Increased expression of transforming growth factor-beta1 in small airway epithelium from tobacco smokers and patients with chronic obstructive pulmonary disease (COPD).

Tobacco smoke is believed to cause small airway disease and then chronic obstructive pulmonary disease (COPD), but the molecular mechanisms by which small airway obstruction occurs remain unknown. To study the gene expression levels of transforming growth factor (TGF)-beta1, a potent fibrogenic factor, in small airway epithelium from smokers and patients with COPD, we harvested highly pure samples of epithelial cells from small airways under direct vision by using an ultrathin bronchofiberscope BF-2.7T (outer diameter 2.7 mm with a biopsy channel of 0.8 mm in diameter). The expression levels of TGF-beta1 were evaluated by reverse transcription-polymerase chain reaction (RT-PCR). The mRNA levels of TGF-beta1 corrected by beta-actin transcripts were significantly higher in the smoking group and patients with COPD than those in nonsmokers (p < 0.01). Furthermore, among smokers and patients with COPD, TGF-beta1 mRNA levels correlated positively with the extent of smoking history (pack-years) and the degree of small airway obstruction as assessed by measurements of flow-volume curves. Immunocytochemistry of the cells demonstrated more intense stainings for TGF-beta1 in samples from smokers and patients with COPD than from nonsmokers. Spontaneously released immunoreactive TGF-beta1 levels from cultured epithelial cells were more elevated in subjects with a history of smoking and patients with COPD than in nonsmokers. Our study showed a close link between smoking and expression of TGF-beta1 in small airways. Our results also suggested that small airway epithelial cells might be involved in obstructive changes found in smokers and patients with COPD.

Increased expression of inflammatory mediators in small-airway epithelium from tobacco smokers.

To study the inflammatory responses of small-airway epithelium in smokers, we harvested enough living epithelial cells (1.97 x 10(6) +/- 0.74 x 10(6)) with a new ultrathin fiberscope from the very peripheral airways of 22 current smokers and 17 subjects who never smoked after informed consent was obtained. The cells were keratin positive and composed mainly of nonciliated cells. The expression levels of inflammatory markers [interleukin (IL)-8 and intercellular adhesion molecule (ICAM)-1] were evaluated with RT-PCR. The magnitude of the mRNA levels corrected by beta-actin transcripts of IL-8 and ICAM-1 was significantly higher in the smokers than in the nonsmokers (P < 0.001). Furthermore, among current smokers, IL-8 mRNA levels correlated positively with the extent of smoking history [in pack. years (packs/day x no. of years of smoking); r = 0.754, P < 0.001]. Spontaneously released IL-8 and soluble ICAM-1 levels (n = 12) from cultured epithelial cells were elevated in subjects with a smoking history than in those without it (IL-8, 1,580 +/- 29.6 vs. 354 +/- 39.4 pg. 10(6) cells(-1). 24 h(-1); P < 0.001; soluble ICAM-1, 356.0 +/- 45.9 vs. 112.9 +/- 12.9 pg. 10(6) cells(-1). 24 h(-1); P < 0.01 by Student's t-test ). In contrast, the epithelial cells from the main bronchi did not show such differences between smokers and nonsmokers. Our study highlighted a close link between smoking and the expression of inflammatory mediators such as IL-8 and ICAM-1 in small airways. Our results also suggested that this new ultrathin bronchofiberscope promised a good approach for the evaluation of cellular changes in the small airways.

Simultaneous continuous 13C, 12C analysis of expired gas in the 13C breath test.

