Outbreak of autoimmune disease in silicosis linked to artificial stone.

BACKGROUND: There is a well-established association between inhalational exposure to silica and autoimmune disease. We recently observed an outbreak of silica-related autoimmune disease among synthetic stone construction workers with silicosis referred for lung transplantation assessment. AIMS: To characterize the rheumatologic complications in silicosis within these highly exposed, clinically well-characterized patients. METHODS: We systematically reviewed data from all cases of silicosis due to synthetic stone dust referred to our pulmonary institute for lung transplant assessment, which represents the national centre for all such referrals. In addition to silicosis-specific data, we extracted data relevant to the clinical and serological manifestations of autoimmune diseases present in these patients. RESULTS: Of 40 patients in our advanced silicosis national data, we identified nine (23%) with findings consistent with various autoimmune diseases. Among these nine, three also had findings consistent with pulmonary alveolar proteinosis. Based on an expected autoimmune disease prevalence of 3% (based on the upper-end estimate for this group of diseases in European international data), the proportion of disease in our group represents a >7-fold excess (prevalence ratio 7.5; 99% confidence interval 2.6-16.7). CONCLUSIONS: These cases underscore the strong link between silicosis and multiple distinct syndromes of autoimmune diseases. Vigilance is warranted for the recognition of autoimmune complications in persons with known silicosis; so too is consideration of the occupational exposure history in persons presenting with manifestations of autoimmune disease.

Decreased diffusion capacity on lung function testing in asymptomatic patients with systemic lupus erythematosus does not predict future lung disease.

BACKGROUND: In a previous study performed 9 ± 3.6 years ago, 74 asymptomatic patients with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) underwent lung function testing. A significantly low diffusion capacity (DLCO) ranging from 45% to 70% was recorded in 28 of the 74 (37.8%) patients who were all free of respiratory symptoms. AIM: The aim of this report is to assess the clinical importance and the predictive value of a low DLCO in asymptomatic patients with SLE or APS. METHODS: Asymptomatic patients with SLE and/or APS who were found to have a low DLCO in the previous study were contacted. Of the 28 patients, 15 were recruited and reevaluated in the current study (SLE with APS (n = 7), SLE without APS (n = 7); primary APS (n = 1)). A full history, physical examination, nail bed capillaroscopy, current laboratory tests and full lung function tests including DLCO were performed. RESULTS: During a surveillance period of 9 ± 3.6 years, none of the patients developed lung disease. Diffusion capacity corrected for alveolar volume (DLCO/VA) improved in the study group during this period from 60.4% ± 7.0 to 76.1% ± 11.2 (p < 0.0001). Lung function tests including total lung capacity (TLC) and forced expiratory volume in one second (FEV1) remained within normal limits. Capillaroscopy studies did not reveal changes compatible with scleroderma in any of the patients. CONCLUSION: Low DLCO findings on lung function testing does not have a positive predictive value for the development of future lung disease in patients with SLE, with or without APS, who are free of respiratory symptoms. Our results suggest that a finding of low DLCO in asymptomatic patients with SLE, with or without APS, does not necessarily require further evaluation and imaging and may improve spontaneously over time. Further studies in a larger group of patients are needed to validate these findings.

Chest wall shrapnel-induced beryllium-sensitization and associated pulmonary disease.

Chronic beryllium disease (CBD) is an exposure-related granulomatous disease mimicking sarcoidosis. Beryllium exposure-associated disease occurs mainly via inhalation, but skin may also be a source of sensitization. A 65-year-old male with a history of war-related shrapnel wounds was initially diagnosed with pulmonary sarcoidosis. Twenty years later, the possibility of a metal-related etiology for the lung disease was raised. A beryllium lymphocyte proliferation test, elemental analysis of removed shrapnel, and genetic studies were consistent with a diagnosis of CBD. This case demonstrates that retained beryllium-containing foreign bodies can be linked to a pathophysiologic response in the lung consistent with CBD.

Non-invasive diagnosis of chronic beryllium disease in workers exposed to hazardous dust in Israel.

