Increased concentrations of human beta-defensins in plasma and bronchoalveolar lavage fluid of patients with diffuse panbronchiolitis.

BACKGROUND: Human beta-defensin (HBD)-1 and -2 are antimicrobial peptides present in the respiratory tract. Recent reports have indicated reduced activity of beta-defensins in cystic fibrosis, suggesting that beta-defensins may play an important role in the pathological process of chronic respiratory tract infection. Diffuse panbronchiolitis (DPB) is a progressive disease characterised by frequent episodes of superimposed infection, typically caused by Pseudomonas aeruginosa. The aim of this study was to elucidate the role of these antimicrobial peptides in this disease. METHODS: The concentrations of HBD-1 and HBD-2 in plasma and bronchoalveolar lavage (BAL) fluid from 33 patients with DPB and 30 normal adults were measured by radioimmunoassay. Localisation of HBD-2 was investigated immunohistochemically in an open lung biopsy specimen obtained from a patient with DPB. RESULTS: High concentrations of HBD-1 and HBD-2 were noted in BAL fluid from DPB patients. Increased plasma concentrations of HBD-2, but not HBD-1, were found in patients with DPB compared with control subjects. In patients with DPB the HBD-2 concentration in BAL fluid correlated significantly with the numbers of cells recovered from the BAL fluid (total cells, neutrophils, and lymphocytes) and with the BAL fluid concentration of IL-1beta. Synthetic HBD-2, but not HBD-1, had dose dependent bactericidal activity against P aeruginosa. Treatment of 14 patients with macrolides significantly reduced BAL fluid concentrations of HBD-2 but not HBD-1 or plasma concentrations of HBD-1 and HBD-2. Immunohistochemistry of lung tissue showed localisation of HBD-2 in the epithelia of the distal bronchioles. CONCLUSIONS: These results indicate that beta-defensins, particularly HBD-2, participate in antimicrobial defence in the respiratory tract in DPB, and that the BAL fluid concentration of HBD-2 may be a useful marker of airway inflammation in patients with DPB.

[A case of bird fanciers' disease caused by parrot droppings].

A 50-year-old woman who had been treated for Parkinson's disease was admitted to our hospital because of exertional dyspnea and weight loss. Her chest computed tomography showed diffuse ground glass opacities in both lung fields. Bronchofiberscopy was performed, and the bronchoalveolar lavage fluid showed an elevated lymphocyte count. The serum Ouchterlony test yielded positive results for parrot droppings as well as for pigeon serum and droppings. She had had a parrot for several years, but no pigeon, and so we diagnosed bird fanciers' disease associated with parrot droppings. This responded well to steroid therapy. This case of bird fanciers' disease was caused by the droppings of only one parrot.

[Clinical features in twenty-three patients with paragonimiasis westermani].

We assessed the clinical features in twenty-three cases diagnosed as paragonimiasis westermani from April 1988 to May 2000 in our clinic at Miyazaki Medical College Hospital. Twenty-one patients had eaten wild boar or crab meat. Their symptoms included productive cough, chest pain and hemosputum. The findings of radiography and computed tomography (CT) were nodules, masses, infiltrative shadows and pleural effusion. The percentages of eosinophils in the peripheral blood were elevated in 16 of 23 patients, and the serum IgE values were elevated in 12 of 18 patients. Serologic tests, which are very helpful for diagnostic purposes were performed on the blood sera of all patients, and on the pleural effusions of five patients. It is often difficult to diagnose paragonimiasis westermani in patients in whom eosinophilia or increased serum IgE is not present. However, paragonimiasis westermani should also be considered as a possible diagnosis when abnormal shadows are found in chest radiographs and chest CT.

Structural analysis of human beta-defensin-1 and its significance in urinary tract infection.

Human beta-defensin-1 (hBD-1) is a 36-amino-acid antimicrobial peptide that functions in the host innate defense. We developed a highly sensitive radioimmunoassay for hBD-1 and identified several hBD-1 peptides in human kidney, urine, and plasma by amino acid sequencing and mass spectrometry. Large quantities of hBD-1 peptides are produced in the kidney, are released into the tubular lumen as 47-amino-acid pro-hBD1, and then undergo proteolytic processing and generate multiple truncated forms. The respective urine and plasma concentrations of hBD-1 in patients with pyelonephritis are 48.1 +/- (SEM) 15.7 pmol/mg creatinine and 2.66 +/- 0.41 pmol/ml, 3.1-fold and 1.8-fold those of normal individuals. hBD-1 is thought to contribute to mucosal defense in the urinary tract. Our findings provide a better understanding of the biosynthesis of this peptide and its pathophysiological significance in infectious diseases.

