Teduglutide-induced acute gastric mucosal necrosis in short bowel syndrome with hepatorenal failure: Case report

INTRODUCTION

Short bowel syndrome (SBS) resulting from acute aortic dissection (AAD)-induced visceral malperfusions leads to chronic intestinal failure (CIF), necessitating patients to adopt home parenteral nutrition to prevent malabsorption. Teduglutide (TED), a glucagon-like peptide-2 analog, is a promising pharmacotherapy for intestinal rehabilitation that reduces parenteral support and improves the quality of life. Gastric mucosal necrosis, a rare gastrointestinal disorder, had never been observed as an adverse event relevant to this drug. We report a case of mucosal necrosis in the stomach after TED treatment for SBS-CIF with hepatorenal failure.

PRESENTATION OF CASE

A 68-year-old Japanese man who underwent massive intestinal resection for AAD experienced malnutrition and diarrhea caused by SBS-CIF. The patient received TED to improve intestinal absorption and entero-hepatic circulation besides controlling infectious diseases. Endoscopy showed mucosal hyperplasia in the stomach and duodenum 1.5 months after TED administration. The patient consented to enteral nutrition via a nasogastric tube because of anorexia. The nutritional status gradually improved after initiating enteral feeding. However, the patient experienced hematemesis 13 days after enteral feeding, and endoscopy revealed acute gastric mucosal necrosis, followed by fatal septic shock.

DISCUSSION

For patients with SBS, TED is expected to increase intestinal absorption through epithelial proliferation. When SBS is accompanied by multiple ischemic organ failure, TED therapeutic effects remain unclear as malnutrition-associated infectious diseases are refractory, and many underlying mechanisms can be involved.

CONCLUSION

TED administration should be deliberately considered for patients with SBS-CIF and multiple organ failure experiencing uncontrolled systemic infection.

A Novel Hidden Stitching Method for Preventing Complications in Laparoscopic Hernia Repair

PURPOSE

Barbed suture provides a rapid and effective method for closure in minimally invasive surgery. However, postoperative complications involving barbed suture have been reported in recent years. The aim of this study is to introduce a novel hidden stitching technique for peritoneal closure in laparoscopic hernia repair.

METHOD

This study retrospectively analyzed the data of patients with laparoscopic transabdominal preperitoneal patch (TAPP). In the hidden stitch (HS) group, the barbed suture was hidden on the dorsal side of the peritoneum and two stitches were returned in the opposite direction after the suture reached the end point. In the non-hidden stitch (NHS) group, the barbed sutured was exposed in the peritoneal cavity with a tail stump of approximately 10 mm preserved to prevent the peritoneal sutures from loosening.

RESULTS

Twenty-seven patients in the HS group were compared with 53 in the NHS group. There were no differences in age, body mass index, surgical bleeding, or length of hospital stay between the two groups. The peritoneal defect closure time was slightly longer (3 min) in the HS group, but the overall operation time was not significantly extended. There were 8 cases of postoperative complications (P = .035) including 4 cases of bowel obstruction due to the tail of the barbed thread penetrating the small intestine mesenteric and two cases of seroma. There were no postoperative complications in the HS group.

CONCLUSIONS

The hidden stitch method is a safe and feasible peritoneal closure technique that may reduce postoperative complications caused by barbed suture in laparoscopic hernia repair.

Serum Cytokine Changes in a Patient with Chronic Pulmonary Aspergillosis Overlapping with Allergic Bronchopulmonary Aspergillosis: A Case Report

Allergic bronchopulmonary aspergillosis (ABPA) and chronic pulmonary aspergillosis (CPA) are diseases caused by Aspergillus infection, and CPA can develop from ABPA in some cases. We herein report a patient with CPA overlapping with ABPA. Serum cytokine levels were evaluated at 4 time points: the ABPA diagnosis, CPA diagnosis, 6 months after the start of voriconazole (VRCZ), and 12 months after re-administration of VRCZ. Interleukin (IL)-13 levels decreased upon glucocorticoid treatment, whereas IL-25 and IL-33 levels decreased rapidly with the initiation of antifungals. Early antifungal therapy may be important to control disease progression and prevent CPA overlap.

Bowel obstruction and perforation secondary to barbed suture after minimally invasive inguinal hernia repair: report of two cases and literature review

BACKGROUND

Laparoscopic transabdominal preperitoneal patch (TAPP) is now commonly used in the repair of inguinal hernia. Barbed suture can be a fast and effective method of peritoneal closure. We report two rare cases of small bowel obstruction and perforation caused by barbed suture after TAPP.

CASES

Patient 1 is a 45-year-old man who underwent laparoscopic repair of a right inguinal hernia. Barbed suture was used to close the peritoneal defect. At 47 days after the operation, he was diagnosed with a small bowel obstruction caused by an elongated tail of the barbed suture. Emergency laparoscopic exploration was performed for removal of the embedded suture and detorsion of the volvulus. The second patient is a 50-year-old man who was admitted with a small bowel perforation one week after TAPP herniorrhaphy. Emergency exploration revealed that the tail of the barbed suture had pierced the small intestine, causing a tiny perforation. After cutting and releasing the redundant tail of the barbed suture, the serosal and muscular defect was closed with 2 absorbable single-knot sutures. Both patients have recovered well. Finally, we searched the PubMed database and reviewed the literature on the effectiveness and safety of barbed suture for TAPP.

CONCLUSIONS

Surgeons should understand the characteristics of barbed suture and master the technique of peritoneum closure during TAPP in order to reduce the risk of bowel obstruction and perforation.

Laparoscopic surgical treatment for hydrocele of canal of Nuck: A case report and literature review

Background

Hydrocele of canal of Nuck (HCN) is a rare disease in adult female. The diagnosis and treatment of HCN is still a challenge for surgeons.

Case presentation

A 56-year-old female presented with recent onset of occasional pain during exercise and an asymptomatic left groin swelling. Ultrasonography results were suspicious for left inguinal hernia incarceration and computed tomography (CT) scan showed no intestinal obstruction, which was considered as HCN. Laparoscopic hydrocelectomy of the HCN and a routine laparoscopic hernia repair via the transabdominal preperitoneal (TAPP) approach were performed. Postoperative pathology showed no malignant lesions or endometriosis.

Conclusions

The preoperative diagnosis of HCN is extremely important. Surgeons should choose appropriate surgical methods for different anatomical HCNs based on the preoperative diagnosis.

Laparoscopic assisted hydrocelectomy of the canal of Nuck: a case report

Background

Accurate diagnosis and complete resection of hydrocele of canal of Nuck (HCN) is still a challenge for surgeons.

Case presentation

A 28-year-old woman presented with a suspected inguinal hernia due to swelling in her right groin and was introduced for surgical treatment. Computed tomography scan revealed local cyst formation in the right groin and eliminated intestinal incarceration. In order to further confirm the diagnosis, we used laparoscopic exploration; after excluding a combined hernia, HCN was surgically removed using a conventional anterior peritoneal approach and a mesh patch repair was not needed. Postoperative pathology results showed no endometriosis or malignancy.

Conclusions

Laparoscopic assisted anterior approach provides both an accurate intraoperative diagnosis and a quick complete resection of HCN; it is the preferred treatment for women of childbearing age with pure HCN.

Comparison of 12-Week Additional Effect Features of Formoterol Co-Inhalation and Tulobuterol Patch on Budesonide Inhalation in Elderly Patients With Asthma

Background

For asthma strategy, to avoid the aggravation of bronchial inflammation and contraction, the long acting beta agonist (LABA) addition on inhaled corticosteroids (ICS) has been recommended.

Objectives

To know whether there is any clinical difference between the additional efficacies of Formoterol (FOR) and Tulobuterol (TUL) onto Budesonide (BUD) may be useful for the elderly patients' asthma treatment strategy.

