Factors Affecting the Ability to Discontinue Oral Corticosteroid Use in Patients with EGPA Treated with Anti-Interleukin-5 Therapy

INTRODUCTION

Patients with eosinophilic granulomatosis with polyangiitis (EGPA) and some with severe eosinophilic asthma require continuous long-term oral corticosteroid (OCS) treatment for disease control. The anti-interleukin-5 agent, mepolizumab, has recently become available for the treatment of severe eosinophilic asthma and EGPA, with promising results and safety profiles. The proportion of patients with EGPA who discontinued oral steroids was 18% in the MIRRA trial. To compare patients with EGPA who were able to discontinue steroids with mepolizumab with those who could not.

METHODS

Twenty patients with EGPA treated with mepolizumab were evaluated at Osaka Habikino Medical Center. The OCS dose, asthma control test score, fractional exhaled nitric oxide levels, peripheral eosinophil count, and spirometric parameters were evaluated before and after treatment.

RESULTS

There was a significant reduction in the mean OCS dose from a prednisolone equivalent of 8.88 ± 4.99 mg/day to 3.18 ± 3.47 mg/day (p < 0.001). In this study, 40% of patients discontinued oral steroids. The most common reason for the failure to discontinue steroids in patients was poor asthma control. The percentage of predicted forced expiratory volume in 1 s significantly improved in patients with EGPA who could discontinue steroids after receiving mepolizumab.

CONCLUSION

In this real-world study, treatment with mepolizumab for EGPA was associated with a significant reduction in OCS use; however, poor asthma control was identified as an inhibiting factor for steroid reduction.

Successful Treatment of Eosinophilic Chronic Rhinosinusitis and Secretory Otitis Media in Refractory Asthma With Thymic Stromal Lymphopoietin (TSLP) Receptor Monoclonal Antibody

Eosinophilic chronic rhinosinusitis (ECRS) is a type 2 inflammatory disease that frequently co-occurs with bronchial asthma. The current treatment options for ECRS include endoscopic sinus surgery and oral corticosteroid therapy (OCS). However, recurrence after surgery is common, and OCS therapy may cause side effects. We present the case of a 74-year-old woman with severe asthma, ECRS, and secretory otitis media with possible eosinophilic otitis media, who experienced significant improvement in both conditions after treatment with tezepelumab, an anti-thymic stromal lymphopoietin (TSLP) antibody. Tezepelumab treatment led to a reduction in blood and tissue eosinophil counts. It improved the nasal polyp and computed tomography scores, tympanic and hearing test results, and asthma symptoms without using OCSs. Our findings suggest that tezepelumab may be a promising option for those patients with asthma, ECRS, and secretory otitis media who do not respond well to conventional treatment because upstream of the type 2 inflammation pathway is suppressed. Further to this case report, future studies are required to confirm the long-term efficacy and safety of tezepelumab in treating ECRS and secretory otitis media due to type 2 inflammation.

Benralizumab monotherapy was insufficient to induce remission in patients with active eosinophilic granulomatosis with polyangiitis

Eosinophils play an important pathogenetic role in the development of eosinophilic granulomatosis with polyangiitis (EGPA). EGPA has long been treated with systemic corticosteroids and immunosuppressive agents. However, in recent years, biologic agents targeting eosinophils (anti-IL-5 antibody; mepolizumab) have also been used. Evidence regarding the effectiveness of using benralizumab, anti-IL-5 receptor α monoclonal antibody that depletes eosinophils via antibody-dependent cell-mediated cytotoxicity, has been growing. Benralizumab is used as a steroid-sparing treatment option for EGPA. Clinical studies have evaluated the effects of using mepolizumab or benralizumab in combination with steroids for the treatment of EGPA. However, to date, there have been no reports of using biologics alone. Herein, we describe the case of a patient with active EGPA refractory to benralizumab monotherapy. The patient achieved significant improvement in symptoms after administration of corticosteroids during hospitalization. Benralizumab monotherapy might not be considered a therapeutic option for patients with active EGPA in whom corticosteroids are initially indicated.

Nationwide survey of refractory asthma with bronchiectasis by inflammatory subtypes

RATIONALE

Bronchiectasis and bronchiolitis are differential diagnoses of asthma; moreover, they are factors associated with worse asthma control.

OBJECTIVE

We determined clinical courses of bronchiectasis/bronchiolitis-complicated asthma by inflammatory subtypes as well as factors affecting them.

METHODS

We conducted a survey of refractory asthma with non-cystic fibrosis bronchiectasis/bronchiolitis in Japan. Cases were classified into three groups, based on the latest fractional exhaled NO (FeNO) level (32 ppb for the threshold) and blood eosinophil counts (320/µL for the threshold): high (type 2-high) or low (type 2-low) FeNO and eosinophil and high FeNO or eosinophil (type 2-intermediate). Clinical courses in groups and factors affecting them were analysed.

RESULTS

In total, 216 cases from 81 facilities were reported, and 142 were stratified: 34, 40 and 68 into the type 2-high, -intermediate and -low groups, respectively. The frequency of bronchopneumonia and exacerbations requiring antibiotics and gram-negative bacteria detection rates were highest in the type 2-low group. Eighty-seven cases had paired latest and oldest available data of FeNO and eosinophil counts; they were analysed for inflammatory transition patterns. Among former type 2-high and -intermediate groups, 32% had recently transitioned to the -low group, to which relatively low FeNO in the past and oral corticosteroid use contributed. Lastly, in cases treated with moderate to high doses of inhaled corticosteroids, the frequencies of exacerbations requiring antibiotics were found to be higher in cases with more severe airway lesions and lower FeNO.

CONCLUSIONS

Bronchiectasis/bronchiolitis-complicated refractory asthma is heterogeneous. In patients with sputum symptoms and low FeNO, airway colonisation of pathogenic bacteria and infectious episodes are common; thus, corticosteroids should be carefully used.

