Circulating thymus- and activation-regulated chemokine/CCL17 is a useful biomarker for discriminating acute eosinophilic pneumonia from other causes of acute lung injury

A case of

Pneumocystis jirovecii pneumonia (PCP) in patients with acquired immune deficiency syndrome (AIDS) shows eosinophilic pneumonia like condition. The detailed mechanisms how AIDS-associated PCP causes eosinophilic pneumonia has not been elucidated, but it has been suggested that beta-D-glucan, a major component of Pneumocystis jirovecii, and T helper type 2 immunity may be involved in the mechanism of eosinophilia in the lung. We experienced the case who developed an eosinophilic pneumonia-like condition in a patient with AIDS-associated PCP, whose clinical course indicated the importance of TARC/CCL17 but not IL-4 and IL-5 as involved in eosinophilia caused by HIV and Pneumocystis jirovecii infection.

What does elevated TARC/CCL17 expression tell us about eosinophilic disorders?

Eosinophilic disorders encompass a large spectrum of heterogeneous diseases sharing the presence of elevated numbers of eosinophils in blood and/or tissues. Among these disorders, the role of eosinophils can vary widely, ranging from a modest participation in the disease process to the predominant perpetrator of tissue damage. In many cases, eosinophilic expansion is polyclonal, driven by enhanced production of interleukin-5, mainly by type 2 helper cells (Th2 cells) with a possible contribution of type 2 innate lymphoid cells (ILC2s). Among the key steps implicated in the establishment of type 2 immune responses, leukocyte recruitment toward inflamed tissues is particularly relevant. Herein, the contribution of the chemo-attractant molecule thymus and activation-regulated chemokine (TARC/CCL17) to type 2 immunity will be reviewed. The clinical relevance of this chemokine and its target, C-C chemokine receptor 4 (CCR4), will be illustrated in the setting of various eosinophilic disorders. Special emphasis will be put on the potential diagnostic, prognostic, and therapeutic implications related to activation of the TARC/CCL17-CCR4 axis.

Biology and Clinical Applicability of Plasma Thymus and Activation-Regulated Chemokine (TARC) in Classical Hodgkin Lymphoma

Thymus and activation-regulated chemokine (TARC) is produced by different cell types and is highly expressed in the thymus. It plays an important role in T cell development, trafficking and activation of mature T cells after binding to its receptor C-C chemokine receptor type 4 (CCR4) and consecutive signal transducer and activator of transcription 6 (STAT6) activation. Importantly, TARC is also produced by malignant Hodgkin and Reed-Sternberg (HRS) cells of classical Hodgkin lymphoma (cHL). In cHL, HRS cells survive and proliferate due to the micro-environment consisting primarily of type 2 T helper (Th2) cells. TARC-mediated signaling initiates a positive feedback loop that is crucial for the interaction between HRS and T cells. The clinical applicability of TARC is diverse. It is useful as diagnostic biomarker in both children and adults with cHL and in other Th2-driven diseases. In adult cHL patients, TARC is also a biomarker for treatment response and prognosis. Finally, blocking TARC signaling and thus inhibiting pathological Th2 cell recruitment could be a therapeutic strategy in cHL. In this review, we summarize the biological functions of TARC and focus on its role in cHL pathogenesis and as a biomarker for cHL and other diseases. We conclude by giving an outlook on putative therapeutic applications of antagonists and inhibitors of TARC-mediated signaling.

Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia

Eosinophilic pneumonia (EP), including acute EP and chronic EP, is characterized by the massive pulmonary infiltration of eosinophils into the lung. However, the mechanisms underlying the selective accumulation of eosinophils in EP have not yet been fully elucidated. We reported that bronchoalveolar lavage fluid (BALF) from EP patients induced the transmigration of eosinophils across endothelial cells in vitro. The concentrations of eotaxin-2 (CCL24) and monocyte chemotactic protein (MCP)-4 (CCL13), which are CC chemokine receptor (CCR) 3 ligands, were elevated in the BALF of EP patients, and anti-CCR3 monoclonal antibody inhibited the eosinophil transmigration induced by the BALF of EP patients. The concentration of macrophage inflammatory protein 1β (CCL4), a CCR5 ligand that induces eosinophil migration, was increased in the BALF of EP patients. Furthermore, the concentration of interleukin (IL) 5 was increased in the BALF of EP patients, and it has been reported that anti-IL-5 antibody treatment resulted in remission and the reduction of glucocorticoid use in some cases of chronic EP. The concentrations of lipid mediators, such as leukotriene (LT) B₄, damage-associated molecular pattern molecules (DAMPs), such as uric acid, or extracellular matrix proteins, such as periostin, were also increased in the BALF of EP patients. These findings suggest that chemokines, such as CCR3/CCR5 ligands, cytokines, such as IL-5, lipid mediators, such as LTB₄, DAMPs, and extracellular matrix proteins may play roles in the accumulation or activation of eosinophils in EP.

TARC expression in the circulation and cutaneous granulomas correlates with disease severity and indicates Th2-mediated progression in patients with sarcoidosis

BACKGROUND

Sarcoidosis is a systemic disorder characterized by the accumulation of lymphocytes and monocyte/macrophage lineage cells that results in the formation of non-caseating granulomas. Thymus- and activation-regulated chemokine (TARC)/CCL17 is an important chemokine in the amplification of Th2 responses, which are achieved by recruiting CCR4-expressing CD4⁺ T lymphocytes. TARC concentrations are known to increase in the serum of sarcoidosis patients; however, its role in the assessment of severity and prognosis of sarcoidosis remains unknown. The objective of this study is to elucidate the role of TARC in sarcoidosis by investigating its expression in peripheral blood and at inflammatory sites. We also examined its relationship with clinical features.

METHODS

Serum levels of TARC, soluble interleukin 2 receptor, angiotensin-converting enzyme, and lysozyme were measured in 82 sarcoidosis patients. The Th1 and Th2 balance in circulating CD4⁺ T cells was evaluated by flow cytometry. The immunohistochemical staining of TARC and CCR4 was performed in order to identify the source of TARC in affected skin tissues.

RESULTS

TARC serum levels were elevated in 78% of patients and correlated with disease severity. The percentage of CCR4⁺ cells and the CCR4⁺/CXCR3⁺ cell ratios were significantly higher in sarcoidosis patients than in normal subjects (P = 0.002 and P = 0.015, respectively). Moreover, TARC was expressed by monocyte/macrophage lineage cells within granulomas. The abundancy as well as distribution of TARC staining correlated with its serum levels.

CONCLUSIONS

The present results suggest that elevations in TARC drive an imbalanced Th2- weighted immune reaction and might facilitate prolonged inflammatory reactions in sarcoidosis.

Drug-induced interstitial lung disease in the treatment of malignant lymphoma as a potential diagnostic marker: a comparison of serum Krebs von Lungen-6 and thymus and activation-regulated chemokine/CC chemokine ligand 17

Purpose

Cure-oriented treatment of malignant lymphoma (ML) is possible even in an advanced stage; however, the progression of drug-induced interstitial lung disease (DILD) sometimes accounts for poor clinical outcomes. This study aims to assess the incidence and clinical characteristics of DILD among patients with ML and compares the serum level of Krebs von den Lungen-6 (KL-6) with that of circulating thymus and activation-regulated chemokine (TARC)/CC chemokine ligand 17 (CCL17) as a diagnostic biomarker for DILD.

Patients and methods

Between July 2011 and August 2016, we enrolled 36 patients with ML who were undergoing systemic chemotherapy at our hospital. Then, we evaluated the serum concentration of KL-6 and TARC/CCL17 by a sandwich-type electrochemiluminescence immunoassay and enzyme-linked immunosorbent assay, respectively.

Results

DILD developed in 22.2% of patients with ML. All patients recovered immediately after the discontinuation of causative drug and/or glucocorticoid therapy. Although the sensitivity of both TARC/CCL17 and KL-6 was almost equal, the mean concentration of serum KL-6 after the progression of interstitial lung disease was significantly higher than that before progression.

