Clinical Features and Outcome of Dogs with Epiglottic Retroversion With or Without Surgical Treatment: 24 Cases.

BACKGROUND: Published information describing the clinical features and outcome for dogs with epiglottic retroversion (ER) is limited. HYPOTHESIS/OBJECTIVES: To describe clinical features, comorbidities, outcome of surgical versus medical treatment and long-term follow-up for dogs with ER. We hypothesized that dogs with ER would have upper airway comorbidities and that surgical management (epiglottopexy or subtotal epiglottectomy) would improve long-term outcome compared to medical management alone. ANIMALS: Twenty-four client-owned dogs. METHODS: Retrospective review of medical records to identify dogs with ER that underwent surgical or medical management of ER. RESULTS: Dogs with ER commonly were middle-aged to older, small breed, spayed females with body condition score (BCS) ≥6/9. Stridor and dyspnea were the most common presenting signs. Concurrent or historical upper airway disorders were documented in 79.1% of cases. At last evaluation, 52.6% of dogs that underwent surgical management, and 60% of dogs that received medical management alone, had decreased severity of presenting clinical signs. In dogs that underwent surgical management for ER, the incidence of respiratory crisis decreased from 62.5% before surgery to 25% after surgical treatment. The overall calculated Kaplan-Meier median survival time was 875 days. CONCLUSION AND CLINICAL IMPORTANCE: Our study indicated that a long-term survival of at least 2 years can be expected in dogs diagnosed with epiglottic retroversion. The necessity of surgical management cannot be determined based on this data, but dogs with no concurrent upper airway disorders may benefit from a permanent epiglottopexy to alleviate negative inspiratory pressures.

A TLR6 polymorphism is associated with increased risk of Legionnaires' disease.

Legionella pneumophila (Lp), the etiologic agent of Legionnaires' disease (LD), is an important cause of community-acquired and nosocomial pneumonia. However, the host immune and genetic determinants of human susceptibility to Lp are poorly understood. Here we show that both TLR6 and TLR1 cooperate with TLR2 to recognize Lp in transfected HEK293 cells. We also perform a human genetic association study of 14 candidate single-nucleotide polymorphisms in Toll-like receptors (TLRs) 1, 2 and 6 in 98 LD cases and 268 controls from the Netherlands. No polymorphisms in TLR1 or TLR2 were associated with LD. A TLR6 polymorphism, 359T>C (rs5743808), was associated with an elevated risk of LD in genotypic and dominant (odds ratio (OR) 5.83, P=7.9 × 10(-5)) models. The increased risk in persons with 359 TC or CC genotypes was further enhanced among smokers. In a multivariate model, 359T>C was associated with a higher risk of LD (OR 4.24, P=0.04), than any other variable, including age and smoking. Together, these data suggest that the human TLR6 variant, 359T>C, is an independent risk factor for LD.

Toll-like receptor 4 region genetic variants are associated with susceptibility to melioidosis.

Melioidosis is a tropical infection caused by the Gram-negative soil saprophyte Burkholderia pseudomallei. Despite broad exposure of northeastern Thais, disease develops in only a small proportion of individuals. Although diabetes is a risk factor, the mechanisms of host susceptibility to melioidosis are still poorly understood. We postulated that Toll-like receptors (TLRs) regulate host susceptibility to disease, and that genetic variation in TLRs is associated with melioidosis. We analyzed the frequency of eight previously described TLR pathway polymorphisms in 490 cases compared with 950 non-hospitalized controls or 458 hospitalized controls. Based on these results, we then analyzed the frequency of additional TLR4 or TLR6-1-10 region polymorphisms in cases and controls. We found that the TLR4(1196C>T) variant was associated with protection from melioidosis when compared with non-hospitalized controls. The TLR1(742A>G) and TLR1(-7202A>G) variants were associated with melioidosis when compared with hospitalized controls. In further analyses, we found that two additional TLR4 region polymorphisms were associated with disease. In diabetics, three other TLR6-1-10 region polymorphisms were associated with disease when compared with hospitalized controls. We conclude that TLR genetic variants may modulate host susceptibility to melioidosis. Confirmation of these findings and further investigation of the mechanisms are required.

