a unique window into the biological interactions between the human host and M.tb within the broncho-alveolar microenvironment, the site of natural infection. Studies of bronchoalveolar cells (BACs) and lung tissue evaluate innate, adaptive, and regulatory immune mechanisms that collectively contribute to immunological protection or its failure. In aerogenically M.tb-exposed healthy persons lung immune responses reflect early host pathogen interactions that may contribute to sterilization, the development of latent M.tb infection, or progression to active disease. Studies in these persons may allow the identification of biomarkers of protective immunity before the initiation of inflammatory and disease-associated immunopathological changes. In healthy close contacts of patients with tuberculosis (TB) and during active pulmonary TB, immune responses are compartmentalized to the lungs and characterized by an exuberant helper T-cell type 1 response, which as suggested by recent evidence is counteracted by local suppressive immune mechanisms. Here we discuss how exploring human lung immunity may provide insights into disease progression and mechanisms of failure of immunological protection at the site of the initial host-pathogen interaction. These findings may also aid in the identification of new biomarkers of protective immunity that are urgently needed for the development of new and the improvement of current TB vaccines, adjuvant immunotherapies, and diagnostic technologies. To facilitate further work in this area, methodological and procedural approaches for bronchoalveolar lavage studies and their limitations are also discussed.