The 13C breath test is a method of clarifying the metabolism of loaded substances by administering 13C-labelled materials and calculating the 13CO2 and 12CO2 ratio (13C/12C isotope ratio) in the expired gas. The materials are metabolized and expelled in the expired gas. Because simultaneous continuous measurement of 13CO2 and 12CO2 in expired gas has been difficult up to the present, respective expired gases, including dead space before and after administration, have been sampled to separate sampling bags and 13C/12C has been measured in the bags and changed fraction of 13C/12C after administration (delta) has been used to judge the metabolic process. This method is affected by the contamination of the dead space gas. In the present study, in order to exclude the dead space effect, simultaneous continuous analysis of 12CO2 and 13CO2 of expired gas identifying alveolar gas was applied to the 13C-urea breath test in addition to the conventional sampling bag method. Both isotope detectors were attached to a mass spectrometer. Fifty-six cases receiving stomach health check-ups for Helicobacter pylori were examined. Delta was calculated in the bag or in phase III of continuous gas measurement. Because the bag contains dead space, delta was reduced and sensitivity and specificity with reference to gastric fluoroscopy or Helicobacter pylori IgG antibody were reduced. Decreasing the dead space contamination is important in reducing the measurement error in the 13C breath test and simultaneous continuous measurement is a good tool for this purpose.

[High concentrations of interleukin-8 in bronchoalveolar lavage fluid from a patient with adult respiratory distress syndrome].

A 75-year-old man was admitted to the hospital due to acute onset of a dry cough and dyspnea on exertion. Arterial blood gas analysis showed hypoxemia (PaO2 = 63 Torr) on room air. Chest radiography and computed tomography showed diffuse bilateral infiltrates. Adult respiratory distress syndrome was diagnosed from the findings described above and from the lack of evidence of left heart failure. Diffuse alveolar damage was confirmed at autopsy. During the course of his illness, the patient underwent bronchoalveolar lavage five times. The recovered fluid had high concentrations of interleukin-8 (IL-8), with a maximum of 6260 pg/ml and a minimum of 190 pg/ml, and these values correlated with the number of polymorphonuclear cells in the fluid. Levels of leukotriene B4, another chemotactic factor for PMN, in the lavage fluid were not high. We conclude that IL-8 was a major chemoattractant for PMN in the alveoli of this patient.

Mycobacterium avium-intracellulare pleuritis with massive pleural effusion.

Atypical mycobacterial infection is seldom accompanied by pleural involvement. We report a very rare case of Mycobacterium avium-intracellulare pleuritis with massive pleural effusion. The patient was a non-immunocompromised 35-year-old Japanese male with insidious onset of fever, chest pain and anorexia. The pleural effusion gradually resolved with empirical antimycobacterial treatment, leaving considerable pleural adhesion and thickening.

[A case of tropical eosinophilia associated with pleural effusion].

A 52-year-old man was admitted to Keio University Hospital for determination of the etiology of a bilateral pleural effusion associated with marked eosinophilia (10200 cells/mm3). He had been in Vietnam for three years and had returned to Japan in May 1993. He was suffering from tropical eosinophilia, as clearly indicated by eosinophilia, elevation of serum IgE level (708 IU/ml), the presence of anti-dirofilarial antibodies, and the absence of microfilaria in the blood. The pleural effusion was an exudate and 51% of the cells in the effusion were eosinophils. In the effusion, no parasites were detected but anti-dirofilarial antibodies were found (the titer was as high as that in the serum). Diethylcarbamazine was given, and a steroid had to be superimposed because of wheezing. These treatments successfully reduced the bronchoconstriction, eosinophilia and accumulation of pleural effusion. Tropical eosinophilia has generally been thought not to be associated with pleural effusion. This is only the third case report of tropical eosinophilia with authentic pleural effusion.

Long-term course of bronchiectasis and bronchiolitis obliterans as late complication of smoke inhalation.

We describe the long-term course of a patient with bronchiectasis and bronchiolitis obliterans, both of which developed as late complications of a smoke inhalation injury. Sequential chest X-rays obtained during the observation period showed gradual progression of bronchiectasis from the saccular to the cystic type. Symptoms, spirometry and blood gas analysis, however, remained stable for 15 years. We believe that symptoms and physiological derangement were due mainly to bronchiolitis obliterans, and that once the pathophysiological condition had been established following the initial injury, it could be maintained by conservative medical management.

Assessment of an ultrathin bronchoscope that allows cytodiagnosis of small airways.

