Broncheoalveolar Lavage Research Articles

Amifostine Analog, DRDE-30, Attenuates Bleomycin-Induced Pulmonary Fibrosis in Mice.

Bleomycin (BLM) is an effective curative option in the management of several malignancies including pleural effusions; but pulmonary toxicity, comprising of pneumonitis and fibrosis, poses challenge in its use as a front-line chemotherapeutic. Although Amifostine has been found to protect lungs from the toxic effects of radiation and BLM, its application is limited due to associated toxicity and unfavorable route of administration. Therefore, there is a need for selective, potent, and safe anti-fibrotic drugs. The current study was undertaken to assess the protective effects of DRDE-30, an analog of Amifostine, on BLM-induced lung injury in C57BL/6 mice. Whole body micro- computed tomography (CT) was used to non-invasively observe tissue damage, while broncheo-alveolar lavage fluid (BALF) and lung tissues were assessed for oxidative damage, inflammation and fibrosis. Changes in the lung density revealed by micro-CT suggested protection against BLM-induced lung injury by DRDE-30, which correlated well with changes in lung morphology and histopathology. DRDE-30 significantly blunted BLM-induced oxidative stress, inflammation and fibrosis in the lungs evidenced by reduced oxidative damage, endothelial barrier dysfunction, Myeloperoxidase (MPO) activity, pro-inflammatory cytokine release and protection of tissue architecture, that could be linked to enhanced anti-oxidant defense system and suppression of redox-sensitive pro-inflammatory signaling cascades. DRDE-30 decreased the BLM-induced augmentation in BALF TGF-β and lung hydroxyproline levels, as well as reduced the expression of the mesenchymal marker α-smooth muscle actin (α-SMA), suggesting the suppression of epithelial to mesenchymal transition (EMT) as one of its anti-fibrotic effects. The results demonstrate that the Amifostine analog, DRDE-30, ameliorates the oxidative injury and lung fibrosis induced by BLM and strengthen its potential use as an adjuvant in alleviating the side effects of BLM.

Antibiotic Resistance Pattern and Stewardship Programme in Critical Care Settings

Sensitivity pattern of isolates from patients’ specimens associated with infection, admitted to the critical care centers with empiric or prophylactic antibiotic use were assessed. Till identification of the organism and resultant sensitivity awaited; and compared with sensitive antibiotic to the isolates which could be used for management. This analytical cross sectional study carried out during the period of April 2016 to July 2016 in the Critical Care Centre (CCC) of Combined Military Hospital, Dhaka Cantonment. Urine and other specimens including wound swab, pus, sputum, tracheal aspirate, catheter tip, nasal swab, high vaginal swab, broncheoalveolar lavage, blood, urethral discharge were collected from the patients following aseptic precautions. Isolate identification was done using standard procedures at the Armed Forces Institute of Pathology (AFIP). Sensitivity was tested using antibiotic disc diffusion technique. A total of one thousand six hundred and seventy patients were dealt with in the study, and positive yield obtained in 190 (11.38%) cases. Of those, 116 were urine specimens which constituted 69 (57.76%) female and 47(42.24%) male patients. A total of 1088 discs of antibiotics were used on an average 9 discs per isolate. Six hundred and forty nine (59.65%) showed resistance to the antibiotic used against them, while four hundred and thirty nine (40.35%) showed sensitive response. The study population was of 2-80 years age group. Other specimens included 74 isolates, fifty (67.57%) were males and twenty four (32.43%) were females. A total of eight hundred and twenty seven (11.18 discs per isolate) antibiotic doses were used 479 (57.92%), showed resistant and 348 (42.08%) sensitive result. Enteric gram negative bacilli (GNB) were the majority of isolates in both types of specimens. The study indicated that, newer antimicrobials have a substantial impact in decreasing human morbidity and mortality rates. It encourages to expand surveillance of antibiotic resistance determinants and to exercise caution in dispensing antibiotics to maximize their continued efficacy. Excess or injudicious use is causing increase in cost as well as inducing drug resistance among the common bacterial isolates. A work on the clinical presentation with trends of antimicrobials used in the CCC setup right now in tertiary care hospital would be of supplemental value for the study.

