Pulmonary AL amyloidosis in a patient with primary Sjögren syndrome

Abstract The condition of a 29-year-old woman with primary Sjögren syndrome (SS) was complicated by amyloid light chains- (AL-) type amyloidosis in the paranasal sinus. She had not complained of respiratory symptoms, but her chest computed tomography (CT) scan revealed bilateral multiple nodular shadows. Lung biopsy specimens using video-associated thoracoscopy showed amyloidoma in a subpleural nodular lesion and amyloid deposits in the interstitial parenchymal walls and pulmonary vessels. Pulmonary AL amyloidosis, presumably related to a chronic inflammatory lymphoproliferative process in SS, has rarely been reported.

Successful treatment of reactive hemophagocytic syndrome by plasmapheresis and high-dose γ-globulin in a patient with systemic lupus erythematosus

Abstract A 31-year-old woman who had been administered corticosteroid and immunosuppressive agents for systemic lupus erythematosus (SLE) without flare-up was diagnosed as having reactive hemophagocytic syndrome (HPS) with severe disseminated intravascular coagulation. The causative underlying disease was uncertain, but it was not the SLE itself. Her fulminant HPS with increased serum ferritin and inflammatory cytokines (sIL-2R, TNF-α, IL-6, and IFN-γ) was successfully treated with plasmapheresis and high-dose γ-globulin therapy.

Ribosomal P protein P0 as a candidate for the target antigen of anti-endothelial cell antibodies in mixed connective tissue disease

OBJECTIVE

To evaluate the presence of anti-endothelial cell antibodies (AECA) in patients with mixed connective tissue disease (MCTD) compared to those with systemic sclerosis (SSc) and to determine the candidates for the endothelial auto-antigen that reacts with AECA in patients with MCTD using a molecular cloning strategy.

METHODS

AECA were measured by a cellular enzyme-linked immunosorbent assay (ELISA) using fixed human umbilical vein endothelial cells (HUVEC) in 47 MCTD patients, 68 SSc patients, and 52 normal controls. A HUVEC cDNA expression library was immunoscreened with pooled sera from 6 patients with high AECA levels determined by cellular ELISA to explore the endothelial autoantigens in MCTD. An ELISA assay for anti-ribosomal protein P0 antibodies was used to assess the correlation with AECA levels.

RESULTS

The candidate target proteins recognized by AECA in MCTD included: (i) ribosomal protein P0; (ii) a putative oncogene derived from dek mRNA; (iii) SS-B/La protein; (iv) U1 RNA-associated 70K protein; and (v) DNA-binding protein B. A significant correlation between the levels of AECA and anti-ribosomal protein P0 antibodies was demon-strated in MCTD, but not in systemic sclerosis. The sera containing high levels of AECA from patients with MCTD frequently cross-reacted with ribosomal protein P0. On the other hand, sera without AECA activity from patients with MCTD never reacted with ribosomal protein P0.

CONCLUSION

AECA were more frequently seen in patients with MCTD than in patients with SSc. Ribosomal protein P0 may be one of the major target antigens of AECA in patients with MCTD.

Nonspecific interstitial pneumonia pattern as pulmonary involvement of rheumatoid arthritis

The pathologic patterns of lung involvement were evaluated in 16 patients with rheumatoid arthritis (RA). They consisted of six females and ten males, with a median age of 67.5 years and diagnosed according to the American Rheumatism Association revised criteria. High-resolution computed tomography (HRCT) of the lungs was performed in all patients, and honeycomb formation was apparent in seven. Histopathologically, seven patients were diagnosed with usual interstitial pneumonia (UIP) pattern, seven with nonspecific interstitial pneumonia/fibrosis (NSIP) pattern, and two with UIP/NSIP hybrid pattern. There were no apparent honeycomb formations on HRCT in patients diagnosed with NSIP pattern. In conclusion, the present study demonstrates that NSIP pattern is also a significant histologic classification of interstitial pneumonia associated with RA.

KL-6, a human MUC1 mucin, is expressed early in premature lung

KL-6, one of the MUC1 antigens, is a mucin-like high-molecular-weight glycoprotein, which is strongly expressed on type II pneumocytes. Serum levels of KL-6 have been shown to correlate with activity of interstitial pneumonia (IP). During embryonic development, MUC1 expression coincides with the onset of epithelial sheet and glandular formation. To investigate the potential role of KL-6 in lung morphogenesis, we examined KL-6 expression by immunohistochemistry on autopsied lung tissue specimens of 35 neonates and infants with gestational age from 23 to 40 weeks. Hyaline membranes (HMs) were detected in 13 of 35 cases. Simultaneously, antibody against surfactant protein A (SP-A) was employed in the study which is a distinct marker for type II pneumocytes. In all cases studied with gestational age above 23 weeks, staining for KL-6 was strongly positive in alveolar epithelial cells and in HMs found in 13 cases, whereas immunoreaction for PE10 varied depending on gestational age and duration of postnatal survival. Our findings suggest that KL-6 is expressed earlier in premature lung and may act as an important factor contributing to morphogenesis and function of developing lung in early gestation.

Reduced bone mineral density in Japanese premenopausal women with systemic lupus erythematosus treated with glucocorticoids

Abstract We evaluated bone mineral density (BMD) in Japanese female patients with systemic lupus erythematosus (SLE) and assessed the influence of the use of glucocorticoids. Lumbar BMD was measured by dual x-ray absorptiometry (DXA) in 60 premenopausal females who previously had been receiving glucocorticoid therapy. Therapeutic- and disease-related variables for SLE were analyzed and bone resorption or formation markers were measured. Osteoporosis was defined as a T-score below 2.5 SD by DXA; 12 patients (20%) showed osteoporosis, and 30 (50%) had osteopenia. Compared with the nonosteoporotic group (n = 48), the osteoporotic group (n = 12) had a significantly longer duration of glucocorticoid treatment (P = 0.01), a cumulative prednisolone dose (P = 0.002), and an SLE damage index (SLICC/ACR). There was no difference in the incidence of osteoporosis either with or without the previous use of methyl-prednisolone pulse or immunosuppressive drugs. There was a significant positive correlation between urinary type I collagen cross-linked N-telopeptides (NTx) and serum bone-specific alkaline phosphatase (BAP) (r = 0.404, P = 0.002), but these bone metabolic markers showed no difference between the osteoporotic and nonosteoporotic groups. A good significant negative correlation was shown between BMD and the cumulative glucocorticoid dose (r = -0.351, P = 0.007). Stepwise logistic regression analysis showed that the cumulative glucocorticoid intake was independently associated with osteoporosis. Glucocorticoid-induced osteoporosis was frequently observed in Japanese SLE patients, as in Caucasian populations. The cumulative glucocorticoid dose was associated with an increased risk for osteoporosis. Bone metabolic markers such as NTx and BAP were not influenced by glucocorticoid treatment and could not predict current osteoporosis in SLE patients.

The appearance of S-100 protein-positive dendritic cells and the distribution of lymphocyte subsets in idiopathic nonspecific interstitial pneumonia

Idiopathic interstitial pneumonia (IIP) is a progressive interstitial lung disease of unknown etiology. We investigated dendritic cells in idiopathic nonspecific interstitial pneumonia (NSIP) immunohistochemically, using anti-S-100 protein antibody and anti-HLA-DR antibody and also evaluated the relationship between the distribution of S-100 protein-positive dendritic cells (S- 100 DCs) and the lymphocytic subsets in the lung tissue of NSIP. Fifteen patients with the pathological diagnosis of idiopathic NSIP and six patients with usual interstitial pneumonia (UIP) were recruited into this study. Many S-100 DCs were observed in all the cases of idiopathic NSIP but S-100 DCs were not recognized in UIP cases invariably. In the mirror section method, most S-100 DCs showed a positive reaction of anti-HLA-DR antibody but a negative reaction for anti-CD1a antibody. CD8 and CD4 positive lymphocytes were infiltrated diffusely around S-100 DCs. It was demonstrated that the infiltration of CD8 positive lymphocytes predominated in the fibrosing areas and lymphoid follicles around S-100 DCs more so than CD4 positive lymphocytes.We speculate that the pathogenesis of NSIP is different from UIP and that DC and T cell-mediated immune mechanisms may play a role in the development and perpetuation of NSIP.