Methods

Eighteen outpatients with mild to moderate bronchial asthma with FEV1.0% < 80% treated by intermediate ICS dosages visited Respiratory Division of Nagasaki University Hospital or Isahaya General Hospital, Japan Community Health care Organization were subjected, and were randomly assigned (9 cases per group) to either the FBC group (BUD/FOR 160/4.5 µg, 2 inhalations twice daily) or BUD + TUL group (BUD 200 mcg: 2 inhalations twice daily + TUL 2 mg daily) and were compared in parallel with 2 arms for 12 weeks prospectively. Peak expiratory flow, forced expiratory volume in 1 second, impulse oscillometry (IOS), fractional exhaled nitric oxide (FeNO), Asthma Control Questionnaire, mini-Asthma Quality of Life Questionnaire (mini-AQLQ), and occurrence of adverse reactions were compared.

Results

The "Fres" of IOS was improved in FBC group (p = 0.03). The "emotion" domain of mini-AQLQ was improved in BUD + TUL group (p = 0.03).

Conclusion

By changing the drug formulation, the patch was superior in terms of satisfaction, but it was thought that the inhaled combination was superior in improving the respiratory function itself. It is necessary to pay attention to the characteristics of the patient when selecting treatment.

Evacuatory Dysfunction after Stapled Hemorrhoidopexy: A Case Report of Rectal Pocket Syndrome

A 60 year-old male was referred to the authors' hospital with a persistent urge to defecate. The patient had undergone stapled hemorrhoidopexy (SH) for the treatment of prolapsed hemorrhoids approximately 10 years earlier. He started to have difficulty with defecation and a false sense of urgency shortly after the surgery. Computed tomography showed a diverticulum-like fistula along the circumference of the rectum. Colonoscopy revealed communication between the diverticular cavity and the rectal lumen. The cavity contained a thumbnail-sized fecalith. When the fecalith was removed, the patient's urge to defecate dissipated. The patient was diagnosed with rectal pocket syndrome secondary to SH. The lower rectum was transected, and the remaining rectum and the anal canal were anastomosed by manual suture. Temporary ileostomy with double orifices was performed. The ileostomy was closed 3 months later. The patient experienced no subsequent difficulty with defecation or urgency.

Liposomal Amphotericin B Fosters the Corticosteroids' Anti-inflammatory Effect on Murine Allergic Bronchopulmonary Aspergillosis Model Airways

Fungus is an antigen for bronchial asthma causing allergic bronchopulmonary mycosis (ABPM). As a therapy other than corticosteroids, itraconazole (ITCZ) is known to suppress the allergic inflammation induced by Aspergillus fumigatus (Af). However, the efficacy of liposomal amphotericin B (LAMB) with/without corticosteroid on ABPM is unknown. Mice sensitized to Dermatophagoides farinae (Df) allergen were intranasally infected with Af (DfAf group). After the infection, corticosteroid (dexamethasone (Dex)) was administered for 5 days (DfAf/Dex group). The effects of ITCZ or LAMB with/without Dex were also evaluated. Pathologically, Dex and LAMB combination treatment decreased the allergic inflammation evidently. The bronchoalveolar lavage fluid (BALF) concentrations of IL-5, IL-13, and MIP-2 were significantly elevated in DfAf mice compared with control mice (p < 0.05, each). In DfAf mice, ITCZ and LAMB significantly decreased the elevation of MIP-2 (p < 0.05 vs the DfAf group). The addition of both Dex and LAMB suppressed the MIP-2 elevation in DfAf mice (p < 0.05 vs the Df/Af/Dex/LAMB group), but the addition of Dex and ITCZ did not (DfAf/Dex/ITCZ group). None of Dex, ITCZ, or LAMB decreased pulmonary IL-13 concentration. It was suggested that combination of antifungal drugs and corticosteroid enhanced the suppressing effect of airway inflammations. This finding will give a hope for the treatment of severe fungus-related asthma.

Fluctuation of Hepatic Focal Nodular Hyperplasia Size with Oral Contraceptives Use

Patient: Female, 44

Final Diagnosis: Focal nodular hyperplasia

Symptoms: Liver masses

Medication: —

Clinical Procedure: CT • MRI • Pathology

Specialty: General and Internal Medicine

A baseline impedance analysis in neurologically impaired children: A potent parameter for estimating the condition of the esophageal mucosa

BACKGROUND

The aim of the present study was to investigate whether the baseline impedance (BI) value is a useful parameter to evaluate the condition of the esophageal mucosa in neurologically impaired (NI) children undergoing multichannel intraluminal impedance pH measurements (pH/MII).

METHODS

The retrospective study included 55 NI patients ≤15 years. The patients were divided into acid gastroesophageal reflux disease (GERD), non-acid GERD and GERD (-) groups. Furthermore, the patients in the acid GERD group were subdivided into erosive reflux disease (ERD) and non-erosive reflux disease (NERD) groups. pH/MII parameters and BI values (Z1-6) were compared among three groups or between two groups, respectively. A Spearman's correlation analysis was used for the correlation analysis of pH/MII parameters and BI values. A receiver operator characteristic curve analysis was used to evaluate the optimum cut-off values of BI to discriminate ERD patients.

KEY RESULTS

The BI values of the proximal and the distal channels in ERD group were significantly lower than those in NERD group. The BI values of the distal channels demonstrated significant negative correlations with acid exposure related pH/MII parameters. The optimal cut off value of BI in the most distal channel was determined to be 1500 Ω.

CONCLUSIONS & INFERENCES

The present study suggested that NI children with reflux esophagitis were likely to suffer mucosal damage up to the proximal esophagus and cut-off BI values may help estimate the presence of reflux esophagitis. Baseline impedance is a potent parameter, reflecting the esophageal mucosal damage in NI children who have difficulty in undergoing endoscopic examinations.

Pulmonary Artery Sarcoma Overexpressing Platelet-derived Growth Factor Receptor α

Pulmonary artery sarcoma is highly malignant and easily metastasizes to the systemic organs. Both the introduction of novel diagnostic procedures and the development of new treatment modalities are required to achieve long-term survival. Several studies have shown that platelet-derived growth factor receptor α (PDGFRα) gene amplification is frequently observed in pulmonary artery sarcoma. PDGFRα is known to be involved in cell proliferation in certain malignancies. PDGFRα may become a potential biological marker in pulmonary artery sarcoma. We report a case in which a diagnosis of pulmonary artery sarcoma overexpressing PDGFRα was made using endovascular catheter biopsy following positron emission tomography with integrated computed tomography (PET/CT) scans.

Anal Canal Adenocarcinoma in a Patient with Longstanding Crohn's Disease Arising From Rectal Mucosa that Migrated From a Previously Treated Rectovaginal Fistula

BACKGROUND This study reports the pathogenesis of anal canal adenocarcinoma in a patient with longstanding Crohn's disease (CD). CASE REPORT A 50-year-old woman with a 33-year history of CD presented with perianal pain of several months' duration. She had been treated surgically for a rectovaginal fistula 26 years earlier and had been treated with infliximab (IFX) for the previous 4 years. A biopsy under anesthesia revealed an anal canal adenocarcinoma, which was removed by abdominoperineal resection. Pathological examination showed that a large part of the tumor consisted of mucinous adenocarcinoma at the same location as the rectovaginal fistula had been removed 26 years earlier. There was no evidence of recurrent rectovaginal fistula, but thick fibers surrounded the tumor, likely representing part of the previous rectovaginal fistula. Immunohistochemical analysis using antibodies against cytokeratins (CK20 and CK7) revealed that the adenocarcinoma arose from the rectal mucosa, not the anal glands. CONCLUSIONS Mucinous adenocarcinoma can arise in patients with CD, even in the absence of longstanding perianal disease, and may be associated with adenomatous transformation of the epithelial lining in a former fistula tract.