OBJECTIVES: Chronic beryllium disease (CBD) is caused by prolonged occupational exposure to beryllium and is characterised by various clinical presentations, mostly pulmonary. The inflammatory process involves non-caseous granulomas and proliferation of CD4+ cells. CBD is diagnosed by lung biopsy showing tissue granuloma formation, and by the beryllium lymphocyte proliferation test (BeLPT) for past exposure and sensitisation to beryllium. The induced sputum (IS) technique was developed for diagnosing asthma, chronic obstructive pulmonary disease and interstitial lung diseases. A CD4/CD8 ratio >2.5 in T cells from IS is a positive result for granulomatous lung diseases. We previously revealed that dental technicians are exposed to excessive levels of beryllium. The efficacy of IS (CD4/CD8 >2.5) and BeLPT in diagnosing CBD in 17 workplaces where beryllium was present was evaluated. METHODS: All consecutive patients with a clinical suspicion of CBD referred to our institution for diagnosis and management were enrolled. Results of the gold standard lung biopsy with BeLPT were compared to the non-invasive IS+BeLPT. Kappa and McNemar tests evaluated agreement levels. Correlations between demographic and clinical parameters and a confirmed diagnosis of CBD were analysed. RESULTS: The two approaches were compared in 57 of 98 subjects. There was a high level of agreement (kappa 0.920) between IS+BeLPT and biopsy+BeLPT. IS+BeLPT had a specificity of 97.3% and sensitivity of 87.5%. 21 of 87 exposed workers (24%) had CBD, of whom 12 were dental technicians (p=0.044 dental technicians versus all other occupations). CONCLUSIONS: This study demonstrated that the CD4/CD8 ratio in IS together with positive/negative BeLPT findings can be used in diagnosing CBD.

High extracellular induced sputum haem oxygenase-1 in sarcoidosis and chronic beryllium disease.

BACKGROUND: Sarcoidosis and chronic beryllium disease (CBD) are inflammatory conditions in which oxidative stress state may be crucial for disease outcome. This study compares haem oxygenase-1 (HO-1) extracellular activity for the first time in patients with sarcoidosis or CBD and in healthy controls. MATERIALS AND METHODS: Induced sputum was recovered using a standard protocol. Pulmonary function tests (PFT) were performed by conventional methods. T lymphocyte subsets (CD4 and CD8) were measured by flow activated cell shorter (FACS). The HO-1 and nitrite levels were measured by a bilirubin-biliverdin reductase-dependent reaction and Greiss reaction respectively. Ferritin and iron levels were measured by enzymatic reaction and chemiluminometric immunoassay respectively. RESULTS: The mean percentage of lymphocytes was significantly higher in the 36 sarcoid patients compared with that in the 17 controls (P=0.001). The mean CD4/CD8 ratio was significantly higher in the sarcoid and the 10 CBD patients compared to that in controls (P=0.000 and 0.002 respectively), as was the mean HO-1 activity (P=0.045 and 0.041 respectively). The HO-1 activity did not differ with the sarcoidosis stage. The HO-1 level and PFT parameters were negatively correlated. The differences in mean nitrite, ferritin and iron levels were non-significant between the three groups. The HO-1 and ferritin levels were correlated (P=0.008). CONCLUSIONS: We succeeded in non-invasively measuring the activity of HO-1 from cells of airways in spite of its being an intracellular enzyme. The HO-1 levels in sarcoidosis and CBD were abnormally elevated.

HO-1 and VEGF gene expressions are time dependant during exposure to welding fumes.

Hemeoxygenase-1 (HO-1) is a defensive enzyme against oxidative stress. Vascular epithelial growth factor (VEGF) is a potent cytokine which promotes angiogenesis. We used induced sputum (IS) technology to study HO-1 and VEGF expressions in neutrophilic inflammation in asymptomatic welders. Aircraft plant employees were divided into three groups: Welders 1 (n=30) had short-term exposure to aluminum/iron, Welders 2 (n=16) had long-term exposure to cadmium/chromium/iron/nickel, and controls (n=27 non-exposed individuals). Participants underwent pulmonary function tests (PFTs), IS, differential cell counts, and determination of particle size distribution in IS samples. HO-1 and VEGF gene expressions were analyzed by real-time polymerase chain reaction, and protein levels were measured by bilirubin reductase-dependant reaction and ELISA, respectively. All subjects had normal PFTs. Welders 2 had neutrophilic inflammation and higher percentages of particles between 2-5 micron than the other groups. HO-1 inversely correlated with VEGF gene expression: HO-1 was significantly higher and VEGF was significantly lower in the Welders 1 group than in the other groups. There was a correlation between HO-1 expression and protein activity (r=0.33, P=0.05). Particulate matters significantly influenced HO-1 and VEGF gene expressions, caused neutrophilic inflammation and promoted oxidative stress in welders with long-term exposure.

Pulmonary dysfunction in systemic lupus erythematosus and anti-phospholipid syndrome patients.