We developed a new type of bronchoscope (BF-2.7T) and cytology brush (BC-0.7T) that permit collection of pulmonary cells during direct observation of the small airways. This kind of cell collection has been previously impossible. With our cytology brush, 3.58 +/- 2.76 x 10(4) cells were collected from small airways. The rate of living cells was 33.13 +/- 3.61 percent from the small airways. Analysis of endoscopic findings and investigation of pulmonary cells are very important for elucidating the pathophysiologic state of the small airways. The use of the BF-2.7T allowed collection of cancer cells under direct endoscopic vision in all five patients with peripheral lung cancer. They also contribute to our understanding of the relationship between exogenous factors and cells that compose the lung, and will provide means for treatment and prevention of diseases.

Ventilation-perfusion inequality and diffusion impairment in acutely injured lungs.

To assess the significant role of diffusion impairment and its unequal distribution in acutely injured lungs with alveolar flooding, oleic acid was intravenously injected into twenty-five mongrel dogs. The animals were divided into two groups, A and B. 0.1% CO in air was delivered, as an inspired gas, to the animals of group A. Simultaneously, saline containing a trace amount of six foreign inert gases was infused through a peripheral vein. While allowing the animals in group B to breathe air, saline containing ethylene, acetylene and freon 22 was infused. After injection of oleic acid, group A revealed increase in intrapulmonary shunt accompanied by a marked broadening of ventilation-perfusion (VA/Q) and diffusing capacity-perfusion (G/Q) distributions. A considerable amount of total cardiac output was received by the lung areas with low G/Q ratios where significant diffusion limitation was predicted to occur. Group B showed that excretion of freon 22 (gas with lower diffusivity) in injured lungs was considerably distorted as compared to those of ethylene and acetylene (gases with higher diffusivities), again ascertaining the importance of diffusion limitation in lungs with exudate in alveolar regions.

Serum concentration of 7S collagen and prognosis in patients with the adult respiratory distress syndrome.

BACKGROUND--7S collagen, an N-terminal peptide of type IV collagen, is a primary constituent of the basement membrane. To evaluate whether the serum concentration of 7S collagen reflects the severity of inflammatory lung disease, the serum concentration of 7S collagen was measured in patients with adult respiratory distress syndrome (ARDS) and idiopathic pulmonary fibrosis (IPF). METHODS--A radioimmunoassay was used for the measurement of 7S collagen. Gas exchange abnormality was expressed as the arterial oxygen tension (PaO2) divided by the fractional concentration of inspired oxygen (FiO2). RESULTS--The mean (SD) concentration of 7S collagen was 2.7 (0.9) ng/ml in 10 healthy subjects, 5.0 (1.5) ng/ml in 11 patients with IPF, and 14.8 (9.7) ng/ml in 13 patients with ARDS. Significant differences were observed between the patients with ARDS and both healthy subjects and the patients with IPF. In the patients with ARDS serum concentrations of 7S collagen were strongly related to PaO2/FiO2 (r = -0.61). Moreover, the mean (SD) serum concentration of 7S collagen in the eight patients with ARDS who died (19.5 (10.2) ng/ml) was considerably higher than that of the five who survived (7.1 (2.1) ng/ml). CONCLUSION--These results suggest that serum levels of the 7S fragment of type IV collagen may have some prognostic value in ARDS.

[Gastric metastasis of primary lung cancer].

A 74-year-old man was admitted to Keio University Hospital because of an abnormal shadow in the right upper lung field on chest roentgenogram. Bronchoscopic examination revealed malignant cells, by which large cell carcinoma of the lung was diagnosed. Systemic survey for metastasis disclosed an ulcerated tumor on the greater curvature of the stomach. Endoscopic examination showed an elevated submucosal tumor suggesting submucosal metastasis of lung cancer to the stomach. A review of 473 autopsies of primary lung cancer at Keio University from 1958 to 1987 showed 16 cases with gastric metastasis (3.4%). Two of 16 cases were detected clinically. Gastric metastases were proven in 15.6% of autopsy cases of large cell carcinoma of the lung. Forty-three cases of primary lung cancer with gastric metastasis were reported in the Japanese literature from 1965 to 1990. Thirteen of these cases had large cell carcinoma.

[A study of localized inflammatory pulmonary lesions by ultra-thin bronchofiberscope].