Transforming growth factor beta1 gene polymorphism in rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory disease and synovial cells, antigen presenting cells, lymphocytes, and their cytokines might be associated with the disease. Transforming growth factor beta1 (TGFbeta1) has been reported to have important roles in unresolved inflammation, immune suppression, fibrosing processes, and angiogenesis. TGFbeta1 is highly expressed in joints in RA and is considered to be a regulator of anti-inflammation in RA. Polymorphisms of TGFbeta1 have been reported to be associated with the production of TGFbeta1 protein, and to increase the risk of acquiring several diseases. It was speculated that these polymorphisms might also be involved in RA, and therefore the TGFbeta1 codon 10 T869C polymorphism in a series of patients and controls was investigated.

METHOD

A total of 155 patients with RA and 110 healthy subjects were studied. DNA was extracted from peripheral leucocytes and TGFbeta1 codon 10 T869C polymorphism was determined by polymerase chain reaction restriction fragment polymorphism.

RESULTS

A significantly higher proportion of patients with RA with the T allele (CT type or TT type) was found compared with the CC type (p=0.039).

CONCLUSION

The T allele, previously reported to be linked with production of TGFbeta1, may be associated with an increased risk of RA.

Nonspecific interstitial pneumonia as pulmonary involvement of primary Sjögren's syndrome

The pathologic patterns of lung involvement in nine patients with Sjögren's syndrome (SjS) are evaluated. The patients consisted of three males and six females, with a median age of 59 years. The SjS was diagnosed according to the criteria of the First International Seminar on SjS. In all patients, high-resolution computed radiographic scanning (HRCT) of the lungs was performed, and apparent honeycomb or microhoneycomb formation was observed in six patients. Pathologically, six patients were diagnosed with usual interstitial pneumonia (UIP), and three were diagnosed with nonspecific interstitial pneumonia/fibrosis (NSIP) (group II). There were no apparent honeycomb formations on HRCT in patients diagnosed with NSIP. In conclusion, NSIP is also a possible histologic classification of interstitial pneumonia associated with SjS.

Transforming growth factor-beta gene polymorphism in sarcoidosis and tuberculosis patients

SETTING

Transforming growth factor-beta (TGF-beta) plays an important role in many diseases, influencing as it does such processes as immune responses, fibrosing processes, and angiogenesis. Recently, polymorphisms have been described for TGF-beta that are associated with the risk of several diseases. In this study, we investigated whether TGF-beta 1 polymorphism has an effect on sarcoidosis and tuberculosis.

OBJECTIVE

TGF-beta 1 Codon 10 T869C polymorphism was investigated in 110 healthy control subjects, 104 sarcoidosis patients, and 101 tuberculosis patients.

DESIGN

The TGF-beta genotype was determined using polymerase chain reaction restriction fragment length polymorphism.

RESULTS

We found no significant differences in TGF-beta genotypes between sarcoidosis patients and healthy controls or tuberculosis patients and controls. The long axis of the tuberculin skin test was larger in the CC type compared with the CT type. However, there was no association between the TGF-beta genotype and the roentgenographic stage, the disappearance of shadows, or organ involvement in sarcoidosis, nor any association between genotype, the extent or type of roentgenographic shadow, or detected volume of tubercle bacilli in tuberculosis.

CONCLUSION

From the results, we believe that TGF-beta polymorphisms on the whole do not have a strong influence on disease onset or clinical progression in sarcoidosis and tuberculosis, although this polymorphism might have an effect on the immune response in a tuberculosis host.

Detection of antivimentin antibody in sera of patients with idiopathic pulmonary fibrosis and non-specific interstitial pneumonia

It has been suggested that the humoral immune system plays a role in the pathogenesis of non-specific interstitial pneumonia (NSIP). Although some circulating autoantibodies to cytoskeletal protein(s) have been suggested, the antimyofibroblast antibody has not been investigated in patients with idiopathic pulmonary fibrosis (IPF) and NSIP. The purpose of this study is to evaluate the existence of antimyofibroblast antibody in the sera of patients with IPF and NSIP. The MRC5 cell line was used as a model of myofibroblast. The anti-MRC5 cell antibody was characterized in a patient with NSIP using Western blotting. Since we found that one of the anti-MRC5 antibodies was an antivimentin antibody, we established an enzyme-linked immunosorbent assay (ELISA) to measure the levels of antivimentin antibody in the sera of patients with IPF (n = 12) and NSIP (n = 23). Initially, two anti-MRC5 cell antibodies were detected in the sera of patients with NSIP, one of which was characterized as the antivimentin antibody by Western blotting. The other was characterized as an antivimentin fragment antibody. We established an ELISA to measure the antivimentin antibody and found significantly higher levels in patients with IPF and NSIP than in normal volunteers. One of the anti-MRC5 cell antibodies in the serum of a patient with NSIP was against vimentin. The serum levels of antivimentin antibody were increased in patients with IPF and NSIP compared with that of normal volunteers. These results suggest that the antivimentin antibody may be involved in the process of lung injury in IPF and NSIP.

Non-specific interstitial pneumonia and Chlamydia pneumoniae infection

Recently, the clinical features of non-specific interstitial pneumonia (NSIP) have been described. We hypothesize that recurrent infection caused by Chlamydia pneumoniae may play a role in the pathogenesis of NSIP. To prove this, we quantified serum IgA and IgG antibodies against C. pneumoniae using the enzyme linked-immunosorbent assay kit. The study included 15 patients diagnosed with NSIP, 20 patients with chronic obstructive pulmonary diseases (COPD) as disease group, and 27 control subjects. IgA antibody against C. pneumoniae was positive in 12 of 15 patients with NSIP, in 16 of 20 patients with COPD, and in 14 of 27 control subjects. IgG antibody against C. pneumoniae was positive in 14 of 15 patients with NSIP, in 17 of 20 patients with COPD, and in 16 of 27 control subjects. If the cut off value (mean +/- 2SD, index more than 3.0) was introduced, IgA and/or IgG antibodies against C. pneumoniae were positive in 8 of 15 patients with NSIP (53.3%), in 9 of 20 patients with COPD (45%), and in 2 of 27 control subjects (7.4%). These results suggest that infection of C. pneumoniae might play a role in the pathogenesis of NSIP.

Lymphocyte subsets in lung tissues of interstitial pneumonia associated with untreated polymyositis/dermatomyositis

This study was designed to evaluate the distribution of lymphocyte subsets in lung specimens obtained by surgical lung biopsy from 12 patients with interstitial pneumonia associated with untreated polymyositis/dermatomyositis (PM/DM). Differences of histological findings and distributions of lymphocyte subsets between PM and DM were also evaluated. Distributions of B lymphocytes, CD4-positive T lymphocytes, and CD8-positive T lymphocytes were evaluated immunohistochemically. Interstitial pneumonia was pathologically classified as basically nonspecific interstitial pneumonia (NSIP) in all patients. Immunohistochemically, the distribution of B lymphocytes was mostly restricted to inside and/or around lymphoid follicles. The CD4-positive T lymphocytes were distributed diffusely in fibrotic areas and unrelated to lymphoid follicles. Most CD8-positive T lymphocytes were diffusely distributed, especially in relatively normal alveoli. There were no significant differences in the distribution of lymphocyte subsets between PM and DM. Although the distribution of B lymphocytes and CD4- and CD8-positive T lymphocytes in the lung were different, there were no significant differences in distributions of lymphocyte subsets between PM and DM.

Non-specific interstitial pneumonia as pulmonary involvement of systemic sclerosis

The pathological features of lung disease in nine patients with systemic sclerosis (SSc) were evaluated. The patients comprised one man and eight women, with a median age of 58 years. SSc was diagnosed according to the criteria of the American Rheumatism Association. In all patients, high resolution computed radiographic scanning of the lungs (HRCT) was performed, and apparent honeycomb formation was seen in four patients. Pathologically, four patients were diagnosed with usual interstitial pneumonia (UIP), three with non-specific interstitial pneumonia (NSIP) group II, one NSIP group II-III, and one NSIP group II with diffuse alveolar damage. HRCT showed no apparent honeycomb formations in patients diagnosed with NSIP. This is the first report describing NSIP as a pulmonary complication of SSc.

