Associated demographics of persistent exhaled nitric oxide elevation in treated asthmatics

BACKGROUND

The fraction of exhaled nitric oxide (FENO) is reduced by anti-inflammatory treatment in asthma. However, the FENO level is also regulated by individual demographics and there is considerable variation among clinically stable patients.

OBJECTIVE

We hypothesized that some demographics may be responsible for persistent FENO elevation despite inhaled corticosteroids (ICS) therapy in asthma.

METHODS

This was a prospective observational study. We initially screened 250 stable asthmatics and determined the FENO cut-off point for identifying poorly controlled asthma defined by one of the following criteria: Asthma control test <20, or forced expiratory volume in one-second % of predicted <80%, or peak expiratory flow variability <80% (Study 1). After 12-weeks, 229 patients who maintained high or low FENO were selected and the independent factors which might contribute to a high FENO were examined (Study 2).

RESULTS

A FENO level >39.5 p.p.b. yielded 67% sensitivity and 76% specificity for identifying the patients with poorly controlled asthma. The persistent high FENO group (≥ 40 p.p.b.) was more likely to be ex-smokers, to show evidence of atopy (positive specific IgE, higher serum IgE and blood eosinophils), and to have allergic comorbidities. Especially, past smoking history, blood eosinophils, and chronic rhinosinusitis were identified to be independent predictors of high FENO. Neither the dose of ICS nor other medication use showed any difference between the groups.

CONCLUSIONS AND CLINICAL RELEVANCE

These results suggested that past smoking history, blood eosinophilia, and chronic rhinosinusitis are involved in the persistent airway inflammation detected by FENO. Although their relative contributions on FENO values should be further quantified, clarification of the features of the subjects with high FENO might provide clues for adjustment of the treatment approach in asthma.

Periostin, a matrix protein, is a novel biomarker for idiopathic interstitial pneumonias

Idiopathic interstitial pneumonias (IIPs) are histopathologically classified into several types, including usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) and cryptogenic organising pneumonia (COP). We investigated whether periostin, a matrix protein, could be used as a biomarker to assess histopathological types of IIPs. We performed immunohistochemical analyses in each histopathological type of IIP, examined serum levels of periostin in IIP patients and analysed the relationship between serum levels of periostin and the pulmonary functions in patients with idiopathic pulmonary fibrosis (IPF). Periostin was strongly expressed in lungs of UIP and fibrotic NSIP patients, whereas expression of periostin was weak in the lungs of cellular NSIP and COP patients, as well as in normal lungs. Serum levels of periostin in IPF were significantly higher than those of healthy subjects and COP patients. Furthermore, periostin levels in IPF patients were inversely correlated with their pulmonary functions. Thus, we have found that periostin is a novel component of fibrosis in IIP. Periostin may be a potential biomarker to distinguish IIP with fibrosis.

Interleukin-18 production and pulmonary function in COPD

Interleukin (IL)-18 production and pulmonary function were evaluated in patients with chronic obstructive pulmonary disease (COPD) in order to determine the role of IL-18 in COPD. Immunohistochemical techniques were used to examine IL-18 production in the lungs of patients with very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage IV, n = 16), smokers (n = 27) and nonsmokers (n = 23). Serum cytokine levels and pulmonary function were analysed in patients with GOLD stage I-IV COPD (n = 62), smokers (n = 34) and nonsmokers (n = 47). Persistent and severe small airway inflammation was observed in the lungs of ex-smokers with very severe COPD. IL-18 proteins were strongly expressed in alveolar macrophages, CD8+ T-cells, and both the bronchiolar and alveolar epithelia in the lungs of COPD patients. Serum levels of IL-18 in COPD patients and smokers were significantly higher than those in nonsmokers. Moreover, serum levels of IL-18 in patients with GOLD stage III and IV COPD were significantly higher than in smokers and nonsmokers. There was a significant negative correlation between serum IL-18 level and the predicted forced expiratory volume in one second in patients with COPD. In contrast, serum levels of IL-4, IL-13 and interferon-gamma were not significantly increased in any of the three groups. In conclusion, overproduction of interleukin-18 in the lungs may be involved in the pathogenesis of chronic obstructive pulmonary disease.

