Eosinophilic Globules in Bronchoalveolar Lavage Fluid of Patients With Systemic Sclerosis-Related Interstitial Lung Disease: A Diagnostically Useful, Previously Unreported Finding

Giulio Rossi, MD; Alessandro Andreani, MD; Paola Morandi, MD; Alessandro Marchioni, MD; Paolo Corradini, MD; Gaia Cappiello, MD; Monica Bortolotti, MD; Ardian Qosja, MD; Carlo Manzini, MD; Clodoveo Ferri, MD; Luca Richeldi, MD; Alberto Cavazza, MD


Am J Clin Pathol. 2008;130(6):927-933. 

In This Article

Materials and Methods

A retrospective and prospective study of BAL features was conducted in patients with idiopathic and secondary ILDs between January 2005 and January 2008 diagnosed at the Section of Pathologic Anatomy, Azienda Policlinico, Modena, Italy. A total of 227 samples from patients undergoing a BAL procedure for ILDs of different causes were consecutively collected for study purposes. Basically, BAL samples were sent to the above-mentioned institution to exclude the presence of infectious agents, by using histochemical or immunohistochemical stains, and cancer cells. In some specific pathologic conditions, pathologists were asked to report the CD4/CD8 lymphocyte ratio (sarcoidosis vs hypersensitivity pneumonitis) and/or the percentage of CD1a+ histiocytes (Langerhans cell histiocytosis) and to highlight asbestos bodies (asbestosis), hemosiderin-laden macrophages (alveolar hemorrhage), and amyloid and proteinaceous deposits. In this study, the differential cell count was simply subdivided as follows: lymphocytosis (lymphocytes >20% of total WBCs), neutrophilia (neutrophils >5%), and eosinophilia (>5%).

BAL was performed as routine clinical evaluation. Bronchoscopy was performed, and the BAL sample was processed using 150 to 200 mL (3-4 instillations of 50 mL) of room temperature sterile physiologic saline in the middle or inferior right lobe. Recovered lavage fluid was obtained by gentle mechanical suction. A mean fluid volume of 80 mL was retrieved. Cells were collected by centrifugation, and slides were stained with H&E and May-Grünwald-Giemsa stains. When requested, additional stains (Grocott, periodic acid–Schiff [PAS], PAS-diastase [PAS-D], Congo red, Perls, Ziehl-Neelsen, Gram, and trichrome) and immunostains (for cytomegalovirus, herpes simplex virus, antiadenovirus, CD1a, CD4, and CD8) were performed.

Immunostains with collagen IV (clone CIV-22, Ventana, Tucson, AZ) and surfactant protein (SP)-A (PE-10, Dakopatts, Glostrup, Denmark) were performed in all cases showing eosinophilic globules in BAL samples by using an automated immunostainer (Benchmark, Ventana); 3,39-diaminobenzidine was used as the chromogen and Harris hematoxylin as the counterstain. BAL interpretation was done in a blinded manner to knowledge of clinical data, imaging features, and lung function parameters.

Overall, the series consisted of 227 cases of ILD undergoing BAL examination Table 1 , including idiopathic UIP (also known as idiopathic pulmonary fibrosis [IPF]), idiopathic NSIP, cryptogenic organizing pneumonia, HP, Langerhans cell histiocytosis, eosinophilic pneumonia, sarcoidosis, Wegener granulomatosis, systemic lupus erythematosus, alveolar hemorrhage, drug toxicity (from statins, amiodarone, and propylthiouracil), pneumoconiosis, lipoid pneumonia, infection (Pneumocystis, cytomegalovirus, Strongyloides, Aspergillus and mycobacteria), AP, polymyositis or dermatomyositis, rheumatoid arthritis, mixed connectivitis, and SSc.

Diagnosis of ILD relied on clinical, laboratory, and imaging studies, and only when clinical, laboratory, and imaging data were insufficiently robust, was histologic examination required.

In all patients with SSc, high-resolution computed-tomography (HRCT) features were evaluated. Cases were then subdivided into 3 main groups, as follows: (1) no pulmonary alterations shown by HRCT, (2) prevalent ground-glass opacities, and (3) reticulonodular and honeycombing changes, suggesting a UIP pattern.

The correlation between different variables was performed by using contingency table methods and tested for significance using the Pearson χ2 test (SPSS, version 13.0, SPSS, Chicago, IL). A difference with probability (P) values less than .05 was considered as significant.


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