Expression of cyclin E and cyclin D1 in non-small cell lung cancers

The relationships between overexpression of cyclin D1 or cyclin E and clinicopathological factors were investigated in 157 patients with non-small cell lung cancers (NSCLCs) using immunohistochemical analysis. Fifty-eight cases of NSCLCs (58/157, 37%) showed the overexpression of cyclin D1, and 64 cases (64/157, 41%) were positive for cyclin E. Cyclin E and cyclin D1 were infrequently concurrently overexpressed (17/157, 10.8%). Overexpression of cyclin E was more frequently observed in squamous cell carcinoma (29/57, 51%) compared with that in adenocarcinoma (28/86, 33%) (P<0.05). In addition, overexpression of cyclin E was more frequently observed in poorly or moderately differentiated NSCLCs (52/103, 50%) than in well-differentiated ones (12/54, 22%) regardless of their histological types (P<0.01). On the contrary, there was no statistically significant relationship between cyclin D1 overexpression and histological types or grade of tumor differentiation. These findings suggest that expression of cyclin E was frequently independent of that of cyclin D1 and played some roles in the grade of tumor differentiation in NSCLCs.

Lymphocyte Subsets in Lung Tissues of Non-specific Interstitial Pneumonia and Pulmonary Fibrosis Associated with Collagen Vascular Disorders: Correlation with CD4/CD8 Ratio in Bronchoalveolar Lavage

This study was designed to evaluate the distribution of lymphocyte subsets in lung specimens that were obtained by open-lung biopsy from 8 patients with idiopathic nonspecific interstitial pneumonia/fibrosis (NSIP) and 10 patients with pulmonary fibrosis associated with collagen vascular disorders (PF-CVD). Distributions of B lymphocytes, CD4-positive T lymphocytes, and CD8-positive T lymphocytes were evaluated immunohistochemically and compared with the cell composition in BALF. Correlation between CD4/CD8 ratios in bronchoalveolar lavage fluids (BALF) and CD4/CD8 ratios in lung tissues was also examined. B lymphocytes were mostly restricted in lymphoid follicles. CD4-positive T lymphocytes were observed inside and around lymphoid follicles and in the thick fibrotic wall of reconstructed alveoli with fibrosis. In contrast, CD8-positive T lymphocytes were diffusely distributed, especially in relatively thin alveoli. Correlation was weak between CD4/CD8 ratios in lung tissue and CD4/CD8 ratios in BALF. However, even in patients with very low CD4/CD8 ratios in BALF, many CD4 lymphocytes were observed in lung tissues, suggesting that CD8-positive lymphocytes diffusely distributed in thin alveolar architecture were more easily recovered in BALF than CD4-positive lymphocytes. Therefore, a low CD4/CD8 ratio in BALF may indicate that the alveolar structure was not severely reconstructed by fibrosis. This is the first report that compared lymphocyte subsets in lung tissues and in BALF.

Vitamin D receptor gene polymorphism and calcium metabolism in sarcoidosis patients

BACKGROUND

Hypercalcemia has been recognized as an important complication of sarcoidosis, caused by overproduction of the active form of vitamin D, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) at sites of granulomatous reactions. Polymorphism of the vitamin D receptor (VDR) gene has recently been shown to be related to bone mineral density, and also associated with hyperparathyroidism and risk of granulomatous disease. In light of the possible impact on hypercalcemia of sarcoidosis, an investigation of calcium metabolism and polymorphism of the VDR gene in sarcoidosis patients was carried out.

METHODS

Genotypes were determined using the polymerase chain reaction and restriction fragment length polymorphism. Maximum calcium, 1,25(OH)2D3, and intact PTH levels were also determined.

RESULTS

Depressed PTH levels were found in sarcoidosis patients, especially in those with the bb genotype, but there was no difference in 1,25(OH)2D3 levels among the VDR genotypes, and this polymorphism also had no association with onset of hypercalcemia.

CONCLUSION

From these results, we speculate that although the VDR gene polymorphism may affect the serum PTH level, it is not a risk factor for hypercalcemia in sarcoidosis.

Circulating cytokeratin 8:anti-cytokeratin 8 antibody immune complexes in sera of patients with pulmonary fibrosis

BACKGROUND

It has been suggested that the humoral immune system plays a role in the pathogenesis of idiopathic pulmonary fibrosis (IPF) and pulmonary fibrosis associated with collagen vascular disorders (PF-CVD). Although circulating immune complexes in patients' sera have been suggested, none of the antigens have been characterized.

OBJECTIVES

The purpose of this study is to characterize the antigen of the immune complexes in patients' sera of pulmonary fibrosis.

METHODS

As we previously established that one of the antibodies against A549 cells (lung alveolar type II cells) was anti-cytokeratin 8 (CK8), we confirmed the existence of anti-CK8 antibody in patients' sera by Western immunoblot. In addition, we tried to demonstrate circulating CK8:anti-CK8 immune complexes in patients' sera by Western immunoblot. Furthermore, we established an enzyme-linked immunosorbent assay to quantitate CK8:anti-CK8 immune complexes.

RESULTS

In patients with pulmonary fibrosis, anti-CK8 antibodies were clearly demonstrated in sera by Western immunoblot. In addition, circulating CK8:anti-CK8 immune complexes were also clearly demonstrated by Western immunoblot. It was possible to establish ELISA to quantitate CK8:anti-CK8 immune complexes. If the cutoff value, which was determined based on the highest value of normal volunteers, was introduced, high CK8:anti-CK8 antibody complexes were demonstrated in 9 of 31 patients (29.0%) with IPF and PF-CVD.

CONCLUSIONS

This is the first study to clarify the antigen of the circulating immune complex in sera of patients with IPF. These results suggest that circulating CK8:anti-CK8 immune complexes may have played a role in the process of lung injury in pulmonary fibrosis.

Elevation of anti-cytokeratin 18 antibody and circulating cytokeratin 18: anti-cytokeratin 18 antibody immune complexes in sera of patients with idiopathic pulmonary fibrosis

In this study, we hypothesize that anti-cytokeratin 18 (CK18) antibody and CK18:anti-CK18 immune complex increase in sera in patients with idiopathic pulmonary fibrosis (IPF). To prove the existence of anti-CK18 antibodies in patients' sera, bovine CK18 was stained with patients' sera using a Western blotting. In patients with IPF, anti-CK18 antibodies were clearly demonstrated in sera by Western blotting. Then, we tried to establish an enzyme-linked immunosorbent assay (ELISA) to quantify anti-CK18 antibodies and CK18:anti-CK18 immune complexes in sera of patients with IPF. Levels of anti-human CK18 antibodies in sera of patients with IPF (0.81 +/- 0.31, mean +/- SD) measured by ELISA were significantly high compared with that of normal volunteers (0.45 +/- 0.06, p < 0.01). In addition, levels of CK18:anti-CK18 antibody complexes in patients' sera (0.64 +/- 0.35, man +/- SD) significantly increased compared with those of normal subjects (0.40 +/- 0.10, p < 0.01). These results suggest that anti-CK18 antibody and its immune complex may have played a role in the process of lung injury in IPF.

[A case of Wegener's granulomatosis with pachymeningitis]

A 62-year-old woman who had been receiving corticosteroid therapy for pachymeningitis since 1997 was admitted to our hospital when an abnormal shadow was noticed in her chest radiograph. In bronchial and nasal mucosal biopsies, the findings of a necrotic granulomatous lesion and vasculitis were compatible with Wegener's granulomatosis, although this is rarely seen with pachymeningitis. After further corticosteroid therapy together with cyclophosphamide treatment, the size of the thoracic X-ray shadow decreased. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the sputum and the nasal fluid, and may have contributed to the advance of the disease in the airway. This case will require continuing careful observation.

Role of carbohydrate antigens sialyl Lewis (a) (CA19-9) in bronchoalveolar lavage in patients with pulmonary fibrosis

BACKGROUND

It has been reported that carbohydrate antigen sialyl Lewis (a) (CA19-9) levels are elevated in serum as well as in bronchoalveolar lavage fluid (BALF) of patients with pulmonary fibrosis. However, the biological significance of CA19-9 is unclear.

