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Pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid: a case report.

Kumagai T, Tomita Y, Inoue T, Uchida J, Nishino K, Imamura F - J Med Case Rep (2015)

Bottom Line: Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated.Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas.Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

View Article: PubMed Central - PubMed

Affiliation: Department of Thoracic Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari-ku, Osaka, 537-8511, Japan. torukumagai@ybb.ne.jp.

ABSTRACT

Introduction: Pleural effusion induced by sarcoidosis is rare, and pleural sarcoidosis is often diagnosed by thoracoscopic surgery. The diagnosis of pleural sarcoidosis using thoracentesis may be less invasive when sarcoidosis is already diagnosed histologically in more than one organ specimen. Here we report the case of a 64-year-old woman with pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis. This case report is important because it highlights the usefulness of the CD4/CD8 lymphocyte ratio in pleural effusion as an indicator of pleural involvement of sarcoidosis.

Case presentation: A 64-year-old Japanese woman visited our hospital with an initial symptom of dyspnea on exertion for a period of 4 months. Chest computed tomography showed bilateral hilar and multiple mediastinal lymphadenopathy, multiple small nodular shadows in her bilateral lungs, small nodular shadows along the interlobar pleura, and bilateral pleural effusion. Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated. Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas. Her bronchoalveolar lavage fluid exhibited a predominance of lymphocytes together with an increase in the CD4/CD8 lymphocyte ratio. The lymphocytic predominance and the increased CD4/CD8 lymphocyte ratio were also detected in the right-sided pleural effusion fluid obtained by thoracentesis. We diagnosed sarcoidosis with pleural involvement. Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

Conclusions: Analysis of the CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis may be helpful for the diagnosis of pleural sarcoidosis when the diagnosis is already made by histological examination of more than one organ specimen.

No MeSH data available.


Related in: MedlinePlus

Histological analysis. All pictures are obtained at 20Ă— magnification. a Hematoxylin and eosin staining of a subcutaneous nodule specimen. b Hematoxylin and eosin staining of a right mediastinal lymph node specimen. c Hematoxylin and eosin staining of an endobronchial nodule specimen. d Hematoxylin and eosin staining of a transbronchial lung biopsy specimen
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Fig4: Histological analysis. All pictures are obtained at 20Ă— magnification. a Hematoxylin and eosin staining of a subcutaneous nodule specimen. b Hematoxylin and eosin staining of a right mediastinal lymph node specimen. c Hematoxylin and eosin staining of an endobronchial nodule specimen. d Hematoxylin and eosin staining of a transbronchial lung biopsy specimen

Mentions: Three weeks later, she was admitted to our hospital for diagnosis and treatment. Neither restrictive pulmonary function disorder nor remarkably reduced diffusing capacity of her lungs was observed. The 6-minute walk test revealed that she could walk up to 370 meters with a minimum blood oxygen saturation (spO2) of 93%, maximum pulse of 126 beats per minute and the worst modified Borg scale of perceived dyspnea of 1. Chest computed tomography (CT) showed multiple skin nodules, bilateral hilar and mediastinal lymphadenopathy, bilateral pleural effusion, and multiple small nodules in both lungs and along the interlobar pleura (Fig. 2a-d). Pulmonary embolism was not observed in chest CT. Multiple subcutaneous nodules were palpable in her neck, back, and bilateral arms. Gallium-67 scintigraphy exhibited abnormal uptake in the right subclavicular area, mediastinum, bilateral hilum, bilateral parotid glands, and spleen, but no abnormal uptake in her heart, suggesting sarcoidosis or malignant lymphoma (Fig. 3a). A tuberculin test was negative. A skin biopsy specimen was obtained and bronchoscopy was performed twice, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), BAL, and transbronchial lung biopsy. Thoracentesis was also performed. Histological analysis of a resected subcutaneous nodule from her left upper arm exhibited non-caseous epithelioid granuloma (Fig. 4a). Ziehl–Neelsen staining and Grocott staining tested negative. Histological analysis of a right mediastinal lymph node (station 4R) obtained by EBUS-TBNA also showed a non-caseous epithelioid granuloma; malignant lymphoma was ruled out (Fig. 4b). The aspiration sample of the lymph node revealed negative findings for bacteria including tuberculosis. In addition, PCR analysis for detection of tuberculosis, Mycobacterium avium and Mycobacterium intracellulare were negative. Bronchofiberscopy revealed multiple small nodules in both the main bronchi (Fig. 3b), and histological analysis of an endobronchial nodule and a transbronchial lung biopsy specimen from the right upper lobe revealed non-caseous epithelioid granulomas (Fig. 4c and d, respectively). The transbronchial lung biopsy specimen also showed negative Ziehl–Neelsen and Grocott staining. BALF obtained from the right middle lobe exhibited an increased number of lymphocytes and an increased CD4/CD8 lymphocyte ratio of 13.43 (Table 1). Bacterial culture, including that of Mycobacteria, was negative. On the basis of these findings, a final diagnosis of sarcoidosis was made.Fig. 2


Pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid: a case report.

