Broncho-alveolar lavage in sarcoidosis. Correlation between alveolar lymphocytosis and clinical data.

Bronchoalveolar lavages (BAL) were performed in patients with pulmonary sarcoidosis and in normal subjects. In both smoking and nonsmoking sarcoid patients, the proportion and number of lymphocytes were significantly increased compared to corresponding controls (p less than 0.001 in each cases). BAL lymphocytes were identified as T lymphocytes (88 +/- 9% formed E rosettes). Neither the radiological stage, nor the duration of disease are related to the lymphocyte number. However, alveolar lymphocytosis is significantly correlated with clinical pattern (p less than 0.02) and with clinical extrathoracic dissemination (p less than 0.001). Black patients have significantly more disseminated disease than Whites (p less than 0.001). The lymphocytosis of the bronchoalveolar space is associated with the presence of granulomas in bronchial biopsies (p less than 0.005). For clinical purposes, the results of BAL were helpful in determining the evolutivity of the disease, particularly progression to stage III. Together with a high lymphocyte count, a significant increase of all the polymorphonuclear leukocytes (PMNL) was found in stage III (4.0 +/- 4.6 X 10(4) PMNL/ml, p less than 0.001) compared to earlier stages (respectively 0.6 +/- 0.5 X 10(4), 0.7 +/- 0.9 X 10(4) and 0.7 +/- 0.9 X 10(4) PMNL/ml for stages I, IIA and IIB). BAL may also be used to follow up sarcoid patients. Repeated BAL were performed in 23 patients. No modification in alveolar lymphocytosis is found in patients with steady state disease, but, in healed patients the lymphocyte number returns to normal.

[Evidence of junctional complexes between cells of monocytic origin in sarcoid granulomas (author's transl)]. / Mise en évidence de complexes jonctionnels entre cellules d'origine monocytaire des granulomes sarcoïdiens.

Ultrastructural studies of lung and lymph nodes biopsies from twelve patients with sarcoidosis were performed. They consistently demonstrated junctional complexes between consistently demonstrated junctional complexes between granulomatous cells issued from the mononuclear phagocyte system. These inter-cellular contacts have a desmosome-like appearance but differ in some of their structural aspects. The role of these complexes appearing between cells of monocytic origin remains to be defined.

Pulmonary gallium uptake in rats with granulomatosis induced by complete Freund adjuvant.

To investigate the mechanism of gallium-67 uptake in lung granulomatosis, we studied 13 rats in which lung granulomatosis was induced by injection of complete Freund adjuvant (CFA) and 14 controls. Gallium uptake was assessed in bronchoalveolar lavage fluid and lavaged lung. The cells responsible for gallium uptake were identified by latent image activation autoradiography. Gallium activity in both lavaged lungs and bronchoalveolar cells (BAC) was higher in CFA-treated animals than in controls [172,205 +/- 134,783 DPM versus 44,456 +/- 14,486 DPM +/- SD (p less than 0.05) and 40,083 +/- 16,350 DPM versus 9100 +/- 4114 DPM (p less than 0.05), respectively]. In control rats, about two-thirds of total lung gallium was located in the interstitium, whereas in CFA-treated rats it was found in the mononuclear cells of lung granulomas. Gallium tracks were more numerous in the alveolar macrophages (AM) of CFA-treated rats than in control AM (28.4 +/- 10.0/field versus 8.4 +/- 3.8/field, p less than 0.001) but the number of tracks was proportional to the number of AM (52.4 +/- 18.7 versus 12.2 +/- 4.3, respectively; p less than 0.001). It is concluded that in rats with CFA-induced lung granulomatosis 1) pulmonary gallium uptake increases, 2) mononuclear cells are responsible for this uptake in both granulomas and AM, and 3) the increased uptake is due to the increased number of mononuclear cells.

Elastase activity of bronchoalveolar cells in advanced pulmonary sarcoidosis.

Elastase activities were investigated in bronchoalveolar lavage (BAL) cells from healthy controls (C, n = 8) and patients with untreated mediastinopulmonary sarcoidosis at different stages: I (n = 5), II (n = 7), IIIA (n = 3), IIIB (n = 4). Elastase activities (EA and ELA) were measured against a synthetic substrate, succinyl-trialanine-paranitroanilide (SLAPN) and radiolabelled ligamentum nuchae 3H insoluble elastin (specific radioactivity 3.7 MBq.mg-1). A significant increase of ELA of BAL cells was observed in patients (S III), in particular those exhibiting fibrotic roentgenographic patterns and a higher number of polymorphonuclear cells. On the contrary, EA of BAL cells showed no variation between different stages of sarcoidosis. ELA was never detected in the macrophage culture medium and appeared to be mainly associated with non-adherent macrophages, whereas EA appeared to be preferentially associated with adherent macrophages. The inhibitory profiles of ELA and EA were investigated using general proteinase inhibitors and also compounds interacting specifically with leucocyte elastase. ELA was mainly due to a serine protease, which has a sensitivity to inhibitors similar to leucocyte elastase and is increased in advanced stages of sarcoidosis. EA appears to be only slightly modified, if at all, in sarcoidosis and is probably related to the action of both a serine protease and a metalloenzyme. Thus, only ELA yields diagnostic information concerning stage III of sarcoidosis associated with a fibrotic or bullous roentgenographic pattern.

