Upper and lower airway inflammation in severe asthmatics: a guide for a precision biologic treatment

Background and aims:

Severe asthma may require the prescription of one of the biologic drugs currently available, using surrogate markers of airway inflammation (serum IgE levels and allergic sensitization for anti-IgE, or blood eosinophils for anti-IL5/IL5R). Our objective: to assess upper and lower airway inflammation in severe asthmatics divided according to the eligibility criteria for one of the target biologic treatments.

Methods:

We selected 91 severe asthmatics, uncontrolled despite high-dose ICS-LABA, and followed for >6 months with optimization of asthma treatment. Patients underwent clinical, functional and biological assessment, including induced sputum and nasal cytology. They were then clustered according to the eligibility criteria for omalizumab or mepolizumab/benralizumab.

Results:

Four clusters were selected: A (eligible for omalizumab, n = 23), AB (both omalizumab and mepolizumab, n = 26), B (mepolizumab, n = 22) and C (non-eligible for both omalizumab and mepolizumab, n = 20). There was no difference among clusters for asthma control (Asthma Control Test and Asthma Control Questionnaire 7), pre-bronchodilator forced expiratory volume in 1 s, serum IgE and fractional exhaled nitric oxide levels. Sputum eosinophils were numerically higher in clusters AB and B, in agreement with the higher levels of blood eosinophils. Allergic rhinitis was more frequent in clusters A and AB, while chronic rhinosinusitis with nasal polyps prevalence increased progressively from A to C. Eosinophils in nasal cytology were higher in clusters AB, B and C.

Conclusion:

Eosinophilic upper and lower airway inflammation is present in the large majority of severe asthmatics, independently from the prescription criteria for the currently available biologics, and might suggest the use of anti-IL5/IL5R or anti IL4/13 also in patients without blood eosinophilia.

The reviews of this paper are available via the supplemental material section.

Griscelli syndrome: characterization of a new mutation and rescue of T-cytotoxic activity by retroviral transfer of RAB27A gene

Griscelli syndrome (GS) is caused by mutations in the MYO5A (GS1), RAB27A (GS2), or MLPH (GS3) genes, all of which lead to a similar pigmentary dilution. In addition, GS1 patients show primary neurological impairment, whereas GS2 patients present immunodeficiency and periods of lymphocyte proliferation and activation, leading to their infiltration in many organs, such as the nervous system, causing secondary neurological damage. We report the diagnosis of GS2 in a 4-year-old child with haemophagocytic syndrome, immunodeficiency, and secondary neurological disorders. Typical melanosome accumulation was found in skin melanocytes and pigment clumps were observed in hair shafts. Two heterozygous mutant alleles of the RAB27A gene were found, a C-T transition (C352T) that leads to Q118stop and a G-C transversion on the exon 5 splicing donor site (G467+1C). Functional assays showed increased cellular activation and decreased cytotoxic activity of NK and CD8+ T cells, associated with defective lytic granules release. Myosin-Va expression and localization in the patient lymphocytes were also analyzed. Most importantly, we show that cytotoxic activity of the patient's CD8+ T lymphocytes can be rescued in vitro by RAB27A gene transfer mediated by a recombinant retroviral vector, a first step towards a potential treatment of the acute phase of GS2 by RAB27A transduced lymphocytes.

Clinical characteristics of small functioning adrenocortical tumors in children

Twenty of 67 children registered on the International Registry of Childhood Adrenocortical Tumors between May 1988 and December 1994 had small adrenocortical tumors (defined for this study as measuring < or = 200 cm3 and/or weighing < or = 100 g). We reviewed the records of these 20 patients to characterize the clinical and pathologic findings and outcomes of children with small adrenocortical tumors. Median patient age was 2 years (range, 4 months to 5 years). There was only one boy. All had clinical signs of virilization, and seven had signs or symptoms of Cushing syndrome. A median 5.5 months (range, 1-40 months) had elapsed between the first signs of endocrine dysfunction and diagnosis. All tumors were surgically resected. Tumor volume was 3.3-195 cm3 (median, -8.7 cm3), and weight was 3.7-100 g (median, 36 gm Tumor samples were histologically reviewed in 18 cases. Eight were adenomas, and 10 were carcinomas (6 low grade and 4 high grade). Pathology records described tumor with diagnostic features of adrenocortical carcinoma in two patients. One patient received mitotane for 8 months after surgery. Only one patient had recurrent disease, which was detected 6 months after diagnosis and proved rapidly fatal. Another has been lost to follow-up. The remaining 18 patients are alive with no evidence of disease at a median 2.3 years (range, 6 months to 6.1 years) after diagnosis. Our data suggest that children with small adrenocortical tumors have an excellent prognosis with surgery as the sole therapy, regardless of tumor histiotype.

[Acute leukemia as secondary neoplasms in children with advanced lymphomas]

In 1985 a new treatment regimen for advanced non-Hodgkin's lymphoma was started in the "Instituto da Criança-HC-FMUSP". The final results are remarkably better than those achieved with former programs. Two cases of children who developed a second neoplasm after the therapy was completed are described and discussed.

[Non-Hodgkin's lymphomas in childhood: results of treatment in patients in stage III]

From January 1980 to December 1984, 22 children with non-Hodgkin's lymphoma were admitted to the "Instituto da Criança-HCFMUPS" and according to the LNH-I-80 Protocol including a remission induction phase (Cyclofosfamide day 1, Vincristine days 3, 10, 17, 24, Daunomycin days 12 and 13, Prednisone for 30 days), followed by a continuation phase (Cyclofosfamide x 7 days + Adriamycin day 8 ARA-C x 4 days + Vincristine day 5, Mercaptopurine x 4 days + Methotrexate day 5) alternating three pairs of drugs during 72 weeks. Mercaptopurine and Methotrexate given during additional 48 weeks completes therapy. Twenty-one out of 22 patients attained complete remission. One patient died after widespread infection. Six relapses occurred, five of them in Burkitt's lymphoma patients. Although highly effective in the non-Burkitt's patients, the LNH-I-80 Protocol failed in keeping Burkitt's patients in event free survival.

[Multicentric osteosarcoma: report of a case with synchronous lesions]

A case of multicentric synchronous osteosarcoma occurring in a 9 year old girl is reported. Some particular features of this rare disease namely its rapid progression despite intensive drug therapy is stressed. Current hypothesis for the occurrence of this unusual form of neoplasm are here discussed.

[Low stage non-Hodgkin's lymphoma: cases studied in 15 years at the HC-FMUSP Children's Institute]

In the recent few years the treatment of the stages I and II of non-Hodgkin lymphomas with the simultaneous use of several drugs showed improvement of results. In the period between 1977 and 1992 three consecutive chemotherapy programs have been developed in the "Instituto da Criança-HC-FMUSP". Between 1977 and 1980 five patients belonging to stage II were treated according to the LSA 2 L-Protocol; complete remission was attained in all of them and three patients have been kept in remission so far. In 1980-1984 period a new regimen (Protocol-I-80) was instituted using the same remission induction strategy as before adding a consolidation with Cyclo and Adria combination and a continuation phase with 6-MP+MTX; five out of six patients have survived free of events till now. In the 1984-1992 period a new protocol was designed (VM-26+ARA-C) replacing Cyclo+Adria. Five patients were included and all of them are disease free survivors.