Granulocyte-colony stimulating factor levels in bronchoalveolar lavage fluid from patients with idiopathic pulmonary fibrosis.

BACKGROUND: Granulocyte-colony stimulating factor (G-CSF) is known as a potent neutrophil chemotactic glycoprotein in vitro but its contribution to chemotactic activity in neutrophil mediated lung diseases is not yet known. The aims of this study were to determine whether G-CSF is present in high concentrations in bronchoalveolar lavage (BAL) fluid of patients with idiopathic pulmonary fibrosis (IPF, also called cryptogenic fibrosing alveolitis), a neutrophil mediated lung disease, and to what extent G-CSF in BAL fluid contributes to neutrophil accumulation in the lung of patients with IPF. METHODS: G-CSF concentrations in BAL fluid samples from 16 healthy volunteers, 24 patients with IPF, and 73 patients with non-IPF lung disease were measured by enzyme linked immunosorbent assay. The relationship between G-CSF concentrations and neutrophil count in BAL fluid was also examined. Neutrophil chemotactic activity (NCA) was measured in BAL fluid in healthy volunteers and patients with IPF. The contribution of G-CSF to overall NCA in lungs with IPF was assessed by repeating the measurement of NCA after a complete neutralisation of G-CSF bioactivity by anti-human G-CSF antiserum. RESULTS: Detectable levels of G-CSF were found in BAL fluid of 83% of patients with IPF while the levels in all healthy volunteers were below the detection limit. In patients with IPF a significant correlation was observed between the BAL fluid neutrophil count and the concentration of G-CSF in the BAL fluid. The neutrophil count also correlated significantly with percentage forced vital capacity. In BAL fluid samples from patients with IPF the mean NCA value was reduced by 35% after neutralisation with an anti-human G-CSF antiserum. CONCLUSIONS: G-CSF may be involved in enhancing neutrophil accumulation in the lungs of patients with IPF.

Pulmonary Nocardia otitidiscaviarum infection in a patient with chronic respiratory infection.

We report a case of pulmonary Nocardia (N.) otitidiscaviarum infection in a 76-year-old man with chronic respiratory infection. The patient responded poorly to intravenous imipenem and oral minocycline, but later improved after treatment with trimethoprim-sulfamethoxazole. Pulmonary infection with N. otitidiscaviarum should be considered in the differential diagnosis of chronic respiratory infections. Further studies are needed to evaluate the correlation between species and drug susceptibility.

[Idiopathic interstitial pneumonia exacerbated by alveolar hemorrhage].

A 60-year-old man, in who idiopathic interstitial pneumonia (IIP) was diagnosed in 1990, was admitted to our hospital in March 1995 with exertional dyspnea, hemosputum and fever. On chest X ray, new infiltrates in the bilateral middle lung fields were seen, in addition to reticulonodular shadows in the bilateral lower lung fields, which had been noted in 1990. Intubation was reformed because of hypoxemia, and bronchoalveolar lavage (BAL) was performed in right B6. The BAL fluid was bloody, and a diagnosis of alveolar hemorrhage was made based on the presence of many hemosiderin-laden macrophages in the fluid. After pulse therapy with methylprednisolone, the hypoxemia and chest X ray findings improved, and he was extubated. Alveolar hemorrhage may be one possible complication leading to an exacerbation of IIP.

Elevated concentrations of defensins in bronchoalveolar lavage fluid in diffuse panbronchiolitis.

