Nivolumab-induced Hypophysitis, Secondary Adrenal Insufficiency and Destructive Thyroiditis in a Patient with Lung Adenocarcinoma.

Nivolumab-induced multiple organ immune-related adverse events (irAEs) have been described in some case reports. The symptoms of endocrinological irAEs are especially nonspecific. A 63-year-old man with a postoperative recurrence of pulmonary adenocarcinoma who was treated with nivolumab presented fever, anorexia and fatigue after the 7th cycle. He underwent a rapid adrenocorticotrophic hormone test, four-hormone tolerance test and thyroid gland scintigraphy. The results were consistent with destructive thyroiditis, hypophysitis and secondary adrenal insufficiency. Nivolumab was restarted following glucocorticoid and thyroid hormone replacement treatment. When a patient presents nonspecific symptoms, the possibility of endocrinological irAEs should be considered as it may enable their early detection.

Treatment of asthma in smokers: A questionnaire survey in Japanese clinical practice.

BACKGROUND: Cigarette smoking in patients with asthma leads to poor symptom control. As patients who are current smokers have been excluded from enrollment in many clinical trials on asthma, there are few reports on the treatment in current smokers with asthma. In this study, we aimed to assess how respiratory physicians manage asthma in current smokers in Japan. METHODS: Respiratory physicians in 16 Japanese hospitals answered a questionnaire on treatment for patients with asthma between December 2014 and February 2015. Medical records were reviewed for 1756 patients with asthma. RESULTS: The mean patient age was 61.1 years, and 62.9% of the patients were female. A total of 102 patients (5.8%) were current smokers, and 546 patients (31.1%) were former smokers. Long-acting muscarinic antagonists (LAMA) were prescribed more frequently for current smokers with asthma than for former smokers and never smokers with asthma (10.8% vs 4.6%, p = 0.01, 10.8% vs 3.8%, p < 0.01). In contrast, macrolides were prescribed more frequently for former smokers and never smokers with asthma than for current smokers with asthma (7.7% vs 1.0%, p = 0.01, 6.4% vs 1.0%, p = 0.03). Triple therapy, i.e., inhaled corticosteroids, long-acting beta agonists, and LAMA concomitantly, was prescribed for current smokers with asthma more frequently than for former smokers and never smokers with asthma (9.8% vs 4.0%, p = 0.01, 9.8% vs 3.3%, p < 0.01). CONCLUSIONS: According to this survey, current smokers with asthma received more intensive therapy, including LAMA, than did former smokers with asthma.

ALK-Positive Squamous Cell Carcinoma Dramatically Responded to Alectinib.

Anaplastic lymphoma kinase (ALK) rearrangement is usually observed in patients with adenocarcinoma. Herein, we report a case of squamous cell carcinoma (SCC) with ALK rearrangement treated with alectinib. The patient was a 73-year-old woman without a smoking history. She consulted us with nonproductive cough and loss of appetite. Computed tomography scan revealed a mass in the left lower lobe of the lung. According to the pathological examinations, we diagnosed the tumor as SCC. Because the patient had never smoked, we searched for driver mutations and found that the tumor harbored ALK rearrangement. We began treatment with alectinib, and the tumor remarkably reduced in volume. No severe adverse events were observed. Although there are only few reports of SCC with ALK rearrangement, this case implies that clinicians should consider searching for driver mutations in patients with SCC when there are atypical findings or characteristics.

[Myelofibrosis ameliorated after treatment for nontuberculous mycobacterial infection].

A 42-year-old female was admitted to our hospital because of continuous fever, anemia, and immature myeloid cells in peripheral blood. Bone marrow biopsy revealed severe myelofibrosis (MF). We performed computed tomography and identified several swollen mediastinal lymph nodes and nodules in the right upper lung. Lymph node biopsy showed an infection with Mycobacterium intracellulare (M. intracellulare), a nontuberculous mycobacterium (NTM). Antituberculosis drugs led to remission of the NTM infection. Bone marrow biopsy revealed marked improvement in MF and red blood cell infusion was not required after therapy. No prior cases of concomitant NTM with M. intracellulare and MF have been reported. This is thus the first reported case showing improvement of myelofibrosis after NTM treatment. This case report offers valuable insights into the pathology of MF.

Evaluation of indeterminate pulmonary nodules with dynamic MR imaging.

