Elsevier

Clinical Immunology

Volume 126, Issue 3, March 2008, Pages 338-344
Clinical Immunology

Evaluation of CD103 as a cellular marker for the diagnosis of pulmonary sarcoidosis

https://doi.org/10.1016/j.clim.2007.11.005Get rights and content

Abstract

A high CD4+/CD8+ ratio in bronchoalveolar lavage fluid is indicative for the diagnosis pulmonary sarcoidosis but this ratio only does not fully discriminate pulmonary sarcoidosis from other interstitial lung diseases. Recently, the integrin CD103 has been implicated in the diagnostic evaluation of sarcoidosis. CD103 is expressed on intraepithelial lymphocytes in mucosal areas, including bronchi, and is possibly involved in the retention of lymphocytes to the mucosa. The Dutch BAL working party initiated an investigation to evaluate the diagnostic value of relative number of CD103 expressing CD4+ T-lymphocytes in the BAL fluid of patients with a variety of interstitial lung diseases. The expression of CD103 was examined on bronchoalveolar lavage cells from 119 patients including 56 patients with pulmonary sarcoidosis. We redefined criteria for alveolar CD4+ T-cell lymphocytosis and for the relative enumeration of CD103 expressing CD4+ T-lymphocytes in the BAL fluid. Our data demonstrate that the combined use of the CD103+CD4+/CD4+ ratio (< 0.2) and the BAL CD4+/CD8+ ratio (> 3) or the relative alveolitis CD4+/CD8+ BAL/PB ratio (> 2) provides a specific tool for discriminating sarcoidosis, also without a clear CD4+ alveolitis, from other interstitial lung diseases.

Introduction

Interstitial lung diseases (ILDs) are a heterogeneous group of pulmonary disorders, comprising over 100 different members that are classified together because of similar clinical, radiographic, physiologic, or pathologic manifestations. The major abnormality in ILDs is disruption of the lung parenchyma. When the lung is injured, epithelial cells are damaged and basement membranes may lose their integrity, heralding the appearance of a variety of inflammatory cells, regenerating type II pneumocytes, and increasing the expression of extracellular matrix components [1], [2], [3].

The most common ILD in the western world is sarcoidosis, with an annual incidence of between 10 and 25 per 100,000 persons in Western Europe and the United States [4], [5].

Sarcoidosis is a chronic systemic inflammatory disorder of unknown origin characterized by the accumulation of macrophages and in particular CD4+ T-lymphocytes in the involved organs, most frequently the lung, ultimately leading to the formation of noncaseating granulomas. Since the key pathologic finding in sarcoidosis is noncaseating granulomas, the diagnosis should be confirmed by a biopsy whenever possible—except in patients with a typical presentation of a Löfgren’s syndrome. Sarcoidosis commonly affects young adults. Because there is spatial, seasonal, and occupational clustering, it is generally believed that the disease is triggered by environmental agents [6].

In the absence of a known causative agent, however, sarcoidosis remains a diagnosis of exclusion. The differential diagnose of sarcoidosis is extensive, including infectious diseases (e.g. tuberculosis), granulomatous diseases associated with exposure to inorganic or organic agents (e.g. hypersensitivity pneumonitis, chronic beryllium disease, drug-induced pneumonitis), autoimmune disorders (e.g. Wegener’s granulomatosis, Churg-Strauss vasculitis), and malignancies (e.g. lymphomas, tumor-related granuloma) [7], [8], [9], [10].

In sarcoidosis, the lungs are frequently affected and bronchoalveolar lavage (BAL) is an important diagnostic tool to sample cells at the site of inflammation. A lymphocytic alveolitis with a CD4+/CD8+ ratio > 3.5 is consistent with pulmonary sarcoidosis. However, the finding of a CD4+ lymphocytosis in BAL is neither specific nor sensitive for the diagnosis of sarcoidosis [9], [11], [12], [13]. Therefore it is of interest to investigate additional cellular markers of the CD4+ T-lymphocytes to specify the characteristics of this cell population in pulmonary sarcoidosis.

The expression of the aEβ7/CD103β7 integrin (CD103) has been related to the retention of intraepithelial lymphocytes (IEL) in mucosal tissues of gut, urogenital tract, and lung. CD103 mediates binding to E-cadherin at the basolateral side of the epithelium and is expressed by lymphocytes within the bronchial epithelium [14], [15], [16], by some alveolar wall lymphocytes and by T-lymphocytes in the bronchoalveolar fluid [17], [18]. It has been shown that the relative amount of CD103-expressing T-cells in the bronchoalveolar lavage fluid differs in patients with ILD, depending on the type of disease. This variation is predominantly seen in the CD4+ T-cell population: patients with idiopathic pulmonary fibrosis (IPF) and hypersensitivity pneumonitis (HP) have a significantly higher proportion of CD4+ T-cells expressing CD103 compared to patients with sarcoidosis [19], [20]. This is corroborative to the concept that lymphocytosis in HP results from the local expansion of mucosal lymphocytes while lymphocytosis in pulmonary sarcoidosis is the result of lymphocytes of nonmucosal origin. The absence of CD103 on CD4+ lymphocytes in the BAL fluid of sarcoidosis patients is consistent with a peripheral origin of these cells. Decreased levels of peripheral CD4+ lymphocytes with increased levels of BAL CD4+ lymphocytes have been described in sarcoidosis [21] and suggest a redistribution from the peripheral blood and compartmentalization in the lung [22].