Cytokine balance in the lungs of patients with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) involves an intense inflammatory response in the lungs, with accumulation of both pro- and antiinflammatory cytokines in bronchoalveolar lavage fluid (BALF). Our goal was to determine how the balance between pro- and antiinflammatory mediators in the lungs changes before and after the onset of ARDS. We identified 23 patients at risk for ARDS and 46 with established ARDS and performed serial bronchoalveolar lavage (BAL). We used immunoassays to measure tumor necrosis factor alpha (TNF-alpha) and soluble TNF-alpha receptors I and II; interleukin 1 beta (IL-1 beta), IL-1 beta receptor antagonist, and soluble IL-1 receptor II; IL-6 and soluble IL-6 receptor; and IL-10. We used sensitive bioassays to measure net TNF-alpha, IL-1 beta, and IL-6 activity. Although individual cytokines increased before and after onset of ARDS, greater increases occurred in cognate receptors and/or antagonists, so that molar ratios of agonists/antagonists declined dramatically at the onset of ARDS. The molar ratios remained low for 7 d or longer, limiting the activity of soluble IL-1 beta and TNF-alpha in the lungs at the onset of ARDS. This significant antiinflammatory response early in ARDS may provide a key mechanism for limiting the net inflammatory response in the lungs.

Antibody treatment of lower respiratory tract infections.

Antibody treatment of lower respiratory infection has a long history of success and is receiving renewed interest. A variety of polyclonal and monoclonal preparations are clinically available. Although used primarily for infection prophylaxis, these agents have limited applications in the treatment of established infections. Immune serum was the first effective treatment for pneumococcal pneumonia. Although long-supplanted by the advent of antibiotics, passive immunotherapy for pneumococcal and other infections is being revisited in an era of increasing antibiotic resistance and growing numbers of immunocompromised individuals. Limited clinical evidence supports the use of immune globulins in the treatment of pertussis and severe streptococcal infection. Bone marrow transplant recipients with lower respiratory infections caused by cytomegalovirus or respiratory syncytial virus also may benefit by adjunctive treatment with immune globulins. Additional indications for antibody treatment of respiratory infection may develop with further investigation.

Anti-inflammatory treatment of acute and chronic pneumonia.

The inflammatory response to infection is necessary for host defense but can contribute to the systemic toxicity and lung injury that may result from pneumonia. In some settings, adjunctive treatment of lower respiratory infections with anti-inflammatory agents can reduce morbidity. Corticosteroids have a well-documented role in the management of Pneumocystis carinii pneumonia complicating human immunodeficiency virus (HIV) infection. Corticosteroids also were found to reduce systemic symptoms of tuberculosis in a number of older studies, but their role as adjuncts to contemporary antimicrobial therapy are less clear. Corticosteroids also may be effective under some circumstances in the treatment of inflammatory sequelae of respiratory tract infection, such as tuberculous pleurisy, bronchiolitis obliterans organizing pneumonia, or prolonged acute respiratory distress syndrome. Nonsteroidal anti-inflammatory drugs may have limited applications in the modulation of chronic airway inflammation. Strategies targeting specific cytokines have not been effective to date, but remain active areas of investigation.

Septic shock and acute lung injury in rabbits with peritonitis: failure of the neutrophil response to localized infection.

The major goal of this study was to investigate the mechanisms that link the host response to a local infection in the peritoneal cavity with the development of sepsis and lung injury. Rabbits were infected by intraperitoneal inoculation of fibrin clots containing Escherichia coli at 10(8), 10(9), or 10(10) cfu/clot. Physiologic, bacteriologic, and inflammatory responses were monitored, and the lungs were examined postmortem. At a dose of 10(8) cfu/clot the animals had resolving infection, and a dose of 10(9) cfu/clot resulted in persistent infection at 24 h, with minimal systemic manifestations. In contrast, inoculation of 10(10) cfu/clot resulted in rapidly lethal local infection, with septic shock and lung injury. The onset of septic shock was associated with a paradoxical lack of identifiable polymorphonuclear leukocytes (PMN; neutrophils) in the peritoneal cavity. The absence of PMN in the peritoneum was due in part to lysis of intraperitoneal PMN, because the peritoneal fluids contained free myeloperoxidase and induced rapid death of normal rabbit PMN in vitro. Although most animals became bacteremic, only those with a severe systemic inflammation response developed lung injury. These data show that control of an infection in the first compartment in which bacteria enter the host is a critical determinant of the systemic response. Above a threshold dose of bacteria, failure of the local neutrophil response is a key mechanism associated with deleterious systemic responses. Bacteremia alone is not sufficient to cause lung injury. Lung injury occurs only in the setting of a severe systemic inflammatory response and an inadequate leukocyte response at the primary site of infection.