Processing of lung lavage fluid causes variability in bronchoalveolar cell count.

To study the effects on cell counts of different ways of processing bronchoalveolar lavage (BAL) fluid, we performed 77 BAL in 19 healthy control subjects and in 58 patients with sarcoidosis. We investigated the role of readers, hemocytometers, mode of identification of macrophages, cell washing, and speed of cytocentrifugation. No significant effect of reader or hemocytometer was observed. The percentage of macrophages, determined as large cells stained with neutral red in a Malassez hemocytometer (63.9 +/- 24.6%, mean +/- SD) was lower than the percentage of macrophages determined by May Grunwald Giemsa staining (76.3 +/- 19.2%, p less than 10(-9)). Cell counts decreased 34% after 2 washings (p less than 0.001), and more lymphocytes were counted after cytocentrifugation at 90 g (33.2 +/- 25.3%) than at 23 g (27.7 +/- 22.1%). We conclude that bronchoalveolar cell counts vary with changes in processing lung lavage fluid and that this variability should be considered when using BAL cell counts.

Respiratory epithelial permeability in complete Freund's adjuvant rat lung granulomatosis.

To investigate Freund's adjuvant-induced changes in respiratory epithelial permeability, we determined the respiratory epithelium clearance of 99mTc-DTPA (RC-DTPA) in rats and the localization of horseradish peroxidase (HRP) across the lung epithelium. RC-DTPA was determined before and after intravenous injection of saline (control) or complete Freund's adjuvant (CFA). Although the respiratory epithelium was not disrupted, RC-DTPA was increased 15 min after injection of CFA and was still high after 3 d but had returned to normal after 7 d, after which it again increased and stayed high from Day 42 through Day 112. Cell number obtained by bronchoalveolar lavage increased from 15 min to 3 d after injection of CFA. Lung granulomatosis was observed 14 to 112 d after injection of CFA; changes in RC-DTPA correlated with changes in alveolar cells. HRP was present in bronchiolar intercellular spaces only in the CFA group. We conclude that (1) RC-DTPA increases in rat lung CFA granulomatosis 15 min to 3 and 42 to 112 d following injection, (2) the increase in RC-DTPA is not related to a rupture of epithelium but (3) is proportional to the cell influx into the lung, and (4) is possibly caused by the opening of tight junctions in small airways.

Serum activity of angiotensin converting enzyme and pulmonary radiography as prognostic criteria in sarcoidosis.

To compare the prognostic value of the serum concentration of angiotensin converting enzyme (SACE) to that of pulmonary radiography, patients with mediastino-pulmonary sarcoidosis were followed over two years and then retrospectively placed in one of 2 groups, designated "cured" (CS) or "not cured" (NCS) on the basis of clinical and biologic criteria. The two groups were then compared with respect to the initial pulmonary radiologic image, and the initial SACE concentration. The initial SACE concentration (CS: 45.6 +/- 15.4 U . ml-1; NCS: 48.5 +/- 27.3 U . ml-1; means +/- SD) and the percentage of patients with elevated SACE (CS: 75%; NCS: 69%) did not differ significantly between the two groups; on the other hand, the percentage of patients with pulmonary nodules on their initial chest film was higher in the NCS group (50%) than in the CS group (21%; p less than 0.05). We conclude that pulmonary radiography is the more reliable prognostic criterion in mediastino-pulmonary sarcoidosis.

Bronchoalveolar cells in advanced pulmonary sarcoidosis.

We performed bronchoalveolar lavage (BAL) in 120 subjects: 94 patients with sarcoidosis, 11 patients with idiopathic pulmonary fibrosis (IPF), and 15 normal volunteers. By counting cells and comparing the results with those from control subjects, we found a high percentage of lymphocytes in BAL fluid from all patients with sarcoidosis and a high percentage of neutrophils (NE) in BAL fluid from patients with IPF. In addition, we observed a significantly higher proportion of NE in the 14 patients with advanced sarcoidosis (i.e., fibrosis and bullous radiological patterns), than was seen in the 80 patients with early stages of involvement (i.e., bilateral hilar lymphadenopathy and/or pulmonary infiltrations) (p less than 0.001). The NE count exceeded the normal value of 3.5% in 9 of the 14 patients with advanced sarcoidosis but only in 1 of the 80 patients with early disease (p less than 0.001). We believe that advanced sarcoidosis is one of the conditions in which a simultaneous increase in both NE and lymphocytes in BAL fluid can be observed. The NE count in bronchoalveolar fluid in patients with sarcoidosis, as in patients with IPF, may indicate evolution of the granulomatous process toward pulmonary fibrosis. These phenomena point out the potential practical value of iterative BAL in patients with sarcoidosis in assessing the prognosis of their disease.

