Bronchoalveolar Lavage Cell Data in Alveolar Proteinosis1 , 2
BERNARD J. MILLERON, ULRICH COSTABEL, HELMUT TESCHLER, ROLF ZIESCHE, JACQUES L. CADRANEL, HEINRICH MATTHYS, and GEORGES M. AKOUN
Introduction Alveolar proteinosis (AP) is a disease of unknown origin characterized by the accumulation of large amounts of phospholipids and amorphous proteinaceous material in the alveoli and distal airways of the lungs (I). The disease can be associated with hematologic neoplasms or occupational dust exposure (2, 3). In the literature, many reports on it deal with the chemical analysis of bronchoalveolar lavage (BAL) fluid, but few data concern cells recovered by BAL (4, 5). We have performed BAL nine times in patients with AP in three different institutions and compiled the findings on cell differentials and lymphocyte subpopulations for comparison with those from healthy subjects. Methods Our populations were as follows. Group 1 (n = 9):patients withAP. Allwere men, with a mean age of 40.3 ± 8.4 yr (table 1). All were cigarette smokers, with a mean smoking history of 27 ± 15 pack-years. In seven patients AP was primary. In the two others (Patients 7 and 8) AP was associated with asbestos and insecticide exposure. Patient 7 had occupational asbestos exposure from 1962 to 1972, and Patient 8, with scabies, had been using daily for 6 months insecticidalpowder([dichloro-diphenyltrichloroethane + hexachlorocyclohexane and essepalletrin (ESDE)-paletrine + piperonyl butoxide] without protection). The diagnosis was exclusivelyachievedby open lung biopsy (n = 6) or transbronchial biopsy (n = 1). For the two other patients, the diagnosis was suspected before the BAL, and it was confirmed by lavage (6). Group 2 (n = 12): healthy subjects. This group was made up of nine men and three women, with a mean age of 34 ± 16 yr. All had a smoking history of 14 ± 9 pack-years. On admission BAL was performed using 100to 200ml of 0.9010 sterile warm saline solution in four or five equal aliquots in the middle lobe or the lingula through a bronchofiberscopeafter local anesthesia. The first aliquot was not separated. The fluid was recovered by gentle aspiration in a siliconized flask kept at 4 C. The percentage of fluid 0
1330
SUMMARY In bronchoalveolar lavage fluid (BAL) from nIne patients wIth alveolar protelnosls (AP), total and differential cell count and T.lymphocyte phenotyplng were done and compared with those In 12 healthy volunteers comparable as to age and tobacco consumption. Although total cell count wes not significantly different from that In control sUbjeeta, the moat prominent feature In patients wes an Increase In the number of CD4 and CD8 T-Iymphocytes within the alveoli. Conversely, the macrophage population wes significantly reduced. The ratio of CD4/CD8 T.lymphocytes tended to be high, but this Increase did not reach statistical significance. The pathophysiologic mechanism and the meaning of these alveolar cen changes In AP remain to be elucidated. AM REV RESPIR DIS 1991; 144:1330-1332
recovered was always above 50% of fluid instilled. The lavage fluid was filtered through sterile surgical gauze and resuspended, and the total cellcount wasdetermined on an aliquot of fluid using a hemocytometer. A differential cell count was done on cytocentrifuge preparations prepared from uncentrifuged lavage fluid and stained with May-Grun- ,
Results
Individual Data