COVID-19 in a Patient With Severe Eosinophilic Asthma on Benralizumab Therapy: A Case Report and Review of Literature

Patients with coronavirus disease 2019 (COVID-19) can develop eosinopenia. Eosinophils have various functions, including immunoregulation and antiviral activity, in addition to modulation of an inflammatory reaction. Benralizumab is an anti-interleukin-5Rα monoclonal antibody that selectively depletes eosinophils through enhanced antibody-dependent cell-mediated cytotoxicity. Whether eosinophil depletion affects COVID-19 prognosis is yet to be elucidated. Here, we present a case of a 60-year-old patient with severe asthma on benralizumab therapy, who tested positive for an acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The patient experienced an asymptomatic COVID-19 course without deterioration of asthma control. Eosinophil depletion did not contribute to a deterioration of the clinical status. Comorbidities play a major role in the severity of COVID-19 in patients with asthma. The findings of our case and a literature review revealed that benralizumab therapy is not associated with a significant negative impact on the disease course in COVID-19 patients.

Retropharyngeal edema: A rare manifestation of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by excessive eosinophil accumulation in the peripheral blood and affected tissues with development of granulomatous vasculitic organ damage. Although upper airway and neck involvement is seen in patients with EGPA, retropharyngeal inflammation has never been reported. We report a case of retropharyngeal edema in a 70-year-old woman with EGPA. Her symptoms improved and the retropharyngeal edema disappeared on computed tomography following treatment. EGPA should be considered as a differential diagnosis in patients with asthma presenting with neck swelling and dysphagia.

Rapid effect of benralizumab for severe asthma with chronic rhinosinusitis with nasal polyps

BACKGROUND

The anti-interleukin (IL)-5 agent benralizumab has recently become available for treatment of severe asthma with promising results; however, it appears effective only in specific subgroups of asthma patients. Severe asthma with chronic rhinosinusitis/nasal polyps (CRSwNP or eosinophilic chronic rhinosinusitis, ECRS) is a severe eosinophilic asthma phenotype that necessitates individualized treatment.

OBJECTIVE

To assess differences in response to benralizumab between severely eosinophilic asthma patients with and without CRSwNP.

METHODS

Seventeen outpatients with severe eosinophilic asthma treated with benralizumab for 1 year were evaluated at the Osaka Habikino Medical Center. Blood eosinophil count, Asthma Control Questionnaire 5 (ACQ5), Asthma Quality of Life Questionnaire (AQLQ), fractional exhaled nitric oxide (FeNO), and spirometry were recorded at weeks 0, 4, 16, 24, and 50.

RESULTS

ACQ5 and AQLQ in CRSwNP(+) groups improved significantly after 4, 16, 24, and 50 weeks (p = 0.0195, 0.0156, 0.0117, and 0.0078 and p = 0.0098, 0.0098, 0.0029, and 0.0098, respectively) of benralizumab treatment. ACQ5 in CRSwNP(-) groups did not improve significantly after benralizumab treatment, but AQLQ improved significantly after 24 (p = 0.0313) and 50 weeks (p = 0.0313). Forced expiratory volume in 1s (FEV1) predicted in CRSwNP(+) groups were improved significantly after 4 weeks (p = 0.0137), 16 weeks (p = 0.0127), 24 weeks (p = 0.0098) and 50 weeks (p = 0.0420) of benralizumab treatment. %FEV1 in CRSwNP(-) groups were improved significantly after 24 weeks (p = 0.0313) and 50 weeks (p = 0.0313) of benralizumab treatment (Fig. 3). Forced vital capacity (FVC) predicted in CRSwNP(+) groups were improved significantly after 24 weeks (p = 0.0195) and %FVC in CRSwNP(-) groups improved significantly after 50 weeks (p = 0.0313) of benralizumab treatment. Maximum mid-expiratory flow rate predicted in CRSwNP(+) groups were improved significantly after 16 (p = 0.0137 and 50 weeks (p = 0.0371) of benralizumab treatment.

CONCLUSIONS

Benralizumab can exert a very rapid therapeutic action, detectable 4 weeks after treatment initiation in patients with severe eosinophilic asthma with CRSwNP. However, severe eosinophilic asthma without CRSwNP takes longer to respond to benralizumab treatment.

Eosinophils depletion therapy for severe asthma management following favorable response to mepolizumab

We described three severe asthmatics whose asthma symptoms were rapidly improved by benralizumab following favorable response to mepolizumab. Benralizumab-induced eosinophil depletion contributed to clinical improvement of severe asthma after mepolizumab-induced eosinophil reduction; thus, prior favorable responses to mepolizumab may predict benralizumab efficacy.

Flare of eosinophilic granulomatosis with polyangiitis related to pregnancy: Case report and review of the literature

Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by excessive eosinophil accumulation in the peripheral blood and affected tissues with development of granulomatous vasculitic organ damage. It is strongly associated with asthma and ear-nose-throat disease. It often affects patients between the ages of 40 and 60 years. It is unknown whether pregnancy impacts the disease activity of EGPA, including initial diagnosis or relapse. Because of its rarity and age of susceptibility, there are few reported cases describing pregnancy in women with quiescent or active EGPA. Here, we describe a young woman who experienced EGPA relapse during pregnancy and subsequently underwent an elective caesarean section for non-reassuring fetal status at 37 weeks without complication.

Spontaneous Regression of Allergic Bronchopulmonary Mycosis Due to Curvularia lunata

Allergic bronchopulmonary mycosis (ABPM) is a pulmonary hypersensitivity disease mainly caused by Aspergillus fumigatus. The mainstay treatment for ABPM is systemic corticosteroid therapy. A 25-year-old man presented with pulmonary infiltrates. His peripheral eosinophil, total serum IgE, and serum Aspergillus-specific IgE levels were elevated. The patient tested positive in a skin test for Aspergillus. However, sputum cultures revealed a Curvularia lunata infection. We therefore diagnosed ABPM possibly caused by C. lunata, which is rare in Japan. The clinical state of the patient improved under observation. Identification of the causative fungus is an important aspect of the ABPM diagnosis.

Soluble CD26 is inversely Associated with Disease Severity in Patients with Chronic Eosinophilic Pneumonia

Backgrounds

CD26, a multifunctional T cell surface glycoprotein, is a type II transmembrane protein containing only six amino acid residues in its cytoplasmic region. In addition to its membrane form, CD26 exists in plasma in a soluble form (sCD26), which is thought to be the extracellular domain of the molecule cleaved from the cell surface. Recent studies indicated CD26 have an important role in the pathogenesis of asthma, known as Th2 like disease. The function of CD26 in the esosinophlic lung disease is not well understood.