Kolopp-Sarda and colleagues investigated the expression of the integrin CD103 on BAL lymphocytes and proposed diagnostic criteria to discriminate sarcoidosis from other ILDs [19]. However, their criteria exclude sarcoidosis patients with a low CD4+/CD8+ ratio (< 2.5) in BAL, whereas such patients may comprise a substantial part of the sarcoidosis patients (see for example Kantrow et al. [12]).

The Dutch BAL working party initiated an investigation to evaluate the diagnostic value of relative number of CD103 expressing CD4+ T-lymphocytes in the BAL fluid of patients with a variety of interstitial lung diseases. We redefined criteria for alveolar CD4+ T-cell lymphocytosis and for the relative enumeration of CD103 expressing CD4+ T-lymphocytes in the BAL fluid. Our results indicate that the combination of CD103+CD4+/CD4+ ratio with an absolute or relative (to peripheral blood) CD4+/CD8+ ratio in BAL is a specific parameter for the diagnosis of pulmonary sarcoidosis, also in sarcoidosis patients without an apparent CD4+ alveolitis. In comparison with the criteria used by Kolopp-Sarda et al., analysis of the BAL using our renewed criteria increases the sensitivity with an equal specificity, predicting the correct group of sarcoidosis patients.

Section snippets

Patients

The diagnoses of the patients are listed in Table 1. In all cases, the diagnosis of sarcoidosis was confirmed by a biopsy obtained from the lung showing noncaseating epithelioid granulomas and after exclusion of other known causes of granulomatosis in accordance with the consensus of the ATS/ERS/WASOG statement on sarcoidosis [23]. In one patient, the diagnosis was made without biopsy because this patient presented with the classic symptoms of Löfgren’s syndrome (i.e. fever, erythema nodosum,

Expression of cell surface markers

A significant higher CD4+/CD8+ ratio in BAL fluid (mean ± SEM) was found for sarcoidosis patients (7.9 ± 0.9, n = 56) compared to patients with other ILDs (2.3 ± 0.3, n = 63, p < 0.0001, Fig. 1). The proportion of CD103+ lymphocytes (mean ± SEM) of total BAL lymphocytes was significantly lower in sarcoidosis patients (23.5 ± 2.0, n = 56) compared to patients with other ILDs (48.4 ± 2.8, n = 63, p < 0.0001) (data not shown).

Figure 2 presents the CD103+CD4+/CD4+ ratio, introduced in the present study, reflecting the

Discussion

Sarcoidosis is characterized by an alveolar CD4+ lymphocytosis. This study demonstrates that the percentage of alveolar CD4+ T-lymphocytes expressing the integrin CD103 in patients with pulmonary sarcoidosis is significantly different from patients with other ILDs. This result suggests that the CD103+CD4+/CD4+ ratio in BAL is an additional cellular marker for pulmonary sarcoidosis. Secondly, as some sarcoidosis patients without an apparent CD4+ alveolitis show a CD4+ depletion in the peripheral

Contributors

The members of the Dutch BAL working party, who contributed to this study, are W.A.T. Slieker, T.J. Haitjema (Alkmaar MCA); A.H.L. Mulder, H. Eidhof (Ziekenhuis Groep Twente, Almelo en Hengelo); H. van Velzen-Blad, J.M.M. van den Bosch, J.C. Grutters, C. Benschop (Nieuwegein Antonius); E.G. van Lochem, I. Bronmans, A. de Jong (Rotterdam Erasmus MC); P.A. Kuiper-Kramer, J.K. van der Molen-Sinke (Zwolle Isala Weezenlanden); and R.J. Slingerland, A. Velthuis, E.D. de Jong (Zwolle Isala Sophia).

Acknowledgments

The authors wish to acknowledge Dr. T.A. Out and Dr. Ir. A.H.L. Mulder for critical reading of the manuscript.

References (35)

  • M.W. Ziegenhagen et al.

    Bronchoalveolar and serological parameters reflecting the severity of sarcoidosis

    Eur. Respir. J.

    (2003)
  • Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999

    Am. J. Respir. Crit. Care Med.

    (1999)
  • C. Agostini et al.

    Pulmonary immune cells in health and disease: lymphocytes

    Eur. Respir. J.

    (1993)
  • S.P. Kantrow et al.

    The CD4/CD8 ratio in BAL fluid is highly variable in sarcoidosis

    Eur. Respir. J.

    (1997)
  • U. Costabel

    CD4/CD8 ratios in bronchoalveolar lavage fluid: of value for diagnosing sarcoidosis?

    Eur. Respir. J.

    (1997)
  • K.L. Cepek et al.

    Adhesion between epithelial cells and T lymphocytes mediated by E-cadherin and the alpha E beta 7 integrin

    Nature

    (1994)
  • P.J. Kilshaw

    Alpha E beta 7

    Mol. Pathol.

    (1999)
  • Cited by (0)

    View full text