OBJECTIVE

The purpose of the present study was to evaluate correlations between CA19-9 levels in BALF and several biochemical as well as clinical parameters in patients with pulmonary fibrosis. In addition, biological functions of CA19-9 were also examined.

METHODS

We studied 24 patients with a diagnosis of pulmonary fibrosis: 16 with idiopathic pulmonary fibrosis (IPF) and 8 with pulmonary fibrosis associated with a collagen vascular disorder (PF-CVD). In BALF, carbohydrate antigens sialyl Lewis (a) (CA19-9), elastase: alpha(1)-proteinase inhibitor complex (E-PI), hepatocyte growth factor (HGF), LDH, IgG, IgA, albumin, and cell differentiation were measured. We also evaluated the effects of CA19-9 on neutrophil functions.

RESULTS

CA19-9/albumin levels in BALF significantly correlated with HGF/albumin, elastase/albumin, LDH/albumin, total number of alveolar macrophages, and total number of neutrophils. Purified CA19-9 had a chemotactic activity for neutrophils. In addition, neutrophil chemotactic activity to C5a, fMLP, and interleukin 8 was significantly stimulated after incubation with purified CA19-9. Furthermore, CA19-9 increased the expression of CD15s on neutrophils.

CONCLUSIONS

Our data demonstrated (i) CA19-9 in BALF correlated with other markers of inflammation in pulmonary fibrosis, and (ii) CA19-9 can modify neutrophil functions. These results suggest that CA19-9 may play a role in the process of lung injury in patients with pulmonary fibrosis.

Sequential changes of KL-6 in sera of patients with interstitial pneumonia associated with polymyositis/dermatomyositis

OBJECTIVE

KL-6 is a mucin-like high molecular weight glycoprotein, which is strongly expressed on type II alveolar pneumocytes and bronchiolar epithelial cells. It has been demonstrated that the KL-6 antigen is a useful marker for estimating the activity of interstitial pneumonia. In this study, it is hypothesised that serum KL-6 is a useful marker to evaluate the activity of interstitial pneumonia associated with polymyositis/dermatomyositis (PM/DM).

METHODS

KL-6 was measured in sera in 16 patients diagnosed with PM/DM. Five had non-specific interstitial pneumonia (NSIP), three had diffuse alveolar damage (DAD), and eight had no pulmonary involvement, and 10 were normal non-smokers as a control group. The correlation was also evaluated between the KL-6 level and each clinical course in patients with pulmonary involvement associated with PM/DM. Immunohistochemical analysis using monoclonal anti-KL-6 antibody was also performed.

RESULTS

KL-6 concentrations in sera of patients with interstitial pneumonia associated with PM/DM were significantly high compared with those of PM/DM without interstitial pneumonia, and normal non-smokers. KL-6 concentrations in sera in patients with DAD significantly increased compared with those of other groups. KL-6 values in sera changed according to the progression or improvement of interstitial pneumonia. Immunohistochemical study using pulmonary tissues obtained from patients with DAD demonstrated that the hyaline membrane, proliferating type II pneumocytes, bronchial epithelial cells and some endothelial cells in pulmonary veins were stained by antihuman KL-6 antibody.

CONCLUSION

These data demonstrate that measurement of serum KL-6 was a useful marker to evaluate the activity of acute interstitial pneumonia associated with PM/DM.

Immunohistochemical study of a patient with diffuse pulmonary corpora amylacea detected by open lung biopsy

The chest radiographs of an asymptomatic 58-year-old Japanese man with pulmonary corpora amylacea (PCA) revealed bilateral patchy and nodular infiltrates. Lung specimens obtained by open lung biopsy were histochemically and immunohistochemically analyzed. In all sections of dissected lung tissue, hematoxylin and eosin staining revealed homogeneous eosinophilic acellular round bodies (50-100 microm in diameter) containing granular black pigments in the alveolar spaces. Some round bodies were surrounded and phagocytized by alveolar macrophages. The laminated round bodies stained positively with PAS and Congo red. In addition, many of the rounded bodies contained particles which stained positively with Berlin blue. Immunohistochemical staining for epithelial membrane antigen (EMA) as well as PE-10 was distinctively positive. This is a very rare case of diffuse PCA found by open lung biopsy. Immunohistochemical examination suggested that PCA consisted of pulmonary surfactant protein and epithelial membrane antigen.

Elevation of cytokeratin 19 fragment in patients with interstitial pneumonia associated with polymyositis/dermatomyositis

OBJECTIVE

Cytokeratin 19 fragment (CK19) levels in serum have been documented as a useful tumor marker for lung cancer. We hypothesize that CK19 may increase in serum in patients with interstitial pneumonia associated with polymyositis/dermatomyositis (PM/DM) and CK19 might be a useful variable to evaluate the activity of lung injury.

METHODS

1. We measured CK19 in sera in 15 patients diagnosed with PM/DM; 6 had nonspecific interstitial pneumonia (NIP), 4 had acute interstitial pneumonia (AIP), and 5 had no pulmonary involvement. We also measured CK19 in 10 healthy nonsmokers serving as a control group. 2. We evaluated the correlation between CK19 level and individual clinical course in patients with pulmonary involvement associated with PM/DM.

RESULTS

CK19 levels in sera of patients with NIP associated with PM/DM were significantly higher versus patients with PM/DM without interstitial pneumonia and healthy nonsmokers. CK19 levels in sera in patients with AIP associated with PM/DM were significantly higher compared with the other groups. CK19 values in sera changed according to the progression or improvement of interstitial pneumonia. Immunohistochemical studies using pulmonary tissues obtained at autopsy from patients with AIP associated with PM/DM revealed that the hyaline membrane was mostly stained by anti-human cytokeratin 19 monoclonal antibody as well as the strong positivity of proliferating type II pneumocytes.

CONCLUSION

These results suggest that the measurement of CK19 was a useful variable to evaluate the activity of lung injury in interstitial pneumonia associated with PM/DM.

Myofibroblasts and S-100 protein positive cells in idiopathic pulmonary fibrosis and rheumatoid arthritis-associated interstitial pneumonia

The aim of this study was to investigate whether idiopathic pulmonary fibrosis (IPF) can be distinguished from rheumatoid arthritis (RA)-associated interstitial pneumonia (RA-IP) by means of quantitatively assessing myofibroblasts and S-100 protein positive dendritic cells. Seven patients with IPF and twelve with RA, in whom the pathological findings were consistent with usual interstitial pneumonia (UIP) were studied. Antibodies to vimentin, alpha-smooth muscle actin (alpha-SMA) and S-100 protein were used for immunohistochemical studies performed using the streptavidin/biotin/peroxidase complex method, applied to dewaxed sections from each case. In fibrosis of RA-IP, appearance of both vimentin- and alpha-SMA-positive cells, namely myofibroblasts, was widely observed, together with the pathological patterns of honeycombing, UIP and bronchiolitis obliterans-organizing pneumonia (BOOP). Fibrosis, in cases of chronic IPF, was found to be characterized mainly by vimentin-positive but alpha-SMA-negative fibroblasts. Pulmonary tissues from RA-IP patients especially when associated with a BOOP pattern, contained many cells positive for S-100 protein. However, such cells were generally hard to find in cases of IPF. These findings suggests that idiopathic pulmonary fibrosis and rheumatoid arthritis-associated interstitial pneumonia can be differentiated from each other, to some extent, based on the appearance of myofibroblasts and the presence of S-100-positive dendritic cells.

