Role of BAL in diagnosis of ILD Part 6 Dr. Sheetu singh

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Role of BAL in diagnosis of ILD
Interventions in ILD

• Bronchoalveolar lavage (BAL) fluid cellular
  analysis should not routinely be used for
  identification of sub-type of ILD
• BAL may be used to diagnose
• certain rare ILDs such as pulmonary alveolar
  proteinosis (PAP), pulmonary langerhans cell
  histiocytosis (PLCH) and eosinophilic pneumonia
• Rule out alternative diseases such as infections,
  malignancy and alveolar hemorrhage

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BAL cellular patterns in various ILDs
Pattern ILD
Lymphocytosis (gt25) Sarcoidosis Hypersensitivity pneumonitis Berylliosis or chronic beryllium disease Cellular NSIP
Lymphocytosis (gt50) Hypersensitivity pneumonitis Cellular nonspecific interstitial pneumonia
Eosinophilia (gt 25) Acute Eosinophilic pneumonia ( 25 ) Chronic Eosinophilic pneumonia ( 40)
Neutrophil (gt 50) Acute lung injury, aspiration pneumonia, or suppurative infection
CD4/CD8 gt 3.5-4 Sarcoidosis (early or active)
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BAL cellular patterns in various ILDs
Pattern ILD
Macrophages containing smoking-related inclusions Smoking-related ILDs
Positive lymphocyte transformation test to specific beryllium antigen Berylliosis
Ferruginous bodies Asbestosis
Dust particles by polarized microscope Silicosis
Lipid-laden macrophages (oil-red-O-stain) Lipoid pneumonia/chronic microaspiration
CD1a positive cells 5/Birbeck granules in macrophages Pulmonary langerhans cell histiocytosis (PLCH)
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Case

• 22 year old non smoker male presents with cough
  and exertional dyspnoea since 4 years

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BAL sample from the patient showing abundant
granular globular material with relative
paucity of macrophages (HE stain 400X)
Specimen from same patient with amorphous
material showing strong PAS positivity. (PAS
stain 400X)
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