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Chairman: Dr H. L. Israel, M.D. the Fine Structure of Sarcoid and Tuberculous Granulomas

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Chairman: Dr H. L. Israel, M.D. the Fine Structure of Sarcoid and Tuberculous Granulomas Postgraduate Medical Journal (August 1970) 46, 496-500. SESSION III Chairman: Dr H. L. Israel, M.D. The fine structure of sarcoid and tuberculous granulomas W. JONES WILLIAMS D. A. ERASMUS E. M. VALERIE JAMES T. DAVIES Welsh National School of Medicine and University College, Cardiff Summary are obviously metabolically active cells, with pro- The granulomas of sarcoidosis and non-caseating perties suggesting both phagocytosis and biosyn- tuberculosis show similar cell-types: two forms of thesis. epithelioid cells, A and B, giant cells, lymphocytes The published accounts of the fine structure of and 'activated' mononuclear cells. The morphology sarcoid granulomas have also not demonstrated any of epithelioid cells suggests that they are primarily causative agent but most investigators agree that biosynthetic rather than phagocytic. epithelioid cells are active cells though there is no The relationship of these various cells to each other unanimity as to their exact function (Bassett et al., is discussed and the following sequence of granuloma 1967; Gusek & Behrend, 1969; Hirsch, Fedorko & development is suggested: circulating lymphocyte -- Dwyer, 1967; Kalifat, Bouteille & Delarue, 1967; activated mononuclears -> A -* B epithelioid cell Kelemen, Soltesz & Mandi, 1969; Wanstrup & whose secretory product stimulates transformation Christensen, 1966). of other circulating lymphocytes. We shall present and discuss our initial fine structural findings and compare the features of the sarcoid granulomas with that of non-caseating Introduction tuberculosis. The fascination of the search for the causation of sarcoidosis continues and embraces ever widening Materials and methods techniques. The sarcoid granuloma, on light micro- The material examined was obtained from one scopy, consists of closely apposed epithelioid cells, sarcoid spleen and two bacteriologically proven intermingled giant cells, often of the Langhan, tuber- tuberculous lymph nodes. On light microscopy the culous type and with admixed or poorly delineated granulomas examined, in both diseases, showed numbers of peripheral lymphocytes. The granulomas identical epithelioid and scanty giant cells without differ from those commonly found in tuberculosis, caseation. by the absence of caseous necrosis, but occasionally One millimetre cubes of tissue, for electron- show minimal 'fibrinoid' necrosis. The sarcoid microscope study, were fixed in 3% glutaraldehyde granulomas are considered to be morphologically (4 hr), followed by 0-1M phosphate buffer, pH 7-4 and histochemically identical with those in the (18 hr), post-fixed in Millonig's phosphate-buffered Kveim test, non-caseating tuberculosis, chronic osmium tetroxide (1 hr), all at 4° C. The blocks were beryllium disease, Crohn's disease and farmer's lung then dehydrated with alcohol and embedded in (Jones Williams, 1967). The epithelioid cells in all Araldite. Sections were cut with an LKB III ultra- the above conditions are rich in residual bodies, end microtome. Multiple photographs, x 4500, were products of lysosomal activity (Jones Williams & taken of single granulomas and montages con- Williams, 1967). They all show high acid phospha- structed to study cell types and their distribution. tases and moderate pentose cycle and mitochon- Thick Araldite sections, (0-5p), stained with toluidine drial enzyme activity (Williams, Jones Williams & blue, were examined under the light microscope, and Williams, 1969). On light microscopy, though no ultrathin sections were stained for electronmicro- causative agent has been detected the epithelioid cells scopy, with uranyl acetate and lead citrate. The fine structure of sarcoid granulomas 497 FIG. 1. 'A' type epithelioid cell. Note extensive rough endoplasmic reticulum (ER) and mitochondria (M). Results plasmic reticulum. 'B' cells (Fig. 2) show very The epithelioid cells, approximately 60pL in prominent Golgi complexes and numerous associ- diameter, consisted of two main types, A and B, ated variably shaped vesicles ranging in size from though indistinguishable on light microscopy. 