Herbert Y. Reynolds

Analysis of cellular and protein content of broncho-alveolar lavage fluid from patients with idiopathic pulmonary fibrosis and chronic hypersensitivity pneumonitis.

To evaluate cellular and protein components in the lower respiratory tract of patients with idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis (CHP), limited broncho-alveolar lavage was done in 58 patients (19 IPF, 7 CHP, and 32 controls). Analysis of the cells and protein in the lavage fluids from patients with IPF revealed an inflammatory and eosinophilic response and a significant elevation of IgG in the lungs. With corticosteroid therapy, inflammation diminished but eosinophils remained. Lavage fluid from patients with CHP also had eosinophils and elevated levels of IgG. However, in contrast to IPF, lavage fluid from CHP patients contained IgM, fewer inflammatory cells, and a strikingly increased number (38-74%) of lymphocytes. Identification of lavage lymphocytes in CHP showed that T lymphocytes were significantly elevated and B lymphocytes were decreased compared to peripheral blood. These studies suggest nthat the lung in IPF and CHP may function as a relatively independent immune organ, and that analysis of cells and proteins in broncho-alveolar lavage fluid may be of diagnostic, therapeutic, and investigative value in evaluating patients with fibrotic lung disease.

Bronchoalveolar Lavage in Interstitial Lung Disease

Cellular and immunoglobulin components of bronchoalveolar fluid recovered by bronchoscopic lavage were evaluated in 32 control patients, 10 normal volunteers, and 60 patients with the following interstitial lung diseases: idiopathic pulmonary fibrosis, pulmonary fibrosis associated with collagen-vascular disease, eosinophilic granuloma, sarcoidosis, and hypersensitivity pneumonitis. The percentage of lymphocytes distinguished two general disease categories: those with increased lymphocytes (sarcoidosis and hypersensitivity pneumonitis); and those with normal lymphocytes (idiopathic pulmonary fibrosis, pulmonary fibrosis associated with collagen-vascular disease, and eosinophilic granuloma). Patients in all five disease categories had elevated IgG levels and percentages of neutrophils compared with control patients, with the highest proportion of neutrophils found in idiopathic pulmonary fibrosis. Immunoglobulin levels also helped distinguish among patient groups, in that patients with hypersensitivity pneumonitis had lavage IgG/albumin ratios greater than 1, whereas patients with sarcoidosis had ratios less than 1; and with infrequent exceptions, the finding of IgM in lavage fluid was limited to patients with hypersensitivity pneumonitis.

Alveolar macrophage-derived chemotactic factor: kinetics of in vitro production and partial characterization.

Alveolar macrophages are the initial phagocytic cells that encounter foreign material and particulates deposited in the terminal airways. We have examined a mechanism by which these cells, after phagocytic challenge, may control or amplify the inflammatory response in lung parenchyma. Normal human alveolar macrophages (AM) were studied from eight subjects. With in vitro culture, AM produced and released two substances into culture media which have potent chemoattractant activity for blood polymorphonuclear granulocytes (PMN) and negligible activity for mononuclear cells. Release of these factors is maximally stimulated by aggregated human immunoglobulin (Ig)G or zymosan particles; however, simple adhesion of the macrophages to plastic surfaces is also sufficient to stimulate release of these chemotactic substances. The larger substance (10,000 daltons) is immunologically distinct from C5a and interacts with a different PMN membrane receptor than that known to exist for formyl-methionyl-leucyl-phenylalanine. Its chemotactic activity is sensitive to the enzymatic effect of trypsin. Although producing a single elution peak on gelfiltration chromatography, electrofocusing in polyacrylamide gels yielded five peaks of radioactivity. Chemotactic activity was localized to a fraction with a pI = 5.0. The smaller molecular weight substance has been less well characterized. Thus, the human AM can produce at least two factors which attract PMN and this capability may augment the local inflammatory response in the lung.

Collagenase in the lower respiratory tract of patients with idiopathic pulmonary fibrosis.