OBJECTIVE: To assess and compare parameters of pulmonary function in systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS) patients. METHODS: Consecutive patients (n = 74) who were free of respiratory symptoms were divided into four groups: 1) SLE (n = 23); 2) SLE with anti-phospholipid antibodies (aPL) (n = 18); 3) SLE with APS (n = 20); and 4) primary APS (PAPS) (n = 13). Pulmonary function testing, single breath diffusion capacity of carbon monoxide (DLCO/SB) and echocardiography studies were performed. Induced sputum cytology was analysed. RESULTS: Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly reduced in SLE compared to PAPS patients (p = 0.039; p = 0.017; p = 0.029, respectively). Elevated pulmonary arterial pressure was observed in two patients with SLE and aPL and in two with SLE and APS. Lymphocyte and eosinophil counts in induced sputum showed no significant differences; however, a trend towards lower CD4 counts in SLE vs. PAPS was noted (p = 0.086), while in patients with both SLE and APS, a low CD4/CD8 ratio was seen. Patients with APS were older than patients without APS (47.12+/-14.86 vs. 34.29+/-12.6, p = 0.0001), while SLE patients were younger than PAPS patients (38.19+/-14.68 vs. 48.53+/-13.97, p = 0.023). CONCLUSION: Abnormal pulmonary functions tests were detected frequently in asymptomatic patients with SLE or PAPS. Although SLE patients were younger, pulmonary function was significantly more impaired in SLE as compared to PAPS patients.

Redefining idiopathic interstitial lung disease into occupational lung diseases by analysis of chemical composition of inhaled dust particles in induced sputum and/or lung biopsy specimens.

There has been increased public awareness of the potential danger from exposure to hazardous dust in various occupations. This study aims to validate the qualitative analysis of scanning electron microscopy (SEM) of lung samples by 1) correlation of induced sputum (IS) findings to clinical findings, 2) comparing hazardous particles in IS to those in biopsied lung specimens, and 3) assessing whether the particles present in the lungs of transplanted patients correlate with occupational history of dust exposure. Forty patients with occupational history were included; of whom 35 filled in questionnaires. Twenty-four of them had SEM analysis of their IS, and 11 of these 24 also had SEM analysis of their lung tissue. Another 11 lung biopsies from patients with occupational history were scanned by SEM and compared with 10 lung biopsies from patients with no occupational history. SEM analysis of IS was as efficient for detecting hazardous particles as was SEM analysis of lung tissue; silica was detected better in sputum. Exposure to silica was the main chemical element associated with a high likelihood to show abnormalities in IS (Odds ratio 19.41 CI = 0.270-1398.33). The average number of detected hazardous chemical elements in patients with an occupational history of exposure was 4 +/- 1.61 in IS and 3.55 +/- 2.02 in lung tissue (P = 0.57); it was 1.5 +/- 0.85 from transplanted occupationally exposed patients compared with 0.36 +/- 0.67 in transplanted non-exposed patients (P = 0.003). SEM analysis of particles in IS and lung tissue can elucidate the causative agent(s) of otherwise idiopathic interstitial lung disease among occupationally exposed workers.

Diagnoses of chronic beryllium disease within cohorts of sarcoidosis patients.

An increase in chronic beryllium disease (CBD) has been suggested due to higher industrial use of beryllium alloys. Since occupational CBD is a perfect phenocopy of sarcoidosis, it might be misdiagnosed as sarcoidosis. In the current it was hypothesised that CBD exists in cohorts of sarcoidosis patients. In a prospective case study, sarcoidosis patients were evaluated for potential beryllium exposure. In those patients in whom beryllium exposure was confirmed and beryllium hypersensitivity demonstrated, the diagnosis of sarcoidosis was rejected and corrected to CBD. In 84 patients seen for re-evaluation or making a diagnosis of sarcoidosis, beryllium exposure was recognised and a diagnosis of CBD was made in 34 out of 84 patients. The time lag between clinical diagnosis of sarcoidosis and the final diagnosis of CBD ranged 0-18 yrs (median 3 yrs) and the mean (range) age at time of diagnosis of CBD was 43.9(25-80) yrs. Beryllium-contaminated workplaces causing disease encompassed a wide spectrum of industries and technical trades in which beryllium-exposure is generally not perceived as a health hazard. In conclusion, chronic beryllium disease still belongs to the spectrum of differential diagnoses of granulomatous disorders.

Effect of montelukast pretreatment on inducible nitric oxide synthase mRNA expression in the lungs of antigen-challenged allergic mice.