Conclusion

DILD developed in patients who were treated with first-line rituximab combined regimen. Remarkably, TARC/CCL17 and KL-6 seemed approximately equal as a predictive biomarkers for DILD; however, KL-6 was more specific than TARC/CCL17.

Eosinophil transendothelial migration induced by the bronchoalveolar lavage fluid of acute eosinophilic pneumonia

BACKGROUND AND OBJECTIVE

Acute eosinophilic pneumonia (AEP) is characterized by a massive pulmonary infiltration of eosinophils. Mechanisms regulating the selective accumulation of eosinophils in AEP have not been fully established. The objective of this study was to evaluate the mechanisms of eosinophil accumulation in alveolar spaces through examination of bronchoalveolar lavage fluid (BALF) from AEP patients (AEP-BALF).

METHODS

Eosinophils were isolated from the blood of healthy subjects and were placed on a human pulmonary microvascular endothelial cell monolayer cultured on Transwell filters (Coster, Cambridge, MA, USA). A saline control solution or BALF from patients with AEP, sarcoidosis or hypersensitivity pneumonitis was applied to the lower compartment, and the transendothelial migration of the eosinophils was evaluated. The concentrations of cytokines and chemokines in BALF were also measured.

RESULTS

Transmigration of eosinophils across endothelial cells was only induced by the AEP-BALF. This transmigration was blocked by anti-β₂ integrin mAb. The concentrations of eotaxin-2 and monocyte chemotactic protein (MCP)-4, which are CC chemokine receptor (CCR) 3 ligands, were elevated in the AEP-BALF, and anti-CCR3 mAb or anti-MCP-4 mAb inhibited the AEP-BALF-induced transmigration of eosinophils. Furthermore, the concentration of leukotriene (LT) B₄ was increased in the AEP-BALF, and an LTB₄ receptor antagonist partially suppressed the AEP-BALF-induced transmigration of eosinophils.

CONCLUSION

These findings suggest that CCR3 ligands including eotaxin-2 and MCP-4, and LTB₄ play a role in the accumulation of eosinophils in AEP.

Eosinophilic Lung Diseases

Eosinophilic lung diseases especially comprise eosinophilic pneumonia or as the more transient Löffler syndrome, which is most often due to parasitic infections. The diagnosis of eosinophilic pneumonia is based on characteristic clinical-imaging features and the demonstration of alveolar eosinophilia, defined as at least 25% eosinophils at BAL. Peripheral blood eosinophilia is common but may be absent at presentation in idiopathic acute eosinophilic pneumonia, which may be misdiagnosed as severe infectious pneumonia. All possible causes of eosinophilia, including drug, toxin, fungus related etiologies, must be thoroughly investigated. Extrathoracic manifestations should raise the suspicion of eosinophilic granulomatosis with polyangiitis.

Circulating thymus and activation-regulated chemokine/CC chemokine ligand 17 is a strong candidate diagnostic marker for interstitial lung disease in patients with malignant tumors: a result from a pilot study

Introduction

Serum Krebs von den Lungen-6 (KL-6) level is an established diagnostic marker of interstitial lung disease (ILD). However, it is also elevated in patients with non-small cell lung cancer (NSCLC). The significance of circulating thymus and activation-regulated chemokine (TARC)/CC chemokine ligand 17 (CCL17) in malignant diseases remains unknown.

Methods

We measured circulating TARC/CCL17 and KL-6 using enzyme-linked immunosorbent assay and electrochemiluminescence immunoassay, respectively, in 26 patients with malignant disease and six patients with benign lung disease (BLD). The cutoff levels were 500 U/mL for KL-6 and 450 pg/mL for TARC/CCL17. The significance of the markers was evaluated in relationship to the presence of ILD (n=10). The statistical significance was set at P<0.05.

Results

The KL-6 positive ratio was significantly higher in the patients with NSCLC (n=17) than in those with BLD. There was a significant difference in the KL-6 positive ratio between the patients with NSCLC without ILD and those with BLD without ILD. However, there were no significant differences in the TARC/CCL17 positive ratio between the patients with NSCLC and BLD or between those with NSCLC without ILD and those with BLD without ILD. The TARC/CCL17 positive ratio was significantly higher in the patients with malignancy and ILD than in those without ILD. There was also a significant difference in the TARC/CCL17 positive ratio between the patients with NSCLC without ILD and those with ILD.