In all patients, recovered volume was above 500/0 instilled fluid (table 2). Patient 4 had an abnormally high increase in the total cell number, but the other eight smoking patients had a normal level of cellularity. wald-Giemsa, In all of the patients the percentage Identification of lymphocyte subpopula- and absolute number of lymphocytes intions was performed with monoclonal anticreased, and the absolute number of bodies. Monoclonal antibodies used to identify CD3, CD4, and CD8 cellsurface antigens on both CD4+ and CD8+ lymphocytes lymphocytes wereOKT3 (Tl6), OKT4 (help- increased. There was no difference between Paer/inducer T-lymphocytes; Ortho Diagnostics, Raritan, NJ), and OKT8(suppressor/cytotox- tients 7 and 8 (asbestos and insecticide exic 'l-lymphocytes; Ortho). Cells obtained by posed, respectively) and the other patients. BAL were washed twice in Hanks' balanced The CD4/CD8 ratio was high in two salt solution (Eurobio, Paris, France) and ad- patients, normal in four, and low in three. justed to a concentration of 2 X 107 cells/ml. Both of the two patients with secondary For each assay, 100ul of this cell suspension PA (Patients 7 and 8) had low CD4/CD8 was placed into a tube 75 x 13 mm, and 10 ratios. ul of the monoclonal antibody at the proper dilution wereadded. Cells wereincubated at Mean Data 40 C for 30 min and then washed three times in phosphate-buffered saline (pH, 7.4) con- Patients and control subjects are compared in table 3. There was no statistitaining O.lOJo sodium azide (PBS-azide). Immunoperoxidase and immunofluorescenceslide techniques wereused for Patients 1 to 6 and 7 to 9, respectively. Results from (Received in original form January 28, 1991 and control subjects are given using an immuno- in revised form April 22, 1991) peroxidase slide assay, but they did not sigI From the Centre de Pneumologie et de Reaninificantly differ from those obtained by immunofluorescence (data not shown). In both mation Respiratoire, Hopital Tenon, Paris, France, methods, at least200lymphocytes werecount- the ABT. Pneumologie/Allergologie, Ruhrlanded, and the percentage of positive lympho- klinik Essen, and the ABT.Pneumologie, Medicale Universitat Klinik, Freiburg, Germany. cytes was noted. 2 Correspondence and requests for reprints All results are expressed as mean ± SD. should be addressed to Georges M. Akoun, Centre Statistical comparison between both groups de Pneumologie et de Reanimation Respiratoire, was made using Student's t test for unpaired Hopital Tenon, 4, rue de la Chine, 75970 Paris Cedex 20, France. samples.
LYMPHOCYTIC ALVEOLITIS IN ALVEOLAR PROTEINOSIS
1331
TABLE 1 CHARACTERISTICS OF PATIENTS Pulmonary Function Tests" Patient No. 1 2 3 4 5 6 7 8 9 Mean ± SD
Sex M M M M M M M M M
Age (yr) 51 30 35 50 43 48 43 30 33 40.3 8.4
Tobacco Consumption
(pack-years)
Etiology
Diagnostic Procedure
33 6 45 36 40 14 45 9 15 27 15
P P P P P P S S P
OLB OLB OLB BAL BAL TBB OLB OLB OLB
Paco. (mmHg)
Pac>. (mmHg)
77
33 40 39 37 40 29 35 32 36 35.6 3.8
97 72 65
77 76 72 73 68 75.2 9.1
Definition of abbreviations: P E primary; S = secondary; OLB = open lung biopsy; SAL transbronchial biopsy. • All results, except Pac, and Paco" are expressed as percent predicted values.
VC 95 75 62 65
77 51 72 72 82 72.3 12.5
= bronchoalveolar
FEV,
Kco
97 93 68 75 95 61 71 72 80 79.1 12.9
ND ND ND 74 72 60 88 97 50 73.5 17.3
lavage; TBB =
cally significant difference between the patient group and the control group for the mean total number of cells (331 ± 163.1 x 103 cells/ml versus 537 ± 482.1 x 103 cells/ml). The most prominent overall features of BAL cells in patients with PA were: a decrease in the percentage (p < 0.(01) and the absolute number (p < 0.05) of macrophages and an increase in the percentage (p < 0.001)and the absolute number (p < 0.001) of lymphocytes. This increase was related to a significant expansion in the percentage (p < 0.05) and the absolute number (p < 0.001) of CD4+ lymphocytes and in the absolute number (p < 0.01) of CD8 + lymphocytes.The CD4/CD8 ratio tended to be increased but in a nonsignificant way. Discussion
TABLE 2 TOTAL AND DIFFERENTIAL CELL COUNT AND T-CELL SUBSETS IN BAL FROM NINE PATIENTS WITH AP (INDIVIDUAL DATA) Patient No.
