Benralizumab treatment in an elderly patient with eosinophilic esophagitis resulted in remission: a case report.

BACKGROUND: Interleukin-5 (IL-5) has recently been shown to play a crucial role in eosinophil-mediated diseases, implying that an IL-5 receptor alpha chain (IL-5Rα) antibody (benralizumab) can be effective against eosinophilic esophagitis (EoE). Here, we present a case in which benralizumab significantly improved the symptoms and signs of an elderly Asian woman with EoE who had inadequate response to existing treatments. Case presentation A 73-year-old woman with an 8-year history of bronchial asthma (BA) and a 7-year history of dysphagia presented to our hospital with worsening dysphagia, vomiting, chest pain, and difficulty in eating. Blood biochemical findings revealed an increase in the eosinophil fraction of white blood cells (42.2%), and a conventional chest computed tomography scan revealed esophageal wall thickening. An upper gastrointestinal endoscopy revealed mucosal edema as well as multiple esophageal rings, and esophageal biopsy specimens showed an eosinophilic infiltrate of more than 15 cells/ high power field. Based on these findings, she was diagnosed as EoE complicated by BA. We firstly administrated 20 mg/day of prednisolone, rabeprazole sodium and liquid budesonide oral suspension for 5 months; however, they were ineffective and her dysphagia worsened over time. Then, benralizumab treatment in combination with these drugs was started. Her dysphagia completely disappeared 2 weeks after starting benralizumab, and an upper endoscopy showed that the clinical findings had completely disappeared after another 6 weeks. Benralizumab was then given to her for 41 months, and her symptoms remained in remission. In addition, she had no EoE recurrence for more than 12 months after discontinuing benralizumab. CONCLUSIONS: Benralizumab in combination with other multiple drugs significantly improved the symptoms and examination findings of an elderly patients with EoE. Furthermore, she experienced no recurrence even after discontinuing benralizumab withdrawal, suggesting that benralizumab could be an appropriate therapeutic option for EoE.

Multisystem Inflammatory Syndrome in an Adult on Hemodialysis with Markedly Elevated Procalcitonin and Ferritin Levels.

A 21-year-old man on hemodialysis was hospitalized for coronavirus disease 2019 (COVID-19) pneumonia. After admission, he had a persistent high fever and developed erythema induratum on his extremities. Laboratory tests conducted 25 days after onset showed markedly increased procalcitonin (PCT) levels (>100 ng/mL). The patient developed impaired consciousness and hypotensive shock and required endotracheal intubation. Based on the presence of erythema induratum and multiorgan dysfunction, he was diagnosed with multisystem inflammatory syndrome (MIS). The MIS resolved after treatment with intravenous immunoglobulin and methylprednisolone. This report illustrates that MIS can occur in adults and may be accompanied by high PCT levels.

Cyclic stretch enhances reorientation and differentiation of 3-D culture model of human airway smooth muscle.

Activation of airway smooth muscle (ASM) cells plays a central role in the pathophysiology of asthma. Because ASM is an important therapeutic target in asthma, it is beneficial to develop bioengineered ASM models available for assessing physiological and biophysical properties of ASM cells. In the physiological condition in vivo, ASM cells are surrounded by extracellular matrix (ECM) and exposed to mechanical stresses such as cyclic stretch. We utilized a 3-D culture model of human ASM cells embedded in type-I collagen gel. We further examined the effects of cyclic mechanical stretch, which mimics tidal breathing, on cell orientation and expression of contractile proteins of ASM cells within the 3-D gel. ASM cells in type-I collagen exhibited a tissue-like structure with actin stress fiber formation and intracellular Ca2+ mobilization in response to methacholine. Uniaxial cyclic stretching enhanced alignment of nuclei and actin stress fibers of ASM cells. Moreover, expression of mRNAs for contractile proteins such as α-smooth muscle actin, calponin, myosin heavy chain 11, and transgelin of stretched ASM cells was significantly higher than that under the static condition. Our findings suggest that mechanical force and interaction with ECM affects development of the ASM tissue-like construct and differentiation to the contractile phenotype in a 3-D culture model.

Regulation of PD-L1 expression by matrix stiffness in lung cancer cells.