Intrauterine vaccination induces a dose-sensitive primary humoral response with limited evidence of recall potential.

Induction of the local mucosal immune system within the reproductive tract is widely considered to be a key component in the development of effective prophylactic vaccines to control the spread of sexually transmitted infections. Here, we examine the capacity of the upper reproductive tract to act as a site of immune induction following. Two vaccines formulated with a triple adjuvant combination and either recombinant bovine herpesvirus (tgD) protein or ovalbumin (OVA) were delivered at varying doses to the uterine lumen of rabbits and the resulting immune response evaluated after 32days. Intrauterine vaccination produced a dose-dependent induction of both antigen-specific IgG and IgA in serum. Both uterine and broncheoalveolar lavage of the high and medium-dose vaccine group contained a significant increase in both anti-OVA and anti-tgD IgG, but no significant quantities of antigen-specific IgA were observed. The restimulation of splenocytes from the high-dose vaccine group with ovalbumin (OVA) only resulted in a small but significant increase in gene expression of the Th1 cytokines (IL2/IFNγ) in the absence of an observable increase in proliferation. Collectively, the results confirm the capacity of the uterine immune system to generate a primary response following stimulation.

Strongyloides Stercoralis: An Unusual Cause of Diffuse Alveolar Hemorrhage in an Asthmatic Patient on Chronic Steroid Use

SESSION TITLE: Student/Resident Chest Infections SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Strongyloides stercoralis is an intestinal parasite endemic in tropical and subtropical regions. We report an unusual case of respiratory failure and diffuse alveolar hemorrhage secondary to S. stercoralis hyperinfection syndrome. CASE PRESENTATION: The patient is a 42-year-old male with a past medical history of asthma and deep vein thrombosis who presented with diffuse abdominal pain, anorexia, vomiting, diarrhea and dizziness for approximately one week. Patient also noted a painful penile ulcerated lesion for three days prior to admission. Patient was taking PO dexamethasone chronically for his asthma. His physical exam was remarkable for diffuse abdominal tenderness, an erythematous, maculopapular rash with occasional pustules over anterior abdomen, and erythematous vesicular lesions on the shaft and head of penis. Labs were remarkable for an elevated WBC count without eosinophilia, hyponatremia, mild hypokalemia, and hypoalbuminemia. Abdominal CT scan demonstrated bowel wall thickening and inflammatory stranding involving the cecum, ascending colon, and transverse colon concerning for colitis and stool cultures showed heavy growth of S. stercoralis. Patient was started on albendazole at this time. Colonic biopsy revealed changes consistent with strongyloides-associated colitis. On hospital day 5, he developed acute hypoxic respiratory failure from strongyloides superinfection and was intubated. Bronchoscopy with broncheoalveolar lavage revealed friable mucosa seen diffusely and S. stercoralis isolated from gram stain smear. Patient switched to ivermectin due to known superior efficacy compared to albendazole and indication in suspected superinfection, however due to the patient developing an ileus with NG set to suction, FDA approval was required for subcutaneous dosing (which is only available in veterinary forms) and obtained from outside veterinarian hospital. Patient was extubated on hospital day 10, and his pan colitis resolved over the course of two weeks on therapy. DISCUSSION: Patient showed significant clinical improvement after subcutanous ivermectin treatment, warranting further infestigation into dosing and toxicity of therapy in S. stercoralis superinfection. CONCLUSIONS: S. stercoralis is an uncommon cause for diffuse alveolar hemorrhage; however, in an immunocompromised patient from an endemic area, a strong clinical suspicion is warranted as delay in diagnosis carries a high mortality rate. Reference #1: Annick Datry, Ingibjôrg Hilmarsdottir, Rubén Mayorga-Sagastume, Mohamed Lyagoubi, Philippe Gaxotte, Sylvestre Biligui, Jeff Chodakewitz, Donald Neu, Martin Danis, Marc Gentilini, Treatment of Strongyloides stercoralis infection with ivermectin compared with albendazole: results of an open study of 60 cases, Transactions of the Royal Society of Tropical Medicine and Hygiene, Volume 88, Issue 3, 1994, Pages 344-345, ISSN 0035-9203, http://dx.doi.org/10.1016/0035-9203(94)90110-4. DISCLOSURE: The following authors have nothing to disclose: Daniel Mathew, Shyam Kapadia, Ricardo Restrepo-Jaramillo, Stephen Clum No Product/Research Disclosure Information