Instilled liquid, ml Fluid recovered, % Total cell count, /1l1 Macrophages, 0Al Macrophages, /).11 Lymphocytes, % Lymphocytes, /).11 CD3+. % CD3./).11 CD4+. %
CD4+,/).11 CD8+. %
CD8+./).11 CD4:CD8 Polymorphonuclear, % Polymorphonuclear, /).11
100 70 111 19 21 78 86 89 79 66 56 24 20 2.8 3.3 3.6
2
3
4
5
6
7
8
9
100 72 207 25 51.7 73 151 95 143 84 126 17 25.6 5.0 2 4.1
100 61 175 40 70 58 101 80 80 60 60 34 34.3 1.8 1.1 1.9
100 64 550 16 88 82 451 95 428 47 211 47 211 1.0 0.5 2.7
100 70 170 67 113.9 25 42 90 37 55 23 40 16.8 1.4 8 13.6
100 60 433 61 264 34 147 72 105 51 75 31 45.5 1.8 4 17.3
200 60 437 35 174 64 279 82 228 23 64 44 122 0.52 1 4.3
200 70 473 40 189.2 57 269 ND ND 33 88 38 102 0.86 3 14.1
200 50 426 49 208.7 46 196 80 156 26 50.9 50 98 0.51 5 21.3
TABLE 3 BRONCHOALVEOLAR CELL DATA IN PATIENTS AND CONTROL SUBJECTS· Proteinosis Total cell count. 1).11 Macrophages. % Macrophages. 1).11 Lymphocytes, % Lymphocytes, 1).11 CD3+. % C03+./).11 C04+. % CD4+ ./).11 CD8+, % C08+./).11 CD4:CD8 .PoIymOrphonuclears. % Po!ymorphonuclears. /).11 • Values are mean ± SO.
331 39.1 131.1 57.4 191.3 85.3 157 49.4 83.7 36.1 75 1.7 3.1 9.2
± ± ± ± ± ± ± ± ± ± ± ± ± ±
163.1 17.7 81.5 19.5 125.6 8.17 124 19.8 55.4 10.8 64.5 1.4 2.3 7.3
Healthy Subjects 537 96 515.8 2.6 11.8 74.5 8.9 35.4 3.9 45.5 6 0.9 1 5.6
± ± ± ± ± ± ± ± ± ± ± ± ± ±
482.1 2.5 459 1.6 9 5 6.6 7.8 2.6 11.9 5.1 0.4 1 8.1
p Value NS
< 0.001 < 0.05 < 0.001 < 0.001 NS
< 0.001 < 0.05 < 0.001 NS
< 0.01 NS
< 0.05 NS
Alveolar proteinosis is currently recognized as a disease either of unknown origin or associated with hematologic malignancies and lymphoma (2, 7-9), or else caused by exposure to mineral dust (lOB). In our series, two patients had such an environmental exposure. In the alveoli, there is an overproduction and/or a disturbed clearance of proteinaceous material similar to the pulmonary surfactant produced by alveolar type II pneumocytes (3, 4, 12). Many investigators have pointed to the chemical composition of this substance (14, 15), the diagnostic value of BAL fluid analysis (6), and the therapeutic interest of performing multiple BAL in AP. In contrast, there are few data on the cell profile of BAL in AP. According to our results, three characteristics seem to be present in BAL from patients with AP when compared with healthy smokers. (1) The low number of macrophages. This has been reported by few investigators (5, 6, 10, 16), but there are several in vitro sudies that have shown evidence of functionally defective macrophages (17,18). This could explain the high incidence of infectious pulmonary complications, in particular the opportunistic infections in AP (7, 18). It is possible that the low number of macrophages and their low activity playa role in the mechanism of AP and the high incidence of pulmonary infections. (2) The increase in the number oflymphocytes. To the best of our knowledge this has not been reported. In contrast, pathologic examinations have shown only a low number of inflammatory cells
1332
in lung parenchyma. However, the inflammatory cellcount was higher in BAL fluid than in parenchyma (5). (3) The variable CD41CD8 ratio. In our patients it was either high, as in sarcoidosis, or normal or low, as in hypersensitivity pneumonitis, but all the patients were smokers, and in the healthy smokers, the CD4/CD8 ratio was lower than that in the nonsmokers (19-21). Thus, there was a tendency towards an increase in CD4/CD8 ratio because of a predominant expansion of alveolar CD4+ T-cells in AP when compared with that in healthy smokers of the same age. However, the CD4/CD8 ratio observed in our patients seems to be a misleading indicator, given its wide variability. In summary, the main changes in AP BAL were the increased number of CD4 and CD8lymphocytes. Presumably, this finding would appear as a nonspecific reaction against the alveolar proteinaceous content rather than a process related to the primary mechanism causing the disease or to a lymphocyte accumulation by an interruption in lymphocyte traffic.
