Haruhiko Furusawa

Th1 and Th17 immune responses to viable Propionibacterium acnes in patients with sarcoidosis

BACKGROUND Propionibacterium acnes and Mycobacterium tuberculosis have emerged as probable candidates responsible for sarcoidosis. This study was conducted to investigate the Th1/Th17 responses elicited by these pathogens in sarcoidosis and to clarify the causative role of these pathogens. METHODS Peripheral blood mononuclear cells (PBMCs) obtained from patients with sarcoidosis and from healthy volunteers were, respectively, co-cultured with viable P. acnes, with Bacille de Calmette et Guérin (BCG) as a viable M. tuberculosis complex, and with the early secretory antigenic target (ESAT)-6. Th1 cytokine production was measured using RT-PCR and enzyme-linked immunospot (ELISPOT) assays, and interleukin (IL)-17 mRNA expression was measured by RT-PCR. RESULTS IL-2 secretion from PBMCs after stimulation with P. acnes was significantly higher in patients with sarcoidosis than in the controls. Similarly, IL-2 and IL-12 mRNA expression after stimulation with P. acnes was significantly higher in PBMCs from patients with sarcoidosis than in PBMCs from controls. In contrast, IL-17 mRNA expression was significantly lower in PBMCs from patients with sarcoidosis than in PBMCs from controls. No significant differences between the groups were observed in the responses to stimulation with BCG or ESAT-6. CONCLUSION Sarcoidosis may arise from an imbalance of Th1/Th17 immune responses against viable P. acnes, but not M. tuberculosis complex.

Pathogenesis of cBFL in common with IPF? Correlation of IP-10/TARC ratio with histological patterns

Background: A Th1 predominant immune response has been shown in acute hypersensitivity pneumonitis. Predominance of Th2 appears to favour the development of pulmonary fibrosis through the profibrotic process and has been described as crucial in the progression of idiopathic pulmonary fibrosis. Chronic bird fancier’s lung (cBFL) can present with a histological pattern of usual interstitial pneumonia (UIP)-like lesions. Little is known about the Th1/Th2 balance in the pathogenesis of cBFL. Methods: To evaluate the relevance of Th1-type chemokines (interferon-inducible protein, IP-10) and Th2-type chemokines (thymus- and activation-regulated chemokine, TARC) and their receptors (CXCR3 and CCR4) to the histological patterns of cBFL, 40 patients with cBFL who underwent surgical lung biopsies, 12 with acute BFL (aBFL) and 10 healthy volunteers were analysed. IP-10 and TARC levels in serum and bronchoalveolar lavage (BAL) fluid were measured by ELISA. Immunohistochemistry for CXCR3 and CCR4 was performed on surgical lung specimens. Results: The ratio of TARC to IP-10 in the serum of patients with UIP-like lesions was significantly higher than in patients with cNSIP/OP-like lesions, aBFL and healthy volunteers. The ratio of CCR4 to CXCR3 in patients with UIP-like lesions was significantly higher than in those with cNSIP/OP-like lesions and fNSIP-like lesions. The ratio of CCR4-positive to CXCR3-positive cells correlated with the ratio of TARC to IP-10 in serum. Conclusions: A Th2 predominant immune response may play an important role in the development of UIP-like lesions, as already observed in idiopathic pulmonary fibrosis. A Th1 predominance may play a role in the development of cNSIP/OP-like lesions in cBFL.

Propionibacterium acnes catalase induces increased Th1 immune response in sarcoidosis patients

BACKGROUND Propionibacterium acnes is one of the most commonly implicated etiologic agents of sarcoidosis. We screened antigenic proteins from this indigenous bacterium that increase Th1 responses in sarcoidosis patients. METHODS Antigenic bacterial proteins were screened by probing western blots of P. acnes whole cell lysates with blood plasma samples from 52 sarcoidosis patients and 34 healthy volunteers. Soluble protein antigens from the bands most frequently detected on blotting membranes were analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF/MS). Recombinant proteins were prepared from DNA sequences of the proteins identified by MALDI-TOF/MS and analyzed by immunologic assays. RESULTS MALDI-TOF/MS analysis identified propionyl-CoA carboxylase subunit beta, arginine deiminase (ADI), catalase (KAT), and UDP-N-acetylglucosamine pyrophosphorylase (UAP). Successfully prepared recombinant proteins from ADI, KAT, and UAP provoked humoral and cellular immune responses in mice immunized with P. acnes when measured by enzyme-linked immunosorbent assay for serum antibodies and enzyme-linked immunospot assay for interferon (IFN)-γ-secreting cells (ELISPOT IFN-γ assay) with lymph node cells. Plasma IgG and IgA titers to KAT and UAP were significantly higher in sarcoidosis patients than in healthy volunteers. When Th1 immune responses to ADI, KAT, and UAP were measured by ELISPOT IFN-γ assay with peripheral blood mononuclear cells from 12 sarcoidosis patients, 13 other pneumonitis patients, and 11 healthy volunteers, only the KAT protein provoked a significantly higher response in sarcoidosis patients (p=0.0032). CONCLUSION These results suggest that P. acnes KAT is an antigen that provokes allergic Th1 immune responses in sarcoidosis patients.

