Bronchoalveolar lavage fluid profiles in sarcoidosis, tuberculosis, and non-Hodgkin's and Hodgkin's disease. An evaluation of differences

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma associated with coeliac disease

Pulmonary mucosa-associated lymphoid tissue (pMALT) lymphomas are rare, representing <1% of lung malignancies. An association between pMALT and autoimmune conditions has been described, but there is a paucity of documented cases linked to coeliac disease. We present the case of a patient with a history of coeliac disease who presented with weight loss but no respiratory symptoms. CT revealed diffuse endobronchial opacities with associated bronchial dilation and pulmonary nodules. Bronchoscopy confirmed widespread polypoid endobronchial lesions. Histology demonstrated diffuse lymphoid infiltrate which stained positive for CD20. Clonality studies confirmed low grade B cell MALT lymphoma. She was treated with anti CD20 monoclonal antibody, rituximab. Prognosis of pMALT is good with 5-year survival >80%. Thus, an index of suspicion and early detection are vital. This case highlights that pMALT should be considered in patients with non-specific symptoms and coeliac disease. Bronchoscopy is a valuable diagnostic tool to be used in these cases.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma: A case report

Primary pulmonary lymphoma (PPL) is a rare entity with the most common presentation as mediastinal lymphadenopathy. The most common form of PPL is Mucosa-Associated Lymphoid Tissue Lymphoma (MALToma) which is an extranodal B-cell lymphoma originating from the mucosal layers involving different organs such as the gastrointestinal tract as well as the lung. Herein, we present a case of a 51-year-old woman with progressive dyspnea for 6 months and no prior medical history. The computed tomography (CT scan) revealed bilateral multifocal consolidation and ground-glass opacities as well as interlobular septal thickening. Bronchoscopy was normal and CT-guided biopsy of lung consolidations was conclusive of MALToma. Complete extrapulmonary evaluations inducing bone marrow aspiration were unremarkable. The primary pulmonary MALToma is an extremely rare entity that presents with non-specific symptoms and a wide variety of CT findings such as mediastinal, hilar lymphadenopathy, and single or multiple lung nodules ranging from 2 to 8 cm. the disease has a favorable prognosis, so prompt diagnosis is essential.

Combined detection of lymphocyte clonality and MALT1 translocations in bronchoalveolar lavage fluid for diagnosing pulmonary lymphomas

Diagnosis of pulmonary lymphoma using small tissue samples is difficult and often requires surgical procedures; thus, a less invasive sampling method is desirable. We previously showed that pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma can be diagnosed by detecting MALT lymphoma translocation gene 1 (MALT1) translocations in bronchoalveolar lavage fluid (BALF) cells. Analysis of B-cell clonality based on immunoglobulin heavy chain (IGH) gene rearrangements was also reportedly useful for diagnosing pulmonary lymphoma. The aim of this prospective multicenter study was to evaluate the yet unknown diagnostic potential of combined detection of MALT1 translocations and clonality using BALF. We analyzed B- and T-cell clonality based on IGH and T-cell receptor (TCR) rearrangements together with MALT1 translocations using BALF of patients with clinically suspected pulmonary lymphomas. In total, 39 patients were evaluated and categorized into three groups: B-cell lymphoma, lymphoproliferative disorders, and other diseases. IGH rearrangement detection for B-cell lymphoma diagnosis exhibited sensitivity and specificity of 88.9% and 90.0%, respectively. TCR rearrangements were not observed in patients with B-cell lymphomas. The presence of IGH rearrangements together with the absence of TCR rearrangements indicated 96.0% specificity for the diagnosis of B-cell lymphoma. The sensitivity and specificity of MALT1 translocations for diagnosing MALT lymphoma were 28.6% and 100%, respectively. The combined detection of lymphocyte clonality and MALT1 translocations using BALF is suitable for screening and diagnosis of B-cell lymphomas. Analysis of specific genes such as MALT1 should improve the precision of B-cell lymphoma diagnosis.

Lung Cancer in Patients With Tuberculous Fibrothorax and Empyema: Computed Tomography and 18F-Fluorodeoxyglucose Positron Emission Tomography Findings

OBJECTIVE

The aim of this study was to describe the characteristics of lung cancers in patients with tuberculous fibrothorax or empyema.