'A' 0-5-0'7512 dia. Some vesicles in type B contain cells appear heavily stained and 'B' lightly stained. lightly stained finely granular material; others, in Some epithelioid cells with features of both 'A' and the absence of attached ribosomes, probably repre- 'B' were designated as transitional cells. Giant cells sent smooth endoplasmic reticulum. Occasional very were scanty. Lymphocytes were scanty and located lightly stained cells with sparse organelles are seen, mainly at the outer limit of the granulomas. Occa- and appear to be degenerate B cells. The transitional sional other lymphocyte-like cells were present and type cells show abundant but localized rough were termed 'activated mononuclears'. All these endoplasmic reticulum with the remaining cyto- cell-types were present and showed similar features plasm showing similar features to the B cell. in both the sarcoid and tuberculous granulomas. Giant cells (150L dia.) are most frequent in the Their distribution however was different as from a tuberculosis cases with cytoplasm showing the study of montages, B cells predominate in sarcoi- feature of type B epithelioid cells. They are very rich dosis and A cells in tuberculosis. in mitochondria, Golgi complexes and vesicular Both types of epithelioid cells show similar nuclei bodies with mainly vesicular RER. As in the epi- containing nucleoli and peripherally arranged chro- thelioid cells there are no recognizable tubercle matin. They show numerous mitochondria, varying bacilli. amounts of endoplasmic reticulum, Golgi complexes The lymphocytes, 7-10 dia., are round or oval and vesicles. Neither type shows identifiable phago- in section, show no interdigitations and contain cytosed material and evidence of pinocytosis was scanty organelles usually confined to one pole. practically absent. The cell membranes show many Some lymphocyte-like cells-activated mononuclears fingerlike processes interdigitating with those of (Fig. 3), contained more abundant widely distri- adjacent cells. A few however show broad club-like buted organelles and in particular showed small processes. The 'A' type (Fig. 1) is distinguished by amounts of lamellar rough endoplasmic reticulum. the presence of abundant lamellar rough endo- In sarcoid and tuberculous granulomas interstitial 498 W. Jones Williams et al. FIG. 2. 'B' type epithelioid cell. Very numerous Golgi complexes (G) and secretory vesicles (SB). tissue is prominent and shows both 50A and are primarily phagocytic or biosynthetic, (b) the 350A dia. fibres, some of which showed 650A relative distribution of Types A and B and (c) the collagen-banding. relationship of cells A and B to one another and to other cells in the granulomas. Discussion In view of our light microscopy findings (Jones The above results show that epithelioid and other Williams & Williams, 1967 and Williams et al., cells in the granuloma of sarcoidosis and tuber- 1969), we expected epithelioid cells to show features culosis are similar. We found two types of epi- of phagocytosis-pinocytosis with numerous dense thelioid cells, Aand B, which agrees with the results bodies (lysosomes) and complexed phago-lysosomes of Wanstrup & Christensen (1966) and Gusek & (residual bodies), together with features of bio- Behrend (1969) in sarcoidosis and with Gusek (1965) synthesis. Evidence of phagocytosis in these cells, in tuberculosis. Our findings raise many problems, however, even in tuberculous granulomas, was about epithelioid cells, in particular (a) whether they practically absent. It is important to note that, in The fine structure ofsarcoid granulomas 499 ''''.' i.ii ·i.".;U@l::i:'lii86;ii:·;:. :riii:'" '':';' i: i,ii :,:,: ai·pii ..e! i.''':; .:..i:...··;:; Ci·iiifi a· :.· .::.·ii: ·r·: .·1:·I·s·:·::·:.· ;:· ····:;·· '·:·f :+·:: .. ··:a:. :C:.1. :·':i···· ·:P:·······: i,,,xcP....r"i , i i*iil ;·li ......::W. pi :a· ·w* l.i.iT.ti .w:w ··i.:· ···,.i:'fic. :*:.:w :F··..,1 Pl.i· ·i·% *;r .iP.''" *"" :.3i.-· ;i, .B-···i.·".;i.ajdE 9··: i;l: m· ···· :i· :a·'··" FIG. 3. Activated mononuclear cell. Lymphocyte-like but with increased number of organelles and presence of lamellar rough endoplasmic reticulum. Labelling as in Fig. 1. this and previous studies by others, special tech- munoglobulins. The B-type epithelioid cell with its niques for the identification of lysosomal enzymes numerous Golgi complexes and associated vesicles at electron microscopy were not done. is also a biosynthetic cell and may be producing Evidence of biosynthetic activity in both types of lipo- and muco-proteins. It is also possible that, as epithelioid cells was plentiful. The morphology of intracellular end products of lysosomal digestion Type A is reminiscent of plasma cells and is therefore were very scanty, the B cells are producing lysosomal consistent with a protein, possibly immunoglobulin, enzymes for 'export'. This conjecture, with others, producing cell. It is of interest that the level of just await the results of our lysosomal enzyme immunoglobulins is often raised in sarcoidosis studies. (Norberg, 1967) but reports do not show any con- As a result of our present investigations it sistent pattern, further, that by immunofluorescent appears, therefore, that the majority of epithelioid techniques Wanstrup & Elling (1968) showed that cells are more concerned with biosynthesis than with epithelioid cells contain both IgM and IgA im- phagocytosis. 500 W. Jones Williams et al. The study of the montages showed an interesting
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