Methods

Serum sCD26 was determined by enzyme-linked immunosorbent assay in patients with acute eosinophilic pneumonia, chronic eosinophilic pneumonia (CEP), and sarcoidosis, and in healthy volunteers, to establish its value for discriminating between disease entities and as marker of disease activity.

Results

Soluble CD26 was significantly reduced in CEP and was related to disease severity. In particular, sCD26 was inversely correlated with arterial oxygen tension in CEP.

Conclusion

Serum levels of sCD26 might appear to be useful as a new marker of CEP disease activity.

Does allergic rhinitis make a difference to the respiratory resistance and reactance of asthma?

BACKGROUND

Concomitant allergic rhinitis (AR) in asthmatic patients can contribute to increased asthma exacerbations and poorer symptom control. A recent study indicated that impulse oscillometry is a more sensitive measure of change in airway function than spirometry, but this has not been used to compare asthmatic patients with or without AR.

OBJECTIVE

We used impulse oscillometry (Mostgraph-01) to examine the impact of AR on asthma.

METHODS

Impulse oscillometry and spirometry were assessed in 50 patients with asthma only and 95 patients with asthma and AR.

RESULTS

Mean age in the asthma only group was significantly higher than in the asthma with AR group. Therefore, analysis of covariance adjusted for age was used to compare between these two groups. Percentage of mean forced expiratory volume in 1 s (FEV1), respiratory resistance at 5 Hz (R5) minus respiratory resistance at 20 Hz (R20), and resonant frequency (Fres) in the asthma with AR group were significantly less severe than in the asthma only group. Parameters of resistance and reactance were correlated with age and body mass index only in the asthma with AR group but not in the asthma only group. Correlations were observed between rate of change of maximum mid-expiratory flow and impulse oscillometry values of R5 and Fres in the asthma only group, but not between the rate of change of FEV1 and impulse oscillometry values.

CONCLUSION

Asthma with AR was associated with higher lung function and better values of resistance and reactance than asthma only.

Effectiveness of omalizumab in a patient with severe asthma, low serum IgE level, and lack of sensitized allergens induced by oral steroid therapy: the usefulness of impulse oscillation for assessment of omalizumab therapy

BACKGROUND

Omalizumab is a humanized monoclonal anti-IgE antibody that was recently approved for the treatment of severe allergic asthma. However, omalizumab is not licensed for allergic asthma in patients with a low serum IgE level (<30 IU/mL) or negative results for specific allergen tests.

CASE HISTORY

We present a patient with severe asthma and low serum IgE levels who had negative results for specific allergens induced by oral steroid therapy. Omalizumab administration improved asthma exacerbated forced expiratory volume in 1 s (FEV(1)) and respiratory resistance measurements based on the impulse oscillation technique (Mostgraph-01). The response to omalizumab therapy was evidenced by a decrease in airway resistance at 1 month.

CONCLUSIONS

The findings of this case report indicate that omalizumab treatment had beneficial effects in a patient with severe asthma and low total serum IgE levels with negative results for specific IgE, which may have been induced by long-term corticosteroid administration.

Drug-induced interstitial lung disease: mechanisms and best diagnostic approaches

Drug-induced interstitial lung disease (DILD) is not uncommon and has many clinical patterns, ranging from benign infiltrates to life-threatening acute respiratory distress syndrome. There are two mechanisms involved in DILD, which are probably interdependent: one is direct, dose-dependent toxicity and the other is immune-mediated. Cytotoxic lung injury may result from direct injury to pneumocytes or the alveolar capillary endothelium. Drugs can induce all types of immunological reactions described by Gell and Coombs; however, most reactions in immune-mediated DILD may be T cell-mediated.

DILD can be difficult to diagnose; diagnosis is often possible by exclusion alone. Identifying the causative drug that induces an allergy or cytotoxicity is essential for preventing secondary reactions.

One method to confirm the diagnosis of a drug-induced disease is re-exposure or re-test of the drug. However, clinicians are reluctant to place patients at further risk of illness, particularly in cases with severe drug-induced diseases. Assessment of cell-mediated immunity has recently increased, because verifying the presence or absence of drug-sensitized lymphocytes can aid in confirmation of drug-induced disease. Using peripheral blood samples from drug-allergic patients, the drug-induced lymphocyte stimulation test (DLST) and the leukocyte migration test (LMT) can detect the presence of drug-sensitized T cells. However, these tests do not have a definite role in the diagnosis of DILD. This study explores the potential of these new tests and other similar tests in the diagnosis of DILD and provides a review of the relevant literature on this topic.

Deterioration of asthma in a patient with diffuse panbronchiolitis (DPB) after macrolide therapy

Diffuse panbronchiolitis (DPB), an important cause of progressive obstructive lung disease in the Far East, is a distinctive sinobronchial syndrome with characteristic radiologic and histologic features. Asthma is a chronic inflammatory disease characterized by airway narrowing. The major inflammatory cells involved in the pathogenesis of asthma are type 2 helper T (Th2) cells, eosinophils, and mast cells. The authors' patient was diagnosed with DPB and asthma. Although macrolide therapy led to the disappearance of the radiologic abnormalities indicating centrilobular nodular lesions, the respiratory symptoms and pulmonary function worsened. Administration of inhaled corticosteroids improved the respiratory symptoms and pulmonary function. To the authors' knowledge, no case of DPB with asthma has been reported in the English-language literature.

Crazy-paving sign in high-resolution computed tomography in parainfluenza virus pneumonia

The crazy-paving sign is the appearance of a smooth linear pattern superimposed on an area of ground-glass opacity on thin-section computed tomography (CT). A 69-year-old woman was admitted to our hospital for treatment of pneumonia. Thoracic CT showed a crazy-paving sign in the right lung field on admission. She received ceftriaxone and clarithromycin, and the symptoms and infiltration shadow promptly disappeared. Serologic testing revealed a greater than 4-fold increase in the IgG titer for parainfluenza virus I. To our knowledge, there is no previous report of the crazy-paving sign in associated with viral pneumonia in a non-immunocompromised host or with parainfluenza pneumonia.