METHODS

We retrospectively evaluated 138 consecutive patients with a diagnosis of lung cancer combined with fibrothorax (n = 127) or empyema (n = 11) from January 2005 to May 2015. All patients underwent computed tomography, and 105 underwent F-fluorodeoxyglucose positron emission tomography. Clinical, pathologic, and computed tomography characteristics and maximum standardized uptake values on positron emission tomography of 76 cancers ipsilateral to the fibrothorax or empyema (group 1) were compared with those of 62 contralateral cancers (group 2).

RESULTS

The median age at diagnosis of patients was 70 years, with a male-to-female ratio of 8.9:1. The most common type was squamous cell carcinoma (41.3%) followed by adenocarcinoma (39.1%). Most were in the peripheral lung (70.3%), and half abutted the pleura. The median maximum standardized uptake value was 8.9. Tumors in group 1 were larger (median, 48.5 vs 42.8 mm, P = 0.036) and more advanced (T3 or T4) (P = 0.014) than those in group 2.

CONCLUSIONS

Lung cancers ipsilateral to tuberculous fibrothorax or empyema presented larger and advanced T stages, and the diagnosis could be delayed. The most common type cancer was squamous cell carcinoma.

Sarcoidosis vs tuberculosis: Diagnostic mystery still unresolved

Sarcoidosis and tuberculosis are chronic, multisystemic, granulomatous disease of alike clinical, radiological and histopathological manifestations. Idiopathic nature of the disease and a strong clinical similarity with tuberculosis make the effectiveness of various clinical examinations for the diagnosis of sarcoidosis difficult in a tuberculosis endemic area. Presently confirmation of a diagnosis of sarcoidosis in most cases requires a biopsy which is often not confirmatory. A variety of novel medical approaches is under research to replace invasive diagnostic procedures for a simple non-invasive investigation for the identification of sarcoidosis. Here we discussed the studies focussing on the features that can be useful for distinguishing sarcoidosis from tuberculosis. Multiple studies have found molecular, cellular, immunological and clinical biomarkers efficient to lead the way of clinicians for the exact diagnosis of sarcoidosis.

The impact of ACE gene polymorphism on the incidence and phenotype of sarcoidosis in rural and urban settings

INTRODUCTION

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Current theory on the etiology of this disease involves participation of genetic factors and unknown antigens present in the patients' environment. The aim of the study was to evaluate the prevalence of different polymorphic forms of the ACE gene in healthy individuals and sarcoidosis patients, and to estimate the risk of sarcoidosis in carriers of different ACE genotypes living in rural and urban settings.

MATERIAL AND METHODS

The study group included 180 patients with pulmonary sarcoidosis. Assessment of the disease was based on clinical features, laboratory and imaging examinations, as well as bronchoscopy with bronchoalveolar lavage (BAL). ACE gene polymorphism was examined in DNA isolated from peripheral blood or BAL fluid (BALF) leukocytes.

RESULTS

Incidence of sarcoidosis was not influenced by gender, age or place of residence of the patients. There were no differences in the frequency of particular genotypes in patients with sarcoidosis and in healthy individuals. The risk of disease did not depend on the ACE gene polymorphism. There were no differences in the frequencies of the different genotypes and alleles of the ACE gene in patients with sarcoidosis divided by gender, age and place of residence or by clinical manifestation of sarcoidosis.

CONCLUSIONS

Our results do not support the previous concept which suggested a higher incidence of sarcoidosis in individuals living in rural areas and in carriers of selected ACE genotypes. It is possible that this is related to the changing environment of rural areas, increasing urbanization and pollution.

Pulmonary mucosa-associated lymphoid tissue lymphoma revisited

This general review sought to clarify the pathophysiological, diagnostic, prognostic, and therapeutic features of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma.MALT lymphoma is the most common pulmonary B-cell lymphoma, which usually occurs in the context of acquired MALT. The disease is slow-growing with an asymptomatic chronic alveolar opacity visible on radiography. Diagnosis requires tissue samples that should be retrieved using minimally invasive techniques, such as bronchoscopy or computed tomography-guided biopsies. The pathophysiology includes cytogenetic abnormalities and autoimmune diseases, whereas an association with a chronic pulmonary infection is still suspected but not yet demonstrated. Disease prognosis is typically excellent and the current available treatments are discussed in this review, including the decision not to treat, surgery, and single- or double-agent chemotherapy.