PURPOSE: We prospectively assessed whether enhancement characteristics on dynamic magnetic resonance (MR) imaging could distinguish indeterminate pulmonary nodules. METHODS: We evaluated 51 pulmonary nodules in 51 consecutive patients (11 female, 40 male; mean age, 64 years) using dynamic MR images acquired at 0, 10, 20, 30, 40, 50, 60, 70, 80, 90, 120, 150, 180, 210, 240, 360, 480, 600, 720, and 840 s following injection of contrast material. We prospectively evaluated morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout of nodules and analyzed statistics to determine any differences between MR parameters, patient age, tumor size, and final diagnosis. RESULTS: We found 25 malignant, 12 active inflammatory, and 14 benign nodules. Nodule diameter was significantly larger for malignant than nonmalignant, and benign nodules (P≤0.01). Patients with malignant nodules were significantly older than those with nonmalignant (P=0.01) and active inflammatory (P=0.02) nodules. However, morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout characteristics at 2, 4, 8, and 12 min showed no significant difference between malignant and nonmalignant nodules and among malignant, active inflammatory, and benign nodules. CONCLUSION: Prospective assessment of dynamic MR images demonstrated their inadequacy for distinguishing indeterminate pulmonary nodules.

A case of adalimumab-associated interstitial pneumonia with rheumatoid arthritis.

A 64-year-old woman with rheumatoid arthritis (RA) began to complain of recurrent non-productive cough 5 months after starting adalimumab. The chest radiograph and high-resolution computed tomographic findings revealed diffuse ground-glass attenuation. Her clinical course suggested that interstitial pneumonia (IP) may have been induced by adalimumab, and she was successfully treated with a medium dose of corticosteroid. This case indicates that adalimumab-associated IP should be considered if a RA patient develops non-productive cough following adalimumab therapy.

Depletion of CD8+ T cells enhances airway remodelling in a rodent model of asthma.

Airway remodelling is induced by persistent airway inflammation and may lead to severe asthma. T cells play a pivotal role in asthmatic airway inflammation but their role in remodelling is poorly understood. Although previous studies have revealed that CD8(+) T cells inhibit the late airway response and airway inflammation in a rat model of asthma, their effects on airway remodelling have not been evaluated. The aim of this study was to examine the role of CD8(+) T cells in airway remodelling. Brown Norway rats were sensitized with ovalbumin (OVA) on day 0. CD8(+) T cells in rats were depleted during the repeated challenges by treating them with a CD8alpha monoclonal antibody (OX-8). Control rats were treated with mouse ascites. Sensitized rats were challenged with OVA on days 14, 19 and 24 or were sham challenged with phosphate-buffered saline. On day 29, bronchoalveolar lavage and lung tissues were harvested. Repeated OVA inhalations evoked significant increases in the numbers of periodic acid-Schiff-positive epithelial cells and proliferating cell nuclear antigen-positive epithelial cells, and in airway smooth muscle mass compared to the control group. CD8-depleted rats had significant enhancement of these changes, principally affecting the large airways. These results suggest that endogenous CD8(+) T cells have inhibitory effects on airway remodelling in this model of asthma.

Gamma-delta T cell is essential for allergen-induced late asthmatic response in a murine model of asthma.

BACKGROUND: Gamma-delta (gamma-delta) T cells regulate immune responses at mucosal surfaces. Whether they can modify allergen-induced early (EAR) and late airway responses (LAR) is unknown. OBJECTIVE: We have tested the hypothesis that the gamma-delta T cells enhance allergen-induced airway responses in mice. METHODS: BALB/c wild-type (WT) mice and gamma-delta T cell-deficient (gamma-delta T-cell KO) mice were sensitized by intraperitoneal injection of ovalbumin (OVA) on days 1 and 15, immunized with 1% OVA aerosol on days 29-31, and challenged with 5% OVA or saline on day 33. Enhanced pause (Penh) was measured and BAL fluid was collected after challenge. Serum IgE was measured before challenge. The percentage of interleukin (IL)-4 and interferon (IFN)-gamma producing T cells in splenocytes from sensitized animals was determined by flow cytometry. RESULTS: Both EAR and LAR were observed in OVA-challenged WT mice. LAR but not EAR was inhibited in OVA-challenged gamma-delta T-cell KO mice. Gamma-delta T-cell KO mice showed less eosinophilia in BALF and serum OVA-specific IgE. In the sensitization period, the percentage of IFN-gamma producing alpha-beta T cell in gamma-delta T-cell KO mice was higher than that in WT mice. CONCLUSION: gamma-delta T cells enhance LAR and airway inflammation but not EAR in this model of asthma.