The use of frequency scale for the symptoms of GERD in assessment of gastro-oesophageal reflex symptoms in asthma

In adult asthmatics the incidence of gastro-oesophageal reflux disease (GERD) reportedly ranges from 34% to 89%. Oesophageal pH monitoring and endoscopy are not required in the patient with typical GERD symptoms before the initiation of a therapeutic trial. Diagnosis of GERD on the basis of history is the simplest and quickest method, placing no demand on patients. Recently, a new questionnaire (FSSG; Frequency Scale for the Symptoms of GERD) was produced to evaluate the severity and the therapeutic response of GERD. The FSSG (F-scale) was used to assess the GERD in subjects with persistent moderate to severe asthma treated with anti-inflammatory asthma medication. In the present study, 27.4% of the patients with asthma had symptoms suggestive of GERD. There is significant correlation between GERD symptom (F-scale score) and severity of cough and sputum. The observations suggested that reflux symptoms, not gastric dysmotility symptoms, significantly associated with severity of cough, not of sputum. It is the first such study to use a FSSG as incidence of GERD symptoms in asthmatics and examine the relationship between F-scale score and asthmatic symptoms.

Increased serum ADAM8 concentration in patients with drug-induced eosinophilic pneumonia-ADAM8 expression depends on a the allergen route of entry

BACKGROUND

ADAM8 (a disintegrin and a metalloprotease 8) has been linked to asthma and eosinophilic pneumonia (EP). ADAM8 cleaves a variety of substrates and is a sheddase for CD23, the low affinity IgE receptor. The concentration of soluble ADAM8 (sADAM8) is increased in bronchoalveolar lavage fluid (BALF) from patients with smoking-induced acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP), but not drug-induced EP (Drug-EP). In AEP, the BALF sADAM8 concentration significantly correlates with the soluble CD23 concentration (sCD23).

METHODS

To evaluate the involvement of ADAM8 in the pathogenesis of eosinophilic pneumonia, we measured the concentrations of sADAM8 and its substrate, soluble CD23 (sCD23), in serum from patients with AEP, CEP, and Drug-EP. We also measured the change in the sADAM8 concentration after a provocation test.

RESULTS

In contrast to the BALF findings, serum sADAM8 concentrations were increased in Drug-EP (mean+/-SEM; 639.6+/-49.15) and serum ADAM8 levels correlated positively with the serum sCD23 levels in patients with Drug-EP (P=0.0080, R(2)=0.8465). Serum sADAM8 concentrations were also increased in AEP (409+/-76.91) and CEP (644.7+/-87.03). Serum ADAM8 concentrations were also elevated after the provocation test.

CONCLUSION

Serum ADAM8 concentrations were elevated in Drug-EP, although the sADAM8 concentrations were not increased in the BALF in Drug-EP. Thus, the pathogenesis of AEP and Drug-EP may be distinct with regard to allergen exposure; AEP may be caused by the inhalation of antigens, whereas Drug-EP may be caused by bloodstream antigens. These findings indicate that ADAM8 levels reflect the route of eosinophilic inflammation in EP.

ADAM8 in allergy

ADAM (a disintegrin and metalloprotease) family members are membrane-anchored proteins with wide ranging functions, including proteolytic cleavage of cell surface molecules, cell fusion, cell adhesion and intracellular signaling. ADAM8, also known as CD156a, is expressed mainly in cells of the immune system, such as monocytes, neutrophils, eosinophils, dendritic cells, and B cells. It can cleave a variety of substrates and is a sheddase for CD23 and L-selectin. ADAM8 has an important role in allergic inflammation. ADAM8 mRNA expression is increased with disease progression in asthma. ADAM8 is strongly induced by allergens and Th2 cytokines in the lung in experimental asthma. Soluble ADAM8 is elevated in the bronchoalveolar lavage fluid of patients with eosinophilic pneumonia and has a physiologic role in protecting against allergic pulmonary disease in experimental murine asthma. Together, these findings support the view that ADAM8 might be a therapeutic target for allergic respiratory diseases. This review discusses novel strategies for immune intervention in allergic respiratory disease.

Influence of age on symptoms and laboratory findings at presentation in patients with influenza-associated pneumonia

Influenza virus infection is a major respiratory infectious disease that generally induces pneumonia. The clinical manifestations of influenza virus infection and community-acquired pneumonia (CAP) differ between elderly persons and younger adults. To determine the clinical features of influenza-associated pneumonia, we studied 21 adult patients with influenza-associated pneumonia, as indicated by positive test results for influenza virus antigen. At presentation, the higher-age patients (> or =75 years; n=12) with influenza-associated pneumonia had lower body temperature than did the lower-age (<75 years) patients (n=9). Conversely, the laboratory data indicated significantly higher C-reactive protein (CRP) concentration in higher-age patients than that in lower-age patients. None of the 18 patients undergoing neuraminidase inhibitor therapy died, but two of three patients who did not receive this therapy died from complications of advanced pneumonia. In this study, vaccination did not appear to be an important factor for prevention of pneumonia. High-age patients with CAP have lower body temperature, raising the possibility that diagnosis and treatment may be delayed in these patients. Increased CRP levels in these patients at presentation, however, could contribute to early detection of this serious pulmonary complication.

[An autopsy case of sarcomatoid malignant mesothelioma mimicking adenocarcinoma with sarcomatoid elements of lung]

A 62-year-old man with pain in his hip joints and back was admitted to our hospital. His chest radiograph and CT showed a huge mass extending from the left upper pericardium to the left hilum, but no pleural effusion or other lesions. A contrast-enhanced abdominal CT showed multiple metastases to bones and both kidneys. Bronchoscopy revealed obstruction of the left B3 by a visible tumor. The biopsy specimens of the initial immunohistochemical staining were slightly positive for calretinin. However, we diagnosed the condition as sarcomatoid carcinoma of the lung on the basis of the clinical evaluation. Although radiotherapy was administered, his condition rapidly deteriorated and he died due to progression of the disease. Autopsy revealed extensive invasion, suggesting mesothelioma. Therefore, immunohistochemical staining was performed; the findings revealed sarcomatoid malignant mesothelioma. In conclusion, we encountered a rare case of sarcomatoid malignant mesothelioma (stage IV).

Asthma and sinusitis: association and implication

BACKGROUND

Sinusitis occurs frequently in asthmatic patients. Epidemiologic data on sinusitis and lower airway disease must be evaluated with caution because they are based mostly on symptoms and do not include nasal endoscopic or computed tomography (CT) findings. Clinical support and evidence for this association are lacking. We evaluated the impact of sinusitis on lower airway disease in patients with well-characterized asthma.