Primary pulmonary lymphoma mimicking a refractory lung abscess: A case report

The current study presents a case of primary pulmonary lymphoma (PPL) mimicking refractory lung abscess that was diagnosed at autopsy. An 80-year-old male with clinically inapparent aspiration presented with a large cavitated mass and pleural effusion. A lung abscess and empyema was diagnosed, therefore, antibiotics were administered and the pleural effusion was drained. Various examinations, including a biopsy, yielded no specific diagnosis. The lesion was considered inoperable due to the poor general condition of the patient. Subsequently, the mass that had been diagnosed as a refractory lung abscess became enlarged and a repeat biopsy resulted in a diagnosis of diffuse large B-cell lymphoma. The patient succumbed to sudden respiratory failure, and the final diagnosis of PPL was confirmed at autopsy. PPL is a rare disease that accounts for 0.45% of all pulmonary malignant tumors and is difficult to diagnose in inoperable cases. Therefore, patients with PPL who do not undergo surgery can be misdiagnosed and consequently treated inappropriately. PPL should therefore be considered in the differential diagnosis of a refractory lung abscess.

[Pulmonary malt lymphoma]

This review will describe the current knowledge in the pathophysiology, diagnosis, prognosis and treatment of pulmonary MALT (Mucosa Associated Lymphoid Tissue) lymphoma. Pulmonary MALT lymphomas are low-grade B cell lymphoma and are the most frequent lymphomas arising from the lung. Tumour cells arise from mucosa associated lymphoid tissue. Unlike other sites, no pathogen has been associated with pulmonary location of MALT lymphoma. However addictive translocations involving the MALT1 gene are frequently evidenced Patients are frequently asymptomatic and present with a chronic alveolar opacity. Diagnosis requires histology that may be retrieved by minimally invasive procedures during bronchial endoscopy or by CT scan guided percutaneous biopsies. Prognosis is good and treatment may vary with abstention, surgery, radiotherapy, immunotherapy or chemotherapy.

[The presence of mycobacteria in bronchoalveolar lavage fluid from an immunocompetent patient does not necessarily imply tuberculosis]

Mycobacterium tuberculosis is the most frequently identified mycobacterium in the bronchoalveolar lavage fluid (BALF) of immunocompetent patients. Lung infections due to non-tuberculous mycobacteria (NTM) are rare in such patients and then often occur in the context of pre-existing chronic lung disease. We report the case of an immunocompetent 85-year-old woman without pre-existing lung disease in whom M. abscessus was recovered from BALF. Cytological examination of the BALF revealed an increased number of neutrophils and some acid-fast bacilli, all located within neutrophil cytoplasm. This case report contributes a cytological description of BALF in the context of M. abscessus infection, which is poorly detailed in the literature.

[Malt lung lymphoma]

MALT lung lymphoma is a low-grade primarily B-cell lymphoma. Most cases develop in a pain free patient presenting a chronic alveolar opacity. In this review, we describe the clinical radiological and pathological features as well as the diagnostic approach to this pathological entity. Prognosis is excellent. Therapeutic options are discussed.

Lung cancer in patients with tuberculosis

BACKGROUND

Coexistent lung cancer and pulmonary tuberculosis is an urgent problem of thoracic surgery presenting a challenging task for diagnosis and surgical treatment.

MATERIALS AND METHODS

From 1990 to 2005, 2218 patients with lung cancer underwent surgical treatment in Department of Thoracic Surgery and Oncology, Institute of Oncology, Vilnius University. In 46 (2.1%) patients coexistence of lung cancer and tuberculosis was found. Central lung cancer was diagnosed in 37 (80.4%) and peripheral--in 9 (19.6%) patients. Epidermoid cancer was diagnosed in 24 (52.2%) patients, adenocarcinoma--in 10 (21.7%) and adenoepidermoid carcinoma--in 12 (26.1%) patients. Stage I cancer was diagnosed in 12 (26.1%), stage II--in 11 (23.9%), and stage IIIA--in 23 (50%) patients.