Elevated serum and BAL cytokeratin 19 fragment in pulmonary fibrosis and acute interstitial pneumonia

Cytokeratin 19 fragment (CK19) levels in serum have already been documented as a useful tumour marker for lung cancer. In the present study, it was hypothesized that CK19 may be increased in the serum and epithelial lining fluid of the respiratory tract from patients with pulmonary fibrosis. CK19 was measured in the serum and bronchoalveolar lavage fluid (BALF) of patients with pulmonary fibrosis and the correlation between CK19 levels and clinical parameters evaluated. Nineteen patients diagnosed with idiopathic pulmonary fibrosis (IPF), eight with pulmonary fibrosis associated with a collagen vascular disorder (PF-CVD), seven patients with acute interstitial pneumonia (AIP), and 10 normal smokers as a control group were studied. CK19 levels in sera of patients with IPF and patients with PF-CVD were significantly increased compared to those of normal smokers. CK19 levels in sera of patients with AIP were significantly increased compared to those of other groups. CK19 values in the BALF of patients with pulmonary fibrosis were significantly elevated compared to those of normal smokers. CK19 values in sera charged according to the progression or improvement of the acute lung injury. Immunohistochemical study using pulmonary tissues obtained from patients with AIP demonstrated that the hyaline membrane and proliferating type II pneumocytes were stained by anti-human cytokeratin 19 antibody. These data demonstrated that the measurement of cytokeratin 19 fragment is a useful parameter to evaluate the activity of lung epithelial cell damage and repair.

Elevation of anti-cytokeratin 19 antibody in sera of the patients with idiopathic pulmonary fibrosis and pulmonary fibrosis associated with collagen vascular disorders

It has been suggested that cytokeratin 19 is expressed in regenerated bronchoepithelial cells in patients with pulmonary fibrosis, and serum cytokeratin 19 fragment is elevated in patients with pulmonary fibrosis. We hypothesized that serum antibodies to cytokeratin 19 may be formed in patients with pulmonary fibrosis. To prove the existence of anti-cytokeratin 19 antibodies in patients' sera, human recombinant cytokeratin 19 was stained with patients' sera by a Western immunoblot. Then, we tried to establish an enzyme-linked immunosorbent assay to quantitate anti-cytokeratin 19 antibody in the sera of patients with idiopathic pulmonary fibrosis (IPF) and pulmonary fibrosis associated with collagen vascular disorders (PF-CVD). We demonstrated the anti-cytokeratin 19 antibody in patient' sera by a Western immunoblot. In patients with IPF and PF-CVD, significantly high anti-cytokeratin 19 antibody was demonstrated compared with normal volunteers, patients with chronic bronchitis, and patients with pneumonia. These results suggest that anti-cytokeratin 19 antibody may have played a role in the process of lung injury in pulmonary fibrosis.

Prognostic value of serum hepatocyte growth factor in patients with acute coronary syndromes

The present study examined whether or not hepatocyte growth factor (HGF), an endothelium-specific growth factor that stimulates regeneration of the endothelium, is increased or has a prognostic significance in patients with acute coronary syndromes. HGF was measured in 106 patients with coronary artery disease (20 stable effort angina, 12 unstable angina without adverse events, 24 unstable angina with adverse events and 50 acute myocardial infarction) on admission and 21 normal volunteers. The measurements in all patients were recorded before administration of heparin, and in acute myocardial infarction patients they were recorded from days 2 to 6 after heparin discontinuation on day 1. HGF levels (ng/ml) were 0.30+/-0.06 for the controls, 0.31+/-0.08 for stable effort angina patients, 0.31+/-0.08 for unstable angina patients without adverse events, 0.40+/-0.20 for unstable angina patients with adverse events and in acute myocardial infarction patients they were 0.45+/-0.18 on day 0, 0.57+/-0.45 on day 2, 0.50+/-0.35 on day 3, 0.48+/-0.32 on day 4, 0.44+/-0.20 on day 5, and 0.38+/-0.14 on day 6. HGF plays a crucial role in the restoration of injured endothelial cells and is a predictor of adverse events in patients with acute coronary syndromes.

Comparison between fenoterol and fenoterol plus oxitropium bromide delivered by metered-dose inhaler with InspirEase to relieve acute asthma attack

Although the inhalation of beta2-agonists has frequently been used to relieve acute asthma attacks, the efficacy of anticholinergic agents for acute asthma attacks still remains unclear. This study was designed to compare the inhalation of fenoterol and the inhalation of fenoterol plus oxitropium bromide delivered by a metered-dose inhaler with holding chamber (InspirEase) to relieve acute asthma attacks. To accomplish this, 69 patients who had presented with an acute asthma attack were randomized to receive either fenoterol (1 puff [200 microg/puff] every 1 min for 5 min; total 1000 microg) or fenoterol plus oxitropium bromide (2 puffs [100 microg/puff] every 1 min for 5 min; total 1000 microg). The peak expiratory flow (PEF) and forced expiratory volume in 1 sec (FEV1) values were measured before treatment, and 1, 15, 30, and 60 min after the inhalation therapy. The ratios of improvement, PEF (or FEV1) after treatment divided by PEF (or FEV1) before treatment, were also calculated. Thirty-three patients were evaluated in the combination group and 31 patients were evaluated in the fenoterol group. The PEF value at 60 min after inhalation therapy of the fenoterol plus oxitropium bromide group (261 +/- 18 L/min, mean +/- standard error) was significantly higher compared to that of the fenoterol group (210 +/- 17 L/min). In addition, the ratios of improvement of PEF at 1, 15, 30, and 60 min after inhalation therapy were significantly higher in the fenoterol plus oxitropium bromide group compared with the fenoterol group.

Clinical features of non-specific interstitial pneumonia

The clinical features of 24 patients with non-specific interstitial pneumonia (NIP) were evaluated. The patients consisted of seven men and 17 women, with a median age of 60 years. In seven patients, the disease was idiopathic and eight had collagen vascular diseases. Cough, dyspnoea and fever were frequently observed. The time interval between the onset of symptoms and open lung biopsy was 3 months. Mild increases of IgG, CRP, and LDH were also frequently observed. The average per cent VC was 65.1 +/- 3.2% and the average PaO2 was 71.3 +/- 2.4 Torr. Bronchoalveolar lavage was done in 20 patients, and a moderate increase in lymphocytes (27.8 +/- 6.7%) with a low CD4/CD8 ratio (0.86 +/- 0.22) was observed. Multiple patchy infiltration or diffuse interstitial shadows, located predominantly in the lower fields of both lungs were the characteristic chest CT findings. Lung biopsies in this group were characterized by varying proportions of chronic interstitial inflammation and fibrosis which was temporarily uniform. Patients were given steroid pulse therapy or oral steroids. The results were mild to marked improvements in chest roentgenographic findings and lung functions. Four patients (16.7%) died because of respiratory failure caused by NIP. This is the first report to describe clinical features of NIP since the original report by Katzenstein and Fiorelli.

Heterogeneous point mutations of the p53 gene in pulmonary fibrosis

Lung cancer is a frequent complication in pulmonary fibrosis. Overexpression of p53 proteins has been demonstrated by immunostaining in bronchoepithelial cells in patients with idiopathic pulmonary fibrosis. However, it is still unclear whether this overexpressed p53 protein is wild-type or mutant. It was hypothesized that pulmonary fibrosis may be a precancerous lesion with deoxyribonucleic acid point mutations in bronchoepithelial cells. Mutations of the p53 gene were tested for by fluorescence-based single-strand conformation polymorphism (FSSCP), cloning-sequencing and immunostaining techniques. Out of 10 tissue samples that demonstrated overexpression of p53 protein by immunostaining, nine (90%) exhibited point mutations and eight (80%) exhibited heterogeneous point mutations of the p53 gene. The mutations found in pulmonary fibrosis were scattered throughout the central part of the p53 gene, and both guanine (G):cytosine (C) to adenine (A):thymine (T) and A:T to G:C transitions were frequently observed. In conclusion, frequent heterogeneous point mutations of the p53 gene were detected in pulmonary fibrosis. These mutations may have resulted from several types of deoxyribonucleic acid damage that occurred in bronchoepithelial cells and this may explain previous findings of a very high incidence of lung cancer complicating pulmonary fibrosis.

Detection of anti-cytokeratin 8 antibody in the serum of patients with cryptogenic fibrosing alveolitis and pulmonary fibrosis associated with collagen vascular disorders

BACKGROUND

It has been suggested that the humoral immune system plays a role in the pathogenesis of cryptogenic fibrosing alveolitis (CFA). Although circulating autoantibodies to lung protein(s) have been suggested, none of the lung proteins have been characterised. The purpose of this study was to determine the antigen to which the serum from patients with pulmonary fibrosis reacted.