The usefulness of KL-6 and SP-D for the diagnosis and management of chronic hypersensitivity pneumonitis

BACKGROUND It is believed that Krebs von den Lungen-6 (KL-6) and surfactant protein D (SP-D) are useful biomarkers for the diagnosis of various types of interstitial lung diseases, including hypersensitivity pneumonitis (HP). The clinical features of chronic HP are similar to those of idiopathic interstitial pneumonias, especially idiopathic pulmonary fibrosis (IPF). OBJECTIVE We sought to clarify the usefulness of serum KL-6 and SP-D for the diagnosis and management of chronic HP. METHODS We examined serum KL-6 and SP-D levels and retrospectively evaluated the clinical parameters of acute HP (n = 35), chronic HP (n = 57), IPF (n = 54), collagen vascular disease-associated interstitial pneumonia (CVD-IP) (n = 67), and sarcoidosis (n = 47). We analyzed the relations between the two biomarkers and clinical data in chronic HP. RESULTS Serum KL-6 and SP-D levels in acute HP (2710 U/ml and 338 ng/ml, median) and chronic HP (1500 U/ml and 264 ng/ml, median) were significantly higher than in IPF, CVD-IP, and sarcoidosis. The area under the curve (AUC) values for serum KL-6 and SP-D between chronic HP and IPF were 0.771 and 0.729, respectively. Serum KL-6 levels in chronic HP were significantly higher during episodes of acute exacerbation than 1 month before acute exacerbation. The serum KL-6 levels had correlations with serum SP-D and the percentage of lymphocytes in bronchoalveolar lavage fluid. CONCLUSIONS Serum KL-6 and SP-D levels are useful for the diagnosis and management of chronic HP.

Antigen avoidance tests for diagnosis of chronic hypersensitivity pneumonitis

BACKGROUND Chronic hypersensitivity pneumonitis (HP) is induced by the inhalation of specific antigens. Patients with chronic HP may be able to improve their prognosis by avoiding these antigens. Chronic HP is often difficult to distinguish from idiopathic interstitial pneumonias (IIPs). OBJECTIVE This study was performed to find out how antigen avoidance tests contribute to the diagnosis of chronic HP. METHODS A retrospective analysis was conducted on 265 patients who underwent 2-week antigen avoidance tests between April 2002 and March 2012. The patients were classified into the following categories: acute HP, chronic HP, collagen vascular disease-associated interstitial pneumonia (CVD-IP), lung dominant connective tissue disease (LD-CTD), and IIPs. The following seven clinical parameters were evaluated: vital capacity, alveolar-arterial oxygen pressure difference, Krebs von den Lungen-6, surfactant protein-D, white blood cell count, C-reactive protein, and body temperature. These parameters were compared between the chronic HP group and a control group consisting of CVD-IP, LD-CTD, and IIPs. RESULTS One-hundred and ninety-six patients with chronic HP and 43 control subjects were evaluated. All clinical parameters improved significantly in the chronic HP group but showed no significant changes in the control group. Four of the parameters changed significantly compared with the control group. Diagnostic criteria established using these data had a sensitivity of 51.0% and a specificity of 80.7%. CONCLUSIONS It was difficult to diagnose chronic HP based solely on 2-week antigen avoidance tests; however, improved clinical parameters among patients supported the diagnosis of HP.

