Examining the biology of tuberculosis.

The task of critically reviewing current advances in a scientifically burgeoning topic such as tuberculosis is daunting. From 2965 published articles on tuberculosis in 1997 cited in MEDLINE, 180 were selected, and approximately one third of those are included in this review. This paper highlights how molecular biology has greatly advanced our understanding of the epidemiology and transmission of tuberculosis worldwide. In addition, recent data on the dynamics of transmission between close contacts are provided that may challenge conventional views. A global view of drug-resistant tuberculosis is presented, and new data on the prevalence of tuberculosis in diabetics, bone marrow transplant recipients, patients with renal disease, and HIV-infected persons are highlighted. Recent studies on the genetic susceptibility of tuberculosis are outlined, and we review immunotherapy and the impact of tuberculosis on the natural course of HIV infection. Chemoprevention, duration of therapy, and bacille Calmette-Guérin vaccination in the setting of HIV are discussed. The value and limitation of nucleic acid amplification tests in rapid diagnosis is addressed, and old diagnostic tests are revisited with new data. Novel mycobacterial culture systems are discussed and screening-for-infection approaches are revisited, including tuberculin skin testing in bacille Calmette-Guérin vaccinees. Therapeutic issues addressing antituberculous drug absorption in HIV-infected patients, the role of pharmacokinetics in predicting clinical outcomes, and important drug-drug interactions are discussed.

Effect of dose and release rate on pulmonary targeting of liposomal triamcinolone acetonide phosphate.

PURPOSE: To demonstrate the importance of dose and drug release rate for pulmonary targeting of inhaled glucocorticoids using an animal model of intrapulmonary drug deposition. METHODS: Liposomes composed of 1,2-distearoyl phosphatidylcholine (DSPC), 1,2-distearoyl phosphatidylglycerol (DSPG) and triamcinolone acetonide phosphate (TAP) or liposomes containing triamcinolone acetonide (TA) were prepared by a mechanical dispersion method followed by extrusion through polycarbonate membranes. Encapsulation efficiency was assessed after size exclusion gel chromatography by reverse phase HPLC. The effect of liposome size (200 nm and 800 nm) on the release kinetics of water-soluble encapsulated material was determined in vitro at 37 degrees C using 6-carboxyfluorescein as a marker and Triton X-100 (0.03%) as a leakage inducer. To investigate the relationship between drug release and pulmonary targeting, 100 micrograms/kg of TAP in 800 nm liposomes was delivered to male rats by intratracheal instillation (IT) and the results compared to data for 100 micrograms/kg TA liposomes (recently shown to exhibit a rapid drug release under sink conditions) and to previous studies reported for an equal dose of TAP in solution and TAP in 200 nm (1). Pulmonary targeting was assessed by simultaneously monitoring glucocorticoid receptor occupancy over time in lung and liver using an ex vivo receptor binding assay as a pharmacodynamic measure of glucocorticoid action. To assess the effect of dose on pulmonary targeting experiments were performed using 2.5, 7.5, 25, 100, and 450 micrograms/kg of TAP in 800 nm liposomes. RESULTS: The in vitro efflux of 6-carboxyfluorescein from (DSPC:DSPG) liposomes after exposure to Triton-X was biexponential. The terminal half-lives of 3.7 h and 9.0 h for the 200 nm and 800 nm liposomes, respectively, demonstrated that larger liposomes promote slower release of encapsulated water-soluble solute while previous results already indicated that encapsulation of lipophilic TA does not result in sustained release. Pulmonary targeting, defined as the difference between cumulative lin and liver receptor occupancies was most pronounced for the 800 nm liposomes (370%xh), followed by the 200 nm preparation (150%xh). No targeting was observed for TAP in solution (30%xh) or the rapid releasing TA liposome preparation. Correspondingly, the mean pulmonary effect time (MET) increased from 2.4-3.0 hr for TA liposomes or TAO in solution to 5.7 h and > 6.2 h for TAP in 200 nm and in 800 nm liposomes, respectively. Escalating doses of TAP encapsulated in 800 nm liposomes revealed a distinct bell shaped relationship between the TAP dose and pulmonary targeting with a maximum occurring at 100 micrograms/kg (370%xh). CONCLUSIONS: The in vivo data presented here confirm that pulmonary residence time and dose affect the extent of lung targeting of glucocorticoids delivered via the lung.

Three-dimensional volumetric assessment of abnormally low attenuation of the lung from routine helical CT: inspiratory and expiratory quantification.

