Judah A. Denburg

CHRONIC COUGH: EOSINOPHILIC BRONCHITIS WITHOUT ASTHMA

Sputum cell-counts were studied in 7 non-smokers with corticosteroid-responsive chronic cough productive of sputum and 8 smokers with a clinical diagnosis of chronic bronchitis, all of whom had normal lung function tests and methacholine airway responsiveness, and in 10 non-smokers with asthma, examined during an exacerbation. Sputum from asthmatic patients and subjects with corticosteroid-responsive cough contained eosinophils and metachromatic cells. Macrophages were by far the dominant cell type in sputum from subjects with chronic bronchitis. Airway inflammation with eosinophils and metachromatic cells is not always accompanied by increased airway responsiveness, and current definitions of obstructive airways disease may need to be revised.

A research method to induce and examine a mild exacerbation of asthma by withdrawal of inhaled corticosteroid

This study evaluated a research method to examine an exacerbation of asthma induced by corticosteroid withdrawal. Ten non‐smoking adult asthmatics who were stable on treatment with inhaled steroid underwent a graded reduction of the daily dose by 200 μg at weekly intervals until an exacerbation of symptoms occurred. A daily symptom, peak expiratory flow rate (PEF) and medication diary was kept. Weekly clinic visits were used to assess symptoms, spirometry, methacholine airway responsiveness (expressed as the provocative concentration to cause a fall in FEV1 of 20%, PC20), circulating eosinophils, basophils and their progenitors (Eo/B‐CFU), and sputum inflammatory cells. The laboratory tests were performed blind to the clinical details. Each subject developed an exacerbation of symptoms, on average at 16 (70–26) days after the onset of steroid reduction. This was accompanied by a deterioration in each of the objective measures. There was a fall in FEV1 by 320 ml (s.e.m. 9.5) and in PC20 from 0.8 to 0.43 mg/ml. Circulating eosinophils rose from 114 (24) × 103/ml to 227 (50) × 103/ml and Eo/B‐CFU rose from 31 (5.6) to 44(11.3)/106 cells. Sputum developed in five subjects and contained 36 (5.2)% eosinophils and 1.98 (0.21)% metachromatic cells (mast cells or basophils). The symptom diary and weekly questionaire were demonstrated to be valid and responsive to change. A deterioration indicated by the daily symptom score preceded changes in PEF. Treatment by an increase in steroid was followed by reversal of each of the changes. We conclude that this research method can safely produce and examine a mild exacerbation of asthma, and that an increase in airway inflammation is an early feature.

Chronic cough with eosinophilic bronchitis: examination for variable airflow obstruction and response to corticosteroid

The purpose of this study was to examine airway responsiveness, sputum cells and the effects of inhaled corticosteroid in the chronic cough syndrome associated with eosinophilic bronchitis. We studied nine consecutive referrals with chronic cough, sputum with >10% eosinophils, normal spirometry, and normal methacholine airway responsiveness. Clinical assessment, sputum analysis, allergy skin tests and a methacholine inhalation test were performed at the first visit. Peak expiratory flow (PEF) was measured twice daily for 1 week followed by an adenosine monophosphate (AMP) inhalation test. Subjects were then treated with inhaled beclomethasone 0.4 mg twice daily for 7 days. Sputum analysis and measurement of methacholine responsiveness were then repeated. Excessive airway narrowing to methacholine was not present in any of the subjects. A methacholine plateau response was present in five subjects. Hyperresponsiveness to AMP was absent in six of the nine subjects, and PEF variability was not increased for eight subjects. Corticosteroid therapy led to a reduction in sputum eosinophil counts from 40.1 (so 21.4)% to 4.0 (4.5)% but there was no significant change in metachromatic cell counts (0.8 so 0.5% vs 0.6 sd 0.6%) or total cell counts. Methacholine responsiveness improved within the normal range in the three subjects in whom it could be determined. Chronic cough associated with eosinophilic airway inflammation can occur in the absence of variable airflow obstruction (asthma) and can improve after treatment with inhaled corticosteroid. This treatment can reduce the level of methacholine responsiveness within the normal range and reduces sputum eosinophils but not mast cells. These results suggest that the occurrence of variable airflow obstruction depends on the baseline level of methacholine responsiveness, the degree of eosinophilic infiltration and the degree to which methacholine responsiveness becomes heightened.

Increased numbers of circulating basophil progenitors in atopic patients

Recruitment of basophils to sites of homocytotropic antibody-mediated hypersensitivity reactions has been well documented in both experimental and clinical situations. Mechanisms underlying tissue basophil accumulation, however, remain unclear and may involve chemotaxis, cell proliferation, or both. We have recently reported the presence in human blood of circulating basophil/mast cell progenitors on the basis of histamine content of granulocyte colonies grown in methylcellulose. In the current studies we have analyzed the peripheral blood of 30 patients with atopy and 25 comparable control subjects for frequency of basophil/mast cell progenitors by analysis of the histamine content of individual granulocyte colonies. Forty percent of granulocyte colonies in cultures of atopic patients contained histamine in comparison to only 11% in cultures of control subjects (p less than 0.001). Histamine content per colony as well as mean histamine per cell in each colony was higher in granulocyte colonies of atopic subjects and could not be related to colony size or culture conditions. Granulocyte colony growth was enhanced by antigen-stimulated, peripheral blood lymphomononuclear cell--conditioned media of atopic patients. Histamine-positive colonies were found more frequently in active versus quiescent atopic disease (p less than 0.05). These results are consistent with the hypothesis that basophils accumulate at sites of allergic reactions at least in part by recruitment of progenitors from circulation and subsequent differentiation in situ in response to lymphokines. Further studies by use of hemopoietic assays could elucidate the contribution of basophil production to the development of allergic conditions.