METHODS

The anti-A549 cell antibody was characterised in a patient with CFA using Western immunoblotting and immunohistochemical staining of A549 cells. As we identified that one of the antibodies against A549 cells was anti-cytokeratin 8, the expression of mRNA of cytokeratin 8 in A549 cells was evaluated. In addition, we attempted to establish an enzyme linked immunosorbent assay to measure the levels of anti-cytokeratin 8 antibody in the serum of patients with CFA and pulmonary fibrosis associated with collagen vascular disorders (PF-CVD).

RESULTS

Initially two anti-A549 cell antibodies were detected in the serum of patients with pulmonary fibrosis, one of which was characterised as anticytokeratin 8 antibody by Western immunoblotting. We were able to establish an ELISA to measure anti-cytokeratin 8 antibody and found significantly higher levels in patients with CFA and PF-CVD than in normal volunteers, patients with sarcoidosis, pneumonia, and pulmonary emphysema.

CONCLUSIONS

One of the anti-A549 cell antibodies in the serum of patients with CFA was against cytokeratin 8. The serum levels of anti-cytokeratin 8 antibody were increased in patients with CFA and PF-CVD. These results suggest that anticytokeratin 8 antibody may be involved in the process of lung injury in pulmonary fibrosis.

[Significance of hepatocyte growth factor measurement in patients with acute myocardial infarction]

The use of hepatocyte growth factor for acute myocardial infarction was investigated. Several other biochemical markers are already used for noninvasive detection of acute myocardial infarction. Hepatocyte growth factor, creatine phosphokinase (CK) and CK isozyme (CK-MB) levels were measured in 10 patients with stable effort angina after diagnostic catheterization, and in 21 patients with acute myocardial infarction twice a day for the first 3 days and once a day for the next 4 days. The time to reach the maximum level and the time to decline to less than half of the maximum level for each patient was also measured. Hepatocyte growth factor levels (ng/ml) were 0.3 +/- 0.1 for patients with angina pectoris, and 10.4 +/- 8.8 within 6 hours and 6.7 +/- 4.5 within 12 hours after the onset for patients with acute myocardial infarction. The time to reach the maximum (hours) and the time to decline to less than half of the maximum level (days) were 9.2 +/- 5.2 and 1.1 +/- 0.3 for hepatocyte growth factor, 19.5 +/- 7.2 and 2.3 +/- 1.1 for CK and 16.3 +/- 7.2 and 1.5 +/- 0.4 for CK-MB, respectively. The correlation coefficients between the maximum level of hepatocyte growth factor and the maximum levels of CK and CK-MB were 0.64 and 0.70, respectively. Hepatocyte growth factor is useful as a prognostic indicator and reflects the clinical course in patients with acute myocardial infarction.

Relationship between electrocardiographic features and distribution of hypertrophy in patients with hypertrophic cardiomyopathy

To evaluate the relationship between the distribution of hypertrophy and the electrocardiographic findings in patients with hypertrophic cardiomyopathy (HCM), 54 HCM patients were studied using magnetic resonance imaging. The patients were divided into 4 groups according to hypertrophic patterns: (i) hypertrophy only at the apex (group I, n=12); (ii) hypertrophy in both the apex and base (group II, n=20); (iii) hypertrophy only at the base with asymmetric septal hypertrophy (ASH) (group IIIa, n=17); and (iv) hypertrophy only at the base without ASH (group IIIb, n=5). Abnormal Q waves in leads II, III and aVF were found in 1/12, 3/20, 10/17 and 0/5, respectively, and in leads I and aVL they were found in 1/12, 8/20, 4/17 and 1/5, respectively. The largest negative T waves (mm) were found in group I (group I vs group II vs group IIIa vs group IIIb: 15.2+/-5.3, 8.2+/-6.1, 1.6+/-2.0, 0.8+/-1.3, respectively). The largest positive T waves (mm) were identified in group IIIb (3.8+/-3.0, 6.8+/-3.2, 5.8+/-3.6, 9.3+/-2.1, respectively). The presence of abnormal Q waves reflected regional hypertrophy in HCM patients but the configuration of T waves represented the difference in the localization of hypertrophy between the basal and apical segments.

Silent thyroiditis after excision of a thymoma

A 61-year-old man developed thyrotoxicosis after excision of a thymoma. His laboratory examination showed an increased level of thyroid hormone and a low thyroidal iodine uptake. No thyroidal autoantibody was detected. With the diagnosis of silent thyroiditis, he was treated with propranolol. He became euthyroid after 2 months. Thymoma often accompanies an autoimmune disease as a paraneoplastic syndrome, and an immunological mechanism is thought to be involved in the onset of silent thyroiditis. This case suggests the involvement of an immunological mechanism in the pathogenesis of silent thyroiditis.

[Behçet's disease with acute inflammatory foci and localized secondary organizing pneumonia]

A 68-year-old man with incomplete-type Behçet's disease was admitted to our hospital with a one-month history of a high fever and a persistent pulmonary infiltration shadow in the left lower lobe. Chest CT films showed localized round air-space consolidation in the left lower lobe. The fever did not responded to antibiotics, but did resolve with administration of prednisolone 15 mg/day. Left lower lobectomy was done to avoid life-threatening hemoptysis. Histological examination of the main pulmonary lesions revealed old vascular changes such as irregular intimal thickening and perivascular fibrosis. Disoriented elastic fibers of arteries was seen in some areas as were acute inflammatory foci with neutrophilic infiltration, and secondary organizing pneumonia with Masson bodies. From these findings Beçet's disease related pulmonary involvement could not be excluded. Localized secondary organizing pneumonia associated with acute inflammatory foci, as found in this case, is a very rare pulmonary manifestation of Behçet's disease.

Overexpression of p53 protein in interstitial lung diseases

The p53 gene is well known as a tumour suppressor gene. In addition, the mutated p53 gene is detected in a variety of human cancers including lung cancer, and is considered as an oncogene. Lung cancer is also frequently associated with interstitial lung diseases. Therefore, it may be possible to hypothesize that there might be some abnormality of p53 gene in interstitial lung diseases. This work examined the relationship between the p53 protein and gene in lung tissues of 28 patients with interstitial lung diseases. Among 28 patients, 13 cases were pathologically diagnosed to have usual interstitial pneumonia (UIP), 12 cases were diagnosed as having collagen vascular lung diseases, and three cases were diagnosed to have a non-specific interstitial pneumonia. Twenty-three tissue samples were obtained by open lung biopsy and five samples were taken by autopsy. Paraffin-embedded tissues were treated by microwave, and stained with an anti-p53 antibody (DO7) by the Avidin-Biotin-Peroxidase (ABC) method. In selected patients, mutations in exons 5-8 of the p53 gene were also examined by single-strand conformation polymorphism (SSCP) analysis and DNA sequence. In addition, the presence of anti-p53 antibodies in patients' sera was screened for by ELISA. Fifteen samples (53.6%) revealed overexpression of the p53 protein in the nuclei of alveolar epithelial cells. However, SSCP or sequence analysis, which was performed in 13 tissues, showed no mutations in exons 5-8 of the p53 gene. In conclusion, p53 proteins were overexpressed in interstitial lung diseases, and the expressed p53 protein was considered to be wild-type. This wild-type p53 protein may play a role in blocking the transformation of proliferative epithelial cells.

Measurement of hepatocyte growth factor in serum and bronchoalveolar lavage fluid in patients with pulmonary fibrosis

The present study evaluated the clinical significance of hepatocyte growth factor (HGF) in patients with pulmonary fibrosis. Twenty-one patients with a diagnosis of pulmonary fibrosis [14 with idiopathic pulmonary fibrosis (IPF) and seven with pulmonary fibrosis associated with a collagen vascular disorder (PF-CVD]) and 21 normal subjects as control were studied. HGF levels in sera of patients with pulmonary fibrosis (0.34 +/- 0.02 ng ml-1) were elevated significantly as compared with normal subjects (0.21 +/- 0.01 ng ml-1) (P < 0.0001). HGF/albumin levels in broncho-alveolar lavage fluid (BALF) of patients with pulmonary fibrosis (72 +/- 17 ng g-1 albumin) were also significantly elevated as compared with normal subjects (under the detection limit) (P < 0.01). HGF levels in sera correlated significantly with elastase levels in sera and C-reactive protein, and correlated negatively with PaO2. HGF levels in sera were significantly higher in smokers with pulmonary fibrosis (0.42 +/- 0.03 ng ml-1) as compared with non-smokers with pulmonary fibrosis (0.29 +/- 0.03 ng ml-1) (P < 0.005). HGF/albumin levels in BALF correlated significantly with elastase/albumin levels in BALF, lactate dehydrogenase/albumin in BALF, Immunoglobulin A/albumin in BALF, total cell count/albumin in BALF, total number of alveolar macrophage/albumin in BALF, total number of neutrophil/albumin in BALF, CEA/albumin in BALF, CA19-9/albumin in BALF, and SCC/albumin in BALF. These results suggest that following lung injury, HGF may be a mediator involved in the repair which leads to pulmonary fibrosis.