Interferon-gamma-dependent inhibition of late allergic airway responses and eosinophilia by CD8+ gammadelta T cells.

We have previously shown that CD8(+)gammadelta T cells decrease late allergic airway responses, airway eosinophilia, T helper 2 cytokine expression and increase interferon-gamma (IFN-gamma) expression. We hypothesized that the effects of CD8(+)gammadelta T cells were IFN-gamma mediated. Brown Norway rats were sensitized to ovalbumin on day 1. Cervical lymph node CD8(+)gammadelta T cells from sensitized animals were treated with antisense oligodeoxynucleotide (5 micromol/l) to inhibit IFN-gamma synthesis or control oligodeoxynucleotide and 3.5 x 10(4) CD8(+)gammadelta T cells were injected intraperitoneally into sensitized recipients on day 13. Rats were challenged with aerosolized ovalbumin on day 15 and lung resistance was monitored over an 8 hr period, after which bronchoalveolar lavage was performed. Control oligodeoxynucleotide treated gammadelta T cells decreased late airway responses and eosinophilia in bronchoalveolar lavage. There was a complete recovery of late airway responses and a partial recovery of airway eosinophilia in recipients of antisense oligodeoxynucleotide treated cells. Macrophage ingestion of eosinophils was frequent in rats administered gammadeltaT cells but reduced in recipients of antisense oligodeoxynucleotide treated cells. These results indicate that CD8(+)gammadelta T cells inhibit late airway responses and airway eosinophilia through the secretion of IFN-gamma. Defective or altered gammadelta T-cell function may account for some forms of allergic asthma.

Resident CD8+ T cells suppress CD4+ T cell-dependent late allergic airway responses.

BACKGROUND: The role of CD8+ T cells in the immune response to airway challenge with an allergen is poorly understood. OBJECTIVE: The aim of this study was to test the hypothesis that resident naive CD8+ T cells modulate the magnitude of CD4+ T cell-dependent allergic airway responses. METHODS: Cervical lymph node CD4+ T cells (2 x 10(6)) were harvested from ovalbumin (OVA)- or sham-sensitized rats and injected intraperitoneally into naive Brown Norway recipients. The recipients were treated with a CD8alpha mAb (OX-8) to deplete the resident CD8+ T cells (n = 12) or mouse ascites (n = 12). Two days after adoptive transfer, the recipient animals were OVA challenged, lung resistance was measured for 8 hours, and bronchoalveolar lavage (BAL) was performed. RESULTS: After OVA challenge, primed CD4-transferred CD8-depleted rats had larger early airway responses and late airway responses compared with primed CD4-transferred CD8-nondepleted rats (early airway responses: 158.6% +/- 19.2% vs 115.7% +/- 5.9%, P < .05; late airway responses: 8.5% +/- 1.7% vs 4.4% +/- 0.9%, P < .05). BAL eosinophilia was also greater (4.67% +/- 0.45% vs 2.34 +/- 0.26%, P < .01). The cells in BAL fluid expressing IL-4 mRNA were not significantly changed by CD8 depletion, but IL-5 mRNA+ cells were higher in number, and IFN-gamma mRNA+ cells were fewer in the CD8-depleted group. CONCLUSIONS: Resident CD8+ T cells downregulate the late allergic response and airway inflammation evoked by CD4+ T-cell transfers in Brown Norway rats. This downregulation does not require antigen priming.

CD8+ alphabeta T cells can mediate late airway responses and airway eosinophilia in rats.

