Cutaneous granulomas associated with high-grade T-cell non-Hodgkin's lymphoma.

We describe a patient with non-Hodgkin's lymphoma treated with a chemotherapy regimen (which included bleomycin, prednisolone and low-dose methotrexate) who developed cutaneous non-caseating granulomas. We felt our patient fitted into the category of 'sarcoid-like granulomas'.

A simple radiographic scoring method for monitoring pulmonary sarcoidosis: relations between radiographic scores, dyspnoea grade and respiratory function in the British Thoracic Society Study of Long-Term Corticosteroid Treatment.

BACKGROUND: We used a simple semi-quantitative radiographic scoring system for a controlled prospective study of long term corticosteroids in pulmonary sarcoidosis, conducted by the British Thoracic Society. METHODS: Radiographic opacities were described in 4 categories: reticulo-nodular shadows [R], mass opacities [M], confluence [C], and shadows associated with possible pulmonary fibrosis [F]. The extent of each type was scored on a 0-4 scale by quartiles, and profusion by a 0-4 scale as absent, minimal (just perceptible), mild moderate or gross. Combined scores for each film were derived by multiplying the extent and profusion for each type of opacity. In the study 149 patients were examined at entry and periodically over a 5-year period. Using the whole study population we examined the relationship between the radiographic scores for extent and profusion, how predominant types change with time and how the scores correlated with other indices of disease severity. RESULTS: R was the predominant abnormality throughout the study with a strong correlation between extent and profusion. Significant correlations in the expected directions were demonstrated between the R and F scores and a dyspnoea score, spirometry and TLCO, both at study entry, after 6 months and after 5 years. Similarly, there were significant relations between changes in spirometry and TLCO over five years and changes in R and F Scores. CONCLUSION: This scoring system would seem to be suitable, perhaps after further validation work, for other prospective clinical studies.

British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment.

BACKGROUND: Corticosteroids suppress disease activity in pulmonary sarcoidosis and their use produces symptomatic, radiographic, and functional improvement. There is, however, uncertainty regarding their effects on the overall natural history of the condition and long term benefit is unproven. METHODS: Patients with pulmonary radiographic shadowing due to sarcoidosis were recruited in a multicentre study. Those who, in the first six months after entry to the study, neither required prednisolone for symptoms nor showed radiographic improvement were allocated at six months to receive either long term steroid treatment (group L) or selective treatment (group S), with regular assessment over the subsequent five years. Patients in group L were scheduled to receive steroid treatment for at least 18 months with the policy of achieving and maintaining maximal radiographic clearing, while in group S treatment was reserved for use only if warranted by later development of symptoms or deteriorating lung function. Symptoms, radiographic appearances, and respiratory function were assessed periodically during the study. RESULTS: One hundred and forty nine patients were followed: 33 required prednisolone for troublesome symptoms within six months of entry and 58 showed radiographic improvement over this period. The remaining 58 patients were allocated to groups L (n = 27) and S (n = 31). Patients in group L showed greater improvements in symptoms, respiratory function, and radiographic appearances than those in group S, although the differences were not large. After adjusting for differences at the time of allocation, the average difference in vital capacity between groups L and S at final assessment was 9% of the predicted value. Side effects of treatment were frequent but usually mild, necessitating withdrawal in only two individuals. CONCLUSIONS: After excluding those individuals who required steroids for control of symptoms, approximately half of the remaining patients with sarcoidosis and pulmonary shadowing showed spontaneous radiographic improvement during six months of observation. In those in whom the radiograph failed to improve, prolonged steroid treatment with the aim of optimising radiographic appearances resulted in a significantly better long term functional outcome.

Effective use of cyclosporin in sarcoidosis: a treatment strategy based on computed tomography scanning.

Cyclosporin was used successfully in a patient with severe pulmonary sarcoidosis, a poor response and unacceptable side-effects from corticosteroid therapy. Computed tomography (CT) scanning initially suggested reversible disease, and subsequently detected improvement earlier than other indices of disease activity. This information was critical in the decision to commence and to continue cyclosporin. The literature on the use of cyclosporin in sarcoidosis is reviewed.

Detection of mycobacterial rRNA in sarcoidosis with liquid-phase hybridisation.

