Pulmonary histiocytosis X (HX) is a disorder characterized by the presence of granulomas in which Langerhans cells (LC) and lymphocytes are abundant. Although the pathogenesis of pulmonary HX remains unknown, an uncontrolled immune response initiated by LC, which are potent antigen-presenting cells in vitro, may play an important role. To further characterize LC and lymphocytes present in granulomas from these patients, we used immunohistochemical techniques and monoclonal antibodies to evaluate the surface phenotype and electron microscopy (EM) to seek evidence for close interactions between both cell types in these lesions. In all samples, HX granulomas contained large numbers of strongly positive CD1a cells in which typical Birbeck granules were identified by EM. The number of Birbeck granules in LC from HX granulomas was strikingly increased compared with that in LC in the bronchioles of normal subjects. Furthermore, unlike normal LC, essentially all LC in HX granulomas expressed CD4 antigens and were strongly positive for CD1c. Lymphocytes infiltrating HX granulomas were almost entirely CD3+ T cells and were mainly CD4 positive (CD4/CD8 ratio 3.7 +/- 1.3). These T lymphocytes expressed almost exclusively alpha/beta T cell receptors, and gamma/delta T cells were rarely observed (< 5% of CD3+ cells). In areas of lymphocytic infiltration, close differentiated contacts between LC and lymphocytes were observed by EM in all samples. These results demonstrate that interactions between activated LC and CD4+ T lymphocytes are prominent in early HX granulomas and support the idea that an immune response in which LC serve as accessory cells is involved in the pathogenesis of this disorder.