RESULTS

Pneumonectomy was performed in 18 (39.2%), lobectomy in 10 (21.7%), bilobectomy in 10 (21.7%), segmentectomy in 8 (17.4%) patients. Postoperative surgical complications were observed in 9 (19.5%) patients, non-surgical complications occurred in 19 patients (41.3%). Six patients (13.04%) died. Combined treatment was applied to 23 (50%) patients.

CONCLUSION

Coexistence of tuberculosis and lung cancer in thoracic surgery is fairly rare. This combination was diagnosed only in 46 cases (2.1%) out of 2218 operated lung cancer patients. Epidermoid carcinoma and stage IIIA disease was diagnosed in 50% of patients. Postoperative surgical complications occurred in 9 patients (19.5%) with lung cancer and tuberculosis. Six patients (13%) died in postoperative period. Surgery is the method of choice in treatment of combination of tuberculosis and lung cancer. Median survival of these patients was 28 +/- 2 months.

Il lavaggio broncoalveolare nelle pneumopatie infiltrative diffuse

Le pneumopatie infiltrative diffuse costituiscono un gruppo eterogeneo di malattie caratterizzate, istologicamente, dalla presenza di un danno a carico della parete alveolare che puÒ essere infiltrata da cellule infiammatorie/neoplastiche/fluidi/tessuto connettivo. Si parla di forme “diffuse” per sottolineare l’interessamento non solo dell’interstizio, ma anche delle strutture acinari e bronchiolari.

Cytometric analysis of BAL T cells labeled with a standardized antibody cocktail correlates with immunohistochemical staining

BACKGROUND

Determining T-cell phenotypes of lung cells obtained by bronchoalveolar lavage (BAL) is frequently clinically useful, particularly for evaluating causes of interstitial lung disease. The current standard of determining CD4/CD8 T-cell subsets by immunohistochemical (IHC) staining of cytocentrifuge slides is labor-intensive and subject to interpreter variation. Flow cytometry (FCM) is a precise and rapid method commonly used in research to characterize cells in the lung. However, few studies address the methodology of analysis of BAL lymphocytes by FCM.

METHODS

Patients underwent bronchoscopy for clinical purposes. A BAL cell differential and T-cell subtype was requested by the treating physician to supplement the evaluation of patients with suspected interstitial lung disease. We used a commercially available T-cell antibody reagent, approved for analysis of blood via FCM, for T-cell subtyping of clinical BAL specimens.

RESULTS

The percentages of CD4 and CD8 T-cell populations, as well as the CD4/CD8 ratios showed excellent correlation with IHC staining of cytocentrifuge slides regardless of the acquisition program used, as long as the gating strategy remained consistent (r > or = 0.9693 for CD4, r > or = 0.9589 for CD8, and r > or = 0.9485 for the CD4/CD8 ratio).

CONCLUSION

These findings validate the use of standardized, commercially available antibody cocktails for BAL lymphocyte subtyping, making this technique available to clinicians and researchers with access to a three-color or four-color flow cytometer.

The role of bronchoalveolar lavage in interstitial lung disease

Considerable progress has been made in understanding the similarities and differences among the forms of the interstitial lung diseases (ILDs), particularly the forms of idiopathic interstitial pneumonia, now recognized as distinct clinicopathologic entities. Lung parenchymal evaluation by high-resolution CT scanning of the chest may provide images that are virtually diagnostic of certain forms of ILD, but other testing, including bronchoalveolar lavage (BAL) and lung biopsy, may be required for accurate diagnosis. The differential diagnosis of these disorders rests on the clinician's interpretation of the clinical presentation and physical examination findings, pulmonary function testing, radiographic imaging, and, if required, sampling of lung tissue. This discussion examines the usefulness of BAL in the diagnosis of specific forms of ILD.