Because sarcoidosis resembles tuberculosis clinically and histologically, it has been suggested that mycobacteria might have a role in the pathogenesis of the disorder. Mycobacteria have not been found in sarcoid tissues by conventional culture techniques, so we have used a liquid-phase hybridisation method to see whether we could detect mycobacterial rRNA in such tissues. RNA was extracted from five sarcoid and five normal spleens. Extracts were assayed by liquid-phase DNA/RNA hybridisation with a DNA probe specific for the rRNA of the Mycobacterium tuberculosis complex. Hybridisation obtained with the sarcoid spleens, from which mycobacteria were neither seen on microscopy nor cultured with standard methods, was 4.8 times higher than that with normal spleens (p less than 0.001). Our demonstration of mycobacterial nucleic-acid components in sarcoid splenic tissues supports the notion that mycobacteria play a part in the cause of sarcoidosis.

The association of germ cell tumours of the testis with sarcoid-like processes.

Sarcoid-type pulmonary lymphadenopathy associated with testicular cancer is a rare condition which has been previously reported in only 14 cases. Earlier case reports have failed to distinguish between generalized sarcoidosis as opposed to a local granulomatous reaction to tumour. We describe a further 8 cases of the association and provide strong supportive evidence for systemic sarcoidosis in 5 of our patients. In 3 of our patients with systemic sarcoidosis there was coexisting testicular cancer requiring additional treatment. We therefore advise caution in the interpretation of the clinical and histological findings in these patients, and recommend thorough investigation of all such cases.

Chemical inactivation of the Kveim reagent.

In an attempt to identify the nature of the active principle, Kveim reagent was exposed to chemical fractionating agents. Thirty-one patients with sarcoidosis underwent simultaneous intradermal injection with fractionated and unfractionated Kveim material. Kveim reagent was stable in the presence of DNAse, RNAse, pronase, 95% phenol, neutral detergent, and to lipid extraction with chloroform-methanol. Kveim reagent was also stable in the presence of both 8 M urea (8MU) and 2-mercaptoethanol (2ME) when used alone. When both these agents were used together, Kveim reagent was inactivated. Fourteen patients had a positive test to unfractionated Kveim reagent; of these, only 2 gave a positive response to material fractionated by exposure to 8MU and 2ME. Simultaneous exposure to 8MU and 2ME was more likely to inactivate Kveim reagent (10/10 tests) than sequential exposure to 8MU and 2ME (2/4 tests). Chemical analysis of the fractionated material showed that it retained granuloma-generating activity despite the lack of carbohydrates. Protein loss in terms of total and relative amino acid composition was progressive and non-specific throughout processing. These results are consistent with a protein-active principle which is dependent on three-dimensional structure.

Search for a retroviral cause for sarcoidosis: no evidence from peripheral blood studies.

Twenty six patients with sarcoidosis of recent onset or with severe progressive disease were studied for evidence of retroviral infection. Peripheral blood mononuclear cells (PBMC) were cultured in vitro and stimulated with phytohaemagglutinin and interleukin-2. Induction of syncytia (SI) and production of reverse transcriptase (RT) were sought as indicators of possible retroviral infection. PBMC from two patients showed syncytia formation and in one of these two there was associated production of low levels of reverse transcriptase. The remaining patients showed neither RT nor SI activity. The predominantly negative results of this study indicate that sarcoidosis is unlikely to be of retroviral aetiology; however, cell populations from sites of active disease should be studied before drawing this conclusion.

Sarcoidosis: in search of Kveim reactivity in vitro.

Granuloma formation in patients with sarcoidosis may be evoked by the intradermal injection of homogenised sarcoid tissue (the Kveim reaction). Attempts to demonstrate an in vitro counterpart of the reaction have been unsuccessful. The cytokine interleukin-2 (IL-2) enhances immune responses in vivo and in vitro. We report here an attempt to amplify the Kveim reaction by the addition of IL-2. We studied the effect of Kveim reagent on the proliferative responses of peripheral blood mononuclear cells (PBMC) in the presence or absence of exogenous IL-2. Twenty-eight patients were studied and 14 healthy subjects served as controls. PBMC were cultured, in vitro, in the presence of Kveim reagent. Recombinant IL-2 or both of these combined. Proliferative responses were measured by [3H]-thymidine incorporation. The response of patients' PBMC in the presence of Kveim reagent at a dilution of 1:40 was significantly below the unstimulated response (P less than 0.01). Kveim reagent at a dilution of 1:40 also inhibited the proliferative response of patients PBMC to IL-2 (P less than 0.005); greater dilutions (1:100 and 1:1000) of Kveim reagent were not inhibitory. Responses of PBMC from control subjects (both unstimulated and IL-2 generated) were reduced in the presence of Kveim reagent, however, these reductions were not statistically significant.