MILLERON, COSTABEL, TESCHLER, ZIESCHE, CADRANEL, MATTHYS, AND AKOUN
References I. Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med 1958; 258:1123-42. 2. Aymard JP, Gyger M, Lavallee R, LegresleyLP, Desy M. A case of pulmonary alveolar proteinosis complicating chronic myelogenous leukemia. Cancer 1984; 53:954-6. 3. Claypool WD, Rogers RM, Matuschak GM. Update on the clinical diagnosis, management and pathogenesis of pulmonary alveolar proteinosis (phospholipidosis). Chest 1984; 85:550-8. 4. Ramirez-R J, Harlan WR. Pulmonaryalveolar proteinosis. Nature and origin of alveolar lipid. Am J Med 1968; 45:502-12. 5. Basset F, Soler P, Turiaf J. Etude ultrastructurale du contenu alveolaire dans la proteinose alveolaire pulmonaire et dans les pseudoproteinoses, Ann Med Interne (Paris) 1973; 124:279-90. 6. Martin RJ, Coalson JJ, Rogers RM, Horton Fa, Manous LE. Pulmonary alveolar proteinosis: the diagnosis by segmental lavage. Am Rev Respir Dis 1980; 121:819-25. 7. Bedrossian CW, Luna MA, Conklin RH, MilIer WC. Alveolar proteinosis as a consequence of immuno-suppression. Hum Patho11980; II(Suppl: 527-35). 8. Carnovale R, Zornoza J, Goldman AM, Luna M. Pulmonary alveolar proteinosis: its association with hematologic malignancyand lymphoma. Radiology 1977; 122:303-6. 9. Green D, Dighe P, Ali NO, Katele OV. Pulmonary alveolar proteinosis complicating chronic myelogenous leukemia. Cancer 1980; 46:1763-6. 10. Miller RR, Churg AM, Hutcheon M, Lam S.