METHODS

Subjects (n = 188) completed a questionnaire designed to provide information about their signs and symptoms related to asthma, allergic rhinitis (AR) and sinus disease. Patients (n = 104) were divided into four groups based on the presence or absence of sinusitis and/or AR. Clinical findings were compared in asthma patients with and without diagnosed sinusitis, by an otorhinolaryngologist or based on sinus CT findings.

RESULTS

The prevalence of sinusitis in patients with asthma was 36.7%. Sinus CT scan abnormalities were detected in 66.3% of patients with asthma. The scans revealed abnormal opacity in 17.9% of asthmatic patients without a history of sinusitis. There was a significant correlation between the rate of asthma severity and sinus morphologic abnormalities in patients with and without sinusitis. In adult-onset asthma (>or=16 years old), sinusitis frequently preceded asthma, whereas in non-adult-onset asthma (<16 years old) it preceded sinusitis. The complication rate of sinusitis in asthmatic patients was significantly higher in adult-onset asthma than in non-adult-onset asthma.

CONCLUSIONS

Our findings suggest that bronchial asthma is closely related to sinusitis and the onset age of asthma is important when considering allergic disease frequency. Whether sinus disease directly affects the intensity of bronchial inflammation remains to be elucidated.

Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients

PURPOSE

The presence of age-related pulmonary crackles (rales) might interfere with a physician's clinical management of patients with suspected heart failure. We examined the characteristics of pulmonary crackles among patients with stage A cardiovascular disease (American College of Cardiology/American Heart Association heart failure staging criteria), stratiffed by decade, because little is known about these issues in such patients at high risk for congestive heart failure who have no structural heart disease or acute heart failure symptoms.

METHODS

After exclusion of comorbid pulmonary and other critical diseases, 274 participants, in whom the heart was structurally (based on Doppler echocardiography) and functionally (B-type natriuretic peptide <80 pg/mL) normal and the lung (X-ray evaluation) was normal, were eligible for the analysis.

RESULTS

There was a significant difference in the prevalence of crackles among patients in the low (45-64 years; n = 97; 11%; 95% CI, 5%-18%), medium (65-79 years; n = 121; 34%; 95% CI, 27%-40%), and high (80-95 years; n = 56; 70%; 95% CI, 58%-82%) age-groups (P <.001). The risk for audible crackles increased approximately threefold every 10 years after 45 years of age. During a mean follow-up of 11 +/- 2.3 months (n = 255), the short-term (< or =3 months) reproducibility of crackles was 87%. The occurrence of cardiopulmonary disease during follow-up included cardiovascular disease in 5 patients and pulmonary disease in 6.

CONCLUSIONS

Recognition of age-related pulmonary crackles (rales) is important because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician's management of cardiopulmonary patients.

Increased urinary leukotriene E4 concentration in patients with eosinophilic pneumonia

Although eosinophils produce cysteinyl leukotrienes (CysLTs) in large quantities, information on the relationship between CysLTs and eosinophilic pneumonia (EP) is lacking. Inflammatory mediator concentrations in urine were quantified to clarify the relationship between CysLT concentrations and EP severity. Leukotriene (LT)E(4), eosinophil-derived neurotoxin (EDN), 9alpha,11beta-prostaglandin F2 and LTB(4) glucuronide concentrations were quantified in the urine of: EP patients during acute exacerbation and clinical remission; asthmatic patients during acute exacerbation and under stable conditions; and healthy control subjects. The urinary LTE(4) and EDN concentrations of EP patients during acute exacerbation were significantly higher than those of asthmatic patients and healthy subjects, and decreased immediately during clinical remission. The urinary LTE(4) concentration was associated with the urinary EDN concentration of EP patients during acute exacerbation. The urinary LTE(4) concentration significantly correlated with the diffusing capacity of the lung for carbon monoxide in EP patients during acute exacerbation. The increased urinary concentrations of leukotriene and eosinophil-derived neurotoxin were associated with acute exacerbation in eosinophilic pneumonia patients. The increased leukotriene concentration significantly correlated with diffusing capacity of the lung for carbon monoxide, suggesting that the monitoring of leukotriene concentration may aid in the management of eosinophilic pneumonia patients.

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

BACKGROUND

The presentation of acute eosinophilic pneumonia (AEP) closely resembles that of acute lung injury (ALI)/ARDS, including its idiopathic form, acute interstitial pneumonia (AIP). AEP usually lacks peripheral eosinophilia at the acute phase; therefore, the establishment of serum biomarkers for AEP would be clinically useful.

METHODS

We measured the levels of thymus- and activation-regulated chemokine (TARC)/CCL17, eotaxin/CCL11, KL-6, and surfactant protein-D (SP-D) in serum for patients with acute parenchymal lung diseases including AEP (n = 17), AIP (n = 13), pneumonia-associated ALI/ARDS (n = 12), and alveolar hemorrhage (n = 7). To evaluate diagnostic ability, each marker was estimated by measuring the area under the receiver operating characteristic curve (AUC).

RESULTS

Serum TARC/CCL17 levels of AEP patients were much higher than those of patients in other disease groups. More importantly, high circulating TARC/CCL17 levels were observed in AEP even at acute phase when peripheral eosinophilia was absent. TARC/CCL17 showed the largest AUC, and the TARC/CCL17 levels with cutoff points from 6,259 to 7,039 pg/mL discriminated AEP from other syndromes with sensitivity and specificity of 100%. The KL-6 level was low in most patients with AEP, and the sensitivity was 81.6% in cutoff with 100% specificity. The AUC for eotaxin/CCL11 and SP-D was small, with values of 0.73 (95% confidence interval [CI], 0.60 to 0.86) and 0.53 (95% CI, 0.31 to 0.64), respectively.

CONCLUSIONS

This study indicates that the measurement of circulating TARC/CCL17 and KL-6 is useful for discriminating AEP from other causes of ALI.

