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

Disclosures

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

In This Article

Results

In this study, we focused our attention on the presence of extracellular, round-to-oval, globular deposits of amorphous, acellular, deeply eosinophilic material of different sizes Image 1A and Image 1B. These deposits had a finely granular appearance, stained for PAS, and were resistant to diastase digestion (PAS-D) Image 1C and Image 1D. May-Grünwald-Giemsa Image 1E and trichrome Image 1F stains confirmed the eosinophilic appearance and possible collagen derivation (green staining), respectively. No staining was observed with other stains (Congo red, Grocott, Ziehl-Neelsen, Gram, or Perls).

A, Globular eosinophilic deposits with mixed granulocytic infiltrate in a bronchoalveolar lavage specimen from a patient with systemic sclerosis (H&E, ×100). B, Note the rounded, well-defined margins and finely granular and homogeneous structure of the globular eosinophilic deposits (H&E, ×200). C and D, Positive staining with periodic acid–Schiff (PAS) (C, ×100) and PAS-diastase (D, ×100). E and F, Eosinophilic appearance with May-Grünwald-Giemsa stain (E, ×200) and green coloration with trichrome (F, ×200) of globular materials.

In immunocytochemical analysis, eosinophilic deposits did not stain with collagen IV and SP-A.

Overall Case Series

We identified the presence of these amorphous eosinophilic deposits in 18 cases (7.9%) of the entire series, but in 16 (32%) of 50 cases of SSc. The 2 additional cases showing the presence of these PAS+ globules had UIP, apparently idiopathic, whereas all other cases did not display these peculiar eosinophilic deposits Table 2 .

Based on previous sporadic observations of these eosinophilic amorphous deposits in advanced ILD in patients with SSc, a presumptive diagnosis of SSc with lung involvement evident in BAL sample features was made prospectively in 4 cases. In all cases, clinical, laboratory, and imaging studies confirmed the diagnosis of SSc.

As expected, the presence of eosinophilic deposits on BAL was significantly associated with a diagnosis of SSc-related ILD (P < .001). Patients with SSc (43 women and 7 men) had no HRCT alterations in 16 cases (32%), ground-glass opacities in 18 cases (36%), and honeycombing in 16 (32%). Eosinophilic deposits were detected in 3 cases with ground-glass opacities and in 13 cases with honeycombing, but not in the HRCT-negative cases (P < .0001). In addition, cases with eosinophilic deposits had neutrophilia (8 cases) or neutrophilia and eosinophilia in the BAL samples, while no deposits were observed in the 23 cases with unremarkable BAL cytologic findings (P < .0001). Finally, also the presence of neutrophilia (15/16, 7 with honeycombing) and eosinophilia (all 16 cases, 7 with honeycombing) was significantly associated with HRCT-evident alterations (P < .0001).

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