Effects of inhaled ciclesonide on circulating T-helper type 1/T-helper type 2 cells in atopic asthmatics after allergen challenge

BACKGROUND

The predominance of T-helper type 2 (Th2) lymphocytes is thought to underlie the pathogenesis of asthma. Allergen inhalation challenge in atopic asthmatic subjects is associated with decreased interferon-gamma (IFN-gamma) positive CD4+ and CD8+ lymphocytes in peripheral blood and induced sputum.

OBJECTIVE

This study examined the effects of an inhaled corticosteroid on these previously described allergen-induced changes in circulating Th1 and Th2 lymphocytes.

METHODS

Subjects were randomized to 7 days of placebo, 40 or 80 micro g ciclesonide in a crossover study. Airway responses and peripheral blood were measured before and after treatment, and 24 h after allergen challenge.

RESULTS

Ciclesonide 40 and 80 micro g significantly attenuated the late response and sputum eosinophils at 8 h post-allergen (P<0.05). Circulating IFN-gamma positive CD4+ lymphocytes decreased after allergen challenge with placebo (P<0.05), and this was inhibited by 40 micro g ciclesonide treatment (P<0.05). There was no effect of allergen inhalation or ciclesonide on IL-4-positive CD4+ lymphocytes or IFN-gamma and IL-4-positive CD8(high) lymphocytes. The allergen-induced change of IFN-gamma/IL-4 ratio on CD4+ cells correlated with the allergen-induced change of peripheral blood eosinophils.

CONCLUSIONS

The results of this study suggest that attenuation of allergen-induced airway responses by ciclesonide may be mediated through regulation of IFN-gamma-positive CD4+ cells.

Clinical study of severe influenza virus pneumonia that caused acute respiratory failure

The mortality of the influenza virus pneumonia is on the increase caused by the decline of the vaccination for the influenza virus in Japan. The purpose of our research is to study the clinical feature of severe influenza virus pneumonia that caused acute respiratory failure. This study included 68 patients with adult influenza virus infection who consulted our hospital between October 1997 and May 1999. Six (8.8%) of 68 were diagnosed as having influenza virus pneumonia that caused acute respiratory failure. All patients with influenza virus pneumonia showed severe conditions with respiratory failure and a high-risk group. Two super high age patients had emergency status with unconsciousness. A super high age patient with influenza virus pneumonia died of aspiration pneumonia 118 days after admission. All patients with influenza virus pneumonia were received antibiotics. Although 4 of 6 patients did not respond to antibiotics, adrenocorticosteroids were administered. As the result, 3 of 4 patients, healing was achieved. We concluded that adrenocorticosteroids might be useful for treating severe influenza virus pneumonia under the administration of appropriate antibiotics.

[Clinical features of deep mycosis in critical care center--comparison of serological tests and cultures for mycosis]

The clinical features of invasive deep mycosis in the critical care center was studied and the usefulness for determinations of plasma (1-->3)-beta-D-glucan, one of the major structural components of fungi, in making the diagnosis of deep mycosis was evaluated in comparison with that of blood culture and candida antigen titer using CAND-tec kit. A total of 92 febrile patients (mean age = 54.5 yr., M/F = 70/22) in our critical care center were enrolled in this study. Seventeen out of the 92 febrile patients (18.5%) were those with deep mycosis. In the deep mycosis group, there were 10 patients with fungal panperitonitis, 5 with fungaemia, one with candidal pneumonia and one with candidal empyema. A total of 52 blood samples were obtained from 17 patients with deep mycosis. Forty five out of the 52 blood samples (86.5%) were positive for serum (1-->3)-beta-D-glucan while only 10 were culture-positive. In contrast, six (15.0%) out of the 40 blood samples were obtained from 17 patients with deep mycosis were positive for candida antigen by CAND-tec kit. In the critical care center, deep mycosis is a common infection and determination of serum concentration of (1-->3)-beta-D-glucan is found to be a very useful examination in screening of deep mycosis with high sensitivity and specificity.