Human neutrophils contain three isoforms of antimicrobial and cytotoxic peptides in the azurophil granules, which belong to a family of mammalian neutrophil peptides named defensins. Here we investigate the role of these peptides in diffuse panbronchiolitis (DPB). Defensins (human neutrophil peptide-1, -2 and -3) were measured by radioimmunoassay in bronchoalveolar lavage fluid (BALF) of 30 patients with DPB, 16 patients with idiopathic pulmonary fibrosis (IPF) and 15 healthy adults. The concentration of defensins was higher in BALF of patients with DPB than in patients with IPF and healthy subjects. DPB and IPF patients also had significantly higher plasma concentrations of defensins than controls. In patients with DPB, BALF concentration of defensins correlated significantly with neutrophil count or BALF concentration of interleukin (IL)-8. Immunohistochemistry of open-lung biopsy specimens from four DPB patients showed localization of defensins in neutrophils and mucinous exudate in the airways, and on the surface of bronchiolar epithelial cells. In vitro studies showed an enhanced extracellular release of defensins following stimulation of neutrophils with phorbol myristate acetate, N-formyl-methionyl-leucyl-phenyalamine, and human recombinant IL-8. Treatment of DPB with macrolides for 6 months significantly reduced neutrophil count and concentrations of defensins and IL-8 in BALF. Our results indicate accumulation of neutrophil-derived defensins in the airway in diffuse panbronchiolitis, and suggest that defensins may be a marker of neutrophil activity in this disease.

Elevated concentrations of human neutrophil peptides in plasma, blood, and body fluids from patients with infections.

Neutrophil peptides, also called defensins, are antimicrobial molecules localized in the azurophil granules of neutrophils. We used a sensitive radioimmunoassay to measure the concentrations of human neutrophil peptides (HNPs) 1-3 in the plasma and blood of 86 healthy volunteers who served as controls and 54 patients with various infections. The respective mean plasma concentrations of HNPs 1-3 in the patients at the onset of bacterial infection, nonbacterial infection, and pulmonary tuberculosis were 4.2, 3.2, and 1.8 times the mean value (+/- SE) for the controls (254.8 +/- 7.1 pg/microL). Plasma concentrations of HNPs 1-3 for the patients were correlated with the peripheral blood neutrophil counts (correlation coefficient = 0.629; P = .0001). The mean concentration (+/- SE) of blood HNPs 1-3 in patients with bacterial infections was higher than the mean value (+/- SE) for controls (10.4 +/- 0.6 ng/microL), whereas the mean concentration (+/- SE) in patients with nonbacterial infections or tuberculosis did not differ from that for controls. Reverse-phase high performance liquid chromatography of plasma samples from patients with bacterial infections showed high concentrations of two precursors of HNPs 1-3, indicating that the biosynthesis of HNPs in neutrophil precursor cells is stimulated in response to infection and/or that the release of pro-HNPs is enhanced. HNPs 1-3 concentrations in the pleural fluid, bronchoalveolar lavage fluid, urine, and cerebrospinal fluid were also elevated in patients with infections. Our results suggest that HNPs have physiological significance in infection and that this family of peptides may be useful in assessing neutrophil function during infection.

[Kartagener's syndrome with aspergilloma].

A 47-year-old man was referred to our hospital because of hemoplysis. He had a history of chronic sinusitis and surgical treatment of a spinal arteriovenous malformation. A chest X-ray film and computed tomographic scan showed dextrocardia, diffuse bronchiectasis, and an aspergilloma in the right upper lung field. The source of the bleeding could not be detected by fiberoptic bronchoscopy. Transbronchial mocosal biopsy was done and examination of a specimen by transmission electron microscopy revealed the lack of inner and outer dynein arms. A chest X-ray film and computed tomographic scan of his nephew, who had a long history of productive cough showed dextrocardia and right lower-lobe bronchiectasis. These findings indicate that hemoptysis in patients with Kartagener's Syndrome can be caused not only by bronchiectasis but also by aspergilloma.

[Acute bronchiolitis due to Mycoplasma pneumoniae and successfully treated with steroids].

A high fever, coughing, stridor, and dyspnea developed in a 52-year-old woman on October 19, 1995. She went to a local clinic and was treated with oral penicillin and intravenous cefpirome. The symptoms worsened, and she was admitted to our hospital on October 26. Coarse crackles and wheezing were heard in both lung fields. The white blood cell count was 9000/mm3 and arterial blood gas analysis revealed a PaO2 of 49.8 Torr on room air. A chest roentgenogram obtained on admission showed a few small bibasilar nodular infiltrates, and a chest CT scan showed thickened bronchial walls along with small nodules having a centrilobular distribution. Of the cells in bronchoalveolar lavage fluid, 88% were neutrophils, but tests for bacteria and mycobacteria were negative. The cold-agglutinin titer was 1:512. The Mycoplasma pneumoniae antibody titer (IIIA) was 1:640 and viral serology tests were negative. Acute bronchiolitis due to M. pneumoniae was diagnosed and treatment with intravenous minocycline was started. The symptoms (coughing, fever, and stridor) resolved and the small nodules on chest CT scan disappeared, but hypoxemia remained. At the same time, an obstructive ventilatory defect (FEV1% 62.8%) and abnormal ventilation/perfusion lung scans were noted. Development into bronchiolitis obliterans was suspected, so administration of methyl prednisolone (1 g/day for 3 days) and prednisolone was started. The response to steroids was good. Pulmonary function improved and the arterial PaO2 at the time of discharge was 86 Torr (room air). Use of steroid therapy in the early phase of bronchiolitis obliterans seemed to be effective.