Sulfonamide antibiotic removal and nitrogen recovery from synthetic urine by the combination of rotating advanced oxidation contactor and methylene urea synthesis process

The combination of nitrogen recovery and pharmaceutical removal processes for livestock urine treatment were investigated to suppress the discharge of pollutants and recover nitrogen as resources. We combined methylene urea synthesis from urea and adsorption and photocatalytic decomposition of sulfonamide antibiotic using rotating advanced oxidation contactor (RAOC) contained for obtaining both safe fertilizer and reclaimed water. The methylene urea synthesis could recover urea in synthetic urine, however, almost all sulfonamide antibiotic was also incorporated, which is unfavorable from a safety aspect if the methylene urea is to be used as fertilizer. Conversely, RAOC could remove sulfonamide antibiotic without consuming urea. It was also confirmed that the methylene urea could be synthesized from synthetic urine treated by RAOC. Thus, we concluded that RAOC should be inserted prior to the nitrogen recovery process for effective treatment of urine and safe use of methylene urea as fertilizer.

Usefulness of antiemetic therapy with aprepitant, palonosetron, and dexamethasone for lung cancer patients on cisplatin-based or carboplatin-based chemotherapy

PURPOSE

The purpose of the study is to investigate the usefulness of the triplet regimen comprising aprepitant, palonosetron, and dexamethasone in patients treated with highly emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC).

METHODS

Patients with lung cancer (aged 65.8 ± 8.4 years) who received carboplatin-based MEC and those treated with cisplatin-based HEC were enrolled. The antiemetic regimen for both types of chemotherapy consisted of aprepitant, palonosetron, and dexamethasone based on the May 2010 guidelines prepared by the Japan Society of Clinical Oncology. The incidence of chemotherapy-induced nausea and vomiting (CINV) and the use of salvage treatment were assessed. The primary endpoints were the percentage of patients with a complete response (CR: no nausea and no salvage treatment) during the entire study period (5 days) after chemotherapy, during the acute phase (day 1), and during the delayed phase (days 2-5).

RESULTS

CR rates for the entire period were 86 and 71% in patients receiving carboplatin-based and cisplatin-based chemotherapy, respectively. CR rates were respectively 98 and 100% in the acute phase versus 87 and 71% in the delayed phase. Most of the patients could ingest food throughout the entire period after chemotherapy. Assessment of various risk factors for acute and delayed CINV (gender, age, prior vomiting due to antineoplastic therapy, prior experience of motion sickness, and history of drinking) revealed no significant influence of these factors on the CR rate for the entire period in patients receiving either carboplatin-based or cisplatin-based chemotherapy.

CONCLUSION

The present triple therapy can be recommended for supporting both carboplatin-based and cisplatin-based chemotherapy regimens.

Cysteinyl leukotriene receptor antagonist regulates allergic airway inflammation in an organ- and cytokine-specific manner

Background

Cysteinyl leukotrienes (cys-LTs) are very important factors in the pathophysiology of bronchial asthma. Cys-LT receptor antagonists (LTRAs) decrease allergic airway inflammation. The aim of the present study was to determine the differential effects of LTRAs and corticosteroids on allergic airway inflammation and allergen-specific cytokine production from lymphoid tissues using a murine model of asthma.

Material/Methods

Four groups of female BALB/c mice [control (Cont); Dermatophagoides farinae allergen-sensitized (AS); pranlukast (Prl), an LTRA-treated AS; and dexamethasone (Dex)-treated AS] were examined. Lung pathology and cytokine production by prepared mononuclear cells isolated from mediastinal lymph nodes (MLNs) and spleen were compared among these groups.

Results

AS mice exhibited allergic airway inflammation and significant increases in allergen-specific Th1 and Th2 cytokines in MLNs and spleen. Prl-treated mice showed significant attenuation of allergic airway inflammation concomitant with reduction of Th2 cytokines and IFN-γ in MLNs but not in spleen. In contrast, Dex significantly decreased Th1 and Th2 cytokines in MLNs and also decreased them (except IL-13 and IL-2) in spleen.

Conclusions

The inflammatory effects of cys-LTs could differ in lymphoid organs. LTRAs potentially regulate allergic airway inflammation in an organ- and cytokine-specific manner, while systemic corticosteroid shows nonspecific effects.

Retrospective cohort study of leukotriene receptor antagonist therapy for preventing upper respiratory infection-induced acute asthma exacerbations

Upper respiratory tract infections (URIs) represent the most frequent cause of acute asthma exacerbations. It has yet to be determined whether leukotriene receptor antagonist (LTRA) treatment prevents URI-induced acute asthma exacerbations in adults. The objective of the present study was to evaluate the preventive effects of LTRA treatment on URI-induced acute asthma exacerbations. The incidences of URI alone, acute asthma exacerbation without URI, and URI-induced acute asthma exacerbation were determined retrospectively by analyzing diary and medical records of 321 adult asthmatic patients (mean age, 56.3 ± 17.2 years; male/female ratio, 117:204) over 1 year. Results were compared between patients who had been taking an LTRA (n = 137) and those who had never taken any LTRA (n = 184) during the study periods. Significantly fewer URIs alone and acute asthma exacerbations without URI occurred in patients with than in those without prophylactic daily use of LTRA. LTRA treatment significantly reduced the durations of URIs alone and of total acute asthma exacerbations, as well as the incidence of mild exacerbations of asthma. In contrast, in patients with URI-induced acute asthma exacerbations, LTRA treatment failed to significantly reduce the interval between URI onset and acute asthma exacerbation, as well as the duration and severity of both URIs and acute asthma exacerbations. Use of an LTRA for adult asthmatic patients appears to reduce the incidences of URIs alone and acute asthma exacerbations without URI, but it failed to prevent URI-induced acute asthma exacerbations once a URI occurred.

Dissociation between sensitizing and colonizing fungi in patients with allergic bronchopulmonary aspergillosis

BACKGROUND

Because allergic bronchopulmonary aspergillosis (ABPA) does not require the presence of Aspergillus fumigatus for diagnosis, serological and radiological findings without cultures usually confirm this condition.

OBJECTIVE

To determine which fungi colonize the airways of patients with definitive ABPA.

METHODS

We enrolled 11 patients (ages 57.5 ± 17.1 years; male: female, 4:7) with ABPA diagnosed by serological and radiological criteria. Fungi colonizing the airway were identified from mucous plugs that were naturally expectorated or obtained by fiberoptic bronchoscopy.

RESULTS

Aspergillus spp. (n = 8) was the most frequently isolated, followed by Schizophyllum commune (n = 4), Candida albicans (n = 2), Rhizopus oryzae (n = 1), and Penicillium spp. (n = 1). Among the Aspergillus spp., A. niger, A. terreus, and A. sydowii were more frequently isolated (total, n = 6) than A. fumigatus (n = 2). Many patients were sensitized with several fungi in addition to Aspergillus, which were dissociated with airway-colonizing fungi.

CONCLUSION

Multiple fungal species can colonize the airway, and dissociation between colonizing and sensitizing species frequently occurs in definitive ABPA. Considering the increased prevalence of azole-resistant Aspergillus spp., administering antifungal drugs that target A. fumigatus without identifying which fungal species colonize the airway might be problematic.

Differential airway inflammatory responses in asthma exacerbations induced by respiratory syncytial virus and influenza virus a

BACKGROUND

Although respiratory viral infections cause acute exacerbations of asthma, the inflammatory responses vary depending on the causative virus. The purpose of this study was to compare the inflammatory responses in the airways of acute exacerbations of asthma induced by respiratory syncytial virus (RSV) and influenza A virus.