A Rare Etiology of Febrile Diarrhea to Remember: Intestinal Tuberculosis

Tuberculosis is a multi-system illness that can present with numerous manifestations. Intestinal tuberculosis represents only 2% of all cases and can result from swallowing infected sputum, ingesting contaminated food, hematogenous spread, or direct extension from adjacent organs. Symptoms include abdominal pain, diarrhea, melena, and rectal bleeding. The ileocecum and jejunoileum are the most common sites of involvement. Intestinal manifestations may be appreciated on colonoscopy as ulcerative or hypertrophic lesions and present with signs of obstruction, perforation, or fistula formation. A 20 y/o F with no PMH presented with the complaint of a productive cough and non-bloody diarrhea for six months. She complained of persistent weight loss but denied night sweats, hemoptysis, and rash. The patient was unsuccessfully treated in the past with amoxicillin for her cough. She stated that she immigrated to the United States from Colombia approximately six months prior and that her uncle had similar symptoms when they departed. In the ER, the patient was febrile at 102.2° F, tachycardic, and tachypnic. Physicial examination was positive for decreased lung sounds bilaterally and mild, diffuse abdominal tenderness to palpation. Tuberculin skin testing was negative. A CT scan of her chest demonstrated bilateral multifocal patchy infiltrates and cavitary lesions in her left lower lobe. The patient underwent bronchosopy with broncheoalveolar lavage, which revealed only reactive epithelial cells, pulmonary histiocytes, and acute inflammation. AFB smears were negative. Because of persistent abdominal pain and diarrhea during the admission, she underwent colonoscopy, which demonstrated a diffuse colitis. Biopsies and cultures returned the growth of acid-fast bacilli three weeks later. Repeat tuberculin skin testing resulted positive, and a quantiferon gold confirmed the presence of tuberculosis. This patient's presentation illustrates a rare case of intestinal tuberculosis in an immunocompetent individual. Although an immigrant, she did not have any of the known identifiable risk factors for intestinal tuberculosis, including a history of diabetes mellitus, corticosteroid use, or HIV/AIDS. Although multiple variations of this condition can exist, we demonstrate that a high index of suspicion based on clinical and radiographic findings may be the only clue towards diagnosis, especially since microbiologic confirmation may take weeks to return.

Pulmonary Delivery of Butyrylcholinesterase as a Model Protein to the Lung.

Pulmonary delivery has great potential for delivering biologics to the lung if the challenges of maintaining activity, stability, and ideal aerosol characteristics can be overcome. To study the interactions of a biologic in the lung, we chose butyrylcholinesterase (BuChE) as our model enzyme, which has application for use as a bioscavenger protecting against organophosphate exposure or for use with pseudocholinesterase deficient patients. In mice, orotracheal administration of free BuChE resulted in 72 h detection in the lungs and 48 h in the broncheoalveolar lavage fluid (BALF). Free BuChE administered to the lung of all mouse backgrounds (Nude, C57BL/6, and BALB/c) showed evidence of an acute cytokine (IL-6, TNF-α, MIP2, and KC) and cellular immune response that subsided within 48 h, indicating relatively safe administration of this non-native biologic. We then developed a formulation of BuChE using Particle Replication in Non-Wetting Templates (PRINT). Aerosol characterization demonstrated biologically active BuChE 1 μm cylindrical particles with a mass median aerodynamic diameter of 2.77 μm, indicative of promising airway deposition via dry powder inhalers (DPI). Furthermore, particulate BuChE delivered via dry powder insufflation showed residence time of 48 h in the lungs and BALF. The in vivo residence time, immune response, and safety of particulate BuChE delivered via a pulmonary route, along with the cascade impaction distribution of dry powder PRINT BuChE, showed promise in the ability to deliver active enzymes with ideal deposition characteristics. These findings provide evidence for the feasibility of optimizing the use of BuChE in the clinic; PRINT BuChE particles can be readily formulated for use in DPIs, providing a convenient and effective treatment option.