Expression of programmed death-ligand 1 (PD-L1) in tumor cells such as lung cancer cells plays an important role in mechanisms underlying evasion of an immune check point system. Lung cancer tissue with increased deposition of extracellular matrix is much stiffer than normal lung tissue. There is emerging evidence that the matrix stiffness of cancer tissue affects the phenotypes and properties of cancer cells. Nevertheless, the effects of substrate rigidity on expression of PD-L1 in lung cancer cells remain elusive. We evaluated the effects of substrate stiffness on PD-L1 expression in HCC827 lung adenocarcinoma cells by using polyacrylamide hydrogels with stiffnesses of 2 and 25 kPa. Expression of PD-L1 protein was higher on the stiffer substrates (25 kPa gel and plastic dish) than on the soft 2 kPa gel. PD-L1 expression was reduced by detachment of cells adhering to the substrate. Interferon-γ enhanced expression of PD-L1 protein cultured on stiff (25 kPa gel and plastic dishes) and soft (2 kPa gel) substrates and in the cell adhesion-free condition. As the stiffness of substrates increased, formation of actin stress fiber and cell growth were enhanced. Transfection of the cells with short interfering RNA for PD-L1 inhibited cell growth without affecting stress fiber formation. Treatment of the cells with cytochalasin D, an inhibitor of actin polymerization, significantly reduced PD-L1 protein levels. Taken together, a stiff substrate enhanced PD-L1 expression via actin-dependent mechanisms in lung cancer cells. It is suggested that stiffness as a tumor environment regulates PD-L1 expression, which leads to evasion of the immune system and tumor growth.

Matrix stiffness regulates migration of human lung fibroblasts.

In patients with pulmonary diseases such as idiopathic pulmonary fibrosis and severe acute respiratory distress syndrome, progressive pulmonary fibrosis is caused by dysregulated wound healing via activation of fibroblasts after lung inflammation or severe damage. Migration of fibroblasts toward the fibrotic lesions plays an important role in pulmonary fibrosis. Fibrotic tissue in the lung is much stiffer than normal lung tissue. Emerging evidence supports the hypothesis that the stiffness of the matrix is not only a consequence of fibrosis, but also can induce fibroblast activation. Nevertheless, the effects of substrate rigidity on migration of lung fibroblasts have not been fully elucidated. We evaluated the effects of substrate stiffness on the morphology, α-smooth muscle actin (α-SMA) expression, and cell migration of primary human lung fibroblasts by using polyacrylamide hydrogels with stiffnesses ranging from 1 to 50 kPa. Cell motility was assessed by platelet-derived growth factor (PDGF)-induced chemotaxis and random walk migration assays. As the stiffness of substrates increased, fibroblasts became spindle-shaped and spread. Expression of α-SMA proteins was higher on the stiffer substrates (25 kPa gel and plastic dishes) than on the soft 2 kPa gel. Both PDGF-induced chemotaxis and random walk migration of fibroblasts precultured on stiff substrates (25 kPa gel and plastic dishes) were significantly higher than those of cells precultured on 2 kPa gel. Transfection of the fibroblasts with short interfering RNA for α-SMA inhibited cell migration. These findings suggest that fibroblast activation induced by a stiff matrix is involved in mechanisms of the pathophysiology of pulmonary fibrosis.

Real-time imaging of mechanically and chemically induced ATP release in human lung fibroblasts.

Extracellular adenosine 5'-triphosphate (ATP) acts as an inflammatory mediator of pulmonary fibrosis. We investigated the effects of mechanical and chemical stimuli on ATP release from primary normal human lung fibroblasts. We visualized the ATP release from fibroblasts in real time using a luminescence imaging system while acquiring differential interference contrast cell images with infrared optics. Immediately following a single uniaxial stretch for 1s, ATP was released from a certain population of cells and spread to surrounding spaces. Hypotonic stress, which causes plasma membrane stretching, also induced the ATP release. Compared with the effects of mechanical stretch, ATP-induced release sites were homogeneously distributed. In contrast to the effects of mechanical stimuli, application of platelet-derived growth factor caused ATP release from small numbers of the cells. Our real-time ATP imaging demonstrates that there is a heterogeneous nature of ATP release from lung fibroblasts in response to mechanical and chemical stimuli.

Antineutrophil Cytoplasmic Antibody-associated Vasculitis Superimposed on Infection-related Glomerulonephritis Secondary to Pulmonary Mycobacterium avium Complex Infection.

A 73-year-old woman was diagnosed with pulmonary Mycobacterium avium complex (MAC) infection and received no treatment. Disease progression was evident one year later with the development of myeloperoxidase-antineutrophil cytoplasmic antibody (ANCA) titers and systemic symptoms of a fever, polyarthritis, purpura, and rapidly progressive glomerulonephritis. Her symptoms did not improve with antibiotic treatment. A renal biopsy revealed crescentic glomerulonephritis with immunodeposition. According to these findings, she was diagnosed with ANCA-associated vasculitis (AAV) superimposed on infection-related glomerulonephritis (IRGN). Although there was a risk of aggravating an underlying infection, the combination therapy of corticosteroid and antibiotics improved AAV, IRGN, and even the lung radiological findings. To the best of our knowledge, this is the first case of AAV and IRGN secondary to pulmonary MAC infection.