To test the hypothesis that idiopathic pulmonary fibrosis (IPF) is mediated through collagenase present in the lower respiratory tract, we used the fiberoptic bronchoscope to obtain fluid from the lower respiratory tract of 24 patients with IPF, 18 controls and nine patients with sarcoidosis. The fluid was analyzed for a variety of enzymes, including collagenase. Fifteen of 21 patients with IPF showed collagenase activity, whereas normal controls and patients with sarcoidosis showed none (P greater than 0.001, for all comparisons). In two patients with IPF who were re-evaluated after eight to 24 months, the collagenase activity was persistent. Fluid from patients with IPF also contained elevated levels of a non-specific neutral protease (P greater than 0.01 compared with controls), but there was no elastase activity in fluid from patients with IPF or from controls. The collagenase found in lavage fluid in IPF cleaved lung collagen into collagenase-specific TCA and TCB fragments. We conclude that in IPF the collagen of the lung is subjected to sustained lysis, followed by disordered resynthesis, and that the presence of active collagenase in the lower respiratory tract is a specific feature of the alveolitis associated with this disease.

Pseudomonas pneumonia: A retrospective study of 36 cases

Abstract The clinical course in 36 cases of Pseudomonas pneumonia collected over a 15 year period (1956 to 1970) at the Clinical Center of the National Institutes of Health were reviewed to identify factors which increased the risk of infection and affected prognosis. In all cases, the patients had a serious underlying disease which predisposed to infection, and the majority had neoplastic diseases, particularly acute leukemia; cardiac or pulmonary diseases were less frequent. Pseudomonas related mortality was 81 per cent and was not influenced by type of antibiotic therapy or by the year of occurrence. Many patients were neutropenic, usually subsequent to cytotoxic chemotherapy, and frequently had been treated with steroids or antibiotics just prior to the development of pneumonia. Adequate numbers of circulating granulocytes were essential to survival. No patient with a positive blood culture survived. Possibilities for new means of prevention and treatment of Pseudomonas pneumonia are discussed.

Mechanism for the inflammatory response in primate lungs. Demonstration and partial characterization of an alveolar macrophage-derived chemotactic factor with preferential activity for polymorphonuclear leukocytes.

Approximately 4 h after an initial bronchoalveolar lavage (BAL) of a primates lung, an appreciable number of polymorphonuclear leukocytes (PMNs) were noted to accumulate in respiratory fluids when lavage was repeated. Whereas, alveolar macrophages (90%) and lymphocytes (7%) were the principal respiratory cells recovered initially from lavage fluid, later samples contained 45-90% PMNs To explain the observed ingress of PMNs into lung fluids, concentrated BAL fluid was tested for chemoattractant activity. Such fluid obtained 4 and 24 h after an initial lavage contained material that produced directed migration (chemotaxis) for PMNs and mononuclear cells isolated from peripheral blood of normal donors. Gel filtration chromatography of BAL disclosed two peaks of chemotactic activity in the effluent fractions. Material from the column with an estimated molecular weight of 15,000 daltons was chemotactic for both PMNs and mononuclear cells. Because it was susceptible to inactivation with antiserum against the fifth component of complement, resistant to heating, and unaffected by antiserum against C3, this factor was considered analogous to the cleavage product of the fifth component of complement. C5a. In addition chemotactic activity for PMNs only was contained in an effluent peak having a molecular weight of about 5,000 daltons. This material was heat labile but unaffected by antisera to complement components. To locate the possible source of these factors in respiratory fluid, in vitro cultures of alveolar macrophages were established. These cells, whether stimulated by phagocytosis of opsonized bacteria or merely by attachment to a glass surface, produced chemotactic material which had physical characteristics similar to the small molecular weight material in BAL. Moreover, it induced preferential chemotaxis for PMNs. Thus, in primate lungs, at least two chemotactic substances may generate an inflammatory response; one which is a fragment of the complement component C5 and another small molecular weight factor which is released from alveolar macrophages.