Pulmonary alveolar proteinosis and aluminium dust exposure. Am Rev Respir Dis 1984; 130:312-5. 11. Xipell JM, Ham KN, Price CO, Thomas DP. Acute silicolipoproteinosis. Thorax 1977; 32:104-11. 12. Corrin B, King E. Pathologenesis of experimental pulmonary alveolar proteinosis. Thorax 1970; 25:230-6. 13. Heppleston AG, Wright NA, Stewart JA. Experimental alveolar lipoproteins following the inhalation of silica. J Pathol 1970; 101:293-307. 14. Daniele RP, Elias JA, Epstein PE, Rossman MD. Bronchoalveolar lavage: role in the pathogenesis, diagnosis and management of interstitial lung disease. Ann Intern Med 1985; 102:93-108. 15. Ito M, Takeuchi N, Ogura T, et al. Pulmonary alveolar proteinosis: analysis of pulmonary washings. Br Dis Chest 1978; 72:313-20. 16. Singh G, Katyal SL, Bedrossian CW, Rogers RM. Pulmonary alveolar proteinosis. Staining for surfactant apoprotein in alveolar proteinosis and in conditions simulating it. Chest 1983; 83:82-6. 17. Golde DW, Territo M, Finley TN, Cline MJ. Defective lung macrophages in pulmonary alveolar proteinosis. Ann Intern Med 1976; 85:304-9. 18. Harris JO. Pulmonary alveolar proteinosis, Abnormal in vitro function of alveolar macrophages. Chest 1979; 76:156-9. 19. Costabel U, Bross KJ, Reuter C, Ruhle KH, Matthys H. Alterations in immunoregulatory T-cell subsets in cigarette smokers. Chest 1986;90:39-44. 20. Nagais, Izumi T. Letter to the editor. Eur J Respir Dis 1986; 68:155. 21. Lawrence EC, Fox TB, Teague RB, Bloom K, Wilson RK. Cigarette smoking and bronchoalveolar T cell populations in sarcoidosis. Ann NY Acad Sci 1986; 465:657-64.
BERNARD J. MILLERON, ULRICH COSTABEL, HELMUT TESCHLER, ROLF ZIESCHE, JACQUES L. CADRANEL, HEINRICH MATTHYS, and GEORGES M. AKOUN
Introduction Alveolar proteinosis (AP) is a disease of unknown origin characterized by the accumulation of large amounts of phospholipids and amorphous proteinaceous material in the alveoli and distal airways of the lungs (I). The disease can be associated with hematologic neoplasms or occupational dust exposure (2, 3). In the literature, many reports on it deal with the chemical analysis of bronchoalveolar lavage (BAL) fluid, but few data concern cells recovered by BAL (4, 5). We have performed BAL nine times in patients with AP in three different institutions and compiled the findings on cell differentials and lymphocyte subpopulations for comparison with those from healthy subjects. Methods Our populations were as follows. Group 1 (n = 9):patients withAP. Allwere men, with a mean age of 40.3 ± 8.4 yr (table 1). All were cigarette smokers, with a mean smoking history of 27 ± 15 pack-years. In seven patients AP was primary. In the two others (Patients 7 and 8) AP was associated with asbestos and insecticide exposure. Patient 7 had occupational asbestos exposure from 1962 to 1972, and Patient 8, with scabies, had been using daily for 6 months insecticidalpowder([dichloro-diphenyltrichloroethane + hexachlorocyclohexane and essepalletrin (ESDE)-paletrine + piperonyl butoxide] without protection). The diagnosis was exclusivelyachievedby open lung biopsy (n = 6) or transbronchial biopsy (n = 1). For the two other patients, the diagnosis was suspected before the BAL, and it was confirmed by lavage (6). Group 2 (n = 12): healthy subjects. This group was made up of nine men and three women, with a mean age of 34 ± 16 yr. All had a smoking history of 14 ± 9 pack-years. On admission BAL was performed using 100to 200ml of 0.9010 sterile warm saline solution in four or five equal aliquots in the middle lobe or the lingula through a bronchofiberscopeafter local anesthesia. The first aliquot was not separated. The fluid was recovered by gentle aspiration in a siliconized flask kept at 4 C. The percentage of fluid 0
1330