OBJECTIVE: The purpose of this investigation was to quantitatively assess abnormally low attenuation of the lung by use of three-dimensional volumetric reconstructions from routine helical CT and to assess their correlation with pulmonary function tests. MATERIALS AND METHODS: Helical CT was performed in 100 patients in full inspiration. Examination was also performed in full expiration in 53 of these patients. Three-dimensional volumetric reconstructions were performed for total lung volumes at inspiration and at expiration, with a threshold of -896 H on inspiratory CT and -790 H on expiratory CT, to quantify emphysematous change. Correlation was made with pulmonary function tests in 79 patients. RESULTS: CT volumetric assessments of abnormally low attenuation of the lung at inspiration and expiration had a high correlation (r2 = .84, p < or = .0001). In comparison with pulmonary function tests, both inspiratory low attenuation of the lung and expiratory low attenuation of the lung correlated well with the logarithm of the ratio of the forced expiratory volume in 1 sec (FEV1) to the forced vital capacity (r2 = .74, p < or = .0001 and r2 = .74, p < or = .0001, respectively) and with the percentage of predicted ratio of the FEV1 to the forced vital capacity (r2 = .69, p < or = .0001 and r2 = .69, p < or = .0001, respectively). Linear correlations were also seen with FEV1, residual volume, and forced residual capacity. CONCLUSION: Three-dimensional volumetric reconstructions of hypoattenuating lung correlate well with pulmonary function tests. In addition, inspiratory and expiratory data are also correlative, suggesting that a dedicated expiratory examination is not needed. This easily obtainable information will prove useful for patients with obstructive lung disease from emphysema, providing a measure of pulmonary function status in this population.

Pharmacokinetic/pharmacodynamic aspects of aerosol therapy using glucocorticoids as a model.

Glucocorticoids are predominantly prescribed in asthma therapy as aerosols to achieve high pulmonary effects with reduced systemic spill-over and pronounced pulmonary selectivity. A variety of pharmacokinetic parameters are potentially important for determining pulmonary selectivity. The intent of this article, is to provide a practice-relevant theoretical approach to put the importance of these parameters on pulmonary targeting using pharmacokinetic/pharmacodynamic modeling as a tool in perspective. The applied pulmonary pharmacokinetic/pharmacodynamic model revealed that, in addition to recognized parameters such as systemic clearance, oral bioavailability, and efficiency of pulmonary deposition, other factors, such as the pulmonary release (dissolution) rate and dose, are relevant. However, the volume of distribution (for effect parameters not undergoing a diurnal rhythm) and the receptor affinity of a given glucocorticoid are not important for achieving lung targeting.

Pulmonary targeting of liposomal triamcinolone acetonide phosphate.

PURPOSE: To explore the use of triamcinolone acetonide phosphate liposomes as a pulmonary targeted drug delivery system. METHODS: Triamcinolone acetonide phosphate liposomes composed of 1,2-distearoyl phosphatidylcholine and 1,2-distearoyl phosphatidyl glycerol and triamcinolone acetonide 21-phosphate dipotassium salt were prepared by dispersion and extruded through polycarbonate membranes. Encapsulation efficiency and in vitro stability at 37 degrees C were assessed after size exclusion chromatography. TAP liposomes (TAP-lip) or TAP in solution (TAP-sol) were delivered to rats either by intratracheal instillation (IT) or intravenous (IV) administration. Pulmonary targeting was assessed by simultaneous monitoring of glucocorticoid receptor occupancy over time in lung (local organ) and liver (systemic organ) using an ex vivo receptor binding assay as a pharmacodynamic measure of glucocorticoid action. RESULTS: In vitro studies in different fluids over 24 hours, showed that more than 75% of the TAP remained encapsulated in liposomes. Cumulative pulmonary effects after IT administration of TAP-lip were 1.6 times higher than liver receptor occupancy. In contrast, there was no difference in the pulmonary and hepatic receptor occupancy time profiles when TAP was administered intratracheally as a solution. No preferential lung targeting was observed when TAP-lip was administered IV. As indicated by the mean effect times, lung receptor occupancy was sustained only when TAP-lip was administered IT. CONCLUSIONS: Intratracheal administration of TAP-lip provided sustained receptor occupancy, and increased pulmonary targeting which was superior to IT administration of TAP-sol or IV administration of TAP-lip. The use of liposomes may represent a valuable approach to optimize sustained delivery of glucocorticoids to the lungs via topical administration.

Serum antibody response to influenza vaccine in pulmonary patients receiving corticosteroids.