We used a new type of endoscope developed by the authors in 10 patients with localized inflammatory pulmonary lesions in the peripheral areas which were far from the 3 branch and needed to be distinguished from lung cancer. Endoscopic findings revealed reddening, obstruction, stenosis, hypersecretion and dilation in the peripheral airway. The endoscopic findings in this disease were different from those peripheral lung cancer. The combination of thin-section CT, endoscopy and lung biopsy was the best method for determining the morphological changes in localized pulmonary lesions.

[A case of slowly-growing localized malignant mesothelioma].

We report a case of localized malignant mesothelioma. The patient was a 37-year-old male, admitted to our hospital because of a solitary nodular shadow in the right middle lung field noted on chest X-ray. Five years prior to admission, a solitary nodular shadow had been seen in the same area on chest X-ray, and the diameter of the tumor had gradually increased. A transbronchial biopsy specimen revealed proliferation of spindle-shaped tumor cells, suggesting fibrosarcoma. No other lesions were identified as primary foci, so we made the tentative diagnosis of primary pulmonary sarcoma prior performing right upper lobectomy. The resected specimen revealed that the tumor, which partially touched the pleura, contained a number of large and small cystic spaces, and was composed of numerous spindle-shaped tumor cells. Some of the tumor cells were immunohistochemically positive for cytokeratin and epithelial membrane antigen, and many mitotic figures were noted. Thus, we made the histopathological diagnosis of localized malignant mesothelioma.

[Measurements of plasmin-alpha 2 plasmin inhibitor complex and FDP.D dimer levels in the fibrinolytic therapy of acute pulmonary thromboembolism].

The key enzyme for fibrinolysis is plasmin, which is converted from plasminogen by plasminogen activator. Activated plasmin lyses fibrinogen and fibrin to make fibrin degradation products(FDPs) and plasmin is inactivated immediately by alpha 2 plasmin inhibitor. As FDP.D dimer is derived solely from insoluble fibrin, FDP.D dimer is thought of as an index for clot lysis. We measured plasmin-alpha 2 plasmin inhibitor complex(PIC) and FDP.D dimer plasma levels in 3 patients with acute pulmonary thromboembolism treated with recombinant tissue plasminogen activator(tPA). Fifteen million units of tPA(TD-2061) were infused in one hour on the first, second and third hospital days. PIC and FDP.D dimer before tPA infusion showed slightly elevated values as compared to normal ranges. They increased markedly after tPA infusion. These findings suggest that the fibrinolytic system is slightly activated in the acute phase of pulmonary thromboembolism and also strongly activated by tPA infusion. Increased FDP D dimer suggests that fibrin clots are dissolved by activated plasmin. Improvement of arterial oxygen tension was observed after tPA infusion. As sustained higher FDP.D dimer means the existence of fibrin clots, heparin treatment should be continued for prevention of clot formation as long as FDP.D dimer shows higher value. In conclusion, PIC and FDP.D dimer are useful indices not only to detect the activated state of the fibrinolytic system but also to know clot lysis in tPA treatment.

The role of recombinant human tissue-type plasminogen activator in the treatment of acute pulmonary thromboembolism.

The effect of intravenous recombinant human tissue-type plasminogen activator (tPA) on arterial blood gases was compared with the effect of heparin treatment in acute pulmonary thromboembolism. Fifteen patients received heparin alone (group A), 5 cases were treated with 7.7 x 10(6) I.U. of tPA (group B) and 10 cases with 15 x 10(6) I.U. of tPA (group C) combined with heparin treatment. Arterial oxygen tension before treatment was not significantly different among the three groups. PaO2 was dramatically improved on the 1st day in group C. By the 7th day, PaO2 of group B had improved to the level of group C. However, the PaO2 of group A on the 7th day was not significantly different compared to the pre-treatment value. In group C, post-treatment perfusion lung scintigrams were improved compared to the pre-treatment images, but this was not the case in group B. Treatment with tPA is more effective for acute pulmonary thromboembolism than heparin alone and a high dose of tPA (15 x 10(6) I.U.) leads to rapid improvement in arterial blood gases and lung perfusion images.

[Uneven ventilation-perfusion ratio distribution during acute exacerbation of chronic pulmonary diseases].