Phase I study of a combination of irinotecan and ifosfamide in advanced primary lung cancer

We sought to investigate cisplatin-free chemotherapy for patients with primary lung cancer. We therefore conducted a Phase II study to identify; a) the maximum tolerated dose (MTD) of irinotecan (CPT-11) given with a fixed dose of ifosfamide (IFM), and b) the principal toxic effects associated with this regimen in a Phase I study. A total of 27 patients with previously treated or untreated primary lung cancer received CPT-11 on days 1, 8 and 15 in combination with a fixed dose of IFM, 1.5 g/m2/day, on days 1 through 3, given every 4 weeks. The starting dose of CPT-11 was 30 mg/m2, which was increased by amounts of 10 mg/m2. Four patients were assigned to different dosage levels, and drug toxicity was evaluated for the first 2 cycles. The MTD of CPT-11 was 90 mg/m2, with leukopenia being the dose-limiting effect. The response rate was 43% (6/14; 1 complete response) in non-small cell lung cancer, and 78% (7/9; no complete response) in small cell lung cancer. The recommended dose of CPT-11 for a Phase II study is thus 80 mg/m2 on days 1, 8 and 15 with IFM 1.5 g/m2 given on days 1 through 3. This regimen appears particularly encouraging, because of its low toxicity. Phase II trials of the combination are indicated.

[Summer-type hypersensitivity pneumonitis in a family]

We encountered a family in which three of the five members (The parents and a daughter) had summer-type hypersensitivity pneumonitis that occurred in late summer. All three patients had a productive cough and shortness of breath. Chest roentgenograms of the mother and daughter (but not the father) showed diffuse small nodular shadows in both lung fields. Examination of bronchoalveolar lavage fluid from all three patients showed very high total cell counts, high percentages of T lymphocytes, and low ratios of CD4(+)-to-CD8+ cells. Microscopic examination of transbronchial biopsy specimens obtained from the daughter revealed infiltration of mononuclear cells with characteristic Masson bodies in alveolar septa, and granulomas in the interstitium. Both mother and daughter were positive for serum anti-Trichosporon cutaneum (serotype II) antibody, but the father, who was a current smoker was not. Thus, both mother and daughter were given the diagnosis of summer-type hypersensitivity pneumonitis, and in the father that diagnosis was strongly suspected.

[Chronic pulmonary paracoccidioidomyosis in a Japanese Adult]

We encountered a case of chronic pulmonary paracoccidiodomycosis in Japan. A 53-year-old Japanese man, who had worked in Brazil from 1964 to 1969. Came to our hospital because of abnormal shadows on a screening chest roentgenogram. In 1989, he had been treated with fluconazole for mucocutaneous-lymphangitic paracoccidioidomycosis with oral ulceration and neak hymphadenitis. Chest roentgenograms and computed tomograms showed diffuse small nodular and emphysematous shadows. Microscopical examination of specimens obtained by transbronchial lung biopsy showed no abnormality. He was treated with oral fluconazole, and the abnormal radiographic shadows regressed. We believe that this was the first case of chronic pulmonary paracoccidiodomycosis in Japan.

[Assay of specific anti-Chlamydia pneumoniae antibodies by ELISA method. 2. studies on clinical usefulness and serological diagnostic standards]

We measured anti-Chlamydia pneumoniae (C. pneumoniae) specific antibody titers by means of a newly-developed enzyme-linked immunosorbent assay (ELISA) method using an anti-C. pneumoniae specific antibody detection reagent. The clinical usefulness of this method was hereby evaluated. The IgG, IgA and IgM titers in 418 serum specimens obtained from patients with respiratory tract infections were measured by this new ELISA method, and the results were compared with the titers determined for the same specimens with the micro immunofluorescence (Micro-IF) method. The results showed good correlation coefficients for IgG, IgA and IgM. The two assay methods showed high agreement rates for positivity and for negativity. Specimens which did not yield the same results with the ELISA method and the Micro-IF method were subjected to analysis by the Western blot method, and the rates of agreement with the ELISA results were high. In addition, the child (0 approximately 15 yrs old; n = 122) and adult (16 approximately 90 yrs old; n = 133) cases were classified on the basis of being antigen-positive or antigen-negative at the initial examination, and their antibody-positive rates were determined. The adults showed no statistically significant differences in the antibody-positive rates for either IgG or IgA antibodies as a function of the pretreatment antigen status. However, the children showed statistically significant (p < 0.001) differences in the antibody-positive rates for both IgG and IgA antibodies as a function of the antigen status in the antigen-positive group compared with the rates in the antigen-negative group. Furthermore, the IgM-positive rates for the children were high in the antigen-positive group compared with the rates in the antigen-negative group, and the difference was statistically significant (p < 0.001). The IgM-positive rates in the adults were also significantly (p < 0.05) different between the antigen-positive group and the antigen-negative group. The Micro-IF method was applied to 34 specimens from antigen-positive patients, and 22 specimens were found to show an IgG titer of > or = 512 or an IgM titer of > or = 16. The diagnoses of these patients were acute respiratory disease in sixteen, pneumonia in four. Application of the ELISA-method to those 22 specimens showed all of them to exhibit IgG absorbance of > or = 0.6 and IgA absorbance of 0.2. The results described above indicate the clinical usefulness of our new ELISA method for the detection of antibodies specific for C. pneumoniae. The significance of this ELISA method for serological diagnosis of C. pneumoniae infections and the criteria for diagnosis of acute infections were also discussed.