BACKGROUND: The function of CD8+ T-cell subsets in mediating late allergic responses is incompletely understood. OBJECTIVE: We sought to test the hypothesis that CD8+ alphabeta T cells are proinflammatory in the airways in vivo by using a well-characterized animal model and the technique of adoptive transfer. METHODS: Brown Norway rats were administered CD8 + alphabeta T cells (10 6 ) intraperitoneally purified from lymph node cells of either naive or ovalbumin (OVA)-sensitized rats and were challenged with aerosolized OVA 2 days later. Control rats were sensitized to 100 mug of OVA in Al(OH) 3 subcutaneously or sham sensitized to saline and were OVA challenged 2 weeks later. RESULTS: The OVA-sensitized and OVA-challenged group and the recipients of OVA-primed CD8+ alphabeta T cells had significant late airway responses calculated from lung resistance measured for an 8-hour period after challenge compared with the naive CD8 + alphabeta T cell-transferred group and the sham-sensitized control group. The number of eosinophils in bronchoalveolar lavage fluid increased in the OVA-sensitized group and the OVA-primed CD8+ alphabeta T-cell recipients compared with numbers in the naive CD8+ alphabeta T-cell recipients and the sham-sensitized control group. IL-4 and IL-5 cytokine mRNA expression in bronchoalveolar lavage fluid increased in the OVA-sensitized group and the OVA-primed CD8+ alphabeta T-cell recipients compared with that in the sham-sensitized group. CONCLUSION: We conclude that antigen-primed CD8 + alphabeta T cells might have a proinflammatory role in allergen-driven airway responses in the rat.

[Pneumoconiosis diagnosed in a dentist].

A 74-year-old man was admitted to our hospital because of exertional dyspnea in January 2003. He had first noticed slight exertional dypnea in 1997, which had since gradually progressed. He has been a dentist since the age of 23. Chest radiography demonstrated bilateral reticular shadows, infiltrates, and thickened pleural adhesion, which had progressed for one year and five months. Chest CT scans disclosed irregular peribronchial opacities, centrilobular nodules, and interlobular septal lines. Bronchoalveolar lavage fluid showed an increase in total cells and lymphocytosis with an increased CD 4/CD 8 ratio. Transbronchial lung biopsy demonstrated fibrosis around bronchioles, involving adjacent alveolar structures and scattered birefringent particles under polarized light. Energy-dispersive X-ray analysis (EDXA) of the small particles around the bronchioles using electron microscopy showed high peaks for silicon (Si) and aluminium (Al). Pneumoconiosis, possibly induced by some of the mechanical and technical procedures of dentistry, was diagnosed.

CD4+ T cells migrate from airway to bone marrow after antigen inhalation in rats.

BACKGROUND: IL-5-producing T lymphocytes increase in rat bone marrow after inhalational challenge with allergen. OBJECTIVE: To test the hypothesis that T cells migrate from the airways to the marrow, we examined the trafficking of T cells in Brown Norway rats after sensitization and challenge with ovalbumin. METHODS: Purified CD4+ T cells, harvested from cervical lymph nodes of naive and ovalbumin-sensitized donors, were labeled with carboxy fluorescein diacetate succinimidyl ester; 20 x 10(6) cells were placed in the trachea of naive or sensitized recipients under anesthesia, and 18 hours later, animals were challenged with inhaled ovalbumin. Cells were harvested 24 hours later from the bone marrow, bronchoalveolar lavage fluid, lungs, the lung blood pool of cells, lung draining lymph nodes, peripheral blood, and spleen. RESULTS: The number of carboxy fluorescein diacetate succinimidyl ester-positive cells, measured by fluorescence-activated cell sorter, in the bone marrow of ovalbumin sensitized, primed T-cell recipients was higher than either the sham-sensitized, primed T-cell recipients or sham-sensitized, naive T-cell recipients (P < .05). The number of eosinophils in both bone marrow and bronchoalveolar lavage fluid was increased in ovalbumin-sensitized, primed T-cell recipients. The expression of the T-cell chemoattractants eotaxin and IL-16, evaluated by immunohistochemistry, was higher in the bone marrow of ovalbumin-sensitized, primed T-cell recipients. CONCLUSIONS: CD4+ T cells travel from airway to bone marrow after antigen inhalation. The homing of the CD4+ T cells might be facilitated by eotaxin and IL-16 expression in the bone marrow and might contribute to the stimulation of eosinophilopoiesis after airway allergen exposure.

T cell cytokines: animal models.