Pulmonary sarcoidosis

Pulmonary sarcoidosis is one of the most common causes of idiopathic interstitial lung disease. Clinical presentation can range from asymptomatic to respiratory failure. Although some patients never require therapy, many patients with pulmonary sarcoidosis become symptomatic enough to require therapy. Treatment options include corticosteroids.In the past few years, alternatives to corticosteroids have been developed,especially for patients with a chronic condition.

A rapid flow cytometric method for determining the cellular composition of bronchoalveolar lavage fluid cells in mouse models of asthma

Mouse models of allergic asthma are increasingly used to study the immunopathology of this complex disorder. The degree and type of airway inflammation is often studied by determination of differential cell counts on cytospins of bronchoalveolar lavage fluid (BALF) cells stained with May-Grünwald Giemsa, in which the separation of eosinophils (eos) from neutrophils (neutro) and of monocytes (mono) from activated T cells can be quite problematic. In this study, we compared differential cell counts based on morphological criteria on May-Grünwald Giemsa stained cytospins with a newly developed flow cytometric method. BAL fluid cells were identified based on forward and side scatter characteristics (FSC and SSC), autofluorescence of macrophages, and simultaneous one-step staining with antibodies for T cells (CD3-Cy-Chrome), B cells (B220-Cy-Chrome), eosinophils (CCR3-PE), and dendritic cells (DCs) (MHCII-FITC, CD11c-APC). The validity of this flow cytometric determination was tested by morphological analysis of flow-sorted cellular subsets. In an animal model of ovalbumin-induced asthma, this new method correlated very well with the differential counts based on cytospins. Flow cytometric determination of the cellular composition of BAL fluid in mouse models of asthma is a rapid and easy method that can replace differential cell counts based on morphology.

Optimal gating strategies for determining bronchoalveolar lavage CD4/CD8 lymphocyte ratios by flow cytometry

Alterations in bronchoalveolar lavage (BAL) CD4/CD8 T cell subset ratios have been demonstrated in a variety of different respiratory disorders and the measurement of these changes may be diagnostically helpful. Flow cytometry (FCM) is a precise technology that offers many advantages over conventional cytospin techniques to determine T cell subset ratios in tissue fluids such as BAL. However, the optimum gating strategies for evaluating these parameters by FCM have not been evaluated. Here, the CD4/CD8 ratios in 33 BAL samples were compared using three different methods by FCM with two different flow cytometers. Bland Altman analysis demonstrated clinically insignificant differences between two simplified staining and gating strategies and a more complex "gold standard" method. These findings confirm the precision of FCM for BAL T cell subset ratio analysis and suggest that the optimal gating strategy may be a simple panel using only CD45, CD4 and CD8.

Computer program supporting the diagnostic accuracy of cellular BALF analysis: a new release

Recently we developed a validated computer program based on polychotomous logistic regression analysis using bronchoalveolar avage fluid (BALF) results to distinguish between the three most common interstitial lung diseases (ILD): sarcoidosis, idiopathic pulmonary fibrosis (IPF) and extrinsic allergic alveolitis (EAA) or drug-induced pneumonitis. One of the limitations of this program was that it was not useful in discriminating between infectious disorders and non-infectious disorders. Therefore, we added BALF samples obtained from patients with a confirmed bacterial pulmonary infection based on culture results > or = 10(4) cfum l(-1) (group I: n=31) to the study population mentioned above (group II: n=272). Notably, just one variable, i.e. the percentage of polymorphonuclear neutrophils, allowed us to distinguish between infectious and non-infectious disorders. The agreement of predicted with the actual diagnostic group membership was 99.67% (groups I and II). Additionally, 91.2% of the cases with ILD were correctly classified. In conclusion, this updated Windows version 2000 of the validated computer program provides a very reliable prediction of the correct diagnosis for an arbitrary patient with suspected pneumonia or with ILD given information obtained from BALF analysis results, and is thought to improve the diagnostic power of BALF analysis.

Role of bronchoalveolar lavage in interstitial lung disease

Bronchoalveolar lavage remains an important research tool in understanding ILD. It is still an important part of the clinical management of patients with ILD. It is most useful in detecting unusual forms of ILD. It helps the clinician narrow down the possible causes of the interstitial pattern. It also can confirm a clinical impression of certain conditions. Although rarely diagnostic, it is often supportive. In conjunction with high-resolution CT scan, most patients with ILD can be diagnosed using relatively noninvasive methods.