Effect of CD14 blockade in rabbits with Escherichia coli pneumonia and sepsis.

CD14, a pattern recognition receptor found on myeloid cells, is a critical component of the innate immune system that mediates local and systemic host responses to Gram-negative and Gram-positive bacterial products. Previous studies in normal animals have tested the effect of CD14 blockade on the systemic response to i.v. LPS. The goals of the study were to determine whether CD14 blockade protected against the deleterious systemic response associated with Escherichia coli pneumonia and to determine whether this strategy affected the pulmonary response to tissue infection. Rabbits were pretreated with either anti-CD14 mAb or isotype control mAb at 2.5 mg/kg. E. coli (1 x 109 CFU) was inoculated into the lungs, and the animals were observed for either 4 or 24 h. The blockade of CD14 improved the mean arterial blood pressure (p = 0.001) and decreased the i.v. fluid requirements (p = 0.01). Although this therapy protected the vascular compartment, rabbits treated with anti-CD14 mAb had increased bacterial burdens in the bronchoalveolar lavage fluid recovered from the instilled lung (p = 0.005) and widened alveolar-arterial oxygen difference. Blockade of CD14 prevents the deleterious systemic responses that occur in sepsis; however, other measures are necessary to control bacterial proliferation at the primary site of infection.

Diagnostic testing for community-acquired pneumonia.

The microbial cause of community-acquired pneumonia can be identified by noninvasive means in the majority of cases, usually within a few days of presentation. The Gram stain and culture of a pretreatment sputum sample are the most useful tests, but have significant limitations. Methods for detecting pneumococcal antigen in respiratory secretions are particularly helpful in patients who have received antibiotics before evaluation. Testing for specific pathogens such as L. pneumophila, M. pneumoniae, or C. pneumoniae should be guided by clinical suspicion in individual circumstances. Invasive procedures are most helpful in patients suspected of having infection with opportunistic or resistant pathogens, and in those whose initial management has been unsuccessful.

Role of the type 1 TNF receptor in lung inflammation after inhalation of endotoxin or Pseudomonas aeruginosa.

To determine the roles of the type 1 tumor necrosis factor (TNF) receptor (TNFR1) in lung inflammation and antibacterial defense, we exposed transgenic mice lacking TNFR1 [TNFR1(-/-)] and wild-type control mice to aerosolized lipopolysaccharide or Pseudomonas aeruginosa. After LPS, bronchoalveolar lavage fluid (BALF) from TNFR1(-/-) mice contained fewer neutrophils and less macrophage inflammatory protein-2 than BALF from control mice. TNF-alpha, interleukin-1beta, and total protein levels in BALF as well as tissue intercellular adhesion molecule-1 expression did not differ between the two groups. In contrast, lung inflammation and bacterial clearance after infection were augmented in TNFR1(-/-) mice. BALF from infected TNFR1(-/-) mice contained more neutrophils and TNF-alpha and less interleukin-1beta and macrophage inflammatory protein-2 than that from control mice, but protein levels were similarly elevated in both groups. Lung inflammation and bacterial clearance were also augmented in mice lacking both TNF receptors. Thus TNFR1 facilitates neutrophil recruitment after inhalation of lipopolysaccharide, in part by augmenting chemokine induction. In contrast, TNFR1 attenuates lung inflammation in response to live bacteria but does not contribute to increased lung permeability and is not required for the elimination of P. aeruginosa.

The locus of tumor necrosis factor-alpha action in lung inflammation.