Neutrophil elastase: alpha-1-proteinase inhibitor complex in serum and bronchoalveolar lavage fluid in patients with pulmonary fibrosis

It was hypothesized that neutrophil elastase released from activated neutrophils may play an important role in the pathogenesis of pulmonary fibrosis. In the present study, we measured the neutrophil elastase:alpha-1-proteinase inhibitor complex (E-PI) in serum and bronchoalveolar lavage fluid (BALF) in 26 patients with pulmonary fibrosis and evaluated the correlation between E-PI levels and several parameters. E-PI levels in serum of patients with pulmonary fibrosis (635.8+/-112.0 ng.mL(-1)) were significantly elevated compared to normal nonsmokers (122.0+/-4.0 ng.mL(-1)) as well as normal smokers (132.8+/-8.4 ng.mL(-1)) (p<0.01). E-PI levels in serum significantly correlated with hepatocyte growth factor (HGF) levels in serum, C-reactive protein (CRP), and negatively correlated with arterial oxygen tension (Pa,O2), and arterial carbon dioxide tension (Pa,CO2). E-PI/albumin levels in BALF significantly correlated with HGF/albumin levels in BALF, lactate dehydrogenase (LDH)/albumin in BALF, total number of inflammatory cells (alveolar macrophages and neutrophils) in BALF, and several markers derived from epithelial cells in BALF. Our data demonstrated: 1) neutrophil elastase:alpha-1-proteinase inhibitor complex in serum increased in patients with pulmonary fibrosis; and 2) neutrophil elastase:alpha-1-proteinase inhibitor complex in serum and bronchoalveolar lavage fluid correlated with clinical parameters in pulmonary fibrosis. These results suggest that neutrophil elastase may play a significant role in the process of lung injury in pulmonary fibrosis.

The role of neutrophils in the pathogenesis of idiopathic pulmonary fibrosis

STUDY OBJECTIVES

The prognostic value of the neutrophil count in BAL fluid (BALF) has been controversial. The role of neutrophils in this inflammatory lung disease, therefore, was evaluated in this study by additional measures.

MATERIALS AND METHODS

We performed BAL in 22 patients with idiopathic pulmonary fibrosis (IPF) diagnosed by open lung biopsy specimen. Percent polymorphonuclear leukocyte (PMN) in BALF and absolute neutrophil counts were compared with those of normal nonsmokers. Elastase complexed to alpha-1-proteinase inhibitor (alpha1-PI) in plasma and BALF was measured as a marker of elastase burden, and neutrophil distribution in 22 lung tissues was observed by immunohistochemistry using antineutrophil elastase antibody.

RESULTS

Percent PMN and absolute neutrophil counts in BALF did not increase in patients with IPF as compared with normal nonsmokers (n=15); the plasma elastase-alpha1-PI complex value (mean+/-SE) of patients with IPF (668.5+/-112.4 ng/mL) was significantly high as compared with that of normal nonsmokers (130.3+/-21.3, p<0.001). In addition, the BALF elastase-alpha1-PI complex value (mean+/-SE) of patients with IPF was also significantly high (333.1+/-87.0 ng/mg albumin) as compared with that of normal nonsmokers (83.1+/-29.3 ng/mg albumin, p<0.05). Immunohistochemistry demonstrated considerable numbers of neutrophils infiltrating the lung parenchyma in biopsy specimens obtained by open lung biopsy.

CONCLUSIONS

These results suggested that although the neutrophil count in BALF could not represent the distribution of neutrophil in the lung, high levels of neutrophil elastase were demonstrated in lung parenchyma and also in both BALF and sera. Therefore, neutrophils might indeed play an important role in the pathogenesis of IPF.

Hepatocyte growth factor and neutrophil elastase in idiopathic pulmonary fibrosis

It has been hypothesized that hepatocyte growth factor (HGF) may play an important role in regulating the growth of lung epithelium and in the regeneration of the lung as a paracrine or endocrine factor in idiopathic pulmonary fibrosis (IPF). Based on this background, serum HGF was measured in 31 IPF patients (21 male/10 female, median age 60 years). Fifteen age-matched normal non-smokers served as the control. Hepatocyte growth factor was measured by enzyme-linked immunosorbent assay with monoclonal and polyclonal antibodies against human HGF (Otsuka Assay Laboratories, Tokushima, Japan). Elastase: alpha 1-proteinase complex was also measured by enzyme-linked immunosorbent assay. No patients had significant liver or renal dysfunction. As a result, mean (standard error) serum HGF concentration of the patients with IPF was 0.384 (0.022) ng ml-1, which was significantly high compared to normal non-smokers [0.213 (0.012) ng ml-1, P < 0.001, 95% confidence interval was between 0.104 and 0.238]. Serum HGF values correlated strongly with the plasma elastase: alpha 1 proteinase inhibitor complex (R = 0.679, P < 0.001). Immunohistochemical staining of lung tissue with anti-human neutrophil elastase showed scattered immunopositive cells mainly in interstitium. Immunohistochemical staining with mouse anti-human HGF antibody showed that HGF was distributed to the lung epithelial cells in IPF lung specimens obtained by open lung biopsy. These results suggest that HGF may play an important role in the pathogenesis of IPF.

[Immunohistochemical study of myofibroblast and S-100 protein positive cells in interstitial pneumonia associated with collagen vascular disease]

Immunohistochemical study was carried out in patients with collagen vascular disease associated with interstitial pneumonia. The subjects were 16 patients, consisting of seven rheumatoid arthritis (RA), five dermatomyositis (DM) and four progressive systemic sclerosis (PSS), in whom the pathological findings were consistent with usual interstitial pneumonia. Immunohistochemical examinations were performed by the ABC method using antibodies to vimentin (vim), alpha-smooth muscle actin (alpha-SMA), and S-100 protein. In fibrosis associated with RA, proliferation of alpha-SMA-positive myofibroblasts was widely observed in all subjects. Myofibroblasts were present also in patients with DM and PSS, but not as notable as in those with RA. Proliferation of vim-positive fibroblasts was observed in patients with idiopathic pulmonary fibrosis (IPF). Diverse S-100 protein positive cells appeared in patients with acute exacerbations of RA, especially when associated with bronchiolitis obliterans organizing pneumonia (BOOP) pattern. S-100 protein positive cells were observed occasionally also in patients with DM and PSS, but they markedly decreased in number, compared to those with RA. They were generally hard to detect in lungs of patients with IPF. These findings suggest that interstitial pneumonia associated with collagen vascular disease can be fairly clearly differentiated from IPF each other, based on the degree of proliferation of myofibroblasts and on the presence of S-100 protein positive cells in number.

Hepatocyte growth factor(HGF): a new biochemical marker for acute myocardial infarction

The purpose of this study was to investigate the use of hepatocyte growth factor as a biochemical marker for acute myocardial infarction. Several biochemical markers are used for noninvasive detection of acute myocardial infarction. However, hepatocyte growth factor has not been used previously for this purpose. We measured hepatocyte growth factor, creatine phosphokinase, and MB isoenzyme (CK-MB) levels in 6 patients with stable effort angina after diagnostic catheterization (controls) and in 12 patients with acute myocardial infarction (AMI). The measurements in the AMI patients were recorded twice a day for the first 3 days after onset of chest pain and once a day for the next 4 days. Furthermore, in each patient we evaluated the time to reach the maximum level and the time for the level to decline to less than half the maximum. Hepatocyte growth factor levels (ng/ml) were 0.3+/-0.1 for angina pectoris patients, and 15.7+/-9.1 within 6h and 12.5+/-4.6 within 12h after the onset for AMI patients, respectively. The correlation coefficients between hepatocyte growth factor and creatine phosphokinase and between hepatocyte growth factor and CK-MB were 0.68 and 0.74, respectively. The time to reach the maximum (h) and the time to decline to less than half of the maximum level (days) were 6.6+/-2.6 and 1.2 +/-0.2 for hepatocyte growth factor, 19.4+/-8.7 and 2.5+/-1.4 for creatine phosphokinase, and 16.6+/-7.7 and 1.5+/-0.4 for CK-MB, respectively. Hepatocyte growth factor is useful as a prognostic indicator and reflects the clinical course in patients with acute myocardial infarction.