Local synthesis of specific IgG in the cerebrospinal fluid of patients with neurosarcoidosis detected by antigen immunoblotting using Kveim material.

The technique of antigen immunoblotting for detection of specific immunoglobulin G (IgG), using Kveim material as antigen, was applied to paired sera and cerebrospinal fluid from 11 patients with definite neurosarcoidosis, 9 patients with definite sarcoidosis and suspected neurosarcoidosis, 22 patients with possible neurosarcoidosis and 16 patients with other neurological disorders, including multiple sclerosis and optic neuritis. Six of the 11 (55%) patients with neurosarcoidosis, none of the 9 patients with definite sarcoidosis and suspected neurosarcoidosis, 5 of the 22 (23%) with possible neurosarcoidosis, and none of the control patients had local synthesis of specific IgG reacting with Kveim material at some stage in the disease. Six of the 8 (75%) patients with definite neurosarcoidosis who had never received steroids or immunosuppressants had local synthesis of Kveim-specific IgG. Local synthesis of Kveim-specific IgG was not found in patients who had received in the past, or were still receiving, immunomodulating agents, and local synthesis was abolished when such treatment was introduced to those patients who had been positive. Those patients whose cerebrospinal fluid showed local synthesis of oligoclonal total IgG were more likely to have local synthesis of Kveim-specific IgG, but not necessarily in an oligoclonal fashion. Immunoblotting, using Kveim material, may thus be a useful adjunct for the investigation of suspected neurosarcoidosis.

The ultrastructural features of developing Kveim test granulomas.

The Kveim test provides a useful model for the ultrastructural study of developing epithelioid cell granulomas in man. We present a controlled prospective study in which 140 patients with possible sarcoidosis had two simultaneous Kveim tests, one being biopsed at a varying interval and the other at the usual 28 days: 52 patients showed a positive test. Controls were provided by the 88 negative tests, Kveim biopsis from 12 healthy subjects, and biopsies of normal spleen injection sites in a further 12 sarcoid patients. In all three groups the initial response (3 to 5 days) was macrophage influx. From 8 to 10 days, in developing positive tests only, mononuclear cells with abundant rough endoplasmic reticulum appeared. Mature epithelioid cells were seen at 12 to 14 days, when lymphocyte numbers and lymphocyte-histiocyte interactions were at a maximum. Epithelioid cells showed marked secretory activity; the ultrastructural features of the developing epithelioid cell vacuoles are identical to those seen in exocrine cells. Mast cells are not involved in the development of granulomas.

Defective cell mediated immunity in sarcoidosis: effect of interleukin-2.

Interleukin-2 has been reported to enhance the immune response in diseases characterised by defective cell mediated immunity. The effect of exogenous recombinant interleukin-2 was studied on the proliferative and cytotoxic responses of peripheral blood mononuclear cells from 39 patients with sarcoidosis and 14 healthy control subjects. The proliferative response to purified protein derivative was smaller in patients than in control subjects (p less than 0.001) whereas the response to 80 U interleukin-2 alone and to purified protein derivative and interleukin-2 did not differ significantly between the two groups. In addition, in eight patients but no control subjects tritiated thymidine incorporation induced by the combination of purified protein derivative and interleukin-2 was more than twice the sum of that induced by purified protein derivative and interleukin separately. Cytotoxic activity occurring spontaneously and induced by purified protein derivative and interleukin-2 in blood mononuclear cells was significantly less for patients with sarcoidosis than for control subjects (p less than 0.05 spontaneous, less than 0.001 purified protein derivative induced, less than 0.02 interleukin induced). Synergism between antigen and interleukin did not occur with respect to the cytotoxic response in either patients or controls. Defective interleukin-2 production may contribute to, but does not entirely explain, the functional abnormalities of peripheral blood lymphocytes from patients with sarcoidosis.