SUMMARY In bronchoalveolar lavage fluid (BAL) from nIne patients wIth alveolar protelnosls (AP), total and differential cell count and T.lymphocyte phenotyplng were done and compared with those In 12 healthy volunteers comparable as to age and tobacco consumption. Although total cell count wes not significantly different from that In control sUbjeeta, the moat prominent feature In patients wes an Increase In the number of CD4 and CD8 T-Iymphocytes within the alveoli. Conversely, the macrophage population wes significantly reduced. The ratio of CD4/CD8 T.lymphocytes tended to be high, but this Increase did not reach statistical significance. The pathophysiologic mechanism and the meaning of these alveolar cen changes In AP remain to be elucidated. AM REV RESPIR DIS 1991; 144:1330-1332
recovered was always above 50% of fluid instilled. The lavage fluid was filtered through sterile surgical gauze and resuspended, and the total cellcount wasdetermined on an aliquot of fluid using a hemocytometer. A differential cell count was done on cytocentrifuge preparations prepared from uncentrifuged lavage fluid and stained with May-Grun- ,
Results
Individual Data
In all patients, recovered volume was above 500/0 instilled fluid (table 2). Patient 4 had an abnormally high increase in the total cell number, but the other eight smoking patients had a normal level of cellularity. wald-Giemsa, In all of the patients the percentage Identification of lymphocyte subpopula- and absolute number of lymphocytes intions was performed with monoclonal anticreased, and the absolute number of bodies. Monoclonal antibodies used to identify CD3, CD4, and CD8 cellsurface antigens on both CD4+ and CD8+ lymphocytes lymphocytes wereOKT3 (Tl6), OKT4 (help- increased. There was no difference between Paer/inducer T-lymphocytes; Ortho Diagnostics, Raritan, NJ), and OKT8(suppressor/cytotox- tients 7 and 8 (asbestos and insecticide exic 'l-lymphocytes; Ortho). Cells obtained by posed, respectively) and the other patients. BAL were washed twice in Hanks' balanced The CD4/CD8 ratio was high in two salt solution (Eurobio, Paris, France) and ad- patients, normal in four, and low in three. justed to a concentration of 2 X 107 cells/ml. Both of the two patients with secondary For each assay, 100ul of this cell suspension PA (Patients 7 and 8) had low CD4/CD8 was placed into a tube 75 x 13 mm, and 10 ratios. ul of the monoclonal antibody at the proper dilution wereadded. Cells wereincubated at Mean Data 40 C for 30 min and then washed three times in phosphate-buffered saline (pH, 7.4) con- Patients and control subjects are compared in table 3. There was no statistitaining O.lOJo sodium azide (PBS-azide). Immunoperoxidase and immunofluorescenceslide techniques wereused for Patients 1 to 6 and 7 to 9, respectively. Results from (Received in original form January 28, 1991 and control subjects are given using an immuno- in revised form April 22, 1991) peroxidase slide assay, but they did not sigI From the Centre de Pneumologie et de Reaninificantly differ from those obtained by immunofluorescence (data not shown). In both mation Respiratoire, Hopital Tenon, Paris, France, methods, at least200lymphocytes werecount- the ABT. Pneumologie/Allergologie, Ruhrlanded, and the percentage of positive lympho- klinik Essen, and the ABT.Pneumologie, Medicale Universitat Klinik, Freiburg, Germany. cytes was noted. 2 Correspondence and requests for reprints All results are expressed as mean ± SD. should be addressed to Georges M. Akoun, Centre Statistical comparison between both groups de Pneumologie et de Reanimation Respiratoire, was made using Student's t test for unpaired Hopital Tenon, 4, rue de la Chine, 75970 Paris Cedex 20, France. samples.
LYMPHOCYTIC ALVEOLITIS IN ALVEOLAR PROTEINOSIS
1331
TABLE 1 CHARACTERISTICS OF PATIENTS Pulmonary Function Tests" Patient No. 1 2 3 4 5 6 7 8 9 Mean ± SD
Sex M M M M M M M M M
Age (yr) 51 30 35 50 43 48 43 30 33 40.3 8.4
Tobacco Consumption
(pack-years)
Etiology
Diagnostic Procedure
33 6 45 36 40 14 45 9 15 27 15
P P P P P P S S P
OLB OLB OLB BAL BAL TBB OLB OLB OLB
Paco. (mmHg)
Pac>. (mmHg)
77
33 40 39 37 40 29 35 32 36 35.6 3.8
97 72 65
77 76 72 73 68 75.2 9.1
Definition of abbreviations: P E primary; S = secondary; OLB = open lung biopsy; SAL transbronchial biopsy. • All results, except Pac, and Paco" are expressed as percent predicted values.