OBJECTIVE: Despite the recommendation that patients with chronic lung diseases--many of whom receive corticosteroids--receive annual influenza vaccination, it is not known whether corticosteroids influence antibody response to influenza vaccine in this population. The purpose of this study was to assess whether patients with pulmonary conditions receiving long-term corticosteroid therapy develop an adequate antibody response. DESIGN: We prospectively studied 39 consecutive candidates for influenza vaccination, 25 of whom were receiving corticosteroids for underlying lung diseases. Patients with immunosuppression besides corticosteroids were excluded. Serum samples were obtained prior to and 1 month after vaccination with inactivated trivalent influenza vaccine and assayed for antibodies to the three strains using a hemagglutination inhibition assay. No patients had any intercurrent illness compatible with influenza during the study period and patients receiving corticosteroids continued treatment with them during this time. RESULTS: A fourfold rise in antibody titer at 1 month to at least one component was seen in 21 of 25 (84%) of corticosteroid-treated patients, which was similar to patients not receiving corticosteroids (11/14, 79%). There was no corticosteroid-antibody, dose-response relationship. CONCLUSIONS: Patients with pulmonary conditions receiving corticosteroids can generate an adequate antibody response to killed influenza virus vaccine. Long-term therapy with corticosteroids should not preclude influenza vaccination in patients with chronic pulmonary diseases who are deemed vaccine candidates.

Fluoxetine hydrochloride (Prozac)-induced pulmonary disease.

We describe a patient who developed progressive dyspnea, lung infiltrates, and restrictive lung disease in association with the antidepressant fluoxetine hydrochloride (Prozac). The pathologic findings were consistent with hypersensitivity pneumonitis. An associated pulmonary phospholipidosis was also noted.

Assessment of glucocorticoid lung targeting by ex-vivo receptor binding studies in rats.

Triamcinolone acetonide (TA, 22 micrograms) was given to rats by intravenous (i.v.) injection or intratracheal (IT) instillation. Free glucocorticoid receptors were monitored over time in liver and lung using an ex-vivo receptor binding technique. After i.v. administration of a TA solution, the reduction of free receptors over time was very similar in lung and liver (AUCLung = 280 +/- 47% h; AUCLiver = 320 +/- 76% h). Intratracheal instillation of the same solution produced time profiles which mirrored those of i.v. injection (AUCLung = 260 +/- 41% h; AUCLiver = 330 +/- 50% h). The lack of lung targeting was also reflected in the failure to show any significant difference in the pulmonary targeting factor T (AUCLung/AUCLiver) between i.v. (T = 0.84 +/- 0.18) and IT (T = 0.78 +/- 0.03) administration. In contrast, a certain degree of lung specificity was observed after IT instillation of a glucocorticoid suspension (22 micrograms; AUCLung = 160 +/- 135% h; AUCLiver = 65 +/- 91% h, T = 2.3 +/- 0.5) as indicated by significant differences in T between i.v. injection and IT instillation (p = 0.038). The method presented provides a means of simultaneously assessing pulmonary and systemic effects after different forms and routes of administration and might be of value in further studying multiple aspects of inhalation glucocorticoid therapy.

Pulmonary effects of chronic exposure to liposome aerosols in mice.

Administering liposome-encapsulated drugs by aerosols could be a feasible way of targeting drugs to the lung, specifically to pulmonary alveolar macrophages (AM). In the mouse model, we characterized uptake of carboxyfluorescein- (CF-) labeled liposomes by AM in vivo after acute inhalation of liposome aerosols, and the effects of chronic exposure to liposome aerosols on lung histology and AM function. Mice were placed in a nose-only exposure module and exposed to liposome or saline aerosols for 1 h per day, 5 days per week, for 4 weeks. Five mice of both the experimental and control groups were removed weekly and their lungs examined. Liposomes were made from hydrogenated soy phosphatidylcholine (HSPC) at 50 mg/mL. In vivo uptake of liposomes by AM was documented by fluorescence microscopy and flow cytometry of bronchoalveolar lavage (BAL). A consistent amount of 1-3 micrograms of lipid inhaled per dosing per mouse was estimated from fluorescence measurements. Addition of Triton X-100 to BAL caused a significant increase in fluorescence intensity, indicating that liposomes remained intact in the lung for a period of time. The chronic inhalation study showed no histologic changes of the lung or untoward effects on the general health or survival of animals. AM phagocytic function, intracellular killing, and fatty acid composition were not affected. Transmission electron microscopy and morphometry (computerized image analysis) of AM likewise showed no alterations as a result of the treatment. It was concluded that AM uptake of liposomes delivered by aerosol was operant in vivo. This finding validates the concept of alveolar macrophage-directed delivery of liposome-encapsulated agents to the lung via inhalation. It was also concluded that chronic liposome aerosol inhalation in mice produced no untoward effects on survival, histopathology, and macrophage function. These data confirm and extend prior findings regarding the functional and morphologic interactions of liposomes with AM in vitro (Gonzalez-Rothi et al., Exp. Lung Res. 17:687-705, 1991).

