Lymphocyte subpopulations in sarcoid pleural effusion

Scrotal mass and unilateral lung masses with pleural effusion mimicking metastatic testicular malignancy: an unusual presentation of sarcoidosis

Involvement of the genitourinary tract by sarcoidosis may present with a scrotal mass, mimicking infection or malignancy. Sarcoidosis is a systemic granulomatous disease that affects patients of both sexes worldwide. Sarcoidosis of the genitourinary tract is rare. We describe a case of a 33-year-old African-American man who presents with a scrotal mass, mediastinal mass, unilateral lung masses and pleural effusion mimicking testicular malignancy with pulmonary metastases. The histopathological examination of the right testis and lung biopsy revealed granulomatous inflammation consistent with sarcoidosis. Genitourinary sarcoidosis must be a diagnostic consideration, especially in an African-American patient with a scrotal mass. There is a possible association between sarcoidosis and testicular malignancy; hence, underlying malignancy should always be ruled out. Serum tumour markers, ACE, a biopsy of the accessible tissue and intraoperative frozen section analysis aid in establishing the diagnosis of sarcoidosis and leading to appropriate management.

Pulmonary sarcoidosis

Sarcoidosis is an inflammatory granulomatous disease that is characterized by diverse organ system manifestations, a variable clinical course, and a predilection for affecting relatively young adults worldwide. Abnormalities on chest radiographs are detected in 85% to 95% of patients who have sarcoidosis. Approximately 20% to 50% of patients who have sarcoidosis present with respiratory symptoms, including dyspnea, cough, chest pain, and tightness of the chest. The clinical course and manifestations of pulmonary sarcoidosis are protean: spontaneous remission occurs in approximately two thirds of patients; up to 30% of patients have chronic course of the lung disease, resulting in progressive, (sometimes life-threatening) loss of lung function. Morbidity that correlates to sarcoidosis occurs in 1% to 4% of patients.

Pleural effusion in interstitial lung disease

PURPOSE OF REVIEW

This review reports recent information on the occurrence of pleural effusions in association with disorders that produce interstitial parenchymal lung disease.

RECENT FINDINGS

The occurrence of effusions has been expanded to include systemic sclerosis, polymyositis-dermatomyositis, several drugs, and several miscellaneous causes of interstitial lung disease (ILD).

SUMMARY

Pleural effusions occur in patients with various forms of interstitial lung disease. The effusions require a clinical evaluation to exclude complications of therapy and coexisting conditions unrelated to the underlying ILD.

Pleural involvement in sarcoidosis

Pleural sarcoidosis is no longer considered rare, as it occurs in about 3% of all cases of sarcoidosis. However, newer methods of detection may boost this level higher. High-resolution computed tomographic scanning has increased our detection of pleural nodules and pleural thickening. Other manifestations include pneumothorax, chylothorax, and hemothorax. Further studies of large numbers of patients are needed to determine the true prevalence of pleural involvement in sarcoidosis.

Tuberculous pleural effusions: lymphocyte phenotypes in comparison with other lymphocyte-rich effusions

This study investigated whether the analysis of T cell subsets and of activation markers on T cells in pleural fluids can be helpful for diagnostic purposes in tuberculous pleurisy and other lymphocyte-rich pleural effusions. Pleural effusion fluids were obtained from 18 patients with tuberculous pleurisy (TB), 21 with effusions following radiotherapy (RT) for a malignant disease, and 11 with congestive heart failure (CHF). Lymphocyte subsets were analyzed by a battery of monoclonal antibodies using an immunoperoxidase method. The majority of the lymphocytes were CD3-positive T cells (TB, 86 +/- 7% of lymphocytes; RT, 81 +/- 8%; CHF, 84 +/- 12%). The ratios of CD4-positive helper-inducer to CD8-positive suppressor-cytotoxic T cells were higher than those reported for the peripheral blood but not significantly different between the study groups (TB, 3.3 +/- 1.9; RT, 2.8 +/- 1.4; CHF, 2.5 +/- 1.1). The activation marker studies revealed that only a few pleural T cells were positive for CD38, CD25 (interleukin-2 receptor), HLA-DR antigen, and OKT9 (transferrin receptor), the proportion of CD25-positive T cells being higher in TB and in RT than in CHF and the proportion of HLA-DR-positive T cells being higher in TB than in CHF (P less than 0.05). Significant differences were not observed relative to the natural killer-cytotoxic phenotypes staining positive for Leu-7 or for CD16. Thus, we concluded that phenotypic analysis of lymphocytes is of limited diagnostic usefulness to differentiate tuberculous from other nonmalignant effusions.

Diagnostic differentiation between reactive and malignant lymphoid cells in serous effusions

Lymphoid cell components in a total of 34 pleural and ascitic aspirates were investigated immunologically. The results indicate that reactive lymphocytes predominate in effusions from non-haemopoietic malignancies and benign conditions, while a significant proportion of fluids from patients with non-Hodgkins lymphoma show unequivocal evidence of lymphomatous involvement. Immunological typing of lymphocytes in serous effusions is a valuable adjunct to conventional methods of diagnosis particularly in those patients in whom invasive procedures are undesirable.