Respiratory clearance of 99mTc-DTPA and pulmonary involvement in sarcoidosis.

To investigate the relationships between the respiratory epithelial clearance of micronic aerosolized 99mTc-DTPA (RC-DTPA) and pulmonary function, serum angiotensin-converting enzyme (SACE), and lymphocytic alveolitis in patients with sarcoidosis, RC-DTPA was measured in 49 nonsmokers with pulmonary sarcoidosis and 38 normal nonsmokers. Pulmonary involvement was evaluated on chest roentgenograms (type O = normal, type I = hilar adenopathies, type II = hilar adenopathies associated with parenchymal shadows, type III = parenchymal shadows without adenopathy) and by pulmonary function tests. Serum angiotensin-converting enzyme was determined, and a bronchoalveolar lavage was performed for alveolar lymphocyte differential counting (Ly%). RC-DTPA was increased (greater than or equal to 1.96%/min) in 12 of 31 patients with type II or III involvement but was normal in all 18 patients with type O or I involvement (p = 0.002). Patients with increased RC-DTPA had low FVC, TLC, FEV1, and resting Pao2 (p less than 0.05); resting and exercise AaPo2 were increased (p less than 0.05), but RC-DTPA correlated negatively with FEV1 (p less than 0.01), Pao2 at rest (p less than 0.005), and DLCO (p less than 0.05) and positively with resting and exercise AaPO2 (p less than 0.01). In patients with increased RC-DTPA (42 +/- 17%), Ly% did not differ from Ly% in patients with normal RC-DTPA (34 +/- 16%). SACE was increased in patients with increased RC-DTPA (56 +/- 26 U/ml versus 38 +/- 16 U/ml; p = 0.007) and correlated positively with RC-DTPA (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Increased concentration of angiotensin I converting enzyme in the alveolar fluid of patients with sarcoidosis]. / Augmentation de la concentration de l'enzyme de conversion de l'angiotensine I dans le fluide alvéolaire de sujets sarcoidiens.

Angiotensin converting enzyme (ACE) was assayed both in serum (SACE) and in bronchoalveolar fluid lavage (LACE) in 14 healthy controls and in 45 patients with sarcoidosis with mediastinal and pulmonary involvement. Concentration of SACE was 4466 +/- 2202 U x 100 ml-1 (mean +/- SD) in sarcoidosis and 2470 +/- 547 U x 100 ml-1 (chi +/- SD) in sarcoidosis and 2470 +/- 547 U . 100 ml-1 in controls. Concentrations of LACE were 65.2 +/- 48.4 U . 100 ml-1 and 21.1 +/- 14.7 U . 100 ml-1 respectively in sarcoidosis and in controls. These results are in favor of an intraalveolar secretion of ACE in sarcoidosis. LACE could be a better criterium than SACE for the evaluation of the pulmonary activity of sarcoidosis.

Elevation of the bronchoalveolar concentration of angiotensin I converting enzyme in sarcoidosis.

The concentration of angiotensin converting enzyme (ACE) and that of albumin (AIb) were assayed in the serum (SACE, SAlb) and in bronchoalveolar lavage fluid (LACE, LAlb). Three groups of patients were studied: 14 healthy volunteers (Group I), 45 patients with active sarcoidosis (Group II), and 7 patients with sarcoidosis in remission (Group III). The SACE in Group II (4,466 +/- 2,202 U/100 ml, mean +/- SD) was higher (p less than 0.001) than in Group I (2,470 +/- 547 U/100 ml) or in Group III (2,640 +/- 610 U/100 ml); LACE was higher in Group II (65.2 +/- 48.4 U/100 ml, p less than 0.001) than in Group I (21.1 +/- 14.7 U/100 ml), or in Group III (25.7 +/- 14.6 U/100 ml). The SAlb was found to be, respectively, 3,908 +/- 385 mg/100 ml, 3,982 +/- 965 mg/100 ml, and 3.613 +/- 222 mg/100 ml in Groups I, II, and III. The LAlb in Group II (8.2 +/- 6.2 mg/100 ml) was higher (p less than 0.01) than in Group I (2.5 +/- 1.4 mg/100 ml) or in Group III )4.1 +/- 1.0 mg/100 ml). The LACE in Group II increased with the number of alveolar lymphocytes, in nonsmokers (4 = + 0.56, df = 34, p less than 0.001) and in smokers (4 = + 0.88, df = 7, p less than 0.01). In the smokers in this group, LACE was higher with respect to the number of lymphocytes than in the nonsmokers. We conclude from this study (1) that the permeability of the alveolocapillary membrane to albumin and to ACE is increased in active pulmonary sarcoidosis, (2) that LACE increases during sarcoidosis and returns to normal when the disease is cured, and (3) that the concentration of ACE in alveolar fluid increases with tobacco use.