BACKGROUND: Growing evidence suggests that inducible nitric oxide synthase (iNOS) is the main source of the high output of exhaled nitric oxide (NO) in asthma. Treatment of asthmatic patients with glucocorticoids reduces high levels of exhaled NO mainly by inhibiting the transcription of iNOS. A similar reduction in exhaled NO was recently observed in patients treated with the leukotriene receptor antagonists, but the exact interaction between these drugs and iNOS remains obscure. OBJECTIVE: The purpose of this study was to evaluate the effect of a leukotriene receptor antagonist, montelukast, on the expression and activity of iNOS in a murine model of allergic asthma. METHODS: Twenty-four BALB/c mice were sensitized to OVA and were equally divided into 3 groups (Groups 1-3). Eight additional mice were sham sensitized and served as a negative control group (Group 4). Group 1 received montelukast 1 mg/kg/day in their drinking water, Group 2 received dexamethasone 1 mg/kg/day in their drinking water and Groups 3 and 4 received plain tap water. After 1 week, the animals were challenged by inhalation of OVA and, 3 h later, they were killed and their lung cells were isolated by enzymatic tissue digestion. NO generation was measured by a Griess assay, and iNOS mRNA was studied by RT-PCR. RESULTS: A significant increase in iNOS mRNA expression and in NO generation was evident after allergen challenge compared with the controls. Pretreatment with montelukast mildly decreased NO production without producing a concomitant significant decrease in iNOS mRNA expression. CONCLUSION: Unlike pretreatment with glucocorticoids, we failed to find compelling evidence for a major role for montelukast treatment in the modulation of iNOS mRNA in a murine model of acute asthma.

The effect of specific immunotherapy on T-cell receptor repertoire in patients with allergy to house-dust mite.

BACKGROUND: The precise mechanism of specific immunotherapy (SIT), long used for treating allergic diseases, remains undefined. SIT was shown to act by modifying the immune response of T lymphocytes to antigens. We examined the effect of SIT on the expression and use V-alpha, -beta, -gamma and -delta chains of T-cell receptors (TCR) in patients allergic to house-dust mite. METHODS: Peripheral venous blood was taken for lymphocyte TCR analysis from 10 house-dust mite (HDM) allergic adults before initiating SIT and 6 months after initiating the treatment. Twelve similarly allergic patients without SIT served as controls. TCR chains were identified by fluorescence-activated cell sorter (FACS) using the following monoclonal antibodies: CD3, CD14, CD8, pan alpha-beta, pan gamma-delta, V-alpha2, V-alpha12.1, V-beta5a, V-beta5b, V-beta5c, V-beta8a, V-beta8b, V-beta3.1, V-beta13, V-beta12, V-beta6.7, V-delta1, V-delta2, V-gamma9, and V-gamma4. RESULTS: Analyzed before and 6 months after SIT initiation, lymphocyte TCR showed significantly increased V-beta5b, V-beta12 and V-alpha12.1 values compared to controls (without significant changes in other markers). CONCLUSIONS: SIT caused selective expansion of certain V-beta- and V-alpha-expressing T cells in patients allergic to HDM. Our results support the notion that the effect of SIT in patients with allergic rhinitis may be achieved by modifying the T lymphocyte response through the modulation of TCR usage.

Induced sputum-retrieved matrix metalloproteinase 9 and tissue metalloproteinase inhibitor 1 in granulomatous diseases.

Matrix metalloproteinases (MMPs) capable of degrading various components of connective tissue matrices, and tissue inhibitor metalloproteinases (TIMPs) are considered important in lung parenchymal remodeling and repair processes in pulmonary diseases. Induced sputum (IS) is a reliable noninvasive method to investigate pathogenesis, pathophysiology and treatment of lung disease. This study was designed to determine whether IS-MMP9/TIMP1 levels demonstrate lung parenchymal remodeling in sarcoidosis (SA) and Crohn's disease (CRD) patients. Sputum was induced and processed conventionally in 13 SA patients, 18 CRD patients and 9 controls. Two-hundred cells were counted on Giemsa-stained cytopreps, and T lymphocytes subsets (CD4 = T helper and CD8 = T suppressor cytotoxic cells) were analysed by FACS using monoclonal antibodies.MMP-9 and TIMP-1 were measured using commercial ELISA kits. MMP-9 concentrations, but not those of TIMP-1, were significantly greater in the sputum supernatant in SA and CRD patients compared to controls (P = 0.018 and P = 0.0019, respectively). The molar ratio, MMP-9/TIMP-1, was significantly higher in SA and CRD patients compared to controls (P = 0.008 and P = 0.024, respectively). Gelatinase species having a molecular weight similar to that of MMP-9 were demonstrated by zymographic analysis. MMP-9 levels were highly correlated with the CD4/CD8 ratio and DLCO capacity in SA but less in CRD patients. MMP-9 levels in IS provide a sensitive marker for pulmonary damage.