[A case of fulminant psittacosis necessitating mechanical ventilation diagnosed by chlamydial isolation form BALF].

A 51-year-old female was admitted with complaints of fever and general fatigue. Chest X-ray showed diffuse bilateral fine nodular shadows and infiltrates. Complication of hepatic and muscular injury was suspected from increased levels of GOT, GPT and CPK in the serum. Arterial blood gas analysis revealed hypoxemia. Because hypoxemia aggravated despite treatment with intravenous minocycline (200 mg/day), corticosteroids and mechanical ventilation were started, and the administration of minocycline (400 mg/day) and sparfloxacin was added. Consequent, chest X-rays and several laboratory data improved gradually. The final diagnosis was established with a significant rise of both IgG and IgM antibody against Chlamydia psittaci with MIF and identification of Chlamydia with the cell culture method. Chlamydia was successfully isolated from BALF of this patient obtained 5 days after commencement of minocycline treatment. Psittacosis should be considered as a possible cause of severe respiratory failure necessitating emergency care including mechanical ventilation.

[A study of defensins in bronchoalveolar lavage fluid in patients with diffuse panbronchiolitis].

We estimated defensins, antimicrobial and cytotoxic peptides localized in azurophil granules of neutrophils, in bronchoalveolar lavage fluid (BALF) in patients with diffuse panbronchiolitis (DPB). BALF from DPB patients contained a higher concentration of defensins than those from patients with idiopathic pulmonary fibrosis and healthy volunteers. A significant correlation was observed between the concentration of defensins and the number of neutrophils, the concentration of interleukin-8 or neutrophil elastase in BALF of DPB patients. An immunohistochemical defensins in neutrophils and mucinous exudates in the airways and in the surface of bronchiolar epithelial cells. After treatment with macrolide antibiotics, significant reductions in the concentrations of defensins, IL-8 and neutrophil numbers in BALF of DPB patients were observed. These findings suggest that the lung injury in DPB could be caused by defensins released by neutrophils accumulated in the airways.

[Pulmonary endometriosis with recurrent catamenial hemoptysis].

A 32-year-old woman with a history of dilation and curettage for missed abortion at 31 years old had sudden hemoptysis during menstruation on May 25, 1993. She had catamenial hemoptysis again, and was admitted to our hospital on July 21, 1993. After admission, catamenial hemoptysis occurred, and a nodular shadow was noted in the right S4 area on chest roentgenogram and computed tomogram. A few days after menstruation, hemoptysis and the abnormal shadow on chest roentgenogram disappeared. Pulmonary endometriosis was diagnosed by clinical course, past history, and chest roentgenographic findings. During the next menstruation, hemoptysis and a nodular shadow in the right S4 area on chest roentgenogram recurred, so transbronchial lung biopsy and laparoscopy were done. TBLB specimens revealed macrophages with phagocytosed hemosiderin, and laparoscopy revealed pelvic endometriosis. She was treated with buserelin acetate. Catamenial hemoptysis and the nodular shadow on the chest roentgenogram disappeared after treatment.

[Simultaneous production of parathyroid hormone-related protein (PTHrP) and granulocyte colony-stimulating factor (G-CSF) in lung cancer patients with hypercalcemia and leukocytosis].