METHODS

Sputum induction was performed in asthmatic patients with acute exacerbations induced by RSV (n = 6), influenza A (n = 7), and non-upper respiratory infection (URI)-related factors (n = 8). Sputum concentrations of cysteinyl leukotrienes (cysLTs), TNF-α and IFN-γ were measured.

RESULTS

Sputum cysLTs were significantly higher in RSV-induced exacerbations than in influenza A- and non-URI-induced exacerbations. Sputum TNF-α was significantly higher in influenza A-induced exacerbations than in RSV- and non-URI-induced exacerbations. Sputum IFN-γ was significantly lower in RSV-induced exacerbations than in the others.

CONCLUSIONS

RSV and influenza A cause acute exacerbations and have different effects on airway inflammation in asthmatic patients. RSV significantly increased cysLTs, while influenza A significantly increased TNF-α in the airway. The underlying mechanism in virus-induced asthma might depend on the viral species.

Differential effects of dexamethasone and itraconazole on Aspergillus fumigatus-exacerbated allergic airway inflammation in a murine model of mite-sensitized asthma

BACKGROUND

Fungal exposure is associated with particularly severe asthma. Nevertheless, the effects of anti-fungal treatments on fungus-exacerbated asthma need to be determined.

OBJECTIVES

The present study aimed to compare the effects of itraconazole (ITCZ) and dexamethasone (Dex) on Aspergillus fumigatus (Af)-exacerbated preexisting Dermatophagoides farinae (Df) allergen-sensitized allergic airway inflammation.

METHODS

Four groups of BALB/c mice were prepared: control, Df-sensitized plus Af-infected mice (Df-Af), and Df-Af mice treated with Dex (Df-Af-Dex) or with ITCZ (Df-Af-ITCZ). Pulmonary pathology and cytokine profiles in the airway were evaluated. In a different set of experiments, the effects of Dex on alveolar macrophage (AM) phagocytosis of Af conidia were determined in Df-sensitized mice.

RESULTS

Af infection significantly increased the level of eosinophils and neutrophils in the airway of Df-sensitized mice. While Dex significantly decreased eosinophils, ITCZ significantly decreased both eosinophils and neutrophils in Df-Af mice. Dex significantly decreased IL-5, whereas ITCZ significantly reduced MIP-2 in the airway. Compared to controls, AM isolated from Df-sensitized mice had significantly reduced phagocytotic activity of Af conidia. However, Dex significantly improved phagocytotic activity of AM in Df-sensitized mice.

CONCLUSIONS

The present study showed that Dex and ITCZ differently regulated Af-exacerbated allergic airway inflammation; the former inhibits eosinophilic inflammation and the latter inhibits neutrophilic as well as eosinophilic inflammation by regulating different cytokines. Additionally, Dex enhanced the phagocytotic activity of AM in allergic asthma. Thus, a combination of Dex and ITCZ might be effective for the management of fungus-exacerbated asthma.

Adsorptive removal of sulfonamide antibiotics in livestock urine using the high-silica zeolite HSZ-385

The adsorptive removal of seven sulfonamide antibiotics using the high-silica zeolite HSZ-385 from distilled water, synthetic urine and real porcine urine was investigated. The pH greatly affected the adsorption efficiency, and the amounts of all sulfonamide antibiotics adsorbed on HSZ-385 decreased at alkaline conditions compared with that at neutral conditions. During storage, the pH and ammonium-ion concentration increased with urea hydrolysis for porcine urine. We clarified that the adsorption efficiency of sulfonamides in synthetic urine was equivalent to that in distilled water, suggesting that adsorption behavior was not affected by coexistent ions. HSZ-385 could adsorb sulfonamide antibiotics in real porcine urine even though the non-purgeable organic carbon concentration of porcine urine was 4-7 g/L and was two orders of magnitude higher than those of sulfonamides (10 mg/L each). Moreover, the adsorption of sulfonamides reached equilibrium within 15 min, suggesting that HSZ-385 is a promising adsorbent for removing sulfonamides from porcine urine.

Effects of a short course of pranlukast combined with systemic corticosteroid on acute asthma exacerbation induced by upper respiratory tract infection

BACKGROUND

Upper respiratory tract infections (URIs) represent the most frequent cause of acute asthma exacerbation. Systemic corticosteroid (CS) is presently recommended for URI-induced asthma exacerbation, although it might inhibit cellular immunity against respiratory virus infection.

OBJECTIVES

To determine the effects of adding a short course (2 weeks) of a leukotriene receptor antagonist (LTRA) to systemic CS on URI-induced acute asthma exacerbation.

METHODS

Twenty-three adult asthmatics (mean age, 42.8 ± 9.8 y; Male:Female, 10:13) with URI-induced acute asthma exacerbation confirmed by a questionnaire and physical findings were randomly assigned to receive either oral prednisolone (PSL) alone or oral PSL plus the LTRA pranlukast (PRL) for 2 weeks (PSL + PRL). The cumulative doses of PSL and the amount of time required to clear asthma-related symptoms were determined. Levels of respiratory syncytial virus (RSV) RNA and influenza viral (IV) antigen in nasopharyngeal swabs were also determined.

RESULTS

Adding PRL significantly reduced the cumulative dose of PSL and tended to reduce the time required to clear asthma-related symptoms. Either RSV or IV was detected in about one-third of the patients.

CONCLUSION

The combination of an LTRA and CS might be more useful than CS alone for treating URI-induced acute exacerbation of asthma and reducing the cumulative CS dose.

Regulation of dendritic cell functions against harmful respiratory pathogens by a cysteinyl leukotrienes receptor antagonist

Cysteinyl leukotriene receptor antagonist (LTRA) is a widely used medicine for asthma. Cysteinyl leukotrienes (cysLTs) are involved in the regulation of dendritic cell (DC) function. However, the effects of LTRA on DC-related antimicrobial immunity against harmful respiratory pathogens remain unknown. The purpose of this study was to examine the effects of LTRA administered in vivo on DC function against representative respiratory pathogens in vitro. Pulmonary DCs were isolated from four groups of mice: control, mite allergen sensitized (AS), and AS mice treated with the corticosteroid dexamethasone (Dex) or with the LTRA pranlukast (Prl). These DCs were incubated with mite allergen, lipopolysaccharide (LPS), Aspergillus fumigatus, or respiratory syncytial virus (RSV). IL-10 and IL-12 production was then determined. Dex treatment significantly inhibited lipopolysaccharide (LPS)-induced IL-10 and IL-12 production as well as baseline IL-12 production in AS mice. The Prl did not significantly inhibit LPS-induced IL-10 and IL-12 production in AS mice. More importantly, Prl significantly increased IL-10 and IL-12 in AS mice after RSV infection. This study shows that LTRA that is used for asthma potentially up-regulates antimicrobial immunity through modulation of DC function against some respiratory infections without immunosuppression.

Acetaldehyde at a low concentration synergistically exacerbates allergic airway inflammation as an endocrine-disrupting chemical and as a volatile organic compound

BACKGROUND

Acetaldehyde is an endocrine-disrupting chemical (EDC) and a volatile organic compound (VOC). It is also a carcinogen and teratogen that causes bronchoconstriction in a subset of asthmatics. However, the mechanism through which acetaldehyde acts as an EDC/VOC causing allergic airway inflammation remains unknown.

OBJECTIVES

To determine the effects of a low concentration of acetaldehyde, which itself did not trigger airway inflammation, on extant allergic airway inflammation in a murine model of allergic asthma.

METHODS

We compared airway hyperresponsiveness (AHR), lung pathology, serum IgE and airway concentrations of cytokines among four groups of BALB/c mice [control, Dermatophagoides farinae(Df) allergen-sensitized (AS), intranasally acetaldehyde-injected (ALD) and AS-ALD mice].