Amoxicillin-Induced Eosinophilic Pneumonia with Granulomatous Reaction: Discrepancy between Drug-Induced Lymphocyte Stimulation Test Findings and the Provocation Drug Test

A 59-year-old man was admitted to the hospital with pulmonary infiltration, fever, erythema, and eosinophilia. Two weeks before admission, he received amoxicillin, acetaminophen, and shoseiryu-to (a Japanese herbal medicine) for a common cold. Bronchoalveolar lavage was performed, and an increased number of eosinophils was recovered. Transbronchial biopsy specimens showed granuloma and interstitial thickening with eosinophils and lymphocytes. Drug-induced eosinophilic pneumonia was suspected, so all drugs were discontinued. The symptoms and infiltration shadow disappeared. A drug-induced lymphocyte stimulation test (DLST) was positive for acetaminophen but not for amoxicillin. In contrast to the DLST, a provocation test revealed that amoxicillin induced the drug allergy. A very striking observation was the coexistence of pulmonary eosinophilia and granulomatous lung infiltrations. In addition, there was a discrepancy between the DLST and provocation test findings. To our knowledge, there is no previous report of drug-induced eosinophilic pneumonia with a granulomatous reaction.

Drug-induced lymphocyte stimulation test is not useful for the diagnosis of drug-induced pneumonia

Diagnosis of drug-induced pneumonia, which represents pulmonary toxicity caused by certain drugs, is difficult, as a large number of different drugs can elicit various immune-mediated diseases with distinct pathomechanisms. The drug-induced lymphocyte stimulation test (DLST) is widely used for diagnosing drug-induced pneumonia in Japan. Recent reports, however, indicate that DLST is not reliable for diagnosis of drug-induced pneumonia. To diagnose drug-induced pneumonia, a provocation test with the suspected drug is the most reliable method of assessing the relationship between the drug and pneumonia. We examined the correlation between the DLST and the provocation test in 6 cases of suspected drug-induced pneumonia. DLST was performed in all of the patients. The causes of pneumonia in all patients were confirmed by a provocation test. The DLST was positive in 3 of 6 cases of suspected drug-induced pneumonia, but the suspected drugs were ruled out by the provocation test. If we had relied solely on the DLST, these 3 cases would have been labeled as false allergy. The results of the DLST did not coincide with the results of the provocation test in any of the cases. Our results suggest that the DLST is not useful for the diagnosis of drug-induced pneumonia. Following provocation with the causative drug, reappearance of pulmonary infiltration was not observed in any of the cases. These findings indicate that a carefully performed provocation test is the safe and most reliable method.

Corynebacterium ulcerans Infection of the Lung Mimicking the Histology of Churg-Strauss Syndrome

We report the first case of pulmonary Corynebacterium ulcerans infection mimicking Churg-Strauss syndrome (CSS). Productive cough, fever, general fatigue, and weight loss developed in a 50-year-old man. Laboratory data revealed prominent eosinophilia and elevated serum IgE. On chest images, multiple nodules and cavities were predominantly detected in the right lung. Histopathologic examination showed necrotizing granulomas and vasculitis with massive eosinophilic infiltration identical to the findings seen in CSS; however, clusters of Gram-positive, coryneform rods were observed in the alveolar spaces. A toxigenic strain of C ulcerans was isolated from lung tissue. The patient was treated with antibiotics, and a favorable clinical course ensued.

Acute eosinophilic pneumonia caused by Candida albicans

A 36-year-old man was transferred to the hospital for further evaluation of pulmonary infiltration. A diagnosis of acute eosinophilic pneumonia (AEP) was confirmed by clinical symptoms, bronchoalveolar lavage, and computed tomography findings. Skin tests with fungal antigens were performed by intradermal injection. Both the Arthus (8 h) and delay (24 h)-type skin tests were positive for only Candida albicans. A lymphocyte-stimulating test was also positive for C. albicans. The etiology of the AEP was confirmed by a C. albicans inhalation provocation test. In addition, peripheral blood mononuclear cells obtained from the patient produced Interleukin-5 following C. albicans stimulation. This is the first report of C. albicans as a probable cause of AEP. Evaluation of allergy to C. albicans should be performed in AEP before diagnosing the cause as idiopathic.

Minocycline-induced acute eosinophilic pneumonia: controversial results of lymphocyte stimulation test and re-challenge test

We report an instructive case of minocycline-induced eosinophilic pneumonia confirmed by re-challenge test, in which a preceding lymphocyte-stimulation test indicated acetaminophen as the etiologic agent. A 55-year-old woman developed high fever and lung infiltrates with pulmonary eosinophilia after exposure to minocycline, acetaminophen, theophylline and procaterol. All of the medicines were discontinued, resulting in prompt improvement. The lymphocyte stimulation tests provided a positive result for acetaminophen, but not for the other medicines; however, a negative result was given by a re-challenge test with acetaminophen. In contrast, symptoms and hypoxemia reappeared when minocycline was re-administered. We would like to emphasize that lymphocyte stimulation test results need to be carefully interpreted for individual drugs.

Elevated soluble ADAM8 in bronchoalveolar lavage fluid in patients with eosinophilic pneumonia

BACKGROUND

ADAM (a disintegrin and metalloprotease) family members, characterized by a metalloprotease and a disintegrin domain, are membrane-anchored glycoproteins involved in proteolysis and cell adhesion. ADAM8 might have an important role in allergic inflammation. It can cleave a variety of substrates and is a sheddase for VCAM-1 and CD23, the low-affinity IgE receptors.

METHODS

To evaluate the contribution of ADAM8 to the pathogenesis of eosinophilic pneumonia (EP), we measured the concentrations of soluble ADAM8 (sADAM8) and its substrates, soluble VCAM-1 (sVCAM-1) and soluble CD23 (sCD23), in bronchoalveolar lavage fluid from patients with smoking-induced acute eosinophilic pneumonia (AEP), chronic idiopathic eosinophilic pneumonia (CEP), and drug-induced eosinophilic pneumonia (drug-EP).

RESULTS

The sADAM8 and sVCAM-1 concentrations were increased in AEP and CEP. The sCD23 concentration was elevated in AEP. In AEP, but not CEP, the sADAM8 concentration significantly correlated with those of both sVCAM and sCD23.

CONCLUSION

The pathogenesis of AEP, CEP, and drug-EP was distinct with regard to ADAM8. Our results are the first to associate ADAM8 with eosinophilic responses and lung inflammation in humans.