Systematic phenotyping and correlation of biomarkers with lung function and histology in lung fibrosis.

To date, phenotyping and disease course prediction in idiopathic pulmonary fibrosis (IPF) primarily relies on lung function measures. Blood biomarkers were recently proposed for diagnostic and outcome prediction in IPF, yet their correlation with lung function and histology remains unclear. Here, we comprehensively assessed biomarkers in liquid biopsies and correlated their abundance with lung function and histology during the onset, progression, and resolution of lung fibrosis, with the aim to more precisely evaluate disease progression in the preclinical model of bleomycin-induced pulmonary fibrosis in vivo. Importantly, the strongest correlation of lung function with histological extent of fibrosis was observed at day 14, whereas lung function was unchanged at days 28 and 56, even when histological assessment showed marked fibrotic lesions. Although matrix metalloproteinase-7 (MMP-7), MMP-9, and PAI-1 were significantly elevated in broncheoalveolar lavage of fibrotic mice, only soluble ICAM-1 (sICAM-1) was elevated in the peripheral blood of fibrotic mice and was strongly correlated with the extent of fibrosis. Importantly, tissue-bound ICAM-1 was also elevated in lung homogenates, with prominent staining in hyperplastic type II alveolar epithelial and endothelial cells. In summary, we show that lung function decline is not a prerequisite for histologically evident fibrosis, particularly during the onset or resolution thereof. Plasma levels of sICAM-1 strongly correlate with the extent of lung fibrosis, and may thus be considered for the assessment of intraindividual therapeutic studies in preclinical studies of pulmonary fibrosis.

Role of NOS2 in pulmonary injury and repair in response to bleomycin

Nitric oxide (NO) is derived from multiple isoforms of the Nitric Oxide Synthases (NOSs) within the lung for a variety of functions; however, NOS2-derived nitrogen oxides seem to play an important role in inflammatory regulation. In this study, we investigate the role of NOS2 in pulmonary inflammation/fibrosis in response to intratracheal bleomycin instillation (ITB) and to determine if these effects are related to macrophage phenotype. Systemic NOS2 inhibition was achieved by administration of 1400W, a specific and potent NOS2 inhibitor, via osmotic pump starting six days prior to ITB. 1400W administration attenuated lung inflammation, decreased chemotactic activity of the broncheoalveolar lavage (BAL), and reduced BAL cell count and nitrogen oxide production. S-nitrosylated SP-D (SNO-SP-D), which has a pro-inflammatory function, was formed in response to ITB; but this formation, as well as structural disruption of SP-D, was inhibited by 1400W. mRNA levels of IL-1β, CCL2 and Ptgs2 were decreased by 1400W treatment. In contrast, expression of genes associated with alternate macrophage activation and fibrosis Fizz1, TGF-β and Ym-1 was not changed by 1400W. Similar to the effects of 1400W, NOS2−/− mice displayed an attenuated inflammatory response to ITB (day 3 and day 8 post-instillation). The DNA-binding activity of NF-κB was attenuated in NOS2−/− mice; in addition, expression of alternate activation genes (Fizz1, Ym-1, Gal3, Arg1) was increased. This shift towards an increase in alternate activation was confirmed by western blot for Fizz-1 and Gal-3 that show persistent up-regulation 15 days after ITB. In contrast arginase, which is increased in expression at 8 days post ITB in NOS2−/−, resolves by day 15. These data suggest that NOS2, while critical to the development of the acute inflammatory response to injury, is also necessary to control the late phase response to ITB.

