Intravenous Immunoglobulin Monotherapy for Granulomatous Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) is a heterogeneous subset of immunodeficiency disorders. Recurrent bacterial infection is the main feature of CVID, but various non-infectious complications can occur. A 42-year-old woman presented with cough and abnormal chest X-ray shadows. Laboratory tests showed remarkable hypogammaglobulinemia. Computed tomography revealed multiple consolidation and nodules on the bilateral lung fields, systemic lymphadenopathy, and splenomegaly. A surgical lung biopsy specimen provided the final diagnosis of lymphoproliferative disease in CVID, which was grouped under the term granulomatous lymphocytic interstitial lung disease. Interestingly, the lung lesions of this case resolved immediately after the initiation of intravenous immunoglobulin monotherapy.

Effectiveness of Combined Therapy with Pirfenidone and Erythromycin for Unclassifiable Interstitial Pneumonia Induced by HTLV-1-associated Bronchioloalveolar Disorder (HABA)

Human T-cell lymphotropic virus type 1 (HTLV-1) is a retrovirus involved in the pathogenesis of adult T-cell leukemia (ATL) and HTVL-1-associated bronchioloalveolar disorder (HABA). The clinical and pathological findings of HABA have been characterized as either a diffuse panbronchiolitis (DPB) pattern or idiopathic interstitial pneumonia (IIP) pattern. Treatments for HABA include corticosteroids for the IIP pattern and erythromycin for the DPB pattern. We herein report a case of HABA-associated unclassifiable interstitial pneumonia that improved with combined therapy with pirfenidone and erythromycin. This is the first report on the effectiveness of combined therapy with pirfenidone and erythromycin for HABA.

Utility of continuous positive airway pressure therapy for treating chronic coughs in patients with obstructive sleep apnea

We experienced two patients with chronic coughs whose symptoms persisted after initial treatment under a diagnosis of suspected upper airway cough syndrome or cough variant asthma. Neither patient exhibited daytime somnolence, although both were subsequently found to have severe obstructive sleep apnea. Following the administration of nocturnal continuous positive airway pressure therapy, the cough symptoms rapidly improved in both cases. These cases represent the first reports of obstructive sleep apnea-induced chronic cough in Japan.

Comparable effect of a leukotriene receptor antagonist and long-acting beta₂-adrenergic agonist in cough variant asthma

Cough variant asthma (CVA) is a common cause of chronic persistent cough, in which allergic airway inflammation may play a role. Although current guidelines recommend bronchodilators and anti-inflammatory drugs for the treatment, comparison of the efficacy of these medications has not been investigated. This study was designed to evaluate the effectiveness of pranlukast, a leukotriene receptor antagonist, and salmeterol, a long-acting beta₂-adrenergic agonist, in the treatment of CVA. The study was a randomized, controlled, parallel-group, multicenter trial. After a 4-week run-in period, 49 patients with newly diagnosed CVA were assigned to receive oral pranlukast (225 mg, b.i.d.) or inhaled salmeterol (100 μg, b.i.d.) for 4 weeks. Primary outcome measure was cough symptom and secondary outcome measures were pulmonary function and eosinophilic airway inflammation. Treatment with pranlukast and salmeterol each decreased cough symptom scores, where the changes from baseline values were significantly greater in the pranlukast group than in the salmeterol group. Forced expiratory volume in 1 second and peak expiratory flow (PEF) increased in the two treatment groups with the same magnitudes, but significant decreases in diurnal variation of PEF and eosinophil counts and eosinophil cationic protein contents in the peripheral blood and induced sputum were observed only in the pranlukast group. In view of antitussive and anti-inflammatory actions, the leukotriene receptor antagonist pranlukast seems to be more effective than the long-acting beta₂-adrenergic agonist salmeterol in the treatment of CVA.

Macrophage Colony-Stimulating Factor Aggravates Rather than Regenerates Emphysematous Lungs in Mice

BACKGROUND

Lung regeneration is an innovative strategy that may cure pulmonary emphysema. The bone marrow (BM) harbors pulmonary stem cells. Hematopoietic cytokine-driven mobilization of BM cells may thus support lung regeneration.

OBJECTIVES

The aim of this study was to determine whether systemic administration of macrophage colony-stimulating factor (M-CSF) leads to the regeneration of lungs in a murine model of elastase-induced emphysema.

METHODS

C57BL/6J mice were administered elastase intratracheally. Four weeks later, in the absence or presence of elastase treatment, mice were intraperitoneally given either M-CSF or saline on days 1-5 each week for 3 weeks. Lung tissue was harvested 24 h after the last injection.