Hypercalcemia and leukocytosis are often associated with primary lung cancer as a paraneoplastic syndrome. Recently, parathyroid hormone-related protein (PTHrP) and granulocyte colony stimulating factor (G-CSF) have been identified as major causative peptides for hypercalcemia and leukocytosis, respectively. We studied four men with advanced primary lung cancer (stages from IIIA to IV) who presented with hypercalcemia (corrected serum calcium levels: 10.5 mg/dl) and leukocytosis (WBC > 10,000 per mm3). The age of the patients ranged from 59 to 79 years old. The pathological subtypes were squamous cell carcinoma in three and adenocarcinoma in one. The mean serum calcium levels and leukocyte counts were 15.8 +/- 1.4 mg/dl (mean +/- SE) and 24,800 +/- 3,253 cells/mm3 (mean +/- SE), respectively. Abnormally high serum levels of PTHrP and G-CSF were found in three patients (mean +/- SE: 137 +/- 68 pg/ml; normal range in human serum, < 16 pg/ml), and in all four (mean +/- SE: 72 +/- 7.7 pg/ml; normal range in human serum, < 20 pg/ml), respectively. Immuno-histochemical examination of cancerous tissue obtained from these patients showed positive staining for both PTHrP and G-CSF within the cytoplasm of all the cancerous tissue. These results suggest that the association of hypercalcemia and leukocytosis in patients with advanced primary lung cancer is caused by production of both PTHrP and G-CSF by cancerous tissue.

[A case of eosinophilic pneumonia with elevated levels of carcino-embryonic antigen (CEA)].

A 70-year-old woman was admitted for productive cough and infiltrative shadows in the right lower lung field on chest X-ray film. Eosinophilia (17%) in blood, an abnormally high percentage of eosinophiles (7%) in bronchoalveolar lavage fluid and eosinophilic infiltration with proliferated goblet cells in transbronchial lung biopsy specimens led to the diagnosis of eosinophilic pneumonia. Laboratory data on admission also revealed a high level of CEA (17.1 ng/ml) in serum. After administration of prednisolone (30 mg/day), the symptoms ameliorated and the CEA levels were normalized. The proliferated goblet cells were immunohistochemically positive for CEA, which suggests that the high levels of CEA were caused by excessive CEA secretion from the goblet cells associated with eosinophilic pneumonia. These studies showed that serum CEA also may be a marker for disease activity in eosinophilic pneumonia.

Establishment of radioimmunoassay for human neutrophil peptides and their increases in plasma and neutrophil in infection.

Neutrophil peptide, also called defensin, is an antimicrobial peptide localized in azurophil granules in neutrophils. Using a synthetic human neutrophil peptide-1 (HNP-1), we prepared an antiserum against the peptide and established a highly sensitive radioimmunoassay (RIA). This RIA equally recognized HNP-1, -2, and -3 on a molar basis. Analyses of leukocyte and blood extracts obtained from normal individuals and patients with bacterial infection by reverse-phase high-performance liquid chromatography coupled with the RIA showed that the antiserum specifically detected HNP molecules. Concentrations of HNP 1-3 in total in normal human blood and plasma are 13.2 +/- 1.4 (mean +/- SEM) ng/mu 1 and 403.8 +/- 38.9 pg/mu 1, respectively. The values increased in infection and returned to within the normal levels after the recovery of the disorder. Granulocyte colony-stimulating factor (G-CSF) increased the plasma and blood concentrations of HNP 1-3. The RIA established here provides a useful tool to elucidate the pathophysiological significance of HNP and to evaluate the neutrophil functions in infection and inflammation.

[A case of paragonimiasis westermani diagnosed on the observation of parasitic ova in bronchial washing fluid and successfully treated with praziquantel].

A 41-year-old male visited our clinic complaining of cough and dirty hemosputum. Roentgenogram and CT scan of the chest revealed a cavitary nodule in the S1+2 of the left lung. After administration of antibiotics (CFIX, ASPC, FMOX, CLDM), the cavities were disappeared but the size of the nodule remained unchanged. Because the possibility of lung cancer could not be excluded, we underwent transbronchial brushing and bronchial lavage. Then, parasitic ova of Paragonimus westermani was detected in BALF, and an Ouchterlony's double diffusion test showed strong reaction against Paragonimus westermani antigen. The patient was successfully treated with praziquantel. Efficacy of the treatment was confirmed by a remarkable decrease of antibody titer measured by microplate-EIA.

[A case of bilateral Bochdalek hernia in an adult].

A 71-year-old male was found to have bilateral posteromedial masses on routine roentgenogram during admission for treatment of traffic accident related injuries. These masses were initially considered to be posterior mediastinal tumors, however, CT scan demonstrated a left diaphragmatic defect and the adipose nature of the bilateral masses (CT number: left -29, right -132). MRI also demonstrated a large amount of fat accumulation in the abdomen. CT scan and MRI are therefore very useful for the diagnosis of Bochdalek hernia in adults.