The right get with the proper git: Precision of diagnosing pulmonary tuberculous cavities by means of various biopsies

BackgroundDiagnostic rationale of tuberculosis as a specific epidemiological endemic disease depends mainly on clinical signs over and above microbiological and histopathological findings. PurposeThe aim of this study is to differentiate between histopathological features of pulmonary parenchymal cavitary tuberculosis in accordance with different biopsy techniques; fiberoptic bronchoscopic bronchoalveolar lavage, transbronchial lung biopsy, percutaneous guided biopsy (CT computed tomographic/ultrasound). Patients and methodsForty-one patients with pulmonary parenchymal cavitary lesions confirmed to be tuberculous by sputum Ziehl Neelsen staining undertook antituberculous therapy without improvement. Tissue biopsy samples were obtained from radiological shadows by different methods and studied regarding histopathological findings. ResultsCaseating granuloma showed higher diagnostic accuracy in percutaneous biopsy and in open biopsy followed by BAL/TBLB (100% and 80% respectively) while noncaseating granuloma was detected in 20% of broncheoalveolar lavage and transbronchial lung biopsy BAL/TBLB only. Inflammatory smear prevailed in 86.66% of patients who performed BAL/TBLB but was absent in open and percutaneous guided biopsy, on the one hand, smear cellularity of moderate quantity showed higher percentage in percutaneous guided biopsy (88.24%) followed by BAL/TBLB (80%) lastly open biopsy (66.66%). Other pathological findings predominated in patients who had undertaken open biopsy as tuberculous lymphadenitis (55.55%) and interstitial fibrosis (55.55%). Significant statistical differences were found in all pathological lesions (p=0.00). ConclusionDifferentiation between histopathological patterns of parenchymal cavitations symbolizes an important clue about the accuracy of diagnosis between the biopsy methods.

Atypical Pneumonia - Screening in a Tertiary Care Centre.

Pneumonia is one of the leading infectious causes of mortality and morbidity worldwide. Atypical respiratory pathogens account for 30 - 40% of these infections. The three most important atypical pathogens are Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila. To screen for atypical pathogens as cause for community acquired pneumonia. A cross-sectional study was done with 107 patients who had clinical suspicion of atypical pneumonia. The presence of atypical pathogens Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila were screened from the patient's sample. Respiratory samples in the form of sputum, Broncheoalveolar lavage and Non- Broncheoalveolar lavage were used for cultivation of Mycoplasma pneumoniae and Legionella pneumophila. Urine specimen was used for the detection of Legionella antigen. Serum samples were used for the detection of Mycoplasma pneumoniae IgM and Chlamydophila pneumoniae IgM antibodies. Among the 107 samples screened, 13(12.1%) were positive for antibodies against atypical pathogens. Out of which 7(6.5%) had IgM antibodies against Mycoplasma pneumoniae and the rest 6(5.6%) had Chlamydophila pneumoniae IgM antibodies. All the samples were culture negative for Mycoplasma pneumoniae and Legionella pneumophila. Urinary antigen detection for Legionella pneumophila was also negative in patients. Atypical pathogens should also be considered routinely as a cause of lower respiratory tract infections, especially Chlamydia pneumoniae and Mycoplasma pneumoniae in our country. Serological diagnosis by ELISA can be adopted for determining the infections by atypical pathogens as cultivation is difficult and also requires special media and prolonged incubation. This may not be feasible for many laboratories. Early diagnosis and treatment will reduce the complications.

Toll-like receptor ligands LPS and poly (I:C) exacerbate airway hyperresponsiveness in a model of airway allergy in mice, independently of inflammation.