RESULTS

Physiological and histological differences were not evident between ALD and control mice. AS mice developed AHR and allergic airway inflammation characterized by goblet cell hyperplasia and eosinophilic infiltration. Both AHR and airway eosinophilia were significantly enhanced in AS-ALD compared with AS mice. Serum total and Df-specific IgE were significantly increased in both AS and AS-ALD mice compared with control and ALD mice, but comparable between AS and AS-ALD mice. Mite allergen sensitization significantly increased interleukin-5 and granulocyte macrophage colony-stimulating factor, and decreased interferon-γ levels in the airways; injecting acetaldehyde into airways with allergic inflammation significantly increased the levels of these inflammatory cytokines.

CONCLUSIONS

Exposure to acetaldehyde can enhance allergic airway inflammation in asthma.

Effect of respiratory syncytial virus infection on plasmacytoid dendritic cell regulation of allergic airway inflammation

BACKGROUND

Respiratory syncytial virus (RSV) can infect myeloid dendritic cells (mDCs) and regulate their function in the development of allergy. It has been widely reported that plasmacytoid DCs (pDCs) play a critical role in antiviral innate immunity. In contrast, not much is known about the role of pDCs in the interaction between allergy and viral infection. The purpose of the present study was to investigate the effect of RSV infection on pDC function in the regulation of allergic airway inflammation in a murine model of Dermatophagoides farinae-sensitized allergic asthma.

METHODS

Splenic pDCs isolated from D. farinae-sensitized donor mice were infected with live RSV ex vivo. Subsequently, these pDCs were inoculated into the airways of D. farinae-sensitized recipient mice. Lung pathology, lung tissue cytokine profiles, the number of regulatory T cells (T(reg)) and mDCs as well as the effects of IL-10 neutralization in the lung tissue of recipient mice were determined.

RESULTS

Intranasal inoculation of D. farinae-sensitized pDCs significantly inhibited the development of allergic airway inflammation and both Th1 and Th2 immunity. Live RSV infection of these pDCs prior to inoculation interfered with their inhibitory effects through decreasing T(reg) and IL-10 and increasing mDCs.

CONCLUSIONS

In asthmatic airways, pDCs mediate tolerance to inhaled allergens through the regulation of T(reg), IL-10 and mDCs. RSV infection of pDCs potentially inhibits their immunotolerogenic effects and thus exacerbates allergic airway inflammation.

Aspergillus fumigatus regulates mite allergen-pulsed dendritic cells in the development of asthma

BACKGROUND

The role in allergic asthma development of the immune response against fungi with concomitant exposure to other common aeroallergens has yet to be determined. In particular, there is little understanding of how inhaled fungi affect the host response to mite allergens.

OBJECTIVE

To characterize the in vitro and in vivo effects of concurrent exposure of Aspergillus fumigatus (Af) and Dermatophagoides farinae (Derf) on dendritic cells (DCs) in the development of allergic asthma.

METHODS

Murine bone marrow-derived DCs were pulsed with Derf and/or live or heat-inactivated Af. Cytokine production and the expression of pathogen recognition receptors (PRRs) were determined in vitro. Subsequently, these DCs were inoculated into the airway of naïve mice to assess the development of allergic airway inflammation in vivo. The effect of antibodies against PRRs was also evaluated.

RESULTS

Live Af significantly enhanced IL-10 production and the expression of Toll-like receptor (TLR) 2 and Dectin-1 in Derf-pulsed DCs. Live Af infection significantly attenuated Derf-pulsed DC-induced allergic airway inflammation in vivo. Antibodies against either TLR2 or Dectin-1 significantly reversed the inhibitory effects of live Af in the development of Derf-pulsed DC-induced allergic airway inflammation.

CONCLUSION

Concurrent exposure of DCs to fungal antigens has profound influences on the subsequent mite allergen-induced allergic airway inflammation. Live Af could regulate the functions of airway DCs in the development of mite allergen-induced allergic airway inflammation via regulation of their PRRs. Our results suggest that concurrent exposure to pathogens such as fungi and mite allergens has profound influences on the subsequent allergen-induced allergic airway inflammation. Furthermore, modulating PRR signalling could provide a therapeutic regimen for the development of asthma.

Body mass index correlated with forced expiratory volume in 1 second/forced vital capacity in a population with a relatively low prevalence of obesity

BACKGROUND

Obesity is the most common metabolic disease in the world. However, the relationship between obesity and lung function is not fully understood. Although several longitudinal studies have shown that increases in body weight can lead to reductions in pulmonary function, whether this is the case with the Japanese population and whether high body mass index (BMI) status alone represents an appropriate predictor of obstructive lung dysfunction remains unclear. The purpose of present study was to estimate the effect of BMI on lung function measured by spirometry of Japanese patients in general clinics. We measured BMI and performed spirometry on screening patients who had consulted general clinics.

METHODS

Subjects comprised 1231 patients ≥ 40 years of age (mean age (65.0 ± 12.0) years, 525 men, 706 women) who had consulted clinics in Nagasaki Prefecture, Japan, for non-respiratory disease. BMI was calculated and lung function was measured by spirometry.

RESULTS

BMI was found to be positively correlated with forced expiratory volume in 1 second (FEV(1))/forced vital capacity (FVC) in men and with maximum mid-expiratory flow (MMF) in all subjects. Following adjustment for relevant factors, a significant positive correlation between BMI and FEV(1)/FVC was identified for all subjects. Comparison between subjects with normal BMI (18.5 - 25.0) and higher BMI (25.1 - 30.0) also demonstrated that FEV(1)/FVC and percentage of predicted maximum mid-expiratory flow (%MMF) were significantly higher in the latter subjects.

CONCLUSIONS

In a population without marked respiratory disease, higher BMI subjects showed less obstructive pulmonary dysfunction compared to normal BMI subjects. High BMI status alone may be inappropriate as a predictor of obstructive lung dysfunction, particularly in populations with a low prevalence of obesity.

Aspergillus fumigatus synergistically enhances mite-induced allergic airway inflammation

BACKGROUND

Infection is an important trigger of exacerbation of bronchial asthma. The fact that Aspergillus fumigatus (Af) causes a distinct clinical syndrome, allergic bronchopulmonary aspergillosis (ABPA), suggests unique immunological properties in allergic asthma. The present study aimed to determine how Af enhances preexisting allergic airway inflammation and colonizes the airway in asthma.

MATERIAL/METHODS

Six groups of BALB/c mice were prepared: Control; live or dead Af-infected (Live Af or Dead Af); Dermatophagoides farinae (Df) allergen-sensitized (Df); and Df-sensitized plus live or dead Af-infected (Df-live Af or Df-dead Af). Pulmonary pathology, cytokine profiles and mucous production in the airway were evaluated in these groups.

RESULTS

Af infection significantly enhanced Df allergen-induced eosinophilic inflammation via enhancement of Th2-like response. Live, but not dead, Af significantly exacerbated neutrophilic inflammation. Induction of IL-13 and Muc5ac proteins by Df allergen sensitization was significantly enhanced by both live and dead Af infection, resulting in mucous hypersecretion.

CONCLUSIONS

Collectively, the present study showed that mite allergen sensitization concomitant with Af infection enhanced Th2-dominant immune response in the airway, which induced mucous hypersecretion and potentially permitted further colonization by Af spores. It is likely that Af enhances allergic airway inflammation as an allergen, while it enhances neutrophilic airway inflammation as a pathogen. Future studies on pharmacological intervention in the present murine model utilizing glucocorticoid, and anti-fungal drugs are thus promising.

Prevalence of chronic obstructive pulmonary diseases in general clinics in terms of FEV1/FVC

BACKGROUND

The prevalence of chronic obstructive pulmonary disease (COPD) continues to increase all over the world. Nonetheless, COPD is often misdiagnosed in general clinics because of insufficient use of spirometry.

