Winterbauer R H, Lammert J, Selland M, Wu R, Corley D, Springmeyer S C
Section of Pulmonary and Critical Care Medicine, Virginia Mason Clinic, Seattle 98101.
Chest. 1993 Aug;104(2):352-61. doi: 10.1378/chest.104.2.352.
Between February 1, 1984, and February 1, 1989, fiberoptic bronchoscopy was performed on 2,692 patients, 592 of whom had bronchoalveolar lavage (BAL). One hundred twenty-eight patients with 16 percent or more lymphocytes in BAL fluid (BALF) were selected for further study. The group included 27 patients with sarcoidosis, 28 with nonsarcoidosis interstitial lung disease (ILD), 22 with lung infection (organism isolated), 31 with inflammation (presumed infection, no organism isolated), 14 with neoplasm, and 6 with bronchial hyperreactivity.
The percentages of lymphocytes, B lymphocytes, and T lymphocytes, the CD4/CD8 ratio and the percentages of neutrophils and eosinophils were analyzed individually and in combination for discrimination between the sarcoidosis and nonsarcoidosis patients and compared with the diagnostic accuracy of multiple noncaseating granuloma (MNG) on a simultaneous transbronchial biopsy (Tbbx).
Neither the percentages of lymphocytes, T lymphocytes, or B lymphocytes discriminated sarcoidosis from nonsarcoidosis patients. Sarcoidosis patients had higher CD4/CD8 ratios, fewer neutrophils, and 1 percent or less eosinophils in the BAL cell populations. An analysis of CD4/CD8 ratios, and percentages of neutrophils and eosinophils individually revealed that a CD4/CD8 ratio of 4:1 or greater had a positive predictive value of 94 percent in distinguishing sarcoidosis from other ILD but a sensitivity of only 59 percent. The positive predictive value of CD4/CD8 ratio of 4:1 or greater fell to 50 percent in separating sarcoidosis from all other diseases. A CD4/CD8 ratio of less than 1:1 has a 100 percent negative predictive value to exclude the diagnosis of sarcoidosis. Finding 1 percent or less neutrophils in BAL had an 80 percent positive predictive value in distinguishing sarcoidosis from nonsarcoidosis ILD and 51 percent for distinguishing sarcoidosis from all other disease groups. The CD4/CD8 ratio and the percentages of neutrophils and eosinophils also were combined and analyzed for the diagnosis of sarcoidosis.
Results showed a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils has essentially the same specificity and positive predictive value as MNG on Tbbx in distinguishing sarcoidosis from nonsarcoidosis disease. The combination of finding MNG in a Tbbx specimen plus a BALF CD4/CD8 ratio of 4:1 or greater had a 100 percent positive predictive value in separating sarcoidosis from other ILD and an 81 percent value in separating sarcoidosis from all other disease. Finding MNG in a Tbbx specimen plus a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils had a 93 percent positive predictive value in distinguishing sarcoidosis from both nonsarcoidosis ILD and all other diseases.
在1984年2月1日至1989年2月1日期间，对2692例患者进行了纤维支气管镜检查，其中592例患者进行了支气管肺泡灌洗（BAL）。选择了128例支气管肺泡灌洗液（BALF）中淋巴细胞占16%或更多的患者进行进一步研究。该组包括27例结节病患者、28例非结节病性间质性肺病（ILD）患者、22例肺部感染（分离出病原体）患者、31例炎症（推测为感染，未分离出病原体）患者、14例肿瘤患者和6例支气管高反应性患者。
分别分析淋巴细胞、B淋巴细胞和T淋巴细胞的百分比、CD4/CD8比值以及中性粒细胞和嗜酸性粒细胞的百分比，并综合分析以区分结节病患者和非结节病患者，并与同期经支气管活检（Tbbx）时多个非干酪样肉芽肿（MNG）的诊断准确性进行比较。
淋巴细胞、T淋巴细胞或B淋巴细胞的百分比均不能区分结节病患者和非结节病患者。结节病患者的BAL细胞群中CD4/CD8比值较高，中性粒细胞较少，嗜酸性粒细胞占1%或更少。单独分析CD4/CD8比值以及中性粒细胞和嗜酸性粒细胞的百分比发现，CD4/CD8比值为4:1或更高时，区分结节病与其他ILD的阳性预测值为94%，但敏感性仅为59%。将结节病与所有其他疾病区分开来时，CD4/CD8比值为4:1或更高的阳性预测值降至50%。CD4/CD8比值小于1:1对排除结节病诊断具有100%的阴性预测值。BAL中中性粒细胞占1%或更少，区分结节病与非结节病性ILD的阳性预测值为80%，区分结节病与所有其他疾病组的阳性预测值为51%。还对CD4/CD8比值以及中性粒细胞和嗜酸性粒细胞的百分比进行综合分析以诊断结节病。
结果显示，BALF中CD4/CD8比值为2:1或更高、中性粒细胞占1%或更少且嗜酸性粒细胞占1%或更少，在区分结节病与非结节病性疾病方面与Tbbx时的MNG具有基本相同的特异性和阳性预测值。Tbbx标本中发现MNG加上BALF的CD4/CD8比值为4:1或更高，在将结节病与其他ILD区分开来时阳性预测值为100%，在将结节病与所有其他疾病区分开来时阳性预测值为81%。Tbbx标本中发现MNG加上BALF的CD4/CD8比值为2:1或更高、中性粒细胞占1%或更少且嗜酸性粒细胞占1%或更少，在区分结节病与非结节病性ILD以及所有其他疾病方面阳性预测值为93%。