VC 95 75 62 65
77 51 72 72 82 72.3 12.5
= bronchoalveolar
FEV,
Kco
97 93 68 75 95 61 71 72 80 79.1 12.9
ND ND ND 74 72 60 88 97 50 73.5 17.3
lavage; TBB =
cally significant difference between the patient group and the control group for the mean total number of cells (331 ± 163.1 x 103 cells/ml versus 537 ± 482.1 x 103 cells/ml). The most prominent overall features of BAL cells in patients with PA were: a decrease in the percentage (p < 0.(01) and the absolute number (p < 0.05) of macrophages and an increase in the percentage (p < 0.001)and the absolute number (p < 0.001) of lymphocytes. This increase was related to a significant expansion in the percentage (p < 0.05) and the absolute number (p < 0.001) of CD4+ lymphocytes and in the absolute number (p < 0.01) of CD8 + lymphocytes.The CD4/CD8 ratio tended to be increased but in a nonsignificant way. Discussion
TABLE 2 TOTAL AND DIFFERENTIAL CELL COUNT AND T-CELL SUBSETS IN BAL FROM NINE PATIENTS WITH AP (INDIVIDUAL DATA) Patient No.
Instilled liquid, ml Fluid recovered, % Total cell count, /1l1 Macrophages, 0Al Macrophages, /).11 Lymphocytes, % Lymphocytes, /).11 CD3+. % CD3./).11 CD4+. %
CD4+,/).11 CD8+. %
CD8+./).11 CD4:CD8 Polymorphonuclear, % Polymorphonuclear, /).11
100 70 111 19 21 78 86 89 79 66 56 24 20 2.8 3.3 3.6
2
3
4
5
6
7
8
9
100 72 207 25 51.7 73 151 95 143 84 126 17 25.6 5.0 2 4.1
100 61 175 40 70 58 101 80 80 60 60 34 34.3 1.8 1.1 1.9
100 64 550 16 88 82 451 95 428 47 211 47 211 1.0 0.5 2.7
100 70 170 67 113.9 25 42 90 37 55 23 40 16.8 1.4 8 13.6
100 60 433 61 264 34 147 72 105 51 75 31 45.5 1.8 4 17.3
200 60 437 35 174 64 279 82 228 23 64 44 122 0.52 1 4.3
200 70 473 40 189.2 57 269 ND ND 33 88 38 102 0.86 3 14.1
200 50 426 49 208.7 46 196 80 156 26 50.9 50 98 0.51 5 21.3
TABLE 3 BRONCHOALVEOLAR CELL DATA IN PATIENTS AND CONTROL SUBJECTS· Proteinosis Total cell count. 1).11 Macrophages. % Macrophages. 1).11 Lymphocytes, % Lymphocytes, 1).11 CD3+. % C03+./).11 C04+. % CD4+ ./).11 CD8+, % C08+./).11 CD4:CD8 .PoIymOrphonuclears. % Po!ymorphonuclears. /).11 • Values are mean ± SO.