[A case of unilateral hilar lymphadenopathy resembling lung cancer due to mycoplasmal pneumonia in an adult]

A case of unilateral hilar lymphadenopathy due to mycoplasmal pneumonia in an adult patient is presented. A 54-year-old female was admitted to our hospital because of high grade fever and abnormal shadows on chest roentgenograms. She did not have any respiratory symptoms before admission. Chest roentgenograms on admission revealed a tumor-like shadow in the right hilus resembling lung cancer. On the seventh day after admission, abnormal shadows on chest roentgenograms spontaneously improved without therapy. The patient was diagnosed as having mycoplasmal infection based on the serological tests.

Increased incidence of beta-lactamase-plasmid negative, high level methicillin-resistant Staphylococcus aureus (MRSA)

Recently isolated strains of methicillin-resistant Staphylococcus aureus (MRSA) have high levels of resistance to the agent and produce beta-lactamase less frequently than methicillin-susceptible strains (MSSA). This phenomenon has been observed in Japan. The majority of MSSA strains (26 of 30) isolated in 1992 produced beta-lactamase while only 18 of 31 and 25 of 67 MRSA strains, isolated in 1991 and in 1992 respectively, produced the enzyme. We analyzed the beta-lactamase gene (blaZ) in 30 strains each of MRSA and MSSA isolated from our hospital using the polymerase chain reaction. We found that 28 MSSA strains but only 14 MRSA strains possessed the gene. In addition, the present study indicates that many recently isolated MRSA strains, which lacked blaZ gene and were negative for beta-lactamase, consistently produced coagulase of type II (coagulase typing is a marker of epidemiology for Staphylococcus aureus). These beta-lactamase negative, type II coagulase producing and highly methicillin-resistant MRSA strains are considered to have an increased ability to successfully colonize individuals and an increased epidemic potential, probably because of the saving of the energy otherwise expended in beta-lactamase production and of the loss of beta-lactamase plasmid coding the mecA gene repressor, resulting in constitutive PBP2' production. These factors may contribute to the wide spread of these strains of MRSA in a nosocomial environment.

[Antibiotics susceptibilities and other biological properties of methicillin-resistant Staphylococcus aureus: observation in the last 2 years in our university hospital]

We examined biological properties of strains of methicillin-resistant Staphylococcus aureus (MRSA) which were isolated in our ward in 1991 and 1992. A total of 47 MRSA strains were isolated in 1991 and 64 in 1992. The majority of these strains of MRSA were highly resistant to DMPPC, CEZ and IPM, and were intermediately resistant to MINO. All these strains were, however, sensitive to VCM. The number of coagulase type II strains increased from 22 (46.8%) to 51 (79.7%), and that of enterotoxin type A strains from 27 (57.4%) in 1991 to 47 (73.4%) in 1992. The number of strains which produce Toxic Shock Syndrome Toxin-1 (TSST-1) also increased from 19 (40.4%) to 45 (70.3%), and those strains that produce beta-lactamase decreased from 24 (51.1%) to 21 (32.8%). From the above results, we confirmed the recent change in types of the epidemic strains of MRSA. Namely, there was a marked increase in number of strains which produce type II coagulase type A enterotoxin and TSST-1. For the prevention of a patient to patient-, room to room- and ward to ward-spread, strict isolation was indicated both the infection patients, immunocompromised patients who were at high risk for the infection and the proved carriers. Treatment with VCM was started immediately if MRSA infection was thought plausible. These countermeasures seemed to succeed in reducing the incidence of the infection in our ward.