Allergic rhinitis management pocket reference 2008

Allergic rhinitis is a major chronic respiratory disease because of its prevalence, impacts on quality of life and work/school performance, economic burden, and links with asthma. Family doctors (also known as ‘primary care physicians’ or ‘general practitioners’) play a major role in the management of allergic rhinitis as they make the diagnosis, start the treatment, give the relevant information, and monitor most of the patients. Disease management that follows evidence‐based practice guidelines yields better patient results, but such guidelines are often complicated and may recommend the use of resources not available in the family practice setting. A joint expert panel of the World Organization of Family Doctors (Wonca), the International Primary Care Airways Group (IPAG) and the International Primary Care Respiratory Group (IPCRG), offers support to family doctors worldwide by distilling the globally accepted, evidence‐based recommendations from the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative into this brief reference guide.

Basophilic cell progenitors, nasal metachromatic cells, and peripheral blood basophils in ragweed-allergic patients

Circulating hematopoietic progenitor cells giving rise to colonies containing basophilic cells (basophilic cell colony-forming units in culture [CFU-c]), nasal epithelial metachromatic cells (basophils and/or mast cells) (NMC), and blood basophils were enumerated before, during, and after a ragweed-pollen season in patients with ragweed hayfever and patients with perennial allergic rhinitis who were not ragweed allergic. In the patients with seasonal hay fever, the following was observed: basophilic cell CFU-c, measured as basophilic cell or histamine-containing colonies, were significantly reduced during the ragweed season compared to before (p less than 0.005) or after (p less than 0.025) the season in the ragweed-allergic group only. Conversely, peripheral blood basophils were higher during the ragweed season than before or after (p less than 0.001) in the ragweed-allergic group, whereas the number of NMC was higher during the season than before the season in this group (p less than 0.05). There were no such changes during the season in the group of patients with perennial allergic rhinitis. The observed seasonal changes in both NMC and circulating basophilic cell CFU-c are discussed in the context of lineage relationships among metachromatic cell types.

Basophil and eosinophil differentiation in allergic reactions

Basophil and eosinophil participation in allergic reactions constitutes a hallmark of this type of inflammatory state. Mechanisms underlying the accumulation of these cells in tissues where allergen is present include the effect of cytokines and other inflammatory mediators on the egress from blood and migration of these cells into the tissue. Much progress has been made recently in the understanding of in vitro chemotactic and adherence mechanisms putatively involved in the accumulation of the mature basophil and eosinophil in IgE-dependent reactions in vivo? A concept we have developed in our studies over the past decade is that the bone marrow, through the release of progenitors into the peripheral blood, contributes a pool of differentiating cells, which accumulate in response to signals from allergic inflamed tissues. 2s In this review we summarize the basis for this concept, citing both basic and applied studies and expanding on the evidence supporting the progenitor hypothesis for accumulation of basophils and eosinophils by using recently acquired information in an animal model and in human beings.

The role of the bone marrow in allergy and asthma

The above studies have begun to address the fundamental question of the mechanisms of bone marrow involvement and response to allergen challenge in allergic asthmatics. Further studies in this area should complement our investigations in human asthma — which suggest that a particular bias toward differentiation of Eo‐Baso progenitors characterizes the atopic state — as well as our findings in the dog model of allergen‐induced airway hyperresponsiveness, which indicate that the bone marrow responds to inhalation of allergen or corticosteroids. Taken in the context of previous indications that IgE and bronchial responsiveness may both be transferrable through bone marrow transplantation (log), these findings indicate a physiologic role for the bone marrow in allergic inflammation. Likewise, these concepts provide a basis for making certain predictions regarding management and novel therapeutic interventions in atopy and asthma.

Allergen-Induced Changes in Bone Marrow Progenitors and Airway Responsiveness in Dogs

An increased production of inflammatory cell progenitors (colony-forming cells, CFUs) may contribute to airway inflammation, since CFUs increase after allergen inhalation in asthmatics. We examined the effect of allergen inhalation, with or without budesonide pretreatment, on bone marrow CFU production in dogs with allergen-induced airway hyperresponsiveness. Allergen inhalation increased airway responsiveness (p < 0.001) as well as the number of CFUs induced in vitro by recombinant canine stem cell factor (p < 0.001) and granulocyte-colony-stimulating factor (p = 0.035). Budesonide reduced the allergen-induced increases in airway responsiveness (p = 0.005) and abolished the allergen-induced increases in the numbers of CFUs (p < 0.005). These findings provide the first direct evidence that allergen inhalation increases bone marrow granulocyte progenitor production and suggest that such increases may contribute to the development of airway hyperresponsiveness in asthma. The effectiveness of inhaled corticosteroids in asthma may result, in part, from effect on bone marrow production of inflammatory cells.

Bone marrow contribution to eosinophilic inflammation

Allergen-induced bone marrow responses are observable in human allergic asthmatics, involving specific increases in eosinophil-basophil progenitors (Eo/B-CFU), measured either by hemopoietic assays or by flow cytometric analyses of CD34-positive, IL-3R alpha-positive, and/or IL-5-responsive cell populations. The results are consistent with the upregulation of an IL-5-sensitive population of progenitors in allergen-induced late phase asthmatic responses. Studies in vitro on the phenotype of developing eosinophils and basophils suggest that the early acquisition of IL-5R alpha, as well as the capacity to produce cytokines such as GM-CSF and IL-5, are features of the differentiation process. These observations are consistent with findings in animal models, indicating that allergen-induced increases in bone marrow progenitor formation depend on hemopoietic factor(s) released post-allergen. The possibility that there is constitutive marrow upregulation of eosinophilopoiesis in allergic airways disease is also an area for future investigation.