Allergic asthma involves a complex series of reactions within the airways that lead to inflammation and bronchoconstriction. These phenomena are closely linked to the immune response to the allergenic protein mediated by T cells with specificity for the allergen. Antigen presentation by dendritic cells initiates the allergic response, triggering the activation of CD4+ T cells predominantly. These cells secrete Th2 type cytokines, of which IL-4 and IL-5 are best understood, that act on various cells including B cells, eosinophils, macrophages and epithelial cells. These cells mediate, in turn, immunoglobulin E synthesis, and promote an eosinophil rich inflammation through the concerted action of various chemoattractant substances, both lipid-derived and proteins. CD8+ T cells are also activated and may have either anti-inflammatory or pro-inflammatory effects, depending upon the particular experimental model studied. The T cell receptor (TCR) that these cells possess has an important influence on the role they play. TCRalphabeta cells appear more likely to be pro-inflammatory and have antigen specificity whereas TCRgammadelta cells can be either pro- or anti-inflammatory, depending on species and experimental conditions and are not antigen specific. In conclusion, the magnitudes of inflammatory responses and bronchoconstriction following allergen challenge of sensitised animals are T cell driven and are determined, at least in part, by the balance of the T cell subsets that are activated.

The effects of CD8+gammadelta T cells on late allergic airway responses and airway inflammation in rats.

BACKGROUND: Gamma-delta (gammadelta) T cells regulate immune responses to foreign protein at mucosal surfaces. Whether they can modify allergen-induced early (EAR) and late airway responses (LAR) is unknown. OBJECTIVE: We have tested the hypothesis that the CD8+ subtype of gammadelta T cells decreases allergen-induced LAR and airway eosinophilia in the rat. METHODS: Brown Norway rats were administered, intraperitoneally, 3.5 x 10(4) lymph node CD8+gammadelta T cells from naive or sensitized rats. The recipients were sensitized to ovalbumin (OVA) in Al(OH)(3) 3 days after cell transfer and challenged with aerosolized OVA 14 days later. Serum IgE was measured before allergen challenge. After challenge, lung resistance was monitored for 8 hours and then bronchoalveolar lavage (BAL) was analyzed for eosinophil major basic protein (MBP), IL-4, IL-5, IL-13, and IFN-gamma messenger RNA-expressing cells. RESULTS: gammadelta T cells from naive donors significantly decreased LAR in OVA-challenged sensitized rats, whereas MBP(+) eosinophils were decreased by both gammadelta T cells from naive and sensitized donors. EAR and serum IgE levels were unchanged. The expression of IL-4, IL-5, and IL-13 by BAL cells of gammadelta T cell recipients was attenuated compared with OVA-challenged controls. This was accompanied by an increase in the expression of IFN-gamma. CONCLUSIONS: Our results are consistent with a suppressive role of CD8+gammadelta T cells on allergic airway responses. However, only gammadelta T cells from naive donors inhibit LAR.

Cyclosporin A followed by the treatment of acute exacerbation of idiopathic pulmonary fibrosis with corticosteroid.

OBJECTIVE: Idiopathic pulmonary fibrosis (IPF) is a slowly progressive disease with a poor prognosis. Acute exacerbation is the worst stage in the clinical course of IPF, as the condition is unresponsive to most conventional therapies. Corticosteroids and other immunosuppressive drugs have been attempted for the treatment of acute exacerbation, but only with very limited effectiveness. This study was performed to examine the effect of cyclosporin A (CsA) on acute exacerbation of IPF. PATIENTS AND METHODS: Thirteen patients with acute exacerbation of IPF were retrospectively studied. All 13 patients received pulse-therapy with methylprednisolone (1,000 mg per day for 3 days), followed by oral prednisolone (40-60 mg per day). Seven patients were received CsA (1.0-2.0 mg/kg per day) after the treatment with corticosteroids. We attempted to keep the blood trough level of CsA between 100 and 150 ng/ml. RESULTS: Among the 7 patients treated with CsA, 4 patients have survived for 60, 120, 276 and 208 weeks, respectively; 2 did not respond to pulse-therapy with methylprednisolone and died within 8 weeks after the start of CsA treatment. The other patient experienced re-exacerbation and died 87 weeks after the discontinuation of CsA due to the development of viral encephalitis. In contrast, all 6 patients treated without CsA died within 66 weeks after the onset of acute exacerbation. Four of these patients responded to pulse-therapy with methylprednisolone, but their condition deteriorated again while the subsequent prednisolone was being tapered. CONCLUSION: CsA seems to prevent re-exacerbation of IPF and improve the patients' chances for long-term survival.