The pulmonary host response to infection and inflammation appears, at least in part, to be compartmentalized from the systemic host response. Tumor necrosis factor-alpha (TNF-alpha) has been implicated in lung inflammation and injury, but its site(s) of action has not been clearly defined. To investigate this, transgenic mice (surfactant apoprotein C promotor/soluble TNF receptor type II-Fc fusion protein ([SPCTNFRIIFc] mice) were generated in which TNF-alpha was selectively antagonized in the distal lung through tissue-specific expression of sTNFRIIFc, a soluble TNF inhibitor. The lung inflammatory response in these mice to pulmonary challenge with Micropolyspora faeni antigen or lipopolysaccharide (LPS) was compared with the response of wild-type mice, wild-type mice treated with recombinant sTNFRIIFc intravenously, and type I TNF-receptor knockout mice. Recruitment of polymorphonuclear leukocytes (PMN) to the lung after challenge with M. faeni antigen was essentially abolished in the TNFRI knockout mice and markedly reduced in the SPCTNFRIIFc mice. Wild-type mice given sTNFRIIFc intravenously in amounts resulting in lung concentrations similar to those in SPCTNFRIIFc mice also showed significantly reduced lung PMN recruitment, whereas those given doses that achieved such concentrations in the blood but low levels in the lung did not. In contrast, PMN recruitment to the lung following aerosol challenge with LPS was reduced significantly in the TNFRI knockout mice and in mice given high-dose sTNFRIIFc intravenously, but was not reduced significantly in SPCTNFRIIFc mice. Thus, inhibition of PMN recruitment in response to M. faeni antigen correlated largely with the extent of intrapulmonary inhibition of TNF-alpha, whereas the response to LPS correlated best with the extent of extrapulmonary inhibition of TNF-alpha. These studies indicate that TNF-alpha may act at different loci to mediate lung inflammation, with the site of action depending in part on the nature of the inflammatory stimulus, and that SPCTNFRIIFc mice provide a tool by which the locus of TNF action can be addressed.

Antibody-mediated depletion of tumor necrosis factor-alpha impairs pulmonary host defenses to Legionella pneumophila.

Tumor necrosis factor-alpha (TNF-alpha) has been shown to stimulate the resistance of alveolar macrophages and neutrophils to Legionella pneumophila in vitro. To determine whether endogenous TNF-alpha is necessary for host defense against legionellosis in vivo, anti-TNF-alpha IgG or control IgG was administered to rats exposed to aerosolized L. pneumophila. Treatment with anti-TNF-alpha neutralized >90% of the intrapulmonary TNF-alpha response to infection, resulting in persistent pneumonitis and failure to clear L. pneumophila from the lungs. Depletion of TNF-alpha limited the recruitment of mononuclear cells to the lungs and resulted in a progressive increase in the proportion of alveolar macrophages that were infected; neutrophil recruitment and phagocytosis were not impaired. Both systemic and intrapulmonary IFN-gamma levels were significantly higher in rats depleted of TNF-alpha. These observations indicate that TNF-alpha is required for the prompt resolution of pneumonic legionellosis and point to a direct role for TNF-alpha in the activation of phagocytes.

Pulmonary and systemic inflammatory responses in rabbits with gram-negative pneumonia.

The major goals of this study were to define the relationships between intrapulmonary and systemic inflammatory responses in animals with gram-negative pneumonia. We treated rabbits with intrapulmonary Escherichia coli (1 x 10(7) to 1 x 10(10) cfu/ml), and then measured physiologic, cellular, and molecular events in the lungs and systemic circulation for 24 h. The treatment protocols resulted in groups of animals that mimicked the stages of the septic inflammatory response in humans. Animals treated with low inocula had systemic changes consistent with systemic inflammatory response syndrome and cleared the bacteria and inflammatory products from the lungs. Animals treated with high inocula failed to clear bacteria from the lungs, had severe intrapulmonary inflammatory responses, and developed septic shock. Intrapulmonary leukocyte recruitment was directly related to the size of the bacterial inoculum, but lung protein accumulation was not. Tumor neurosis factor-alpha (TNF-alpha), interleukin-8 (IL-8), and GRO were detectable in lung lavage fluid at 4 h and declined by 24 h in animals that cleared intrapulmonary E. coli. In contrast, lavage TNF-alpha, IL-8, and GRO increased over 24 h in animals that failed to clear intrapulmonary bacteria. MCP-1 increased between 4 h and 24 h in the lungs of all of the animals as the histologic response evolved from neutrophilic to mononuclear cell predominance. Thus, the intensity of systemic inflammatory and physiologic responses to intrapulmonary gram-negative infection depends on the inoculum size and whether the bacteria are cleared from or proliferate in the lungs. The results provide experimental support for the recently proposed classification of septic responses in humans.