OBJECTIVES

To estimate the prevalence of COPD in general clinics in Japan, we performed spirometry to screen patients who consulted general clinics.

METHODS

Patients 40 years of age and older who consulted clinics in Nagasaki Prefecture, Japan, for non-respiratory diseases and who met certain inclusion criteria had their airflow limitation measured by spirometry. We defined COPD as forced expiratory volume in the first second (FEV(1)) over forced vital capacity (FVC) (FEV(1)/FVC) of < 70% in patients without active pulmonary disease, including physician-diagnosed asthma.

RESULTS

Of the 1424 patients included in the study, 193 (13.6%) showed airflow limitation. Airflow limitation was significantly related to older age, male gender and cumulative pack-years. FEV(1)/FVC in patients with hypertension and chronic hepatitis were significantly lower than in patients without these diseases when adjusted for age, gender and pack-years.

CONCLUSIONS

We showed that there are potentially a number of cases with COPD that are undiagnosed by general physicians in Japan. Measuring airflow limitation by spirometry in smokers with coexisting diseases, such as hypertension and chronic hepatitis, may be very beneficial because COPD is thought to be a systemic disease. The distribution of spirometers to general clinics is definitely needed to detect undiagnosed COPD.

[Two cases of chronic pulmonary thromboembolism diagnosed clinically as chronic obstructive pulmonary disease]

Two cases of chronic pulmonary thromboembolism accidentally diagnosed in the clinical evaluation of COPD are reported. Case 1, a 69-year-old woman who had never smoked, was given a diagnosis of COPD since she had exertional dyspnea with obstructive pulmonary dysfunction and multiple low attenuation areas on her chest CT. Pulmonary ventilation and perfusion scintigram showed mismatched defects and as chronic pulmonary thromboembolism (CPTE) was finally diagnosed. Case 2, a 70-year-old former smoking man had also been previously given a diagnosis of COPD. He had exertional dyspnea, hypoxemia and multiple low attenuation areas in chest CT. Nonetheless his pulmonary function was normal. Pulmonary ventilation and perfusion scintigram showed mismatched defects and pulmonary angiography identified a floating thrombus in the pulmonary artery. Thus he CPTE was diagnosed. The diagnosis of CPTE in COPD is not easy. Physicians should recognize that CPTE can be associated with COPD and perform further examinations including pulmonary ventilation and perfusion scintigram when patients do not show typical results and/or adequately respond to conventional therapy for COPD.

Observational study of the additive effects of pranlukast on inflammatory markers of clinically stable asthma with inhaled corticosteroids and long-acting beta 2 agonists

BACKGROUND

Little is understood about the additive effects of leukotriene receptor antagonists (LTRA) on asthmatics currently medicated with inhaled corticosteroids (ICS) and long-acting beta(2)-agonists (LABA).

OBJECTIVES

The present study examines the anti-inflammatory effects of the LTRA pranlukast in addition to ICS and LABA, among asthmatic patients with normal pulmonary function and unremarkable clinical symptoms.

METHODS

Fifteen adult asthmatics participated in a 2-month, open-label, uncontrolled, prospective, multicenter, observational trial. Patients stabilized (predicted forced expiratory volume in 1 s >80%) by medication with ICS and LABA were also given pranlukast (450 mg daily). Asthma-related symptoms, pulmonary function, blood eosinophil counts and several inflammatory markers in sputum were monitored at week 0, as well as at 4 and 8 weeks after starting therapy with pranlukast.

RESULTS

Adding pranlukast did not further improve blood eosinophil counts, pulmonary function and symptoms, but significantly attenuated sputum cysteinyl leukotrienes, tumor necrosis factor-alpha and interleukin-5 concentrations.

CONCLUSIONS

Although the clinical relevance remains obscure, adding an LTRA attenuates allergic airway inflammation in some asthmatics undergoing treatment with ICS and LABA.

Effects of repeated respiratory syncytial virus infections on pulmonary dendritic cells in a murine model of allergic asthma

BACKGROUND

Primary and secondary respiratory syncytial virus (RSV) infection differentially regulates preexisting allergic airway inflammation.

OBJECTIVES

The present study was designed to determine the effects of primary and secondary low-grade RSV infections on pulmonary dendritic cell (DC) functions.

METHODS

Eight groups of BALB/c mice were used: one group each for control primary and secondary sensitization, primary and secondary sensitization to Dermatophagoides farinae (Derf) allergen, primary and secondary infection with RSV, and primary and secondary sensitization to Derf plus infection with RSV. CD11c+ pulmonary DCs were isolated from these mice and then transferred to naïve mice followed by intranasal Derf challenge. Furthermore, either anti-IL-12 monoclonal antibody (alphaIL-12 mAb) or anti-IL-10 (alphaIL-10) mAb were injected into donor mice after Derf challenge and during RSV infection to determine the involvement of IL-12 and IL-10.

RESULTS

Primary RSV infection failed to induce polarization in DCs since it failed to induce IL-10 and IL-12 production in Derf-sensitized donor lung. In contrast, secondary RSV infection significantly enhanced IL-12 production from Derf-sensitized donor lung, thereby enhancing both Th1 and Th2 responses. During RSV infection, alphaIL-12 but not alphaIL-10 mAb treatment blocked these immunological effects.

CONCLUSION

Via IL-12, DCs may play a critical role in shifting the immune response in this experimental model of repeated respiratory viral infection in allergic asthma.

[Case of idiopathic bronchiolitis obliterans successfully treated by medication]

A 53-year-old woman visited a clinic for stridor and dyspnea, and was treated with steroid and heparin for bronchial asthma and pulmonary embolism. She was later admitted to our hospital for progressive dyspnea. Blood gas analysis showed severe hypoxemia with hypercapnia. Pulmonary funtion tests revealed severe obstractive pulmonary dysfunction. Chest computed tomography showed a mosaic perfusion pattern. Ventilation-perfusion scanning showed bilateral multiple matched defects, especially in the basal region. Since specimens of Video-assisted thoracoscopic surgical (VATS) lung biopsy showed lymphocytic infiltration in membranous bronchiole and occlusion of the membranous bronchiole lumen, bronchiolitis obliterans was diagnosed. We initiated treatment with steroids, macrolides and bronchodilators and her condition stabilized. Although these therapies did not cure the BO, they did retard its progression.

Cytokine production from peripheral blood mononuclear cells of mite allergen-sensitized atopic adults stimulated with respiratory syncytial virus and mite allergen

BACKGROUND

The interaction between viral respiratory tract infection and allergen sensitization in allergic asthma is unclear. Respiratory syncytial virus (RSV) has attracted attention as an important lower respiratory pathogen during childhood, while recent evidence indicates that RSV is also an important lower respiratory pathogen for adults. Immunity against RSV differs between children and adults. Several reports suggest that RSV infection in children results in a Th2-skewed immune response. The purpose of the present study was to determine the effects of RSV infection in adults who had previously been sensitized with a common aeroallergen.

METHODS

Peripheral blood mononuclear cells (PBMCs) isolated from 9 mite-sensitized atopic subjects and 11 healthy nonatopic subjects were exposed to live or UV-inactivated RSV concomitant to incubation with or without mite allergen, and the subsequent production of cytokines - interleukin (IL)-5, interferon (IFN)-gamma, IL-10 and IL-12p70 - was measured.

RESULTS

Mite allergen significantly increased IL-5 production in atopic PBMCs. RSV infection significantly increased IFN-gamma production from healthy and atopic PBMCs; the levels of IFN-gamma were significantly higher for atopic PBMCs. Live RSV infection significantly attenuated IL-5 production from mite allergen-stimulated atopic PBMCs. UV-inactivated RSV, but not live RSV, significantly enhanced allergen-specific IL-10 production in atopic PBMCs. IL-12 could not be detected in the present study.