Conclusion

TARC/CCL17 may be useful for the diagnosis of ILD in patients with malignancies. Confirmation of the results is warranted through a large-scale study.

Amiodarone-Induced Lung Injury With Bilateral Lung Pneumonitis and Peripheral Eosinophilia

Amiodarone is a widely used antiarrhythmic that is used in the management of a variety of atrial and ventricular arrhythmias. Amiodarone-induced lung injury is an adverse effect in 5% of patients taking amiodarone, usually within 12 months of commencing therapy. Different mechanisms of injury and histopathological changes have been proposed and described. Eosinophilic pneumonia is one uncommon presentation of amiodarone-induced lung injury. The following is a case report of a 62-year-old woman who, after taking 400 mg of amiodarone twice daily for 8 months, developed bilateral interstitial pneumonitis with peripheral eosinophilia. After cessation of amiodarone, she had significant improvement in terms of her clinical symptoms and partial regression of pulmonary infiltrates on radiological imaging. The case underlies the importance of vigilance monitoring patients who are taking potentially pneumotoxic drugs as well as describing a classic example of drug-induced pneumonitis.

Eosinophilic Pneumonia

Eosinophilic pneumonia may manifest as chronic or transient infiltrates with mild symptoms, chronic idiopathic eosinophilic pneumonia, or the frequently severe acute eosinophilic pneumonia that may be secondary to a variety of causes (drug intake, new onset of tobacco smoking, infection) and that may necessitate mechanical ventilation. When present, blood eosinophilia greater than 1 × 10⁹ eosinophils/L (and preferably greater than 1.5 × 10⁹/L) is of considerable help for suggesting the diagnosis, however it may be absent, as in the early phase of idiopathic acute eosinophilic pneumonia or when patients are already taking corticosteroids. On bronchoalveolar lavage, high eosinophilia (>25 %, and preferably >40 % of differential cell count) is considered diagnostic of eosinophilic pneumonia in a compatible setting, obviating the need of video-assisted thoracic surgical lung biopsy, which is now performed only on very rare occasions with inconsistency between clinical, biological, and imaging features. Inquiry as to drug intake must be meticulous (www.pneumotox.com) and any suspected drug should be withdrawn. Laboratory investigations for parasitic causes must take into account the travel history or residence and the epidemiology of parasites. In patients with associated extrathoracic manifestations, the diagnosis of eosinophilic granulomatosis with polyangiitis or of the hypereosinophilic syndromes should be raised. Presence of airflow obstruction can be found in hypereosinophilic asthma, allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, or in the recently identified syndrome of hyperosinophilic obliterative bronchiolitis. Corticosteroids remain the cornerstone of symptomatic treatment for eosinophilic pneumonias, with a generally dramatic response. Relapses are common when tapering the doses or after stopping treatment especially in idiopathic chronic eosinophilic pneumonia. Cyclophosphamide is necessary only in patients with eosinophilic granulomatosis with polyangiitis and poor-prognostic factors. Imatinib is very effective in the treatment of the myeloproliferative variant of hypereosinophilic syndromes. Anti-interleukin-5 monoclonal antibodies are promising in the spectrum of eosinophilic disorders.

Clinical implications of initial peripheral eosinophilia in acute eosinophilic pneumonia

BACKGROUND AND OBJECTIVE

The initial peripheral eosinophil count (PEC) is rarely elevated but tends to increase during the clinical course of acute eosinophilic pneumonia (AEP). We evaluated whether initial peripheral eosinophilia is an indicator of mild disease in patients with AEP.

METHODS

We retrospectively examined associations between initial peripheral absolute eosinophil count, inflammatory markers and clinical characteristics in 85 patients with AEP.