Diagnostic testing to establish a microbial cause is helpful in the management of community-acquired pneumonia.

Antibiotic treatment for community-acquired pneumonia (CAP) can be specifically directed at an identified etiologic agent, or empirically formulated based on consideration of the likely pathogens according to the patient's age, underlying diseases, and clinical presentation. In recent years the empirical approach has become increasingly popular, and there is a growing trend away from efforts to make a microbiological diagnosis. This article reviews the tests that are currently available for the diagnosis of CAP, including stains, cultures, antigen-detection techniques, nucleic acid amplification, and serologies. Arguments then are presented in support of efforts to make a microbiological diagnosis. Clinical and radiographic features of CAP are not sufficiently distinctive to infer a specific microbial cause. Identification of the etiologic agent can be made in the majority of cases, and most microbiological diagnoses can be made rapidly with simple tests. The best opportunity to make an etiologic diagnosis is before antibiotics are administered. Identification of the microbial cause of pneumonia permits specific, narrow-spectrum antibiotic treatment that may be more effective, less toxic, and less expensive than empiric therapy. Microbiological data from individual patients contributes to understanding the local microbial epidemiology of CAP, including the local distribution of pathogens and their antimicrobial resistance patterns, information that is invaluable in the construction and modification of empiric treatment regimens. The reliance on empiric treatment engenders a false complacency, based on the erroneous assumption that broad-spectrum antibiotics will treat all cases of CAP. The unnecessary use of broad-spectrum antibiotic combinations in the empiric treatment of CAP contributes to the growing problem of antimicrobial resistance.

IL-10 enhances the growth of Legionella pneumophila in human mononuclear phagocytes and reverses the protective effect of IFN-gamma: differential responses of blood monocytes and alveolar macrophages.

Legionella pneumophila is a facultative intracellular pathogen that parasitizes human alveolar macrophages and blood monocytes recruited to the lungs. The inhibitory cytokines IL-10, TGF-beta, and IL-4 generally deactivate macrophages and permit enhanced microbial growth in some models of intracellular infection, but their effects on human alveolar macrophages are unknown. We hypothesized that inhibitory cytokines could facilitate the infection of human alveolar macrophages and monocytes by virulent intracellular lung pathogens. Therefore, we tested the effects of IL-10, TGF-beta, and IL-4 in an in vitro model of human alveolar macrophage and monocyte infection with L. pneumophila. We found that unstimulated alveolar macrophages supported over 100-fold greater L. pneumophila growth than did unstimulated monocytes. IL-10 treatment significantly enhanced L. pneumophila growth in monocytes, and completely reversed the protective effect of IFN-gamma against intracellular L. pneumophila replication. IL-10 had similar but less potent effects on alveolar macrophages. In contrast, TGF-beta and IL-4 had no significant effects on L. pneumophila growth in resting or IFN-gamma-activated monocytes or alveolar macrophages. IL-10 blocked TNF-alpha production by infected cells, but exogenous TNF-alpha did not reverse the activating defect in cells cocultured with IFN-gamma and IL-10. Finally, L. pneumophila-infected monocytes produced substantially more IL-10 than did infected alveolar macrophages. In summary, IL-10 significantly enhances the growth of L. pneumophila in human monocytes, reverses the protective effect of IFN-gamma, blocks TNF-alpha secretion, and is secreted by infected monocytes and alveolar macrophages. Induction of IL-10 may be a virulence mechanism that promotes intracellular bacterial replication in human legionellosis.

Roles for tumor necrosis factor alpha and nitric oxide in resistance of rat alveolar macrophages to Legionella pneumophila.