Suppression associated lymphocyte markers in lesions of sarcoidosis.

The presence within the epithelioid granulomas of sarcoidosis of lymphocytes of the "helper" (T4 positive) phenotype suggests that, as in granulomatous diseases of known aetiology, active cell mediated immunity plays a part in the disease. It has, however, been noted that T8 positive lymphocytes are also found on occasion in the granulomas. The presence of cells bearing markers associated with suppressor activity in various lesions of sarcoidosis has been investigated with a range of monoclonal antibodies. T4 positive cells were present in all granulomas; T8 positive lymphocytes were present within the epithelioid cell areas in proportions that varied from 5 to 55/100 of T4 cells. Other lymphocyte markers associated with suppression (Leu8 and SN130) were very rare on lymphocytes within granulomas but common on both T4 positive and T8 positive lymphocytes in the perigranulomatous mantle, which suggests that expression of these markers was down regulated in the granuloma or that cells bearing them are unable to migrate into the granuloma. Nevertheless, suppressor cell mechanisms could mediate the spontaneous resolution of most cases of sarcoidosis, and the presence or absence of cells bearing suppression associated phenotypes in the granuloma or its mantle may have prognostic importance.

Upper respiratory tract involvement in sarcoidosis and its management.

Of some 750 sarcoidosis patients, 27 were found to have involvement of their nasal mucosa. Most had multisystem disease, which was usually chronic. Nasal stuffiness or blockage and crusting were the major symptoms, and were usually present at the first presentation with sarcoidosis. The larynx was involved in five cases. The Kveim test was positive in twelve of the fourteen patients in whom it was performed, serum angiotensin converting enzyme was frequently elevated and sinus radiographs were often abnormal. Topical medication improved symptoms in some patients, but the majority required systemic corticosteroids. It was possible to withdraw medication completely after seven years in only one patient. Relapse was encountered during reduction of dosage in other patients. Random biopsy of macroscopically normal nasal mucosa did not yield histological support for a diagnosis of sarcoidosis in twelve out of thirteen patients, but upper respiratory tract lymphoid tissue may contain granulomas in patients with sarcoidosis.

Dendritic cells in cutaneous, lymph node and pulmonary lesions of sarcoidosis.

To determine whether dendritic cells (DC) are a consistent feature of lesions of sarcoidosis, we have used monoclonal antibodies to identify the HLA-DR-expressing populations of cells in cryostat sections of 15 lymph node, pulmonary and cutaneous lesions. The commonest HLA-DR positive cells in granulomas were epithelioid and giant cells, although lymphocytes within granulomas and tissue macrophages around them were also positive. Dendritic cells with Langerhans cells (NA1/34+ = OKT6+) and interdigitating cell (RFD1+) phenotype were consistently associated with granulomas only in skin lesions. In lymph nodes, interdigitating cells (NA1/34-/RFD1+/HLA-DR++) were confined to paracortical zones as in normal nodes, although a small area of NA1/34+/RFD1+ cells was found in one of three nodes. In lung lesions NA1/34+/RFD1+ dendritic cells were uncommon or absent, except in one chronic case. We conclude that while sometimes present in extracutaneous sites, DC are not an essential feature of sarcoid lesions, and that cells of the classical macrophage group are the most significant HLA-DR-expressing population. We suggest that the presence of DC in lesions of sarcoidosis may indicate an immunological response distinct from that causing granulomas to form. The variability of their involvement may have immunoregulatory significance.

Oro-facial granulomatosis. Response to elemental diet and provocation by food additives.

We report the case of an 8.5-year-old girl with oro-facial granulomatosis associated with clinical atopy, in whom relapse of her granulomatous disorder was shown to be related to exposure to specific food additives, viz. carmoisine, sunset yellow and monosodium glutamate. Treatment with a restricted diet resulted in considerable regression in the facial swelling which has been maintained for 6 months. A brief account of the histological features, both under light and electron microscopy, is given, together with a description of the use of nuclear magnetic resonance scanning in the assessment of this disease. The patient had no evidence to support a diagnosis of sarcoidosis or Crohn's disease.