Lipophilic N-acylpyrazinamide derivatives: synthesis, physicochemical characterization, liposome incorporation, and in vitro activity against Mycobacterium avium-intracellulare.

N-acetyl-(2), N-caproyl-(3), N-capryl-(4) and N-palmitoyl-pyrazinamide (5) were synthesized by reacting pyrazinamide (1) with acetic anhydride to prepare (2), or by reacting (1) in chloroform with the corresponding acid chlorides to prepare (3-5). Products were identified by high resolution mass spectroscopy, elemental analysis, and 1H NMR. Melting points, enthalpies of fusion, solubility and octanol-water partition coefficients were determined. Hydrolysis of (2) indicated a pseudo first-order, pH-dependent degradation reaction. Apparent half life times of degradation ranged from 74.2 hours at pH 3 to 5.4 hours at pH 7.34. Derivative (5) was incorporated in liposomes consisting of soy phosphatidylcholine and dipalmitoylphosphatidylglycerol (7:3 molar ratio). The in vitro susceptibility of Mycobacterium avium-intracellulare (MAI) to the liposomal compound containing (5) was tested. MAI was susceptible to (5) at concentrations of 12.5-25 micrograms/ml, although MAI is not susceptible to the parent drug (1). Thus, a new class of antimycobacterial agents with physicochemical properties suitable for stable incorporation within liposomes and high antibiotic efficacy against MAI is presented.

Liposomes and pulmonary alveolar macrophages: functional and morphologic interactions.

In vitro toxicity of liposomes and their functional and morphologic interactions with rat pulmonary alveolar macrophage (AMs) were investigated using viability (trypan blue exclusion), phagocytic and killing activity (uptake and digestion of live S. cerevisiae), surface adherence, respiratory burst (nitro-blue tetrazolium reduction), and morphometry (computerized image analysis) as indicators. Liposome stability in physiologic solutions and uptake of liposome-encapsulated carboxyfluorescein (CF) by AMs was assessed by fluorescence spectroscopy and microscopy. Liposomes made from saturated phospholipids and cholesterol were stable, whereas liposomes consisting of unsaturated phospholipids without cholesterol lost 30% to 40% of their content over 24 h. However, CF uptake was highest with unsaturated phospholipid preparations, whereas uptake of the three other formulations was comparable. Although liposome exposure did not affect macrophage viability, a reduction in the number of phagocytizing macrophages to 73% of control was noted after 24-h incubation with the highest lipid concentration tested (10 mumol/ml). Phagocytic killing was similar under all circumstances observed. The fraction of intracellularly killed yeast ranged from 32% to 42% for both control and experimental samples. An increase in cell surface area from 166.1 +/- 39.9 microns 2 on day O (n = 709) to 196.3 +/- 57.6 microns 2 on day 1 (n = 516) and 211.2 +/- 48.0 microns 2 on day 4 (n = 834) was observed after liposome treatment. The corresponding average cell areas of control samples did not change during the observation period. There was no net cell loss of adherence from monolayers as determined by protein assay. The respiratory burst, indicating generation of intracellular superoxide, was also similar--84% to 92% of experimental and control cells under all conditions showed a strong nitro-blue tetrazolium reduction. In summary, in vitro exposure of AMs to large concentrations of liposomes, although producing an increase in macrophage size, was not associated with aberrant macrophage morphologic features, function, or toxicity for the parameters examined.

Acute effects of liposome aerosol inhalation on pulmonary function in healthy human volunteers.

Administering liposome-encapsulated drugs by aerosol is a feasible way of targeting drugs to the lungs. Prior to clinical application of aerosolized liposomes as drug carriers, their relative safety must be established. We evaluated the effects of inhaling nondrug-containing liposomes (15 and 150 mg of lipid per milliliter) for 1 h on pulmonary function and on oximetry in ten healthy nonsmoking volunteers. Spirometry was performed prior to and at intervals after inhalation, and subjects were monitored with pulse oximetry. Liposome inhalation was well tolerated, and no oxygen desaturation, decrements in pulmonary function, or side effects were noted. We conclude that inhalation of small particle aerosols of SPC liposomes produces no acute deleterious effects on pulmonary function in healthy subjects.

Microtiter plate assay for selecting "macrophage virulent" strains of Mycobacterium avium intracellulare mycobacteria in mouse pulmonary alveolar macrophages.

