Monocytes from patients with Primary Ciliary Dyskinesia show enhanced inflammatory properties and produce higher levels of pro-inflammatory cytokines.

Patients with Primary Ciliary Dyskinesia (PCD) suffer from recurrent upper and lower airway infections due to defects in the cilia present on the respiratory epithelium. Since chronic inflammatory conditions can cause changes in innate immune responses, we investigated whether monocytes isolated from the peripheral blood of pediatric PCD patients respond differently to inflammatory stimuli, compared to monocytes from healthy children and adults. The receptor for C5a (C5aR) was upregulated in PCD, whereas expression levels of the leukocyte chemoattractant receptors CCR1, CCR2, CCR5, BLT1 and FPR1 on PCD monocytes were similar to those on monocytes from healthy individuals. Also in vitro migration of PCD monocytes towards the ligands of those receptors (CCL2, fMLP, C5a and LTB4) was normal. Compared to healthy children, PCD patients had a higher percentage of the non-classic monocyte subset (CD14+CD16++) in circulation. Finally, PCD monocytes produced higher levels of pro-inflammatory cytokines (IL-1ß and TNF-α) and chemokines (CCL3, CCL5, CCL18 and CCL22) in response to LPS, peptidoglycan and/or dsRNA stimulation. These data suggest that monocytes might exacerbate inflammatory reactions in PCD patients and might maintain a positive feedback-loop feeding the inflammatory process.

Impact of hypochlorite-based disinfection on bacterial contamination of cystic fibrosis patients' home-nebulisers.

Nebulisers are a potential source of bacterial contamination in cystic fibrosis (CF) patients. The aims of the study were to survey patient practice regarding maintenance of home nebulisers and to assess the impact of standardised guidelines derived from a previous in-vitro study. In total, 42 CF patients were studied. During two consecutive home visits, a questionnaire regarding routine patient practice was completed by a nurse while sputum and equipment samples were taken for bacteriological analyses. The first visit took place at baseline, and the second followed the implementation of detailed instructions for cleaning and disinfecting the nebulisers using a 0.5% hypochlorite solution. The first visit identified a great diversity in routine patient practices. Commensal bacteria, environmental bacteria and potential CF pathogens contaminated 78.5%, 57.1% and 14.3% of nebulisers respectively. After hypochlorite disinfection, rate and degree of global contamination decreased significantly, but the number of CF pathogens was not affected. There was no concordance between CF pathogens isolated from patients' sputum and their equipment. We conclude that in this sample of patients, initial routine practices were varied. With regard to CF pathogens, the superiority of a hypochlorite solution over a mix of other disinfection methods was not demonstrated.

Early referral to cystic fibrosis specialist centre impacts on respiratory outcome.

BACKGROUND: Published studies concerning the impact of specialist care on lung disease in cystic fibrosis remain limited and most are either biased due to comparison with historical controls and/or underpowered. METHODS: In this retrospective multicentric study, data from all CF children fulfilling the following criteria were collected: 1) Age 6-<18 at the end of 2003; 2) diagnosis before 8 y; 3) follow-up in an accredited CF Belgian centre; 4) at least 1 spirometry and respiratory culture available for 2003. Group A included children referred > or =2 years after the diagnosis. Patients from Group A were then matched with a single early referred patient on the basis of 2 criteria: same centre, as closest age as possible (Group B). RESULTS: Data from 217 children were collected (Group A: 67/217). Late referred patients had a lower FEV(1) (77.2%+/-22.4 vs 86.7% pred.+/-19.4, p=0.01) and a higher prevalence of Pseudomonas aeruginosa (38.6 vs 17.5%, p<0.05). CONCLUSION: In this population of CF children, a delay of 6.1 y (vs 0.1 y) between diagnosis and referral to a specialist clinic resulted in poorer respiratory outcome at age 13.

Sweat potassium concentration may help to identify falsification of sweat test: a case report.

OBJECTIVES: To document the relevance of sweat potassium concentration in a reported case of a white Caucasian 27-month-old boy who presented with non-specific respiratory symptoms and several abnormal sweat test results compatible with cystic fibrosis (CF). DESIGN AND METHODS: Repeated sweat tests using the Gibson-Cooke technique in the presence and absence of the mother. RESULTS: The high within- and between-test variability, the very low sweat potassium concentrations, several aspects of the family's history and a negative exhaustive genetic analysis to identify any CFTR mutation, raised suspicion for pediatric condition falsification. Two additional sweat tests performed in the absence of the mother were normal. CONCLUSION: CF diagnosis was then discarded and a Munchausen syndrome by proxy diagnosis was proposed.