CONCLUSION

The present findings suggest that RSV infection did not simply enhance allergen-specific Th2-like response in atopic adults. Live RSV-induced IFN-gamma and RSV protein-induced IL-10 appear to play important roles in the regulation of allergic airway inflammation in atopic adults.

[Case of idiopathic chylothorax successfully treated with surgical ligation of thoracic ducts]

A 72-year-old woman visited a clinic for anorexia and general fatigue but no particular abnormality was detected by routine examination at that time. Thereafter, she experienced gradually increasing dyspnea and chest X ray showed right pleural effusion. Idiopathic chylothorax was diagnosed due to the milky effusion with a high concentration of triglyceride (2618 mg/dl) and no apparent causative disease. Irrespective of treatments including dietary restriction, drainage of the pleural space, and somatostatin injections, her effusion did not reduce. The leakage of lymph fluid from the right posterior mediastinum was identified by lymphatic scintigraphy and she was successfully treated with surgical ligation of the thoracic ducts.

Effects of respiratory syncytial virus infection on dendritic cells and cysteinyl leukotrienes in lung tissues of a murine model of asthma

BACKGROUND

Pulmonary dendritic cells (DCs) play critical roles in both allergy and in viral infection. Levels of cysteinyl leukotrienes (cysLTs) increase after allergen sensitization and viral infection and can modulate the migration and functions of DCs. The present study examines the effects of respiratory syncytial virus (RSV) infection on numbers of DCs and cysLT concentrations in lung tissues of mice sensitized with mite allergen.

METHODS

We examined Control, Dermatophagoides farinae allergen sensitized (Df), RSV infected (RSV) and Df allergen sensitized and RSV infected (Df-RSV) Balb/c mice. We then determined the number of CD11c-positive DCs and the LT concentration in lung tissues of the mice and examined lung pathology and cytokine profiles in thoracic lymph nodes.

RESULTS

Infection with RSV significantly enhanced allergic airway inflammation in Df mice with concomitant increases in Th1 and Th2 immunity. The number of DCs and the cysLT concentrations were significantly increased in the lungs of Df and RSV mice and more so in Df-RSV, than in Df mice.

CONCLUSIONS

The present findings suggest that RSV infection increases the number of DCs and the cysLT concentrations in lung tissues of asthma patients, both of which could result in enhanced allergic airway inflammation.

[Case of bronchial asthma complicated with Takotsubo cardiomyopathy after frequent epinephrine medication]

A 62-year-old man with non-topic severe persistent asthma and chronic obstructive disease suffered severe asthma exacerbation. Epinephrine was repeatedly injected subcutaneously (0.3mg x 8 times in four hours) in addition to intravenous methylprednisolone for his severe asthma. Despite these treatments, his symptoms steadily deteriorated and thus he was transferred to our hospital. He did not have chest pain or a sensation of compression, while ECG on admission demonstrated ST elevation, loss of R-wave progression, negative T waves and QT interval prolongation, suggesting ischemic heart disease. Nonetheless creatine kinase and its MB isozyme were within normal range and myosin light chain I and troponin T were only mildly elevated. Echocardiography demonstrated apical dyskinesia and hypersystole in the basal region of the heart. Finally this case was diagnosed as Takotsubo cardiomyopathy, probably due to catecholamine-mediated myocardial stunning by overuse of epinephrine for acute severe asthma exacerbation. Abnormal findings of ECG and echocardiography became normal without any specific treatments for the heart.

[A case of anaphlaxis caused by mite-contaminated Okonomi-yaki]

A 21-year-old man, who had suddenly developed dyspnea with sneeze, cough and nasal congestion following supper, was admitted to our hospital because of hypoxemia and hypercapnia. Physical examination revealed wheezing in all lung fields and skin flushing. He took home-made Okonomi-yaki made from flour, which had been opened few months ago, and then had been remained uncooked at room temperature. Skin prick tests showed positive for problem flour and mite, but negative for just opened control flour. Collectively, we gave his diagnosis of anaphylaxis caused by mite-contaminated Okonomi-yaki.

A clinical evaluation of definitive and clinical allergic bronchopulmonary mycosis

OBJECTIVE

The present study aims to overcome problems associated with the early diagnosis of allergic bronchopulmonary mycosis (ABPM) using the current criteria.

PATIENTS AND METHODS

Clinical features including radiographic findings from 10 patients with definitive ABPM based on the diagnostic criteria of Rosenberg-Patterson were compared with those from 9 patients with ABPM clinically diagnosed by respiratory allergy specialists.

RESULTS

ABPM should be considered in patients with peripheral blood eosinophilia and pulmonary infiltration and/or central bronchiectasis when serum total IgE is elevated. Complication by bronchial asthma suggested ABPM, but was not essential. The expectoration of sputum containing solid components was a critical factor in patients with a history in ABPM. Evaluation of sputum cultures, serum specific IgE antibodies, skin tests and precipitating antibodies were required to establish a diagnosis, but the positive rate of these tests remained low.

CONCLUSIONS

Even when a definitive diagnosis cannot be established, systemic corticosteroid therapy should be initiated for clinically diagnosed ABPM to prevent irreversible pulmonary dysfunction.

Elevation of serum KL-6 levels in patients with hematological malignancies associated with cytomegalovirus or Pneumocystis carinii pneumonia

The level of serum KL-6 antigen has been reported to be a sensitive indicator of various interstitial pneumonitis, but in patients with hematological malignancies who were accompanied by infective interstitial pneumonitis like Pneumocystis carinii or cytomegalovirus (CMV) pneumonia, it is still unknown whether serum KL-6 level is useful as a good marker for the diagnosis or disease activity. In this study, the serum levels of KL-6 and soluble intercellular adhesion molecule 1 (sICAM-1) were evaluated in five patients with malignant lymphoma or adult T-cell leukemia. Serum KL-6 and sICAM-1 levels at the time of diagnosis of P. carinii or CMV pneumonia were 1220+/-323 U/ml (mean+/-SD) and 1246+/-485 ng/ml, respectively. These levels were apparently high, when compared with standard value of serum KL-6 (<520 U/ml) and that of sICAM-1 (115-306 ng/ml). In patients without P. carinii or CMV pneumonia, who had hematological malignancies or AIDS, serum level of KL-6 was not high (299+/-122 U/ml), but sICAM-1 was high (651+/-495 ng/ml) because of the elevation of sICAM-1 in four of five cases. These findings suggest that, in patients with hematological malignancies, serum level of KL-6 antigen rather than sICAM-1 may be useful in the evaluation of CMV or P. carinii pneumonia.

Quantification of WT1 mRNA by competitive NASBA in AML patients

The measurement of Wilms' tumor gene (WT1) mRNA levels by reverse transcriptase-polymerase chain reaction (RT-PCR) is useful in detecting minimal residual disease (MRD) in leukemia patients. In the present study, we quantified the level of WT1 mRNA in the peripheral blood and bone marrow of patients with acute myelocytic leukemia (AML) at initial onset, remission and recurrence by the use of nucleic acid sequence based amplification (NASBA), and then ascertained the clinical usefulness of this method. At initial onset, the level of WT1 mRNA in the peripheral blood was above 10(3) copies/microgram and that in the bone marrow was above 10(4) copies/microgram. The level of WT1 mRNA was decreased in cases where therapy resulted in complete remission, but it was abnormally high in recurring cases. In AML (M3) patients, the relationship between the level of WT1 mRNA and the expression of the PML-retinoic acid alpha receptor (RAR alpha) gene, assessed by fluorescence in situ hybridization (FISH), was investigated. When leukemia was in remission hematologically, the PML-RAR alpha gene was negative and the level of WT1 mRNA decreased. These findings suggest that the quantification of WT1 gene expression by competitive NASBA is useful in assessing therapeutic effects and detecting MRD.