RESULTS

Of 85 patients, 24 (28%) had initial peripheral eosinophilia (>500/μL). Initial peripheral absolute eosinophil count was inversely correlated to white blood cell (WBC) count (ρ = -0.386, P < 0.001), neutrophil percentage (ρ = -0.645, P < 0.001) and C-reactive protein (CRP; ρ = -0.495, P < 0.001). During treatment, peripheral absolute eosinophil counts increased, while inflammatory markers (WBC, neutrophil percentage, and CRP) decreased. Patients with initial peripheral eosinophilia had a longer duration from onset of symptoms to admission (P = 0.006), had lower WBC counts, neutrophil percentages and CRP values (all P < 0.001), and higher oxygen saturation (P = 0.004) than patients with normal peripheral eosinophil counts. Oxygen requirements (P = 0.013), duration of oxygen administration (P = 0.028) and intensive care unit admission rates (P = 0.003) were lower in patients with initial peripheral eosinophilia. All patients survived and recovered fully after corticosteroid or conservative treatment.

CONCLUSIONS

Initial PEC may be related to a milder disease status on admission, compared with normal PEC in patients with AEP. This may help to stratify disease severity in AEP.

Idiopathic acute eosinophilic pneumonia: A retrospective case series and review of the literature

Introduction

Idiopathic acute eosinophilic pneumonia (AEP) is characterized by hypoxemia, pulmonary infiltrates and pulmonary eosinophilia. Data is limited and the purpose of this study is to better understand this disorder.

Methods

A search of the computerized patient records from January 1, 1997 to October 15, 2010 for patients with suspicion of “eosinophilic pneumonia” was conducted. Included patients were 18 years or older with an acute febrile illness, hypoxemia, diffuse pulmonary infiltrates on imaging, and pulmonary eosinophilia. Patients were excluded with other known causes of pulmonary eosinophilia.

Results

Of 195 patients with pulmonary eosinophilia, 8 patients had “definite” or “probable” and 4 patients had “possible” idiopathic AEP. Three patients were categorized as “probable” idiopathic AEP due to exceeding expected maximal 30-day symptom duration and/or a maximal recorded temperature less than 38 °C. Four patients were defined as “possible” idiopathic AEP given histories of polymyalgia rheumatica, eczema or allergic rhinitis. Of the 8 included patients, 63% were male with a median age of 53. Median duration of symptoms was 21 days. Median nadir oxygen saturation was 83%. Median eosinophil count on bronchoalveolar lavage was 36%. Two patients required intubation. Two patients were current smokers, one of whom had reported a change in smoking habits. All patients were treated with steroids (median of two months).

Conclusions

As diagnostic methods and pharmacologic knowledge improve, the number of patients meeting criteria for idiopathic AEP remains small. Much remains to be learned about this truly rare condition, and current criteria may exclude milder presentations of the disease.

Clinical significance of interleukin 33 (IL-33) in patients with eosinophilic pneumonia

BACKGROUND

Interleukin 33 (IL-33) works as a functional mediator in allergic disease by enhancing the activity of eosinophils and inducing expression of T helper 2 (Th2)-associated cytokines. However, the role of IL-33 in pulmonary eosinophilia has not been elucidated. We investigated the levels of IL-33 in eosinophilic pneumonia (EP) together with associated cytokines, and discussed the clinical significance of IL-33 in EP.

METHODS

Sera and bronchoalveolar lavage fluid (BALF) were obtained from 16 patients with EP, including acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP). Twelve patients with acute respiratory distress syndrome (ARDS) were also included for comparison. The concentration of IL-33 and Th2 cytokines (IL-4, IL-5, IL-13) were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The concentration of serum IL-33 was significantly higher in patients with AEP than in CEP. In CEP, only patients with atopic factors showed mild increase of serum IL-33. The concentration of BALF IL-33 was also significantly elevated in AEP, however, it remained quite low in CEP. Among Th2 cytokines, IL-5 was significantly increased in both serum and BALF in AEP, and the level of IL-5 was positively correlated with that of IL-33. ARDS showed no increase of serum and BALF IL-33.

CONCLUSIONS

The remarkable increase of BALF IL-33 in AEP indicated the local production of IL-33 in lungs. IL-33 is considered to be a local key molecule for triggering pulmonary eosinophilia, together with IL-5. BALF IL-33 appears to be a useful marker for discriminating AEP from CEP and ARDS.