Immunohistologic identification of antigen-presenting cells in cutaneous sarcoidosis

Considerable evidence exists to show that activated T lymphocytes preferentially accumulate at sites of disease activity in sarcoidosis. Langerhans cells, which can be recognized by reactivity with an antibody to the T6 antigen are thought to play a primary role in T-lymphocyte activation by the skin, a tissue frequently involved in sarcoidosis. This immunohistologic study examined the distribution of OKT6-positive cells and surface expression of HLA-DR antigen in cutaneous sarcoid lesions. Skin specimens stained with an anti-HLA-DR antibody demonstrated diffuse staining of the granulomas. In addition, keratinocytes, which do not normally express HLA-DR antigens, were found to stain with monoclonal antibody to HLA-DR in an intercellular pattern. Examination of specimens for OKT6-reactive Langerhans cells revealed significantly greater concentrations in the epidermis overlying sarcoidal granulomas (33 +/- 7 cells/mm) than in the epidermis of age-, sex-, and race-matched controls (11 +/- 3 cells/mm, p less than 0.001). Of greater importance was the demonstration that significant numbers of OKT6-positive cells were present within the dermal sarcoid granulomas (19-208/mm2) in a distribution that paralleled that of Leu-3a-positive T lymphocytes. These data suggest that the epidermis may participate in activation of lymphocytes in cutaneous sarcoidosis, and implicate OKT6-positive cells in granuloma formation.

Lymphocyte subpopulations in peripheral blood and malignant effusions of cancer patients

The percentage of total T lymphocytes and helper and suppressor cells was determined in the peripheral blood and pleural and abdominal effusions of patients with advanced cancer. The ratio of helper to suppressor cells in the peripheral blood and in the effusions was calculated in each case. The percentage of total T lymphocytes and suppressor cells was found to be in a normal range. The percentage of helper cells in patients' peripheral blood and in ascites was slightly lower than normal. However, the percentage of helper cells in the pleural effusion was significantly higher than in the blood. The ratio of helper to suppressor cells in the pleural effusion was 1.46, compared to 0.82 in the blood (P less than 0.01). In patients with ascites the ratio in the blood was 1.05 and in the effusion 1.28. The ratio of helper to suppressor cells of all patients in the peripheral blood was 0.94, as compared to 1.36 in the effusion fluid (P less than 0.05). The imbalance in the T cell subsets found is most probably due to immunodepressions in the peripheral blood and immune reactivity in the effusions.

Lymphocyte subpopulations of blood and alveolar lavage in blastomycosis

Patients with blastomycosis were found to have differing lymphocyte populations depending on the extent of disease manifestations and whether or not therapy had been started. Patients with recovering pulmonary blastomycosis who had been receiving antifungal treatment for at least four weeks had lymphocyte subpopulations no different from control donors. Patients with treated extrapulmonary blastomycosis had similar T helper (TH) to T suppressor (TS) ratios compared to recovering pulmonary patients and control subjects; this ratio gives a false impression because extrapulmonary blastomycosis patients had a reduced absolute number of lymphocytes with either marker. In bronchoalveolar lavage fluid, pulmonary blastomycosis patients who were clinically improved while receiving antifungal therapy had fewer TH cells and a greater number of lymphocytes with the TS marker than did control subjects. Patients with pulmonary blastomycosis prior to therapy had a smaller TH/S ratio than the other groups in peripheral blood primarily due to a reduction in the circulating TH fraction in both absolute numbers of cells and in the percentage of total T lymphocytes. Pulmonary blastomycosis patients re-evaluated after at least four weeks of antifungal therapy had TH/S ratios that were similar to normal persons. This increase in TH lymphocytes corresponded to clinical improvement and in a temporal correlation to that described for the development of specific immunity in this illness.

Immunocytochemical staining of T and B lymphocytes in serous effusions

Cell smears from serous effusions containing large numbers of lymphoid cells were stained by the alkaline phosphatase-anti-alkaline phosphatase technique with a panel of monoclonal antibodies, including anti-B and anti-T cell antibodies and anti-HLA-DR. Samples from 17 patients with lymphoproliferative disorders--such as chronic lymphocytic leukaemia and non-Hodgkin's lymphoma--and from 19 patients who had no evidence of lymphoid neoplasia--for example, cases of carcinoma, cardiac failure--were investigated. The majority of lymphoid cells in reactive effusions were T cells, which lacked HLA-DR and showed a marked excess of helper/inducer cells (mean helper to suppressor ratio of 3 X 5). In contrast, lymphoid cells in samples from nine cases of B cell neoplasia were positive for B cell antigen and HLA-DR. In a further four B cell neoplasms most lymphoid cells were reactive T cells. Two cases of T cell lymphoid leukaemia could also be characterised by immunocytochemical staining, both being classified as T helper cell neoplasms. Labelling was performed on routinely prepared, air dried cell smears, which could be stored in the unfixed state for long periods before staining. The technique may therefore be of use in many clinical cytology laboratories for the diagnosis of effusions containing numerous lymphoid cells.