Morphological and biochemical properties of alveolar fibroblasts in interstitial lung diseases.

The phenotype of alveolar-associated fibroblasts (Afb) in sarcoidosis (SA) and idiopathic pulmonary fibrosis (IPF) is unclear. In the present study, we characterized the cytoskeletal proteins and the contraction properties in alveolar-associated fibroblasts recovered by bronchoalveolar lavage (BAL) in the two diseases. Afb were studied from BAL cells in eight IPF and seven SA patients. Cytoskeletal proteins were identified by ELISA and immunofluorescent methods. Biochemical measurements were done by dry chemistry. Contraction was performed by a gel contraction assay. Afb alpha-SM actin measured by ELISA was higher in IPF than in SA (p = 0.042). Vimentin, desmin, myosin, and fibroblast markers were expressed equally. Only in IPF did the Afb reveal the myofibroblast phenotype showing alpha-SM actin immunofluorescence labeling and, by electron microscopy, filaments with associated dense bodies with rough endoplasmic reticulum. Gel contraction showed that cells in IPF contracted significantly more than in SA (p = 0.046 IPF versus SA). The addition of ET-1 increased contraction in all groups. Dry chemistry analysis showed higher levels (p = 0.0065) of creatine phosphokinase (CPK), lower levels of glucose (p = 0.0082), and similar levels of Ca(2+) and lactate in the IPF and SA Afb. Dinitrofluorobenzene (DNFB), a potent inhibitor of CPK, completely abolished spontaneous cell contraction. Afb differentiates into myofibroblasts with different biochemical and energetic properties in IPF. Moreover, Afb from IPF patients showed increased contractile properties. This may explain the difference in the behavior patterns and outcomes of the two diseases.

Induced sputum: opening a new window to the lung.

The interest in sputum assessment as a non-invasive technique to retrieve cells and soluble material from the lung has increased and gained momentum during the last decade. As a marker of inflammation in airway diseases, induced sputum (IS) is a particularly promising procedure since it provides specific information on both the cellular and molecular constituents in inflammation. From 1950-1970, sputum cells had been examined on stained smears, with the procedure having been applied in both research and clinical settings. After having been recovered by spontaneous coughing, the cells were used to study lung cancer and respiratory infections and, later on, to diagnose Pneumocystis carinii pneumonia in patients infected with human immuno-deficiency virus (HIV). The method was widely improved upon by the induction of sputum with aerosol of hypertonic saline and then extended to become part of the assessment of airway inflammation in bronchial asthma and chronic obstructive pulmonary disease (COPD). It was recently shown that IS can be used to study interstitial lung diseases (ILD) and, more specifically, pneumoconiosis, sarcoidosis, non-granulomatous ILD and occupational lung diseases. In light of the fact that immunologic and functional bronchopulmonary abnormalities may be present in up to two-thirds of patients with Crohn's disease, we studied the use of IS in this condition as well. This review analyzes the value of IS and its present applications in pulmonary medicine.

The use of induced sputum in the assessment of pulmonary involvement in Crohn's disease.

OBJECTIVE: Our aim was to evaluate lung involvement in Crohn's disease (CRD) patients by induced sputum (IS). Extraintestinal manifestations are frequent in CRD, but lung involvement is rare. Induced sputum is a reliable noninvasive method of investigating the pathogenesis, pathophysiology, and treatment of lung disease. METHODS: Twenty-four CRD patients and nine control subjects (all nonsmokers) without respiratory symptoms were tested. Sputum was induced by 20' inhalation of 3.5% saline using ultrasonic nebulizer. Samples were studied by differential counts of 200 cells on cytopreps stained by Giemsa. T-lymphocyte subset analyses were done by FACS using three monoclonal antibodies: CD3 = total T cells, CD4 = T helper cells, and CD8 = T suppressor-cytotoxic cells. CD4/CD8 >2.5 was considered abnormal. RESULTS: Four patients did not produce sputum. Of the remaining 20 patients, seven had active CRD and 13 were in remission. They were divided into two groups: Group A patients had abnormal CD4/CD8 ratio of 6.7 +/- 2.5; Group B (seven patients) had normal CD4/CD8 ratio of 1.7 +/- 0.52 (p = 0.0001). The differential counts of IS samples were similar in both groups, but lymphocyte count was significantly higher in CRD patients than in the control group (13.2 +/- 11.2 vs 4.8 +/- 3.6, p = 0.036). There were no differences in spirometry, treatment, extent, or activity of CRD. CONCLUSION: Using a simple noninvasive method, we found that among CRD patients without respiratory symptoms there was a high (65%) incidence of lung involvement.