Kumagai T, Tomita Y, Inoue T, Uchida J, Nishino K, Imamura F - J Med Case Rep (2015)

Histological analysis. All pictures are obtained at 20Ă— magnification. a Hematoxylin and eosin staining of a subcutaneous nodule specimen. b Hematoxylin and eosin staining of a right mediastinal lymph node specimen. c Hematoxylin and eosin staining of an endobronchial nodule specimen. d Hematoxylin and eosin staining of a transbronchial lung biopsy specimen
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4536796&req=5

Fig4: Histological analysis. All pictures are obtained at 20Ă— magnification. a Hematoxylin and eosin staining of a subcutaneous nodule specimen. b Hematoxylin and eosin staining of a right mediastinal lymph node specimen. c Hematoxylin and eosin staining of an endobronchial nodule specimen. d Hematoxylin and eosin staining of a transbronchial lung biopsy specimen
Mentions: Three weeks later, she was admitted to our hospital for diagnosis and treatment. Neither restrictive pulmonary function disorder nor remarkably reduced diffusing capacity of her lungs was observed. The 6-minute walk test revealed that she could walk up to 370 meters with a minimum blood oxygen saturation (spO2) of 93%, maximum pulse of 126 beats per minute and the worst modified Borg scale of perceived dyspnea of 1. Chest computed tomography (CT) showed multiple skin nodules, bilateral hilar and mediastinal lymphadenopathy, bilateral pleural effusion, and multiple small nodules in both lungs and along the interlobar pleura (Fig. 2a-d). Pulmonary embolism was not observed in chest CT. Multiple subcutaneous nodules were palpable in her neck, back, and bilateral arms. Gallium-67 scintigraphy exhibited abnormal uptake in the right subclavicular area, mediastinum, bilateral hilum, bilateral parotid glands, and spleen, but no abnormal uptake in her heart, suggesting sarcoidosis or malignant lymphoma (Fig. 3a). A tuberculin test was negative. A skin biopsy specimen was obtained and bronchoscopy was performed twice, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), BAL, and transbronchial lung biopsy. Thoracentesis was also performed. Histological analysis of a resected subcutaneous nodule from her left upper arm exhibited non-caseous epithelioid granuloma (Fig. 4a). Ziehl–Neelsen staining and Grocott staining tested negative. Histological analysis of a right mediastinal lymph node (station 4R) obtained by EBUS-TBNA also showed a non-caseous epithelioid granuloma; malignant lymphoma was ruled out (Fig. 4b). The aspiration sample of the lymph node revealed negative findings for bacteria including tuberculosis. In addition, PCR analysis for detection of tuberculosis, Mycobacterium avium and Mycobacterium intracellulare were negative. Bronchofiberscopy revealed multiple small nodules in both the main bronchi (Fig. 3b), and histological analysis of an endobronchial nodule and a transbronchial lung biopsy specimen from the right upper lobe revealed non-caseous epithelioid granulomas (Fig. 4c and d, respectively). The transbronchial lung biopsy specimen also showed negative Ziehl–Neelsen and Grocott staining. BALF obtained from the right middle lobe exhibited an increased number of lymphocytes and an increased CD4/CD8 lymphocyte ratio of 13.43 (Table 1). Bacterial culture, including that of Mycobacteria, was negative. On the basis of these findings, a final diagnosis of sarcoidosis was made.Fig. 2

Bottom Line: Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated.Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas.Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

View Article: PubMed Central - PubMed

Affiliation: Department of Thoracic Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari-ku, Osaka, 537-8511, Japan. torukumagai@ybb.ne.jp.

ABSTRACT

Introduction: Pleural effusion induced by sarcoidosis is rare, and pleural sarcoidosis is often diagnosed by thoracoscopic surgery. The diagnosis of pleural sarcoidosis using thoracentesis may be less invasive when sarcoidosis is already diagnosed histologically in more than one organ specimen. Here we report the case of a 64-year-old woman with pleural sarcoidosis diagnosed on the basis of an increased CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis. This case report is important because it highlights the usefulness of the CD4/CD8 lymphocyte ratio in pleural effusion as an indicator of pleural involvement of sarcoidosis.

Case presentation: A 64-year-old Japanese woman visited our hospital with an initial symptom of dyspnea on exertion for a period of 4 months. Chest computed tomography showed bilateral hilar and multiple mediastinal lymphadenopathy, multiple small nodular shadows in her bilateral lungs, small nodular shadows along the interlobar pleura, and bilateral pleural effusion. Her serum angiotensin-converting enzyme and soluble interleukin-2 receptor levels were elevated. Histological analysis of a resected subcutaneous nodule, and biopsy specimens from a right mediastinal lymph node and from her right lung revealed non-caseous epithelioid granulomas. Her bronchoalveolar lavage fluid exhibited a predominance of lymphocytes together with an increase in the CD4/CD8 lymphocyte ratio. The lymphocytic predominance and the increased CD4/CD8 lymphocyte ratio were also detected in the right-sided pleural effusion fluid obtained by thoracentesis. We diagnosed sarcoidosis with pleural involvement. Because pleural effusion did not resolve spontaneously and her symptom of dyspnea on exertion worsened, corticosteroid therapy was initiated, which ameliorated the sarcoidosis and the pleuritis.

Conclusions: Analysis of the CD4/CD8 lymphocyte ratio in pleural effusion fluid obtained by thoracentesis may be helpful for the diagnosis of pleural sarcoidosis when the diagnosis is already made by histological examination of more than one organ specimen.

No MeSH data available.


Related in: MedlinePlus