Exercise-induced anaphylaxis in a cardiopathic patient on chronic aspirin therapy.

We report the case of a 73 year old man on chronic aspirin therapy who went in anaphylactic shock during his daily farm chores following a meal rich in wheat products. The serum specific IgE assay (ImmunoCAP) showed strong positive specific IgE responses to ω-5 gliadin. A two-year period avoiding wheat meals 3 hours prior to exercise, resulted in a lack of further anaphylaxis; this results aided us in making the diagnosis.

N-acetylcysteine reduces the exacerbation rate in patients with moderate to severe COPD.

OBJECTIVE: This study was performed to confirm the efficacy of a 6-month therapy with a formulation of N-acetylcysteine (NAC; 600 mg/day p.o.) on frequency and severity of exacerbations in patients suffering from chronic obstructive pulmonary disease (COPD). METHODS: One hundred sixty-nine patients attending five Italian centres were recruited in an open, randomized, controlled study. The patients were randomly allocated to standard therapy plus NAC 600 mg once a day or standard therapy alone over a 6-month period. At baseline, medical history was evaluated, and physical examination was performed; occurrence and severity of exacerbations and side effects of NAC were analyzed after 3 and 6 months. RESULTS: The results showed a decreased number of exacerbations (by 41%) in the group of patients treated with NAC and standard treatment: 46 patients had at least one exacerbation as compared with 63 patients of the group treated with standard therapy alone. Also the number of the patients with two or more exacerbations was lower in the NAC group (26%) than in the standard-therapy group (49%). The number of sick days was less (82) in the NAC group as compared with the standard-therapy group (155). There was a small but significant improvement in FEV(1) and MEF(50) in the NAC group. NAC once a day was well tolerated. There were no differences in the number of side effects reported in both groups. CONCLUSIONS: These data confirm results of previous studies which reported a reduction in the number of exacerbations in patients having moderate to severe COPD treated with the antioxidant NAC. Further, the once-daily formulation is well tolerated and is likely to improve patient compliance with the prescribed regimen.

[Subclinical interstitial lung involvement in rheumatic diseases. Correlation of high resolution computerized tomography and functional and cytologic findings]. / L'interessamento polmonare interstiziale subclinico nelle malattie reumatiche. Correlazione fra Tomografia computerizzata con alta risoluzione e i reperti funzionali e citologici.

INTRODUCTION: Rheumatic diseases are frequently associated with interstitial lung disease. Since interstitial fibrosis is an irreversible process, understanding the mechanisms leading to fibrosis is necessary for the development of treatment strategies to prevent irreversible pulmonary damage. High-resolution Computed Tomography (HRCT) is superior to chest radiography in assessing the presence and extent of parenchymal abnormalities in diffuse infiltrative lung diseases and provides a sensitive and noninvasive method of quantifying global disease extent. PURPOSE: The aims of this study were to quantify the severity and extent of subclinical interstitial lung disease as depicted on HRCT and to study the relationship between the patterns of lung disease quantified by HRCT and the functional parameters and bronchoalveolar lavage findings in patients with rheumatic diseases. PATIENTS: Eighty nonsmoking patients (24 patients with systemic sclerosis, 24 with primary Sjögren's syndrome, 20 with rheumatoid arthritis and 7 with dermatopolymyositis) were examined. No patient had any signs or symptoms of pulmonary disease. RESULTS: Thirty-three of 80 patients (41.2%) had abnormal HRCT findings, namely isolated septal/subpleural lines, irregular pleural margins and ground-glass appearance. Chest X-ray showed parenchymal abnormalities in only 15 patients (18.7%) who had evidence of fibrosis on HRCT. Abnormal differential cell counts (alveolitis) at bronchoalveolar lavage were found in 46 of 80 patients (57.5%). Three types of alveolitis were observed: pure lymphocyte alveolitis, pure neutrophil alveolitis, and neutrophil alveolitis associated with lymphocytosis (mixed alveolitis). The patients with neutrophil alveolitis had more extensive disease on HRCT than those with lymphocyte alveolitis or with normal cellular patterns at bronchoalveolar lavage. The extent of a reticular pattern on HRCT correlated with the neutrophil rate (p = 0.001) and total count (p = 0.003) on bronchoalveolar lavage. Eosinophil and lymphocyte rate and total count correlated (p < 0.05) with the extent of the ground-glass pattern on HRCT. Lung volumes were not significantly different among patients with ground-glass pattern and those with reticular patterns on HRCT, while the diffusing capacity for carbon monoxide was significantly lower (p < 0.05) in the latter. CONCLUSIONS: HRCT is a sensitive tool in detecting interstitial lung disease in patients with rheumatic diseases with no signs and symptoms of pulmonary involvement. The relationship between the different HRCT patterns and bronchoalveolar lavage cell profiles can identify patients at higher risk of developing irreversible lung fibrosis. A long-term, prospective follow-up study is needed to determine whether these patients will develop over pulmonary disease.