Legionella pneumophila is an intracellular parasite of alveolar macrophages, and recovery from legionellosis is associated with activation of alveolar macrophages to resist intracellular bacterial replication. Gamma interferon (IFN-gamma) is known to activate alveolar macrophages to suppress L. pneumophila, but the role of macrophage-derived cytokines in modulating alveolar macrophage resistance is unknown. To test the hypothesis that macrophage-derived mediators contribute to the resistance of alveolar macrophages to L. pneumophila, we incubated adherent rat alveolar macrophages with Escherichia coli lipopolysaccharide (LPS), recombinant tumor necrosis factor alpha (TNF-alpha), recombinant IFN-gamma, neutralizing anti-TNF-alpha, and/or N(G)-monomethyl-L-arginine (L-NMMA) for 6 h before challenge with L. pneumophila. Monolayers were sonically disrupted and quantitatively cultured on successive days. We also measured bioactive TNF-alpha release by infected macrophages in the presence or absence of IFN-gamma. We found that pretreatment of alveolar macrophages with LPS or, to a lesser degree, TNF-alpha, significantly inhibited intracellular replication of L. pneumophila. Both LPS and TNF-alpha acted synergistically with IFN-gamma at less than the maximally activating concentration to suppress L. pneumophila growth. The independent and coactivating effects of LPS were blocked by anti-TNF-alpha. Killing of L. pneumophila by IFN-gamma at the maximally activating concentration was inhibited by anti-TNF-alpha. The synergistic effects of TNF-alpha. or LPS in combination with IFN-gamma were inhibited by L-NMMA. Infected alveolar macrophages secreted TNF-alpha in proportion to the bacterial inoculum, and secretion of TNF-alpha was potentiated by cocultivation with IFN-gamma. These data indicate that secretion of TNF-alpha is an important autocrine defense mechanism of alveolar macrophages, serving to potentiate the activating effects of IFN-gamma through costimulation of nitric oxide synthesis.

Deposition of particles in the lungs of infant and adult rats after direct intratracheal administration.

The study of neonatal pulmonary defense mechanisms has been limited by difficulty in administering foreign material into the lungs of newborn animals. We have developed and standardized a simple method for the intratracheal instillation of particles into the distal airways of newborn rats. We used this method to compare intrapulmonary particle deposition in neonatal and adult rats. We instilled 51Cr-labeled microspheres (11 microns diameter) by direct intratracheal inoculation into the lungs of neonatal (< 2- or 19-h-old) and adult (6-week-old) Sprague-Dawley rats. Immediately after microsphere instillation, the lobar distribution of the particles was analyzed by scintillation counting. The anatomic location of the particles was determined by autoradiography. The instilled microspheres reached all lobes in both lungs of neonatal and adult rats. The pattern of distribution in the right lung was nearly identical in the neonatal and adult rats. In the left lung, however, particles deposited preferentially in the cranial lobe in neonates but in the caudal lobe of adult rats. Analysis of the location of particle deposition in the lungs indicated that 64% +/- 6.85 (n = 4) reached the distal airways in the neonates vs. 85% +/- 3.3 (n = 6) in the adults, whereas the remainder deposited in the conducting airways. This method provides an effective means of delivering particles into distal airspaces of neonatal rats and can be used to study pulmonary defense mechanisms in newborn animals.

Effects of endotoxin in the lungs of neonatal rats: age-dependent impairment of the inflammatory response.

Age-dependent maturation of the intrapulmonary inflammatory responses to bacterial lipopolysaccharide (LPS) was studied because nosocomial gram-negative infections cause morbidity in newborn infants. Escherichia coli LPS or live E. coli were injected into the airways of neonatal or adult rats; intrapulmonary recruitment of leukocytes was measured 6 h later. Neonates showed age- and dose-dependent impairment of intrapulmonary neutrophil recruitment after intratracheal administration of LPS or live E. coli that persisted for the first 28 days of life. Neonatal and adult alveolar macrophages released similar amounts of neutrophil chemotactic activity and tumor necrosis factor in response to incubation with LPS in vitro. Treatment of neonates with intratracheal or systemic interferon-gamma did not augment the response to LPS. Thus, intrapulmonary inflammatory responses to LPS and gram-negative bacteria are impaired early in life and do not approach adult levels until approximately 4 weeks of age.

Host defenses against respiratory infection.

The respiratory tract is protected from infection by its formidable mechanical and cellular defenses, supplemented when necessary by inflammatory and immune responses. Impairments in these defenses develop as a result of underlying disease and therapeutic interventions. Specific defects in host defenses often predispose to infection with particular etiologic agents. New opportunities for the therapeutic augmentation of defenses are emerging that may be particularly helpful in the care of immunocompromised patients.