A specific database for providing local and national level of integration of clinical data in cystic fibrosis.

It has recently been stated that a database is an essential tool in the management of CF. The purpose of this work is to create a specific database allowing optimal performance of storage, search and retrieval functions on patients with CF. A specific database was developed using a Windev licence, for application via Microsoft supported platforms or Intranet system. The database allows real-time point of care data management of medical, investigational and administrative data. It is currently being used in the 6 Belgian reference centres. It represents a useful tool for gathering information on routine clinical and lab data, bacteriology, treatments, complications and specific outcomes for clinical and research purposes. The ongoing evolution of the database includes enhancements toward research data orientation including comparison of patient data between different centres and completeness of the National CF registry questionnaire. A complimentary copy of the software can be provided to multidisciplinary accredited CF centres worldwide upon request.

Lung mucosal immunity: immunoglobulin-A revisited.

Mucosal defence mechanisms are critical in preventing colonization of the respiratory tract by pathogens and penetration of antigens through the epithelial barrier. Recent research has now illustrated the active contribution of the respiratory epithelium to the exclusion of microbes and particles, but also to the control of the inflammatory and immune responses in the airways and in the alveoli. Epithelial cells also mediate the active transport of polymeric immunoglobulin-A from the lamina propria to the airway lumen through the polymeric immunoglobulin receptor. The role of IgA in the defence of mucosal surfaces has now expanded from a limited role of scavenger of exogenous material to a broader protective function with potential applications in immunotherapy. In addition, the recent identification of receptors for IgA on the surface of blood leukocytes and alveolar macrophages provides an additional mechanism of interaction between the cellular and humoral immune systems at the level of the respiratory tract.

[Cystic fibrosis and normal sweat chloride values: a case-report]. / Mucoviscidose et test à la sueur normal.

UNLABELLED: In a suggestive context, normal sweat chloride values (<60 mmol/L) do not always suffice to exclude the diagnosis of CF. CASE-REPORT: A 19-year-old female presented with a diagnosis of bronchiectasis. Her past medical history was noteworthy for the onset of respiratory symptoms in the infancy, colonization of the respiratory tract by Pseudomonas aeruginosa for three years and previous treatment for allergic bronchopulmonary aspergillosis. She was heterozygote for the DeltaF 508 mutation of the CFTR gene. Sweat chloride values were repeatedly normal, ranging from 25 to 46 mmol/L. The diagnosis of CF was confirmed by the identification of a second CFTR mutation (D1152H) and the demonstration of typical nasal potential. CONCLUSION: It is now estimated that approximately 2% of CF patients will present an "atypical" phenotype with sweat chloride values<60 mmol/L. For these patients, the diagnosis can be confirmed by the identification of a CF-causing mutation in each CFTR allele or in vivo demonstration of CFTR dysfunction by nasal potential difference study.

Reduced epithelial expression of secretory component in small airways correlates with airflow obstruction in chronic obstructive pulmonary disease.

The epithelial polymeric immunoglobulin receptor/transmembrane secretory component (pIgR/SC) transports into secretions polymeric immunoglobulin A (pIgA), which is considered the first line of defense of the respiratory tract. The present study, done with quantitative immunohistochemistry, evaluated epithelial expression of secretory component (SC) and Clara cell protein (CC16) and neutrophil infiltration into the airways of eight patients with severe chronic obstructive pulmonary disease (COPD) who were undergoing lung transplantation, as compared with these processes in six nonsmoking patients with pulmonary hypertension who were used as controls and in lung specimens from five smokers without chronic bronchitis. Staining for SC was significantly decreased in the COPD patients as compared with the controls, both in large (mean optical density [MOD]: 23.4 [range: 21.1 to 27.8] versus 42.2 [range: 28.2 to 49.3], p = 0.003) and in small airways (MOD: 30.8 [range: 20.3 to 39.4] versus 41.5 [range: 39.2 to 46.2], p = 0.003). SC expression in small airways correlated strongly with functional parameters such as FEV1 (Kendall's tau (K) = 0.76, p = 0.008), FVC (K = 0.64, p = 0.03), and midexpiratory flow at 50% of VC (MEF50) (K = 0.74, p = 0.01). The reduced expression of SC in large airways correlated with neutrophil infiltration in submucosal glands (K = -0.47, p = 0.03). Expression of CC16 in the bronchial epithelium of COPD patients was also significantly decreased as compared with that of controls, especially in small airways (MOD: 28.3 [range: 26.8 to 32.4] versus 45.8 [range: 40.7 to 56.0], p = 0.002), but no correlation was observed with lung function tests. In conclusion, this study shows that reduced expression of SC in airway epithelium is associated with airflow obstruction and neutrophil infiltration in severe COPD.