Rapid diagnosis of cytomegalovirus and Pneumocystis carinii pneumonia by using the capillary polymerase chain reaction

We attempted to detect cytomegalovirus DNA (CMV-DNA) and Pneumocystis carinii DNA (P. carinii-DNA) in sputum samples of 18 hematological neoplasm patients with pneumonia, using rapid cycle DNA amplification. A thermal cycler based on recirculating hot air was used for rapid temperature control of 10-microliters samples in this glass capillary tubes. After a total amplification time of 15 min, the amplified products were electrophoresed on agarose gels and visualized with ethidium bromide. In three cases, CMV-DNA was detected at about the time the pneumonia occurred. These patients were successfully treated with ganciclovir in the early stages of infection and CMV was not detected by the virus culture method. In four other cases, P. carinii-DNA was detected in their sputum samples but not detected by Grocott staining. These four cases of P. carinii were successfully treated with sulfamethoxazole-trimethoprim. For detection of CMV-DNA and P. carinii-DNA using the capillary polymerase chain reaction (PCR), a different temperature setting base on the primer difference was not necessary. Therefore, capillary PCR was performed at the same time for detection of CMV and P. carinii. We conclude that capillary PCR amplification is a valuable tool for rapid diagnosis and early treatment of pneumonia due to CMV and P. carinii.

[In vitro and clinical studies of MRSA infections in compromised hosts]

From January to December 1991, 47 clinical cases in when methicillin-resistant Staphylococcus aureus (MRSA) strains were isolate were investigated at our internal medicine ward. The MRSA infection rate was 57.4% (27/47). The mortality due to MRSA bacteremia was 75.0% (9/12) and that due to MRSA pneumonia was 57.1% (4/7). We think that MRSA infections must be treated by multiple antibiotics. At out institution, most of the patients were given a combination therapy of imipenem + fosfomycin or imipenemt + mynocycline. Although in vitro the MICs of imipenem did not show excellent activity against MRSA strains, in vivo these combination therapy including imipenem showed excellent activity against MRSA infections. We think that this result was due to the additive effect of the two drug combination. We determined the MICs of single antibiotics against MRSA strains. Most of the MRSA strains were sensitive to minocycline and arbekacin. All MRSA strains were sensitive to vancomycin we think that vancomycin is a highly useful drug to combat MRSA infection.

[Detection of Chlamydia pneumoniae by polymerase chain reaction]

We aimed at developing a method for early detection of Chlamydia pneumoniae (C. pneumoniae) from clinical specimens. For this purpose, we amplified C. pneumoniae-specific DNA fragments by polymerase chain reaction. A pair of 24 mer of oligonucleotides which were complementary to the sequences within the region encoding the major outer membrane were synthesized and used as primers. As the results, all three standard strains of C. pneumoniae (AR-39, TW-183 and AR-388) were identified by the detection of the amplified products of 174 base pairs, while each strain of Chlamydia trachomatis and Chlamydia psittaci and a total of 11 strains of bacteria and a strain of Mycoplasma pneumoniae were not. Thus, the present method was found to provide a very high specificity and also a high sensitivity of a detectable level of 10 x 10(-9) inclusion-forming units.

[Rapid diagnosis of cytomegalovirus pneumonia and Pneumocystis carinii pneumonia by using polymerase chain reaction DNA amplification]

We attempted to detect cytomegalovirus DNA (CMV-DNA) and Pneumocystis carinii DNA (carinii-DNA) in urine, blood and sputum samples of 16 leukemia patients with pneumonia, using the polymerase chain reaction (PCR). Synthetic oligonucleotide primer pair were used to amplify DNA from the major immediately genes of CMV and genes for the large subunit of mitochondrial ribosomal RNA of P. carinii. Amplified products were detected by gel electrophoresis. In two cases, CMV-DNA was detected at about the time the pneumonia occurred, and in one of the two cases, CMV-DNA was detected in the sputum sample. This patient was treated immediately with ganciclovir. After ganciclovir treatment, clinical and biochemical signs of CMV pneumonia disappeared. In three cases, carinii-DNA was detected in their sputum samples. In their blood and urine samples, carinii-DNA were not detected. This three cases were treated with sulfamethoxazole-trimethoprim and successfully treated episodes of P. carinii pneumonia. We conclude that PCR amplification may be a valuable tool for rapid diagnosing CMV pneumonia and P. carinii pneumonia.