Links between bronchial asthma and allergic rhinitis in the Oita Prefecture, Japan

Recent studies have strengthened the concept that bronchial asthma and allergic rhinitis are manifestations of an inflammatory process within a continuous airway. This study was performed to compare clinical findings in asthma with or without rhinitis in Japan. Nasal symptoms were present in 99.6% of asthma patients. The prevalence of allergic rhinitis in patients with asthma was 52.4%. Bronchial asthma attacks in one third of patients with rhinitis were coincident with worsening of nasal symptoms. In adults (> 16 years of age), rhinitis frequently preceded asthma, whereas asthma preceded rhinitis in children (< 16 years of age). The frequency of rhinitis in asthma decreases with increasing age. This study demonstrated a clear link between upper and lower airway disorders in Japan.

[A case of drug-induced pneumonitis due to bepridil]

A 66-year-old man had been given bepridil for the treatment of atrial fibrillation since April 28, 2002. The patient developed exertional dyspnea with hypoxemia in the middle of June 2002 and was admitted to our hospital. The chest X-ray and chest CT scans showed diffuse reticulonodular infiltrates in the lower lung fields. Pulmonary function tests revealed depletion of diffusion capacity for carbon monoxide. Bronchoalveolar lavage fluid contained increased percentages of lymphocytes, neutrophils and eosinophils, and a CD4/8 ratio was low. The transbronchial lung biopsy specimens demonstrated alveolar septal thickening with infiltration of mononuclear cells and intraalveolar organization. As drug-induced pneumonitis was suspected, bepridil was discontinued, resulting in improvement of dyspnea and hypoxemia. The patient was then treated with corticosteroid, which led to complete resolution of infiltration on chest X-ray. According to the clinical data consistent with drug-induced pneumonia, the prompt improvement after cessation of bepridil and the absence of other possible causes, we diagnosed this case as bepridil-induce pnemonitis.

Early assessment of rapidly progressive interstitial pneumonia associated with amyopathic dermatomyositis

Amyopathic dermatomyositis (ADM) is occasionally complicated by rapidly progressive interstitial pneumonia (RPIP), and in such cases, diffuse alveolar damage (DAD) is usually diagnosed at autopsy. Here, we present three patients with RPIP accompanied by ADM in whom lung disease was assessed at an early stage. High-resolution computed tomography (HRCT) carried out before the onset of dyspnoea revealed uniformly subpleural reticular opacity with faint ground-glass attenuation. At that stage, surgical lung biopsies from two patients showed histological patterns typical of cellular nonspecific interstitial pneumonia (NSIP). Despite pulse methylprednisolone and subsequent high-dose oral administration of prednisolone, lung disease progressed in all patients, with extensive areas of ground-glass opacity and consolidation observed in HRCT scans. DAD was confirmed histologically in one case. Additional administration of cyclosporine, pulse cyclophosphamide or high-dose intravenous administration of immunoglobulin rescued all patients. Our data suggest that ADM-associated interstitial pneumonia takes an aggressive course even when the radiological and histological features are consistent with NSIP. Aggressive combination therapy with high-dose steroids and immunosuppressive agents is required as early as possible for patients with this life-threatening disorder.

[A case of sarcoidosis manifesting as acute febrile polyarthritis following bronchoalveolar lavage]

A 32-year-old man was incidentally found to have abnormal shadows on a chest X-ray film and was admitted on May 2004. His chest images showed mediastinal and bilateral hilar lymphadenopathy. The serum level of angiotensin-converting enzyme was elevated. We also found non-caseating epithelioid cell granulomas in transbronchial lung biopsy specimens, and confirmed the diagnosis of sarcoidosis. We carried out bronchoalveolar lavage (BAL) for evaluation of disease activity of sarcoidosis. After BAL, he suffered high fever and polyarthralgia. Both ankles were extremely inflamed. We suspected infectious arthropathy caused by atypical pathogens and thus administered antibiotics, but they had no effect at all. Also, no findings suggesting collagen-vascular disorders, including rheumatoid arthritis, were detected. His symptoms improved after three-weeks of treatment with non-steroidal anti-inflammatory drugs. Thus, this case was diagnosed as having acute sarcoid polyarthritis. BAL may have influenced the onset of febrile arthritis in this patient This case indicates that sarcoidosis should be considered as a possible cause of acute febrile polyarthritis.

Role of ADAM8 in experimental asthma

A disintegrin and metalloprotease (ADAM) family members, characterized by a metalloprotease and a disintegrin domain, are membrane-anchored glycoproteins involved in proteolysis and cell adhesion. ADAM8 is specifically induced in the experimental murine asthmatic lung. To evaluate novel pathways involved in asthma pathogenesis, using ADAM8 transgenic mice (ATMS2) in a murine model of asthma. Massive cellular infiltrates in peribronchovascular and interstitial lesions were observed in control mice, while in ATMS2 mice there were only occasional. Vascular cell adhesion molecule (VCAM-1) is involved in specific eosinophil adhesions via alpha4beta1 integrin. VCAM-1 shedding was mediated by the ADAM8 metalloprotease. Endothelial cell shedding of VCAM-1 was increased in ATMS2-stimulated human umbilical endothelial cells. ADAM8-mediated shedding of VCAM-1 might be important for the suppression of experimental asthma. Our data suggest that ADAM8 is a useful therapeutic target.

[A case of pulmonary langerhans cell histiocytosis presenting disappearance of coalescing air wall cysts after smoking cessation]

A 17-year-old adolescent was admitted to Oita University Hospital with non-productive cough and exertional dyspnea. She had been smoking approximately 10 cigarettes per day for two years. When the patient was three years old, she underwent surgical removal of skull tumor of Langerhans cell histiocytosis. Initial chest CT scans showed coalescing thick-walled air cysts surrounded by micronodules in both lungs, most predominantly in the middle and upper lung fields. Bronchoalveolar lavage fluid contained 2.3% of CD1a-positive cells and video-assisted thoracoscopic lung biopsy disclosed granulomatous lesions consisting of histiocytic cells containing S-100 protein but without CD68 antigen allowing a diagnosis of pulmonary Langerhans cell histiocytosis. She stopped smoking, resulting in spontaneous resolution of the coalescing air cysts which were replaced by funicular scarring within two years. In case of extra-pulmonary Langerhans cell histiocytosis in children, the close relationship between cigarette smoking and pulmonary involvement should be informed to the parents to prevent the patient starting smoking in the future.