Bronchoalveolar lavage neuregulin-1 is elevated in acute lung injury and correlates with inflammation

Shedding of neuregulin (NRG)-1 from the pulmonary epithelium leads to activation of the epithelial human epidermal growth factor receptor (HER)2 receptor, increased pulmonary epithelial permeability and acute lung injury (ALI). We sought to determine whether NRG-1 was detectable and elevated in bronchoalveolar lavage (BAL) and plasma from patients with ALI compared with controls and to determine whether a correlation exists between NRG-1 and inflammation and outcome in ALI. Matched BAL and plasma samples were obtained from 23 ALI patients requiring intubation and mechanical ventilation. Control patients (n=5) included healthy volunteers. NRG-1 and indices of inflammation were measured in BAL and plasma via ELISA. The mean±sd BAL NRG-1 concentration in ALI patients was 187.0±21.35 pg·mL(-1) compared with 85.50±9.2 pg·mL(-1) in controls (p=0.001). Increased BAL NRG-1 was associated with markers of inflammation, and inversely correlated with ventilator-free days (VFDs; r= -0.51, p=0.015). Plasma NRG-1 was elevated in ALI patients compared with controls (611.7±354.2 versus 25.17±19.33 pg·mL(-1), p<0.001) and inversely correlated with VFDs (r= -0.51, p=0.04). These results confirm shedding of NRG-1 in ALI and suggest that the NRG-1-HER2 pathway is active in patients with ALI.

Nicotine exerts an anti-inflammatory effect in a murine model of acute lung injury

Activation of the cholinergic anti-inflammatory pathway through direct activation of nicotinic acetylcholine receptors on immune cells can inhibit pro-inflammatory chemokine and cytokine release and thereby protect in a variety of inflammatory diseases. The aim of this study was to investigate whether nicotine treatment protected against acute lung inflammation. Mice challenged with intratracheal lipopolysaccharide (LPS, 50 μg) were treated with nicotine (0.2 or 0.4 mg/kg, sc). After 24 h, bronchoalveolar lavage fluid (BALF) was obtained to measure leukocyte infiltration, lung edema, and pro-inflammatory chemokine (MIP-1α, MIP-2, and eotaxin) and cytokine (IL-1, IL-6, and TNF-α) levels. Nicotine treatment reduced the LPS-mediated infiltration of leukocytes and edema as evidenced by decreased BALF inflammatory cells, myeloperoxidase, and protein. Nicotine also downregulated lung production of pro-inflammatory chemokines and cytokines. These data support the proposal that activation of the cholinergic anti-inflammatory pathway may represent a useful addition to the therapy of acute respiratory distress syndrome.

Prognosis in adult patients with idiopathic pulmonary hemosiderosis

BACKGROUND

Diffuse alveolar hemorrhage (DAH) of unknown cause has been characterized as idiopathic pulmonary hemosiderosis (IPH). IPH is a rare disease, which has a high prevalence in children and shows a poor prognosis. However, in adults, since there are few reports about collective cases, the details remain to be determined.

METHODS

Between January 2003 and June 2008, consecutive adult patients strictly defined as unknown cause DAH by chest images, fiberoptic bronchoscopy, autoantibody testing, and exclusion of systemic disease were enrolled. We investigated the clinical characterization and course of the enrolled patients.

RESULTS

Nine patients were included. All patients were middle-aged men (56.1 ± 4.2 year-old) with sudden onset. They did not present with anemia (the hemoglobin level was 13.9 ± 0.5 g/dL) despite the quantity of bleeding. In bronchoalveolar-lavage fluid analysis, the cell count was increased (7.6 ± 1.6×10(5) cells/mL) with neutorophilia (33.3 ± 13.3%). The illness resolved within 2 weeks with or without corticosteroid therapy. All of the patients were alive without recurrence during the follow-up period (45.2 ± 6.2 months) after diagnosis.

CONCLUSION

Adult IPH patients showed good prognosis. However, the present patients are clinically slightly different from the previously characterized IPH.