Secretory mucosal immune mechanisms.

Mucosal immune mechanisms in the airways are the first specific line of defense, protecting the body from pathogens. The respiratory epithelium actively transports locally produced dimeric IgA in the respiratory secretions by transcytosis, through the pIgR. S-IgA production therefore requires epithelial integrity. S-IgA at the epithelial level is active in several non-inflammatory pathways including intracellular neutralization of virus, antigen excretion, binding to bacterial adhesins. Local IgA production is regulated by various growth factors and cytokines of both epithelial and non-epithelial origin. The respiratory epithelium is thought to play a crucial role in this process. In addition, in chronic airway inflammation, IgA production demonstrates a correlation with eosinophil activation both in vitro and in vivo. While increased IgA and S-IgA production is reported in asthmatics, decreased SC production has been documented in CF and COPD patients, further impairing their local defense mechanisms.

Sweet's syndrome with arthritis in an 8-month-old boy.

Sweet's syndrome was diagnosed in a 4-month-old boy. He was successfully treated with systemic corticosteroids. At the age of 8 months, he developed acute arthritis in his right knee. The synovial fluid was analyzed and revealed a very high neutrophil count and neutrophil activation with a detectable level of intraarticular granulocyte-monocyte colony stimulating factor (GM-CSF). Prednisone injection into the knee led to dramatic improvement. No recurrence occurred. Although arthritis and/or arthralgia are common features in adult patients with Sweet's syndrome, this is the first reported case of Sweet's arthritis in a child.

Secretory component production by human bronchial epithelial cells is upregulated by interferon gamma.

Secretory immunoglobulin A (S-IgA) participates in the first noninflammatory line of defence of the respiratory tract. S-IgA consists of dimeric IgA (dIgA) produced by plasma cells and secretory component (SC) produced by epithelial cells. This study compared SC production by primary cultures of human bronchial epithelial cells (HBEC) and by respiratory epithelial cell lines. Among the cell lines, A549 did not produce detectable SC, 16HBE produced very low levels of SC, while CALU-3 produced significant levels of SC. HBEC produced SC in nonpolarized and polarized primary cultures, where it was secreted apically. Polarized HBEC transcytosed radiolabelled and cold dIgA, resulting in the presence of S-IgA in their apical media. SC production and IgA transcytosis by polarized HBEC were upregulated by interferon-gamma (IFN-gamma) after 48 h. By reverse transcription-polymerase chain reaction, no SC messenger ribonucleic acid (mRNA) was detected in A549 and 16HBE, while SC mRNA in CALU-3 was comparable to that of HBEC incubated for 48 h with IFN-gamma. By immunocytochemistry, HBEC expressed SC immunostaining and its intensity increased after 48 h with IFN-gamma. It is concluded that human bronchial epithelial cells produce secretory component and transcytose dimeric immunoglobulin A in vitro. These processes were apically polarized and upregulated by interferon-gamma. Among the cell lines studied, only CALU-3 expressed secretory component-messenger ribonucleic acid and produced detectable secretory component.

Mechanisms of acute eosinophilic inflammation in a case of acute eosinophilic pneumonia in a 14-year-old girl.

BACKGROUND: Acute eosinophilic pneumonia (AEP) is characterized by respiratory distress, eosinophilic infiltration in the lung, acute onset, resolution of symptoms with corticosteroids and the absence of relapse. Studies to identify the pathophysiology of AEP in adults have demonstrated eosinophil activation in the BAL fluid, and the presence of high levels of interleukin 5 (IL-5) in the BAL. OBJECTIVE: To investigate the pathophysiology of AEP with pleural effusion in a paediatric patient. METHODS: ECP levels in the BALand pleural fluid was determined by radioimmunoassay. IL-5 and GM-CSF concentrations in the BAL and pleural fluid were measured by Elisa. Immunohistochemistry studies performed on open lung biopsy included a specific ICAM-1 immunostaining and a ECP specific immunostaining (EG2+). RESULTS: High levels of ECP were found in the BAL (5 microg/L) and pleural fluid (750 microg/L) demonstrating eosinophil activation at these sites. Immunohistochemistry illustrated activated (EG2+) eosinophils in the interalveolar septa and alveolar space and detected increased expression of ICAM-1 on alveolar epithelial cells. High levels of IL-5 were measured in the BAL (1334 pg/mL) and pleural fluid (7014 pg/mL), while elevated concentrations of GM-CSF (150 pg/mL) were found in the BAL. CONCLUSION: We conclude that in this paediatric patient with AEP activated eosinophils were present in the BAL fluid, in the interalveolar septa and in the pleural space while increased ICAM-1 expression was detected on alveolar epithelial cells, contributing, at least partly, for their adhesive interactions. IL-5 and GM-CSF are likely important to the massive eosinophil recruitment and activation in the lung, while IL-5 is probably related to eosinophil accumulation and activation in the pleural space. Thus, lung generation of eosinophil-active cytokines is central to the pathophysiology of AEP in paediatric patients.