Currently used macrophage-mycobacterial in vitro infection models require substantial numbers of macrophages. We developed a miniaturized version of such a model, using microtiter plates, which is comparable to standardly published methods, is reproducible, and requires fewer macrophages. In addition to its ease of handling and its economy in time, number of animals, and supplies, this method is preferable when limited numbers of macrophages are available. We have used this assay as a means of selecting human derived isolates from patients with M. avium intracellulare pulmonary disease for their ability to infect and multiply in cultured mouse pulmonary alveolar macrophages.

Aspergilloma in an open chest cavity.

We present the findings in a patient who underwent pneumonectomy and developed a chronic bronchopleural fistula and empyema and who developed an intrathoracic aspergilloma after open-window thoracostomy. To our knowledge, formation of an aspergilloma in an open intrathoracic cavity has not been reported previously.

Midazolam-associated alterations in cardiorespiratory function during colonoscopy.

Twenty patients undergoing clinically indicated elective colonoscopy were prospectively monitored noninvasively for alterations in cardiorespiratory function. Most of the patients were elderly and many had either cardiac or pulmonary disease. All subjects were premedicated with intramuscular meperidine and continuously monitored with ECG, blood pressure, earlobe pulse oximetry, nasal air flow by thermistor probe, and impedance pneumography. Any use of additional analgesic or sedative was determined by the endoscopist, who was blinded to the physiologic tracings, and dosages of medications given were titrated to each patient's tolerance of the procedures as assessed by the endoscopist. Seventeen patients (85%) required additional sedation with the benzodiazepine, midazolam. These patients exhibited frequent episodes of hypotension (reductions in mean arterial blood pressure of 23 +/- 12 mm Hg from baseline, means +/- SD) and respiratory depression (as noted by the greater number of apneas and arterial oxygen desaturation as low as 7.1 +/- 2% from baseline, means +/- SD). In addition, elderly patients and patients with an underlying history of cardiac or pulmonary disease had a greater incidence of potentially untoward cardiorespiratory events.

Septic pulmonary embolization caused by Citrobacter diversus.

Citrobacter diversus is an unusual human pathogen. This organism has never been reported as a cause of septic pulmonary embolization. We report a case of septic pulmonary embolization caused by C. diversus in a relatively healthy young woman following an otherwise uncomplicated cesarean section.

Do patients with sleep apnea die in their sleep?

Patients with sleep apnea syndrome (SAS) show cardiac dysrhythmias in association with cyclical nocturnal hypoxemia; are they at risk of dying during sleep? To assess this claim, we reviewed the clinical course of 91 patients with polysomnographically documented SAS between July 1978 and June 1986. A control group was comprised of 35 patients who were referred with symptoms suggestive of SAS but had negative sleep studies. Follow-up was obtained by survey questionnaire. Nine of 91 SAS and four of 35 control patients had died by completion of the study. There were no statistically significant differences in mortality between the two groups. None of the SAS patients died in their sleep, but they reported a higher incidence of disability and vehicular mishaps than did control subjects. The findings in this study do not support the hypothesis that SAS patients are at increased risk of dying in their sleep.

Near drowning: consensus and controversies in pulmonary and cerebral resuscitation.

By consensus, the most clinically important consequence of near drowning is hypoxemia. Whether it is due to physiologic shunting induced by diffuse alveolar flooding from saltwater aspiration or to diffuse atelectasis induced by surfactant inactivation from freshwater aspiration, both physiologic disturbances can be reversed with the institution of positive-pressure breathing in the form of PEEP or CPAP, which should be the mainstay of pulmonary management of respiratory insufficiency in these patients. The use of prophylactic antibiotics or corticosteroids as an adjunct in the management of pulmonary insufficiency resulting from near drowning is not warranted, may be detrimental, and remains controversial. The most crucial clinical consequence of the hypoxemia resulting from near drowning is cerebral injury and the consequent neurologic sequelae. The general consensus supported by large clinical studies is that near-drowning victims who, after initial resuscitation, are spontaneously breathing and are not comatose have a uniformly benign neurologic outcome. A significant subset of comatose near-drowning victims survive with eventually normal neurologic recovery when routine aggressive supportive intensive care is administered. Uncontrolled studies reporting improved outcomes with the institution of complex cerebral salvage techniques, such as induction of hypothermia, intracerebral pressure monitoring, induction of barbiturate coma, and the use of corticosteroids and osmotic diuretics, remain controversial. It is now clear that neither induced hypothermia nor barbiturate coma improves survival or neurologic outcome in these patients and may be detrimental.(ABSTRACT TRUNCATED AT 250 WORDS)