RESULTS

M-CSF administration without prior elastase did not affect the mean linear intercept, surface area, or surface area/lung volume. In contrast, M-CSF administration following elastase injury caused a greater increase in the mean linear intercept and greater decreases in surface area and surface area/lung volume than saline administration following elastase, indicating that M-CSF aggravated emphysema. This aggravation of emphysema was accompanied by accumulation of pulmonary alveolar macrophages (AMs) expressing metalloproteinase (MMP)-9 and MMP-12. M-CSF stimulated AMs to express MMPs in vitro.

CONCLUSIONS

These results suggest that M-CSF administration does not support lung regeneration but rather aggravates the lung destruction associated with elastase injury.

Differences in the distribution of CD4+ and CD8+ T cells in emphysematous lungs

BACKGROUND

Recent studies have shown that T cells are the predominant cells infiltrating the alveolar wall of patients with emphysema. Since CD4+ and CD8+ cells have dissimilar function, they may have different distributions in emphysematous lungs.

OBJECTIVES

The aim of this study was to investigate whether CD4+ and CD8+ are differently distributed in the lungs of patients with emphysema.

METHODS

We evaluated CD4+ and CD8+ cell infiltration in lung tissue sections obtained from smokers with pulmonary emphysema who had undergone lung volume reduction surgery (n = 10). Paraffin-embedded lung tissue sections were immunostained using antibodies against CD4+ or CD8+, and distributions of CD4+ and CD8+ cells were evaluated using a morphometric analysis. We determined the degree of emphysema using the area fraction of the alveolar wall (A(A,aw)) and examined its relation to the number of cells per unit area of the alveolar wall (NA).

RESULTS

The majority of CD4+ cells were located in the lung parenchyma of severe emphysematous lesions characterized by the lowest alveolar wall fraction (A(A,aw)). In contrast, more CD8+ cells were located in mild emphysematous lesions than in severe lesions.

CONCLUSIONS

These results suggest that CD4+ and CD8+ cells are differently distributed according to the severity of emphysema. CD4+ T cells are located preferentially in severe emphysematous lesions whereas CD8+ T cells occur preferentially in mild emphysematous lesions.

Increased levels of cell death and proliferation in alveolar wall cells in patients with pulmonary emphysema

BACKGROUND

Pulmonary emphysema, a major component of COPD, is pathologically characterized by destructive alterations in pulmonary architectures as a result of persistent inflammation. However, alterations in the turnover of pulmonary cells are less well understood. This study was designed to examine whether the turnover of alveolar wall cells is altered in patients with emphysema.

PATIENTS AND MEASUREMENTS

We obtained lung tissue specimens from patients with emphysema who had undergone lung volume reduction surgery (13 patients) as well as asymptomatic smokers (7 patients) and nonsmokers (9 patients) undergoing lung resections for solitary lung cancers. Paraffin-embedded lung tissue sections were evaluated for apoptosis and proliferation using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) or immunohistochemistry for Bax, proliferation cell nuclear antigen (PCNA), and topoisomerase IIalpha. Tissue sections were also immunostained for epithelial membrane antigen, surfactant protein A, and CD31.

RESULTS

The percentages of alveolar wall cells undergoing apoptosis and proliferation of the total number of alveolar wall cells were significantly higher in patients with emphysema than in asymptomatic smokers and nonsmokers (p < 0.05). The percentage of TUNEL-positive alveolar wall cells was positively correlated with the percentage of PCNA-positive alveolar wall cells. Most of the TUNEL-positive and PCNA-positive cells were alveolar epithelial cells.

CONCLUSIONS

These results suggest that the turnover of alveolar wall cells is enhanced in emphysematous lungs, compared to healthy lungs. Emphysema may be a dynamic disease process in which alveolar wall cell death and proliferation are repeated.

Immunohistochemical evaluation of oxidative stress in murine lungs after cigarette smoke exposure

Cigarette smoking generates an oxidative stress in the lung, which may contribute to the pathogenesis of chronic obstructive pulmonary disease. We performed an immunohistochemical study to evaluate oxidative stress in the lung after acute cigarette smoke (CS) exposure in mice. Paraffin-embedded lung tissue sections were prepared from mice exposed and unexposed to CS for 1 h. The sections were immunostained with antibodies against 8-hydroxy-2'-deoxyguanosine (8-OHdG), an oxidative DNA adduct, and 4-hydroxy-2-nonenal (4-HNE), a lipid peroxidation product. The bronchiolar and alveolar epithelium of mice unexposed to CS exhibited weak signals for 8-OHdG and 4-HNE, whereas by 1 h after CS exposure the signals in the bronchiolar epithelial cells and the alveolar epithelial cells, particularly type II cells, had increased dramatically. The increases in both were associated with increased 8-OHdG levels in bronchoalveolar lavage fluid as determined by enzyme-linked immunoassay. These results suggest that acute CS exposure imposes oxidative stress predominantly on bronchiolar epithelial and alveolar type II cells, confirming that cigarette smoking causes oxidative damage to the respiratory epithelium.