Nutritional Status and Bacterial Binding in the Lower Respiratory Tract in Patients with Chronic Tracheostomy

Patients with chronic tracheostomy often develop tracheobronchial colonization with enteric gram-negative bacilli, especially Pseudomonas aeruginosa, but pathogenic mechanisms are largely unknown. To examine this problem, we measured in-vitro bacterial adherence to airway epithelial cells from the tracheal surfaces of 15 patients with chronic tracheostomy and 18 healthy, noncolonized controls without tracheostomy. Patients with tracheostomy had more tracheal cell adherence (7.3 +/- 0.4 [SE] bacteria/cell) than controls (4.8 +/- 0.7 bacteria/cell; p = 0.008), but patients colonized by Pseudomonas species had even more binding (9.0 +/- 0.06 bacteria/cell) than those without this finding (5.8 +/- 0.8 bacteria/cell; p = 0.008). Differences between patients in lower airway cell binding of bacteria were largely related to a multifactorial assessment of patient nutritional status, the prognostic nutritional index (r = 0.67, p = 0.005). Thus, nutritional status may account in part for the common problem of tracheobronchial colonization with gram-negative bacteria in patients with chronic tracheostomy.

USE OF A PSEUDOMONAS AERUGINOSA VACCINE IN PATIENTS WITH ACUTE LEUKEMIA AND CYSTIC FIBROSIS

A heptavalent lipopolysaccharide Pseudomonas vaccine was evaluated in 22 patients with acute leukemia and 12 patients with cystic fibrosis during an 18 month interval at the Clinical Center of the National Institutes of Health. Of the 34 patients, 32 had an excellent serum hemagglutinating (HA) antibody response to immunization. In comparison to the patients with cystic fibrosis, the patients with leukemia had a smaller HA antibody response, which lasted a shorter period of time, and also experienced greater toxicity from the vaccine. The mixing of adrenal corticosteroids with vaccine greatly decreased side reactions among the patients with leukemia without significantly inhibiting antibody production. Previous antineoplastic chemotherapy had little influence on antibody response in patients with leukemia, with the exception of methortrexate. Vaccinated patients with leukemia had 1 Pseudomonas infection of 14 bacterial or fungal infections, whereas 2 pseudomonas infections of 5 bacterial or fungal infections occurred in a control group of 20 patients with acute leukemia. Of the 12 patients with cystic fibrosis, 4 had a Pseudomonas infection after vaccination.

Use of bronchoalveolar lavage in humans--past necessity and future imperative.

Abstract. Limited bronchoalveolar lavage (BAL) as an extension of fiberoptic bronchoscopy has permitted the recovery of airway-alveolar space cells and soluble substances in the extracellular lining fluid that have been used diagnostically and as research specimens in patients with a variety of lung diseases and in normal subjects for the study of lung host defenses. During the past three decades, use of BAL specimens has stimulated immunologic and cellular research of pulmonary diseases, which has provided significant insight into local host immunity, inflammation, fibrogenesis, asthma mechanisms, and infections. From this research new methods of antifibrotic therapy of interstitial pulmonary fibrosis, for example, have followed. Moreover, BAL applications have greatly enhanced professional interest in the field of pulmonary medicine. This review attempts to analyze the history and impact of BAL, appraise its current status, and assess its future usefulness.Understanding the immunopathogenesis of many lung diseases is predicated on obtaining in situ specimens from affected lung tissue and airways. BAL provides a direct sample that can be compared with an endobronchial or transbronchial biopsy tissue specimen and with cellular and immunologic components in the vascular circulation. Thus, the recovery of BAL fluid and its components involved directly with a disease process or continguous with interstitial tissue permits a much more detailed assessment of new cellular mediators and cytokines participating in the pathologic process. Furthermore, subjecting BAL cells to microarrays of DNA to discern what genes are activated will be one step closer to identifying intracellular processes involved or deranged. Identification of causative factors may solve questions of causation, so that preventive strategies or definitive therapy can be used.

Pseudomonas aeruginosa Infections: Persisting Problems and Current Research to Find New Therapies

Despite the availability of specific antibiotics, Pseudomonas aeruginosa bacteria still cause troublesome infections in patients with a variety of illnesses: extensive thermal injury, leukopenia from antineoplastic chemotherapy and other forms of immunosuppressive treatment, chronic pulmonary disease such as cystic fibrosis, or intravenous narcotic use. The use of antibiotics has improved the prognosis of pseudomonas infections considerably. However, patients with marginal or defective host immunity may need more extensive therapy to master the infection. By evaluating additional modalities of treatment such as granulocyte replacement, improved usage of antibiotics, and active (prophylaxis) or passive antibody administration, the optimal combination may be found.