A longitudinal study of pulmonary involvement in primary Sjögren's syndrome: relationship between alveolitis and subsequent lung changes on high-resolution computed tomography.

Eighteen non-smoking women suffering from primary Sjögren's syndrome (pSS) with previously documented alveolitis were re-examined, clinically and by pulmonary function tests (PFT), bronchoalveolar lavage (BAL), chest X-ray and high-resolution computed tomography (HRCT) after a 2 yr follow-up period. Longitudinal evaluation revealed unchanged PFT. The final BAL study showed a normal differential count in six of 14 patients with initial lymphocyte alveolitis, and a persistent alveolar lymphocytosis in the remaining eight patients, associated with an increased percentage of neutrophils in one of them. In four patients with initial mixed alveolitis, the BAL cell profile was unchanged 2 yr later. Five of 18 patients (28%) had abnormal HRCT, represented by isolated septal/subpleural lines in three patients, ground-glass opacities with irregular pleural margins in one patient, and ground-glass opacities associated with septal/subpleural lines in another. All these patients had abnormal BAL results with an increased proportion of both neutrophils and lymphocytes. The presence of alveolar neutrophils was associated with a significantly (P=0.005) greater mean rate of reduction of carbon monoxide diffusing capacity (DLCO) -- more than four times the normal rate of loss of DLCO. Chest X-ray, repeated at the end of the 2 yr follow-up period, showed parenchymal abnormalities in only one patient who had evidence of fibrosis on HRCT. This study provides evidence that lung involvement is not an uncommon extraglandular manifestation of pSS and that a BAL neutrophilia may play an important role in the pathogenesis of pulmonary disease in this autoimmune disorder.

Methotrexate-induced pneumonitis in patients with rheumatoid arthritis and psoriatic arthritis: report of five cases and review of the literature.

Pneumonitis is emerging as one of the most unpredictable and potentially serious, adverse effects of treatment with MTX. Its prevalence in rheumatoid arthritis (RA) has been estimated from several retrospective and prospective studies to range from 0.3% to 18%. On the other hand, MTX-induced pneumonitis seems to be very rare in psoriatic arthritis (PsA). Our review of 194 RA patients and 38 PsA patients receiving MTX has identified four RA patients and one PsA patient with MTX-induced pneumonitis, giving a prevalence of 2.1% and 0.03%, respectively. Diagnosis was suggested by clinical history and radiographic findings, but the bronchoalveolar lavage plays an important role both in excluding infectious agents and in providing information for understanding the pathogenesis of lung injury. The presence of a lymphocyte alveolitis with a predominance of CD4+ T cells in 3 RA patients and CD8+ T cells with a concomitant increase in neutrophils in another case suggests that immunologically mediated reactions may be one damage mechanism in MTX-induced pneumonitis. Although risk factors for MTX-induced pulmonary toxicity are poorly understood, the presence in 3 out of 5 of our patients of pre-existing lung disease, represented by diffuse interstitial changes on chest X-ray, and mild bronchial asthma in two RA patients and by pulmonary silicosis in the patient with PsA may account for a predisposition to the development of MTX pneumonitis.

Bronchoalveolar lavage in mixed cryoglobulinaemia associated with hepatitis C virus.