Regional left ventricular contractile dynamics in hypertrophic cardiomyopathy evaluated by magnetic resonance imaging

To assess regional myocardial function in hypertrophic cardiomyopathy (HCM), we examined systolic wall thickening (%WT) and percent change of segmental wall area (%AR) by cine magnetic resonance imaging. We studied 23 normal volunteers without evidence of heart disease (group 1) and 40 patients with HCM (group 2). Short-axis images of the left ventricle were recorded at the base and the apex, and were divided into five segments. There were no significant differences in %WT and %AR among the segments in group 1, while %WT and %AR at the apex were higher than values for corresponding segments at the base. The patients with HCM (group 2) were classified into three groups according to end-diastolic wall thickness: group 2a, less than 12 mm; group 2b, 12-15 mm and group 2c, greater than 15 mm. Both the %WT and %AR at the base were significantly higher in group 2a than in the other groups, but were significantly lower in group 2c than in group 1 or group 2a (%WT and %AR in groups 1, 2a, 2b, and 2c respectively: 51 +/- 29 and 19 +/- 17; 83 +/- 40 and 34 +/- 18; 47 +/- 38 and 16 +/- 14; and 32 +/- 21 and 9 +/- 8). Both %WT (40 +/- 24) and %AR (14 +/- 12) at the apex were significantly lower in group 2c than in the other groups (87 +/- 45 and 38 +/- 31 in group 1; 89 +/- 41 and 39 +/- 31 in group 2a; and 61 +/- 27 and 24 +/- 15 in group 2b). Myocardial shortening in the normal volunteers was greater at the apex than at the base. In patients with HCM, regional myocardial function was decreased in association with the degree of hypertrophy, with the wall function of the normal segments appearing to be increased in a possible compensatory mechanism.

[Immunohistochemical study of fibrosis and S-100 protein-positive cells in idiopathic pulmonary fibrosis and in interstitial pneumonia associated with rheumatoid arthritis]

Immunohistochemical methods were used to distinguish idiopathic pulmonary fibrosis (IPF) from interstitial pneumonia associated with rheumatoid arthritis (RA lung). The subjects were six patients with IPF and seven with RA lung, in whom the pathological findings were consistent with usual interstitial pneumonia. Antibodies to vimentin (Vim), alpha-smooth muscle actin (alpha-SMA), and S-100 protein were used for immunohistochemical studies done by the streptavidin-biotin-peroxidase complex method. In fibrosis associated with RA lung, proliferation of both Vim and alpha-SMA-positive myofibroblasts was widely observed, despite pathological findings of honeycombing, usual interstitial pneumonia, and BOOP. Fibrosis in cases of IPF was found to be characterized mainly by Vim-positive fibroblasts, and on occasion was associated with hyperplasia of smooth muscle. Lung tissues from patients with acute exacerbations of RA lung, especially when associated with a BOOP pattern, had many cells positive for S-100 protein. However, such cells were generally hard to find in cases of IPE. Similar results were obtained with regard to the honeycomb pattern in both IPF and RA lung. These findings suggest that IPF and RA lung can be fairly clearly differentiated based on the proliferation of myofibroblasts and on the presence or absence of cells positive for S-100 protein.

Clinicopathological study on two types of cryptogenic organizing pneumonitis

Clinical and pathological studies on cryptogenic organizing pneumonitis (COP) were performed in 19 cases diagnosed with transbronchial lung biopsy (TBLB). All patients suffered from fever and several respiratory symptoms. Laboratory data showed increases in erythrocyte sedimentation rate, positivity for C-reactive protein, negative tuberculin reactions and increases in complement level. Pathological findings demonstrated that there were two kinds of organizing processes. Fourteen of the 19 cases were treated with prednisolone, and two cases were observed without administration. The remaining three cases could not be followed up after therapy. In 11 of the 16 cases, abnormal shadows in chest X-ray disappeared, but remained present in five cases. As for the relationship between pathological findings and shadows in chest X-ray, Masson bodies without fibrin were observed in the 11 cases which were without shadows on X-ray, but Masson bodies containing or related to fibrin were observed in the five cases in which abnormal shadows remained. These results suggest that there are two types of organizing process in COP. Type I is an unexplained organizing process in which fibrin is not present or involved. It responds well to steroids and the prognosis is favourable. Type II is an organizing process which involves fibrin, and the character of the fibroblast-like cells is very similar to that of myofibroblasts. Type II organizing process responds poorly to steroids. Both processes can be notified relatively easily, even by TBLB tissues.

[Relationship between two types of organization in idiopathic organizing pneumonia and their clinical features]

Idiopathic organizing pneumonia (OP) was classified pathologically into two types, and the clinical profiles were compared. Cases in which fibrin in Masson bodies, alpha-sm-actin and m-actin antibodies were negative were regarded as type I (14 cases), and those in which they were positive as type II (7 cases). No significant differences in age and sex were observed between the two groups. As to clinical symptoms and laboratory findings, dyspnea and CRP positivity were observed more frequently and inflammatory reactions were stronger, in type II than in type I. The two groups could not be distinguished by chest X-ray findings. With regard to treatments and outcome, chest X-ray shadows disappeared completely after steroid therapy in type I, and no deaths occurred despite recurrence in some cases. In type II, chest X-ray shadows partially remained in all cases even after steroid therapy, recurrence was rare, and death occurred in some cases due to exacerbations of the initial episode. These observations suggest that there are two pathological types of OP and that the differences in clinical symptoms, laboratory findings, treatments, and prognosis between the two types must be taken into consideration in treating OP.

[Clinical and pathological studies of organizing pneumonia]

Clinical and pathological studies on organizing pneumonia (OP) were performed in 16 cases diagnosed by transbronchial lung biopsy (TBLB). All patients were elderly and poorly-nourished with underlying disease, and suffered from fever and various respiratory symptoms. Results of laboratory studies in these cases were positive for C-reactive protein, negative for tuberculin reaction and showed high complement levels. Pathological findings demonstrated that there were two kinds of organizing process classified according to whether fibrin exudation was detected in Masson bodies or not. Twelve of the 16 cases were treated with prednisolone, and two cases were observed without administration. In nine of the 16 cases, abnormal shadows in chest X-ray disappeared, although abnormal shadows remained in five. Regarding the relationship between pathological findings and shadows in chest X-ray, Masson bodies without fibrin were observed in nine cases in which abnormal shadows in chest X-ray disappeared, but Masson bodies containing fibrin were observed in five cases in which abnormal shadows remained. These results suggest that there are two kinds of organizing process in OP. Steroid therapy tends to be ineffective in OP demonstrating organization containing fibrin caused probably by infection. However, prednisolone is effective in the OP associated with a fibrosing process, similar to idiopathic BOOP, without or with unrelated fibrin exudation of unknown origin.

[A case of juvenile polyp in an elderly person with hepatocellular carcinoma]

A rare case of a juvenile polyp in association with a hepatocellular carcinoma in a 57-year-old male is reported. Both diseases were discovered after admission to hospital because of chronic active hepatitis. A liver biopsy revealed the presence of a trabecular type of differentiated carcinoma. Then, upon colonic fiberscopy, a solitary small pedunculated polyp was detected in the rectosigmoid region. Histologically, the lesion was found to be a typical juvenile one, and composed of cystic dilatations of some glands, including somewhat hyperplastic glands and a wide stroma consisting of chronic inflammatory granulation. The possible histogenesis of this observed polyp in an elderly person also is discussed.