Protein antigen of bird-related hypersensitivity pneumonitis in pigeon serum and dropping

BackgroundAvian antigen is a common cause of hypersensitivity pneumonitis (HP). Inhalation challenge with pigeon serum and pigeon dropping extract (PDE) elicits a hypersensitivity reaction in patients with bird-related hypersensitivity pneumonitis (BRHP), but the antigenic components in these materials have yet to be fully elucidated.MethodPigeon serum, pigeon intestine homogenates, and PDE were immunoblotted with serum samples from 8 patients with BRHP, 2 patients with summer-type HP, 2 patients with humidifier lung, and 3 healthy volunteers. Among the protein spots found in both pigeon serum and PDE, those that reacted with sera from BRHP patients were identified by mass spectrometry. Immunoassays using recombinant protein were performed to confirm the antigenicity of the identified protein. Cytokine production by peripheral blood mononuclear cells (PBMCs) stimulated with recombinant protein was also assessed.ResultsImmunoglobulin lambda-like polypeptide-1 (IGLL-1) was identified from all spots on 2-DE immunoblots of both pigeon serum and PDE. The BRHP patients exhibited higher levels of serum IgG antibody against the recombinant IGLL-1 (rIGLL-1) compared to the control subjects, as well as a stronger PBMCs proliferative response to rIGLL-1. Cytokine production by PBMCs from BRHP patients after rIGLL-1 exposure indicated that the protein could induce Th1 prone immune responses: an increase in TNF-α and an absence of elevated IL-10 production.ConclusionsPigeon IGLL-1 was identified as the BRHP antigen present in both pigeon serum and PDE.

Direct hemoperfusion with polymyxin B-immobilized fibre treatment for acute exacerbation of interstitial pneumonia

Acute exacerbation of idiopathic pulmonary fibrosis (AE‐IPF) is recognized as an important cause of mortality. AE has also been reported in patients with other interstitial lung diseases such as idiopathic non‐specific interstitial pneumonia (NSIP) and interstitial pneumonia associated with collagen vascular disease (CVD). Current therapies such as high‐dose corticosteroid with immunosuppressive agents have provided little benefit for AE. Direct hemoperfusion (DHP) with a polymyxin B‐immobilized fibre column (PMX) was originally developed for the treatment of endotoxaemia. Recent clinical reports have suggested beneficial effects of PMX‐DHP treatment on patients with AE. In this study, we evaluated the effectiveness and safety of PMX‐DHP treatment for patients with AE.

Development of mediastinal adenitis six weeks after endobronchial ultrasound-guided transbronchial needle aspiration

A 60-year-old man visited our hospital for further examination of an abnormal chest radiograph. Computed tomography (CT) images revealed enlarged mediastinal lymph nodes and multiple pulmonary nodules. Further evaluation by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed and he was diagnosed with sarcoidosis. Six weeks after EBUS-TBNA, he presented to the emergency department with a high-grade fever. CT scan revealed an enlarged mediastinal lymph node. He was diagnosed with mediastinal adenitis and treated successfully with antibiotics. EBUS-TBNA is a highly accurate diagnostic tool, but clinicians should be aware of mediastinal infectious complication that could be asymptomatic for long period of time.

Other Diffuse Lung Diseases: Diffuse Cystic Lung Diseases (LAM, TSC, BHD), Sarcoidosis, Pulmonary Alveolar Proteinosis, and Pulmonary Alveolar Microlithiasis—What Are the Roles of Genetic Factors in the Pathogenesis of These Diseases?

Lymphangioleiomyomatosis (LAM) is a rare multisystem disorder that mostly affects women in their reproductive years and predominantly affects the lungs. LAM occurs in patients with tuberous sclerosis complex (TSC-LAM) and as a sporadic form in patients who do not have tuberous sclerosis (S-LAM). Patients with TSC-LAM have germline mutations either in TSC1 located on chromosome 9q34 or TSC2 located on chromosome 16p13.3, and the majority have a germline mutation in TCS2.

Lung Cancer Diagnosed More Than Five Years after the Development of Polymyositis/Dermatomyositis

Background. The patients with polymyositis (PM) and dermatomyositis (DM) often develop the malignancies in their clinical course. The incidence of cancer is estimated at about 15%. The risk of cancer is the highest within the first year of myositis diagnosis and drops substantially thereafter. The patients with lung cancer diagnosed more than 5 years after the onset of PM or DM are the minority. Methods and Patients. We surveyed the medical records of patients with lung cancer over the period from 1995 to 2011. Results. We found five patients who developed lung cancer more than 5 years after the diagnosis of PM/DM. Three patients were male, and two were female. The median age was 61.2 (±11.7). Histological types were diverse. The clinical stages ranged from IA to IV. Three patients had smoking histories. Four patients suffered from DM, and one suffered from PM. All patients received oral corticosteroid therapy. Two patients also received ciclosporin, and another two received azathioprine. Anti-Jo-1 antibody was positive in one patient. Four patients were complicated with interstitial pneumonia (IP). Conclusion. These lung cancers diagnosed more than 5 years after the onset of PM/DM were probably related to IP or smoking but might not be comorbid with PM/DM.