Epidermal growth factor receptor tyrosine kinase inhibition augments a murine model of pulmonary fibrosis

The inappropriate regeneration of sequentially injured epithelium is an important process leading to pulmonary fibrosis. Previous studies have shown that the epithelial expression of epidermal growth factor receptor (EGFR) is increased in fibrotic lung tissue, compared with normal lung tissue, suggesting that EGFR-mediated signaling is involved in epithelial regeneration in fibrotic lung diseases. We examined the effect of EGFR inhibition using ZD1839, a selective EGFR tyrosine kinase inhibitor (TKI), on bleomycin-induced pulmonary fibrosis in mice. ICR mice were administered a single intratracheal injection of bleomycin (5 units/kg) on day 1. ZD1839 (200 mg/kg) or vehicle alone were administered p.o. 1 h before this injection and on days 1-5 each week for 3 weeks. Lung tissue was harvested on day 21. Lung histology and collagen analysis performed on day 21 showed more severe fibrosis in the mice receiving both bleomycin and the EGFR-TKI than in the mice receiving bleomycin and the vehicle. An immunohistochemistry analysis showed that phosphorylated EGFR and proliferation cell nuclear antigen were highly expressed by the regenerated epithelial cells in the mice treated with bleomycin and the vehicle. In contrast, the expression of these antigens was attenuated in the mice treated with bleomycin and the EGFR-TKI. In vitro studies also demonstrated that the addition of ZD1839 at a concentration of < or =1 microM suppressed the proliferation of type II-like epithelial cells (A549) but not that of lung fibroblasts (IMR90). These results suggest that the inhibition of EGFR phosphorylation augments bleomycin-induced pulmonary fibrosis by reducing regenerative epithelial proliferation. Our data suggest that EGFR-TKIs should be used with caution in cancer patients with pulmonary fibrosis.

Alveolar wall apoptosis causes lung destruction and emphysematous changes

Pulmonary emphysema is characterized by alveolar wall destruction and airspace enlargement. Recent evidence indicates that epithelial or endothelial apoptosis may be involved in the pathogenesis of emphysema. Here, we describe the induction of emphysematous changes, including airspace enlargement, alveolar wall destruction, and enhanced lung distensibility, in mice receiving a single intratracheal injection of active caspase-3 and Chariot, a newly developed protein transfection reagent. Epithelial apoptosis and enhanced elastolytic activity (optimal at pH 5.5) in bronchoalveolar lavage were noted. Emphysematous changes were also generated in mice receiving an intratracheal injection of nodularin, a proapoptotic serine/threonine kinase inhibitor. This murine model provides direct evidence that confirms that alveolar wall apoptosis causes emphysematous changes. Furthermore, this simple technique for protein transfection of lung tissue can be used in a variety of future applications.

[Acute form of eexogenous lipoid pneumonia caused by inhalation of liquid paraffin in a fire-eater]

We report a case of acute exogenous lipoid pneumonia in a 34-year-old-fire-eater. Six hours after inhalation of liquid paraffin, dyspnea, cough, fever, hemoptysis, and chest pain developed in this patient. Chest computed tomography showed nodular infiltrations with ground glass opacities (GGO) in the right middle lobes, GGO alone in the right lower lobes, and consolidations with GGO in the left lower lobes. Lipid-laden alveolar macrophages in bronchoalveolar lavage fluid were detected by lipid staining (Sudan III stain, oil-red-O stain) and transmission electron microscopy. The symptoms and lung infiltrations were improved by treatment with predonisolone, together with antibiotics and urinastatin.

[Exogenous lipoid pneumonia induced by inhalation of insecticide]

We report a case of exogenous lipoid pneumonia induced by insecticide. A 67-year-old man was admitted to our hospital with complaints of dyspnea cough, hemoptysis, and shivering 6 hours after inhaling an insecticide. A chest radiograph on admission disclosed consolidation in the right upper lobe. Chest computed tomography showed nodular infiltrates associated with ground-glass opacities. Bronchoalveolar lavage fluid was hemorrhagic and showed neutrophilia. Pathological examination of transbronchial lung biopsy specimens showed numerous vacuolated macrophages in alveolar spaces. Electron microscopy demonstrated lipid droplets in the cytoplasm of these macrophages. These findings together yielded a diagnosis of exogenous lipoid pneumonia induced by insecticide. In addition, we experimentally induced a similar form of lipoid pneumonia in rats by intratracheal instillation of the same insecticide.