[Quality of the care of the pediatric patient admitted to the emergency room]. / Qualité de la prise en charge de l'enfant admis en salle d'urgence polyvalente.

AIM: By a prospective study, authors tried to analyse the quality of management of the pediatric patient admitted in the emergency department. POPULATION AND METHODS: One hundred admission files were prospectively analysed for characteristics of age (mean age: 70 months), effectiveness of measurement of physiological parameters, evaluation of appropriateness of nursing management according to recorded parameters, length of stay in the emergency department according to the need for hospitalization, blood tests, X-rays and the seniority of the attending medical staff. RESULTS: Parameters were not, or only incompletely, recorded in 65 files. . Although all were recorded in the remaining 35 files, subsequent management was inadequate in seven cases. Mean length of stay in the emergency department was 116 minutes, influenced by the need for hospitalization (145 minutes compared to 102 minutes for the non-hospitalized children), timing of admission (mean: 125 minutes from 8 am to 6 pm, compared to 94 minutes from 6 pm to 8 am), need for blood tests, X-rays or both (mean: 122, 107 and 170 minutes respectively, compared to 55 minutes when no complementary exam was asked) and seniority of attending medical staff (mean: 65 minutes for permanent staff compared to 116 minutes for fellows). CONCLUSIONS: Measurement of physiological parameters must be standard practise in the management of pediatric patients admitted to the emergency department and must lead to appropriate management without undue delay. In order to reach this goal, emergency departments should be more adequately staffed with nurses and senior doctors specifically trained in the care of the pediatric patient. Blood tests and X-rays should be more readily available.

Joint consultation for high-risk asthmatic children and their families, with pediatrician and child psychiatrist as co-therapists: model and evaluation.

Although a very common disease, childhood asthma can be a life-threatening condition. Psychosocial determinants have been acknowledged to trigger severe asthma. The authors review current knowledge about how psychosocial factors influence childhood asthma, with a special focus on compliance with treatment and family interaction. The authors describe their experience of joint treatment of high-risk asthmatic children and their families. The pediatrician and child psychiatrist work as co-therapists, and the results of this intervention are investigated. Forty-one high-risk asthmatics and their families were followed in the joint-consultation program. Two years after the onset of joint consultation, a significant improvement was found in symptom score, treatment score, and compliance score. The number of hospital admissions and of days spent in hospital decreased significantly. The cost of care was subsequently cut by two-thirds, despite the added cost of psychiatric care. The authors conclude that it is possible for doctors of the body and of the mind to share consultation work, with a positive impact on both the patient's health and the cost of treatment.

Respiratory syncytial virus infection enhances neutrophil and eosinophil adhesion to cultured respiratory epithelial cells. Roles of CD18 and intercellular adhesion molecule-1.

Respiratory syncytial virus (RSV) infections in children precipitate acute episodes of respiratory obstruction that are associated with influx of inflammatory cells into the airway. Since RSV can induce the expression of adhesion molecules, particularly intercellular adhesion molecule-1 (ICAM-1), by the respiratory epithelium, the hypothesis has been proposed that ICAM-1 expression contributes to airway inflammation by supporting adhesion and retention of infiltrating inflammatory leukocytes. To test this hypothesis, A549 cells (an immortalized human alveolar epithelial type II cell-like fine) were infected with RSV, and the ability of these infected monolayers to support adhesion by human neutrophils (NEUT) and eosinophils (EOS) was measured. RSV infection significantly increased ICAM-1 expression by A549 monolayers (p < 0.001). Although NEUT adhesion to A549 monolayers was significantly enhanced following RSV infection (p < 0.001), infection alone resulted in little change in EOS adherence. However, if EOS were first activated with phorbol ester (PMA), adhesion to both control and RSV-infected A549 cells was enhanced, with greater levels of adhesion supported by RSV-infected cultures (p < 0.001). The requirement for EOS activation (but not for NEUT activation) before adhesion remained when NEU and EOS were prepared and compared from the same donor. Despite this difference, NEUT and EOS adhesion was reduced by blocking Abs to epithelial ICAM-1 or granulocyte CD18 adhesion proteins (p < 0.01). However, only NEUT adhesion was blocked by Ab to CD11a. Our results show that RSV infections of respiratory epithelial monolayers can promote inflammatory cell adherence which could, in turn, potentially contribute to the airway injury and obstruction that accompanies bronchiolitis.