[Clinical study of infection associated hemophagocytic syndrome]

Hemophagocytic syndrome (HPS) causes pancytopenia, increased blood LDH level, liver dysfunction, DIC, etc. with macrophages appearing in the bone marrow, spleen, lymph nodes, etc. Adult HPS is mostly secondary to various infections, malignant tumors, etc. and sometimes has a serious outcome. Particularly infection associated HPS (IAHS) is triggered by viral, bacterial and fungal infections. The cases of unknown primary disease and suspected IAHS of unidentified pathogenic microorganism are often encountered in the clinical setting. The authors compared IAHS and malignant associated HPS (MAHS) and classified IAHS into viral associated HPS (VAHS), bacterial associated HPS (BAHS) and fungal types to compare the test values based on the test findings at the onset in the HPS cases treated at our Department. The patients consisted of 21 HPS cases, 11 IAHS cases (VAHS 4, BAHS 5, fungal 2) and 10 MAHS cases. Based on the test findings (WBC, Hb, Plt, LDH, ferritin, myelogram, cytokines, [IFN alpha, TNF gamma, IL-6, sIL-2R, M-CSF], adhesion molecules [sICAM-1, sVCAM-1, sELAM-1, sL-selectin]) at the onset, a comparison between IAHS and MAHS and among the IAHS cases classified by pathogenic microorganism was made. In the comparison between IAHS and MAHS, the Hb value was significantly decreased and sIL-2R tended to be increased at the onset in MAHS. When comparing the IAHS cases by pathogenic microorganism, Plt was significantly decreased and sICAM-1 and sVCAM-1 were increased at the onset in the BAHS, The BAHS cases had serious underlying diseases and poor prognosis with high incidence of DIC complications. We are going to accumulate more cases for early diagnosis and treatment of IAHS.

[Fatal lactic acidosis in a patient with acquired immunodeficiency syndrome treated with stavudine, lamivudine and indinavir]

Recently, several class-related adverse events have been recognized with antiretroviral drugs. For nucleoside analogue reverse transcriptase inhibitors. (NRTI), lactic acidosis with hepatomegaly and hepatic steatosis have been reported. These appear to occur at a low frequency, but with a high fatality rate. We report a case of fatal lactic acidosis in a patient with acquired immunodeficiency syndrome (AIDS) treated with stavudine (d4T), lamivudine (3TC) and indinavir (IDV). A 48-year-old male AIDS patient was admitted with complaints of general fatigue and dyspnea. His medications at presentation included d4T, 3TC and IDV. Physical examination demonstrated icteric sclerae and abdominal tenderness with hepatomegaly. Laboratory data demonstrated a severe metabolic acidosis with an anion gap due to lactate accumulation. Despite intensive treatment, cardiorespiratory arrest occurred and this could not be resuscitated.

[Granular lymphocyte-proliferative disorder following initiation of protease inhibitor therapy in a patient with acquired immunodeficiency syndrome]

The authors experienced granular lymphocyte-proliferative disorder (GLPD) with increased lymphocyte and CD4 cell counts after HIV treatment with a protease inhibitor indinavir in a 51-year-old male AIDS patient. GLPD proved to be the chronic type, but we could not differentiate whether it was the T-cell type or the NK-cell type. EB virus was found to be activated and its chronic activity was suggested. We should note in this case that EB virus was involved in the GLPD onset and that GLPD followed the treatment with a protease inhibitor.

[Serum levels of carboxyterminal propeptide of type I procollagen (PICP), cross-linked carboxyterminal telopeptide region of type I collagen (ICTP) and carboxyterminal parathyroid hormone-related protein (C-PTHrP) in hematological malignancies with bone lesions and hypercalcemia]

We measured the levels of carboxyterminal propeptide of type I procollagen (PICP), cross-linked carboxyterminal telopeptide region of type I collagen (ICTP) and carboxyterminal parothyroid hormone-related protein (C-PTHrP) in serum of patients with hematological malignancies. ICTP and C-PTHrP levels in serum of multiple myeloma (MM), non-Hodgkin's lymphoma (NHL) and adult T-cell leukemia (ATL) patients with bone lesions and hypercalcemia were significantly higher than those of patients without bone lesions and hypercalcemia. ICTP and C-PTHrP levels in ATL were significantly higher than in MM and NHL. There was a correlation between ICTP and C-PTHrP in serum of ATL patients, but no correlation in MM and NHL. Serum ICTP levels tended to correlate with serum beta 2-microglobulin and survival in patients with MM. Therefore, ICTP and C-PTHrP levels in serum may be useful in the diagnosis of bone lesions and hypercalcemia in hematological malignancies. In particular, ICTP may be a useful bone resorption marker in MM.

[Anemia due to chronic lead poisoning]

We report a case of anemia due to chronic lead poisoning. A 46-year-old female was admitted to our hospital because of general fatigue and anemia. A peripheral blood smear showed basophilic stippling. There was basophilic stippling and nuclear dysplasia of erythroblasts in the bone marrow. Laboratory findings were as follows: RBC 296 X 10(4)/microliter, Hb 8.5 g/dl, blood lead concentration 67 micrograms/dl, urinary lead concentration 309 micrograms/l, blood delta-ALA dehydrase 0.03 mumol/ml, urinary delta-ALA 25.2 mg/l, urinary coproporphyrin 8,810 micrograms/g.Cr, and blood protoporphyrin 612 micrograms/dl. Chronic lead poisoning was diagnosed and she was treated with Ca-EDTA.

[Soluble interleukin-2 receptor and macrophage colony-stimulating factor (M-CSF) in cerebrospinal fluid in patients with hematological malignancies: clinical significance in adult T-cell leukemia with meningeal infiltration]

We measured soluble interleukin-2 receptor (sIL-2R) and macrophage colony-stimulating factor (M-CSF) levels in the cerebrospinal fluid (CSF) of patients with hematological malignancies with or without meningeal infiltration and meningitis. Levels of sIL-2R and M-CSF in the CSF of adult T-cell leukemia (ATL) patients with meningeal infiltration were significantly higher than those of ATL patients without meningeal infiltration and non-ATL patients with meningeal infiltration. There was a significant positive correlation between sIL-2R levels and numbers of mononuclear cells in CSF of ATL patients with meningeal infiltration. However, M-CSF levels did not correlate with numbers of mononuclear cells. There was no correlation between CSF and serum levels of sIL-2R. There was also no correlation between sIL-2R and M-CSF in the CSF. Therefore, sIL-2R and M-CSF levels in the CSF may be useful in the diagnosis of meningeal infiltration in patients with ATL. In particular sIL-2R may be a sensitive marker.

[Clinical significance of soluble interleukin-2 receptor levels in the cerebrospinal fluid in patients with adult T-cell leukemia complicated with meningeal infiltration]

We measured soluble interleukin-2 receptor (sIL-2R) levels in the cerebrospinal fluid (CSF) of patients with hematological malignancies especially, adult T-cell leukemia (ATL) and non-Hodgkin's lymphoma (NHL) with or without meningeal infiltration. CSF levels of sIL-2R were significantly higher in patients with ATL and NHL with meningeal infiltration than in patients with both diseases without meningeal infiltration. The sIL-2R levels in CSF were elevated in 4/4 ATL patients (100%) and 3/13 NHL patients (23%) with meningeal infiltration. CSF levels of sIL-2R from ATL patients with meningeal infiltration had a tendency to elevate in correlation with numbers of mononuclear cells and lactic dehydrogenase (LDH) in CSF. However, these had no correlation with serum levels of sIL-2R. Therefore, sIL-2 levels in CSF may be useful in the diagnosis of meningeal infiltration in patients with ATL, are probably specific markers for meningeal infiltration of ATL.