Sarcoidosis after antiretroviral therapy in a patient with acquired immunodeficiency syndrome

A 53-year-old man with acquired immunodeficiency syndrome (AIDS) developed clinical and radiological features compatible with sarcoidosis 14 months after starting highly active antiretroviral therapy (HAART). The CD4 lymphocyte count had increased from 5 cells/mm(3) to 235 cells/mm(3) with HAART. Transbronchial lung biopsy showed nonnecrotizing granulomas. All studies for an infectious etiology were negative. His condition improved after treatment with corticosteroids. To our knowledge, this is the fifth case report of sarcoidosis occurring after initiation of antiretroviral therapy for AIDS.

Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology

The present study investigated the usefulness of bronchoalveolar (BAL) fluid cytology in the identification of non-infectious pulmonary conditions in patients hospitalized in the intensive care unit (ICU) and suspected of pneumonia. A total of 182 BAL fluid samples obtained during a 27-month period from 130 ICU patients with suspected pneumonia were quantitatively cultured and investigated for opportunistic pathogens. Cytocentrifuged preparations stained with the May-Grünwald Giemsa and Perls's methods were reviewed. A non-infectious aetiology was considered when cultures yielded micro-organisms in quantities < 10(3) colony-forming units (CFU) per ml, in the absence of any other pathogen and in conjunction with one or more of the following cytological findings: > 20% haemosiderin macrophages, > 10% lymphocytes, the presence of activated lymphocytes, plasma cells, > 5% eosinophils, a preponderance of foamy macrophages, reactive type II pneumocytes or malignant cells. Patients' clinical records were reviewed to identify a clinical diagnosis for these episodes. In thirty-five (19.2%) BAL fluid samples from 26 patients, the cytological findings pointed to a non-infectious origin. An alternative diagnosis was ascertained in 20 of 26 patients. Diagnoses included: drug-induced pneumonitis (n = 7), aspiration of gastric contents (n = 2), pulmonary emboli (n = 3), adult respiratory distress syndrome (n = 4), lung contusion (n = 1), cardiogenic pulmonary oedema (n = 1), and carcinomatous lymphangitis (n = 2). The BAL fluid cytological findings were readily discernable and proved to be useful in the diagnostic work-up of samples obtained from ICU patients with suspected pneumonia.

Characterization of local memory cells in stage-classified pulmonary tuberculosis: preliminary observations

Immunophenotype analysis and proliferative responses were investigated in bronchoalveolar lavage (BAL) cells from 21 patients with stage-classified tuberculosis: six with localized pulmonary infiltrate (LPI); seven with diffuse pulmonary infiltrate (DPI); and eight with pleural effusions (PE). Bronchoalveolar lavage cells from these patients contained a high number of cells/ml. The macrophage number was significantly lower in the DPI group (P < 0.05) compared to the LPI or PE groups. Conversely, neutrophils were markedly increased in DPI patients compared to LPI (P < 0.01) and PE (P < 0.01) patients. Lymphocyte infiltration (97.7 +/- 2.3% CD3+, > 83% alphabeta+ and CD4+ > CD8+) was observed in the three groups. A significant increase in the number of total lymphocytes (P < 0.01) and CD4+ cells (P < 0.05) was observed in the LPI group compared to the PE group. In the LPI group CD4+CD45RO+ cell infiltration was higher than CD4+CD45RA+ cells (P < 0.001), contrasting to similar numbers of these subpopulations in the DPI group. Lymphocytes from three out of three LPI patients (alphabeta+CD4+CD45RO+) responded against tuberculin purified protein derivative contrasting to the unresponsiveness of five patients with either DPI or PE. This impaired response was reverted in two out of five patients by using peripheral blood monocytes instead of alveolar macrophages. It is suggested that, in humans, alphabetaCD4+CD45RO cells are the main lymphocyte type involved in the initial local cell-mediated immune response against Mycobacterium tuberculosis.