Adhesion of activated eosinophils to respiratory epithelial cells is enhanced by tumor necrosis factor-alpha and interleukin-1 beta.

Eosinophilic infiltration and damage to airway epithelium are characteristic features of asthma. To assess possible interactions between eosinophils and airway epithelium, Percoll-purified human peripheral blood eosinophils were evaluated for their ability to adhere to respiratory epithelial cell (REC) cultures. REC (an immortalized cell line, A549, and primary bronchial epithelial cells) were grown in 96-well tissue culture plates, treated with proinflammatory cytokines (TNF-alpha or IL-1 beta), and eosinophil adhesion to these tissues was determined. Cytokine treatment of the REC cultures significantly increased expression of intercellular adhesion molecule-1 (ICAM-1) (P < 0.01). Eosinophils demonstrated a variable baseline adhesion to untreated REC which was then significantly increased following activation with phorbol myristate acetate (PMA) (P < 0.01). Furthermore, treatment of REC monolayers with TNF-alpha or IL-1 beta significantly increased adhesion of PMA-stimulated eosinophils (P < 0.01). To delineate the adhesion proteins involved in the cell-cell interactions, assays were performed in the presence of specific blocking monoclonal antibodies to eosinophil CD18, CD11a, or CD11b, and REC ICAM-1 molecules. Blocking antibodies to ICAM-1 had no significant effect on levels of eosinophil adhesion. In contrast, antibodies to CD18, CD11a, and CD11b significantly decreased (P < 0.01) eosinophil adhesion, thus demonstrating pivotal roles for the CD11/CD18 (beta 2) integrins, but not necessarily for ICAM-1, in interactions between the REC and eosinophils. These data demonstrate that TNF-alpha and IL-1 beta increase eosinophil adhesion to human respiratory epithelial cell cultures by induction of ligands recognized by eosinophil beta 2 integrins.

[The effect of a single dose of formoterol using an aerosol inhaler in asthmatic children. A randomized, controlled, double-blind study]. / Effet d'une dose unique de formotérol par voie d'aérosol-doseur chez l'enfant asthmatique. Une étude randomisée, contrôllée, en double aveugle.

The duration of action of inhaled formoterol, a new long-acting beta-2-agonist, was compared to inhaled salbutamol and placebo in a double-blind, randomized, cross-over study in 16 children (8-12 years old) with stable moderate to serve asthma. Mean baseline FEV1 was 68 +/- 8% predicted. On the 4 study days, baseline FEV1 was within 15% of the FEV1 on visit 1. Two-three days apart, each patient inhaled either placebo, salbutamol (200 micrograms) formoterol (12 or 24 micrograms). FEV1 and PEF were measured repeatedly during 8 and 12 hours respectively. After formoterol, improvement over placebo remained significant at 8 hours for FEV1 (p = 0.006) and 12 hours for PEF (p = 0.01). When compared to salbutamol, it was significant at 8 hours for PEF (p = 0.03). There were no significant differences in lung function when comparing the 12 micrograms and 24 micrograms doses of formoterol. Side-effects were minimal.

Compliance with treatment in asthma and Munchausen syndrome by proxy.

Among 1648 asthmatic patients, 17 families (1%) were identified as having Munchausen syndrome by proxy. Ten families did not treat their children's, attacks or refused medical care, and seven exaggerated the severity of symptoms to obtain invasive investigations and treatment. All the families had disturbed psychosocial backgrounds. The abuse consisted mainly of neglect, in that necessary treatment was not given. In some cases a more direct form of abuse was observed, when useless and sometimes harmful investigations and treatment were given. We conclude that medical control of the compliance of both parents and children is necessary in the management of childhood asthma.