Prognostic value of bronchoalveolar lavage in sarcoidosis: the critical influence of disease presentation.

There has been considerable disagreement about the prognostic value of bronchoalveolar lavage lymphocyte measurements in patients with sarcoidosis. This study looks at the influence of the type of disease presentation and the time since onset of symptoms on lavage fluid lymphocyte profiles in 99 patients studied at the time of their initial diagnosis. Patients who had an acute inflammatory onset of disease with erythema nodosum (n = 32) or acute uveitis (n = 17) almost invariably had high T lymphocyte helper:suppressor (TH:TS) ratios (mean 10.1, 95% confidence interval 7.7-12.5) and had a higher proportion of T lymphocytes in cells obtained at lavage (40%, 35-46%) than patients with a pulmonary presentation (n = 38) (TH:TS 2.9, 0.2-5.7; T lymphocytes 21%, 15-27%) or those studied after resolution of erythema nodosum (n = 12). The patients with recent erythema nodosum had the highest TH:TS ratios of any group (10.4, 8.1-12.7). Thus lavage T lymphocyte percentage and TH:TS are highest in patients with sarcoidosis studied soon after an acute onset with an inflammatory condition such as erythema nodosum or uveitis. Patients with an acute onset of sarcoidosis have a better prognosis than those with a more insidious presentation. The major influence of type of disease presentation and, in the case of patients with erythema nodosum, of time since onset of symptoms may in part explain why different centres have reported such diverse results regarding the value of bronchoalveolar lavage in predicting outcome in sarcoidosis. Studies where the case mix of patients includes a high proportion of patients with acute onset will not find a high TH:TS ratio or increased numbers or proportions of lavage lymphocytes to be indicators of a poor prognosis.