We studied ventilation-perfusion ratio (VA/Q) unevenness in terms of alveolar-arterial gas tension difference (AaDO2 and aADN2) and of multiple inert gas elimination technique during the chronic stable periods and the acute exacerbation periods of seven cases with chronic pulmonary diseases. Three had idiopathic pulmonary fibrosis, 2 had pulmonary emphysema, 1 had bronchiolitis and the other had a sequelae of pulmonary tuberculosis. Sulfur hexafluoride and cyclopropane dissolved in saline were infused into a peripheral vein at a constant rate and these 2 gases were used as the indicator gases to make analysis of two compartmental VA/Q. During exacerbation all cases showed lower PaO2 than in the stable period. All cases except idiopathic pulmonary fibrosis showed higher PaCO2. Five cases also had higher AaDO2 and aADN2. One case with pulmonary emphysema and one with bronchiolitis actually had lower AaDO2 and aADN2 values during acute exacerbation than during the chronic stable period. We introduced the difference between the logarithm of higher VA/Q and lower VA/Q values (log [(VA/Q)H/(VA/Q)L)] as an index of VA/Q unevenness. Two compartmental VA/Q analysis revealed greater VA/Q differences in all cases during acute exacerbation. This included cases who showed lower AaDO2 and aADN2 values in the acute exacerbation period. In conclusion, worsened VA/Q distribution, during the acute exacerbation period, was elucidated quantitatively using the multiple inert gas elimination technique.

[Standard values and normal limits for arterial blood gases in healthy elderly Japanese subjects].

We studied the standard values and normal limits for arterial blood gases in healthy elderly Japanese subjects. The criteria for inclusion were; 1) older than 60 years and able to walk independently, 2) non-smoker, 3) no respiratory symptoms, 4) no thoracic deformity, 5) no clinical signs of chest disease, 6) no abnormal findings in chest X ray, and 7) no cardiac disease or obesity. The number of subjects was 78. The oldest subject was a 96-year-old female. Arterial punctures were performed with the subjects in a recumbent position. PaO2 ranged from 79 to 106 Torr, with a mean value of 89.8 Torr. PaCO2 ranged from 32 to 48 Torr with a mean value of 39.6 Torr. Maximum values of alveolar-arterial O2 tension difference and arterial-alveolar N2 tension difference were 20.2 Torr and 11.6 Torr, respectively. The regression equation for PaO2 with respect to age was; PaO2 = 99.32-0.126 x (age), and its residual standard deviation was 6.06 Torr. These values were not different from those obtained in healthy young Japanese subjects.

[Clinical significance of gallium-67 scintigraphy in assessing pulmonary lesions of sarcoidosis and idiopathic pulmonary fibrosis].

To evaluate whether one can predict the course and prognosis of interstitial lung diseases from lung gallium-67 (67Ga) uptake, we studied 31 subjects with sarcoidosis and 28 with idiopathic pulmonary fibrosis (IPF) retrospectively. We quantified the lung 67Ga uptake using posterior scans by Line's method, and calculated a visual index (VI). The normal range of 67Ga uptake was defined as less than 65 VI values, obtained from the 95 percent confidence interval of the control subjects. All subjects with stage I sarcoidosis, having only bilateral hilar lymphadenopathy (BHL) on chest X-ray, revealed normal lung 67Ga uptake. Fifty percent of patients with stage II sarcoidosis, with both BHL and pulmonary involvement on chest X-ray, showed increased lung 67Ga uptake. The patients with increased lung 67Ga uptake showed decreased percent vital capacity and increased alveolar-arterial oxygen tension difference, but none of them showed clinical deterioration during the follow-up period of more than 6 months. Fifty-four percent of subjects with IPF showed increased lung 67Ga uptake. But there was no difference between the subgroups with normal and increased lung 67Ga uptake with respect to the severity of dyspnea, percent vital capacity, arterial oxygen tension, or alveolar-arterial oxygen tension difference. There was also no difference between the two subgroups of IPF in the cumulative percent survival after either the onset of symptoms or the 67Ga scintigram. We conclude that lung 67Ga uptake was not able to predict the clinical course or the prognosis of patients with sarcoidosis and IPF.