[Idiopathic chronic eosinophilic pneumonia - a diagnostic challenge]

CASE REPORT

A 43-year-old woman with clinical signs of a febrile respiratory infection with cough and dyspnea despite several antecedent antibiotic treatments was admitted to hospital because of persistent bilateral pulmonary infiltrates.

DIAGNOSIS, THERAPY, AND COURSE

In the diagnostic work-up, the most striking laboratory abnormality was an eosinophilia of 31% within the differential blood count. Specimen obtained from bronchoalveolar lavage showed an abnormally high level of eosinophils as well. In the absence of other known causes of an eosinophilic pulmonary disease the diagnosis of idiopathic chronic eosinophilic pneumonia was made. After initiation of corticosteroid medication the abnormal laboratory results, the clinical signs, and the radiologic findings almost completely normalized within 1 week.

CONCLUSION

If an apparent pneumonia fails to respond to conventional antibiotic treatment, a blood eosinophil count should be obtained. If blood eosinophils are abnormally high, diagnosis of idiopathic acute or chronic eosinophilic pneumonia should be considered and confirmed by demonstrating an excess of eosinophils in bronchoalveolar lavage fluid. Due to prognostic and therapeutic consequences idiopathic acute and chronic eosinophilic pneumonia should be distinguished from one another. A rapid response to glucocorticoid therapy supports the diagnosis. In order to avoid relapses, patients with chronic eosinophilic pneumonia have to complete a 6-month treatment.

Cord immunoproteins as predictors of respiratory outcome in preterm infants

OBJECTIVE

The purpose of this study was to evaluate the role of cord blood proteins and antenatal factors in the prediction of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD).

STUDY DESIGN

The prospectively collected cohort included 163 infants. All infants were born between 1998-2002 in a single regional hospital before 32 weeks of gestation and survived the first hospitalization. Altogether, 107 cord blood proteins were analyzed. Twenty-two antenatal clinical factors were included in the data mining and logistic regression analyses.

RESULTS

The incidence of RDS was 64% and of BPD was 25%. Histologic chorioamnionitis protected from RDS (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11-0.53; P < .001). Besides the length of gestation, other clinical factors poorly predicted the outcomes. Matrix metalloproteinase-9 independently predicted RDS (OR, 8.3; 95% CI, 3.0-23.1; P < .001). Soluble glycoprotein 130 independently predicted BPD (OR, 6.07; 95%CI, 2.20-16.7; P < .001).

CONCLUSION

Specific antenatal immunologic activation predicts either acute or chronic respiratory disease in very preterm infants.

Serum thymus and activation regulated chemokine levels post-lung transplantation as a predictor for the bronchiolitis obliterans syndrome

The main reason for mortality after lung transplantation is the bronchiolitis obliterans syndrome (BOS), which represents chronic rejection. As soluble CD30, which is produced mainly by activated T helper 2 (Th2) cells, was shown to be related to development of BOS, we aimed to investigate the relation between development of BOS and Th2 chemoattractant thymus and activation regulated chemokine (TARC/CCL17). In 54 patients we measured serum TARC levels prior to transplantation by enzyme-linked immunosorbent assay, and in 44 of these patients sera were analysed at months 1, 2 and 3 after lung transplantation. In addition, longitudinal measurements were performed in sera from eight healthy controls and 14 patients, the latter taken over a period of 2 years post-transplantation from seven patients developing BOS plus seven clinically matched BOS-free patients. Median serum TARC levels post-transplantation of patients who developed BOS were significantly lower than those of the matched BOS-free patients (P = 0.05). A receiver operating characteristics analysis (area under the curve 0.77), together with a Kaplan-Meyer analysis, showed that serum TARC levels below 325 pg/ml in the first month post-transplantation can predict development of BOS post-transplantation (P = 0.001). In contrast, pretransplant serum TARC levels were not significantly different between patients developing BOS, BOS-free patients or healthy controls. In conclusion, pretransplantation serum TARC levels do not predict the development of BOS post-transplantation, but measurement of the serum TARC levels in the first month directly after transplantation can provide us with a tool to identify the group at risk of developing BOS.