331 39.1 131.1 57.4 191.3 85.3 157 49.4 83.7 36.1 75 1.7 3.1 9.2
± ± ± ± ± ± ± ± ± ± ± ± ± ±
163.1 17.7 81.5 19.5 125.6 8.17 124 19.8 55.4 10.8 64.5 1.4 2.3 7.3
Healthy Subjects 537 96 515.8 2.6 11.8 74.5 8.9 35.4 3.9 45.5 6 0.9 1 5.6
± ± ± ± ± ± ± ± ± ± ± ± ± ±
482.1 2.5 459 1.6 9 5 6.6 7.8 2.6 11.9 5.1 0.4 1 8.1
p Value NS
< 0.001 < 0.05 < 0.001 < 0.001 NS
< 0.001 < 0.05 < 0.001 NS
< 0.01 NS
< 0.05 NS
Alveolar proteinosis is currently recognized as a disease either of unknown origin or associated with hematologic malignancies and lymphoma (2, 7-9), or else caused by exposure to mineral dust (lOB). In our series, two patients had such an environmental exposure. In the alveoli, there is an overproduction and/or a disturbed clearance of proteinaceous material similar to the pulmonary surfactant produced by alveolar type II pneumocytes (3, 4, 12). Many investigators have pointed to the chemical composition of this substance (14, 15), the diagnostic value of BAL fluid analysis (6), and the therapeutic interest of performing multiple BAL in AP. In contrast, there are few data on the cell profile of BAL in AP. According to our results, three characteristics seem to be present in BAL from patients with AP when compared with healthy smokers. (1) The low number of macrophages. This has been reported by few investigators (5, 6, 10, 16), but there are several in vitro sudies that have shown evidence of functionally defective macrophages (17,18). This could explain the high incidence of infectious pulmonary complications, in particular the opportunistic infections in AP (7, 18). It is possible that the low number of macrophages and their low activity playa role in the mechanism of AP and the high incidence of pulmonary infections. (2) The increase in the number oflymphocytes. To the best of our knowledge this has not been reported. In contrast, pathologic examinations have shown only a low number of inflammatory cells
1332
in lung parenchyma. However, the inflammatory cellcount was higher in BAL fluid than in parenchyma (5). (3) The variable CD41CD8 ratio. In our patients it was either high, as in sarcoidosis, or normal or low, as in hypersensitivity pneumonitis, but all the patients were smokers, and in the healthy smokers, the CD4/CD8 ratio was lower than that in the nonsmokers (19-21). Thus, there was a tendency towards an increase in CD4/CD8 ratio because of a predominant expansion of alveolar CD4+ T-cells in AP when compared with that in healthy smokers of the same age. However, the CD4/CD8 ratio observed in our patients seems to be a misleading indicator, given its wide variability. In summary, the main changes in AP BAL were the increased number of CD4 and CD8lymphocytes. Presumably, this finding would appear as a nonspecific reaction against the alveolar proteinaceous content rather than a process related to the primary mechanism causing the disease or to a lymphocyte accumulation by an interruption in lymphocyte traffic.
MILLERON, COSTABEL, TESCHLER, ZIESCHE, CADRANEL, MATTHYS, AND AKOUN
References I. Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med 1958; 258:1123-42. 2. Aymard JP, Gyger M, Lavallee R, LegresleyLP, Desy M. A case of pulmonary alveolar proteinosis complicating chronic myelogenous leukemia. Cancer 1984; 53:954-6. 3. Claypool WD, Rogers RM, Matuschak GM. Update on the clinical diagnosis, management and pathogenesis of pulmonary alveolar proteinosis (phospholipidosis). Chest 1984; 85:550-8. 4. Ramirez-R J, Harlan WR. Pulmonaryalveolar proteinosis. Nature and origin of alveolar lipid. Am J Med 1968; 45:502-12. 5. Basset F, Soler P, Turiaf J. Etude ultrastructurale du contenu alveolaire dans la proteinose alveolaire pulmonaire et dans les pseudoproteinoses, Ann Med Interne (Paris) 1973; 124:279-90. 6. Martin RJ, Coalson JJ, Rogers RM, Horton Fa, Manous LE. Pulmonary alveolar proteinosis: the diagnosis by segmental lavage. Am Rev Respir Dis 1980; 121:819-25. 7. Bedrossian CW, Luna MA, Conklin RH, MilIer WC. Alveolar proteinosis as a consequence of immuno-suppression. Hum Patho11980; II(Suppl: 527-35). 8. Carnovale R, Zornoza J, Goldman AM, Luna M. Pulmonary alveolar proteinosis: its association with hematologic malignancyand lymphoma. Radiology 1977; 122:303-6. 9. Green D, Dighe P, Ali NO, Katele OV. Pulmonary alveolar proteinosis complicating chronic myelogenous leukemia. Cancer 1980; 46:1763-6. 10. Miller RR, Churg AM, Hutcheon M, Lam S.
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