A case of diffuse panbronchiolitis (DPB) in a patient positive for HTLV-1

Diffuse panbronchiolitis (DPB), an important cause of progressive obstructive lung disease in the Far East, represents a distinctive sinobronchial syndrome with typical radiologic and histologic features. Human T-cell lymphotrophic virus (HTLV-1) is a retrovirus that clinically and experimentally suppresses T-cell function and immune responses. The clinical and immunologic features of DPB in HTLV-1 carriers are unclear, because DPB and HTLV-1 endemic areas around the world are mostly non-overlapping. However, both diseases are endemic in Japan. We present a patient with DPB positive for HTLV-1 whose cellular and humoral immune responses were markedly impaired. Six y after diagnosis of DPB, the patient developed respiratory failure and died in spite of treatment with clarithromycin.

Elevated Concentrations of Soluble IL-2 Receptor in both Bronchoalveolar Lavage Fluid and Serum in a Patient with BOOP

Activated soluble IL-2 receptor (sIL-2R) levels are elevated in a variety of diseases associated with T-cell activation. There are no reports of sIL-2R elevations in broncholitis obliterans organizing pneumonia/cryptogenic organizing pneumonia (BOOP/COP), although activated T cells are increased in BOOP/COP. We present a patient with BOOP/COP with an elevated concentration of soluble IL-2 receptors in both serum and bronchoalveolar lavage fluid. Concomitant resolution of the high serum sIL-2R and the roentogenographic findings after steroid treatment suggested that serum sIL-2R levels increase in response to a localized lymphocytic inflammatory reaction in the lung.

Aortic aneurysm involving a right-sided arch complicating aortobronchopulmonary and aortoesophageal fistula

A 66-year-old man with hemoptysis, chest pain, fever, and hoarseness was admitted to our department. A right-sided aortic arch and three aneurysms in the proximal arch, distal arch, and descending aorta were confirmed by aortography and surgery. Fistula formations were discovered between the proximal arch aneurysm and the right upper lobe (aortobronchopulmonary fistula: ABF), and between the descending aorta and the esophagus (aortoesophageal fistula: AEF). Concomitant ABF and AEF are very rare. Aortopulmonary and/or aortoesophageal fistula complicated by a right-sided aortic arch have not been previously reported.

Infected lung bulla with elevated cancer antigen 125 both in serum and aspirated fluid

A 78-year-old man was admitted to the hospital for treatment of an infected lung bulla. Cancer antigen 125 (CA125) was elevated in both his serum and fluid aspirated from the bulla. Concomitant resolution of the high serum CA125 level and the bullous fluid was observed after combination treatment of antibiotics and percutaneous fluid drainage, suggesting the appearance of CA125 in response to a localized inflammatory reaction in the bullous cavity.

[Acute empyema caused by Streptococcus milleri in early pregnancy]

A 40-year-old woman was admitted to our department complaining of left lateral chest pain and fever. She smoked 10 cigarettes per day. Chest radiographs revealed increased density in the upper left lung field and air-fluid level in the lower left lung field. A diagnosis of acute empyema was made, because pus was aspirated by thoracentesis. Streptococcus intermedius (Streptococcus milleri group) was isolated from samples of pleural effusion. The patient was successfully treated with a combination of antibiotics and surgical drainage. It became clear after discharge that she was in her 6th week of pregnancy. Laboratory findings showed decreased lymphocyte transformation in the PHA and Con-A tests. We reasoned, therefore, that smoking and decreased cellular immunity due to pregnancy might be causes of bacterial infections such as empyema.

Pyomyositis associated with Bacteroides fragilis in a patient with multiple myeloma

Pyomyositis is an infection of the skeletal muscle that is usually caused by Staphylococcus aureus. We report a 68-year-old Japanese woman who developed pyomyositis caused by Bacteroides fragilis following treatment for multiple myeloma. There are only two cases of pyomyositis associated with multiple myeloma in the literature. After receiving melphalan and prednisolone for five days, she developed multiple abscesses in the muscles of the right arm and thigh. Purulent exudate was aspirated from the abscess, and B. fragilis was identified. This is the first case of B. fragilis pyomyositis. Magnetic resonance imaging aided the diagnosis. Treatment consisted of surgical incision and drainage, with antibiotic administration. The immunosuppression caused by the myeloma and/or the chemotherapy presented a risk factor for the unusual infection observed in this patient.

[Drug-induced pneumonitis with eosinophilic infiltration due to tosufloxacin tosilate]

A 74-year-old man had been given tosufloxacin tosilate for the treatment of acute bronchitis on December 6,1996. Seven days after initiating tosufloxacin tosilate treatment, the patient developed headache and a high fever. He was admitted for dyspnea and generalized erythema. Chest X-ray and chest CT revealed multiple patchy infiltrates in both lung fields and minimal pleural effusion. Bronchoalveolar lavage fluid showed a marked increase in total cell number, and in the percentages of lymphocytes, neutrophils and eosinophils. Transbronchial lung biopsy specimens demonstrated prominent eosinophilic infiltration of the alveolar walls and spaces with fibrin formation. With the tentative diagnosis of drug-induced pneumonitis, all drug administration was discontinued and the patient was treated with corticosteroid. Following the initiation of corticosteroid treatment, dyspnea and erythema improved quick and chest X-rays became clear. The challenge test for tosufloxacin tosilate obtained positive results. Based on these findings, a diagnosis of eosinophilic pneumonia due to tosufloxacin tosilate was made. To our knowledge, no previous cases of pulmonary hypersensitivity to tosufloxacin tosilate have been reported.

[A case of diaphragmatic paralysis following herpes zoster]

We report a case of diaphragmatic paralysis after herpes zoster. A 82-year-old woman developed shortness of breath on effort after about two months of a typical herpes zoster eruptions affecting the C4 and C5 dermatomic areas on the right side. A chest x-ray showed an elevated right diaphragm. The diaphragmatic evoked potential by stimulation of the right phrenic nerve at the posterior border of the sternocleidomastoid muscle was not elicited. Chest CT and cervical MRI were normal. The viral antibody titers of herpes zoster were elevated in the serum. Cervical herpes zoster should be considered as a possible cause of hemidiaphragmatic paralysis.