In order to evaluate the presence of an inflammatory process of the lower respiratory tract in patients with mixed cryoglobulinaemia (MC) associated with hepatitis C virus (HCV), bronchoalveolar lavage (BAL) was performed in 16 non-smoking females free of clinical pulmonary symptoms and with normal chest roentgenograms. Pulmonary function tests including diffusion capacity for carbon monoxide (DLCO) were also carried out. Thirteen healthy subjects were evaluated as the control group. Patients with MC had a lower percentage of alveolar macrophages (75% vs 92%, P = 0.001) and a higher percentage of lymphocytes (19.7% vs 7%, P = 0.001) than healthy controls. The percentage of CD3+ lymphocytes was higher in MC patients than in controls (86.5% vs 70%, P = 0.004). No significant differences in the percentage of CD4+, CD8+ and CD19+ lymphocytes, neutrophils and eosinophils were found. Pulmonary function tests showed significantly lower values of forced expiratory flow (FEF) 25-75 (P = 0.05) and DLCO (P = 0.05) in MC patients than in healthy controls. No correlations between BAL results and pulmonary function tests were found. The 5 yr follow-up of five patients did not demonstrate deterioration in lung function. Thus, BAL results indicate a subclinical T-lymphocytic alveolitis in MC HCV+ patients that is not associated with a risk of deterioration in lung function.

[Pulmonary inflammation in systemic sclerosis. An assessment by bronchoalveolar lavage]. / L'infiammazione polmonare nella sclerosi sistemica. Valutazione mediante lavaggio broncoalveolare.

Interstitial pulmonary fibrosis is a common feature of systemic sclerosis (SS). Clinicopathologic observations suggest that interstitial and alveolar inflammation may appear prior to fibrosis. Using the bronchoalveolar lavage (BAL) technique, we have characterized the nature of the inflammatory process in the lower respiratory tract of 15 non-smoking scleroderma patients and compared the results with those found in eight normal subjects. Alveolitis was detected in 11 patients (73%). Abnormalities in the cellular constituent included a significant increase of the proportion of lymphocytes (20.8 +/- 3.2 vs 8.1 +/- 1.2; p = 0.01) and neutrophils (3.3 +/- 0.8 vs 0.8 +/- 0.2; p = 0.04). T cell subsets, evaluated by flow cytometry, showed a significant increase of CD8+ T cells (36.6 +/- 3.2 vs 25, 1 +/- 3.3; p = 0.04) and a decrease of CD4+/CD8+ ratio (1.1 +/- 0.1 vs 2.1 +/- 0.4; p = 0.04). Seven patients with an elevation of proportional BAL (lymphocyte count > 15%) had greater dyspnoea and chest radiographic score than patients without lymphocytic alveolitis (p = 0.02) and they had greater reduction in carbon monoxide diffusing capacity (DLco) (p = 0.04). Furthermore, a statistically significant correlation between the total lymphocyte cell count and the DLco (p = 0.03) was observed. Finally the stepwise multiple regression analysis identified lymphocyte count in lavage fluid as the predictor most strongly associated with an abnormal interstitial radiographic pattern (p = 0.001). Our results report the notion that the lymphocytes, in addition to the macrophages and neutrophils, may play roles in the pathogenesis of lung injury.

[Respiratory rehabilitation in the pneumology department of Iesi Hospital. Statistical findings and program considerations]. / La riabilitazione respiratoria nel presidio pneumologico di Jesi. Rilievi statistici e considerazioni programmatiche.

The Authors refer the results a clinical-statistical research revealing that more than one-third of the yearly admissions to the pneumological divisions of the U.H. in Jesi are represented by patients who re-enter because of COLD with R.I. at various degree. On the basis of the selective criteria which can be found in literature, it's shown that the above patients can largely take advantage of rehabilitating treatment aiming both at the functional recovery and at the prevention of relapses, with a consequent fall in hospital admissions, carrying doubtless social advantages. The Authors also assert that such a treatment, though involving an équipe-approach, must be carried out by the pneumologist as the respiratory rehabilitation is to be considered, both for its aims and its methodologies as a branch of pneumology. Starting from this introductory statement the Authors go on making consideration on regional health programming in the pneumology field, particularly the rehabilitating one.