It is well-established that bacterial and viral infections have an exacerbating effect on allergic asthma, particularly aggravating respiratory symptoms, such as airway hyperresponsiveness (AHR). The mechanism by which these infections alter AHR is unclear, but some studies suggest that Toll-like receptors (TLRs) play a role. In this study, we investigated the impact of TLR3 and TLR4 ligands on AHR and airway inflammation in a model of pre-established allergic inflammation. Female BALB/c mice were sensitised and challenged intranasally (i.n.) with either PBS or ovalbumin (OVA) and subsequently i.n. challenged with poly (I:C) (TLR3) or LPS (TLR4) for four consecutive days. The response to methacholine was measured in vivo; cellular and inflammatory mediators were measured in blood, lung tissue and broncheoalveolar lavage fluid (BALF). OVA challenge resulted in an increase in AHR to methacholine, as well as increased airway eosinophilia and TH2 cytokine production. Subsequent challenge with TLR agonists resulted in a significant increase in AHR, but decreased TLR-specific cellular inflammation and production of immune mediators. Particularly evident was a decline in LPS-induced neutrophilia and neutrophil-associated cytokines following LPS and poly (I:C) treatment. The present data indicates that TLRs may play a pivotal role in AHR in response to microbial infection in allergic lung inflammation. These data also demonstrate that aggravated AHR occurs in the absence of an exacerbation in airway inflammation and that allergic inflammation impedes a subsequent inflammatory response to TLRs. These results may parallel clinical signs of microbial asthma exacerbation, including an extended duration of illness and increased respiratory symptoms.

1034-LBO: Differential microRNA expression profiling in lung allograft recipients who develop donor specific antibody and Bronchiolitis Obliterans Syndrome

Aim Bronchiolitis Obliterans Syndrome (BOS), clinically diagnosed as chronic rejection, has remained a major setback following lung transplantation (LT). However, its pathogenesis is poorly understood and no predictive biomarkers have been identified. Expression of microRNA (miRNA) in blood is deregulated in physiopathological conditions including immunological disorders. Methods In this study, we hypothesized that miRNA profiles from peripheral blood mononuclear cells (PBMCs) in LT recipients (LTxR) could identify patients at risk of BOS. MiRNA expression profiling was performed using TaqMan Human MicroRNA Array in PBMCs collected from three groups of LTxR: 10 stable, 10 who developed DSA and 10 who developed BOS. Results There were 98 miRNAs upregulated in LTxR with BOS compared to that of stable transplants (relative fold > 2.5); and 32 miRNAs downregulated with BOS (relative fold > 2.5). In addition, we found that there were 16 miRNAs upregulated (including miR-99a, miR-147, and miR-124 ∗ ) with BOS compared to that of DSA; and 5 miRNAs downregulated (including miR-34b, miR-363 ∗ , and miR-155 ∗ ) in BOS compared to DSA, indicating that these miRNAs may play a role in BOS with DSA. We validated those differential miRNAs in independent PBMCs and broncheoalveolar lavage cells using Taqman real-time PCR. In addition we focused on one miRNA, miR-99a, which caused upregulation of 2.8-fold in LTxR with BOS compared to that of DSA. Bioinformatics prediction indicated that miR-99a can mediate gene-expression regulation of TNIK (TRAF2 and NCK interacting kinase) and TRAF4 (TNF receptor-associated factor 4), which were involved in regulating NF- κ B signaling pathway. Conclusions In conclusion our results demonstrate that differential miRNA expression profile has the potential to predict BOS and development of DSA following LT.

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Introduction: In this report, we describe a 4 year old with cystic fibrosis (CF) who presented with respiratory distress secondary to non-typeable H. influenza pneumonia, leading to purulent pericarditis with cardiac tamponade. In patients with CF, H.influenzae is the most common organism isolated from broncheoalveolar lavage. Purulent pericarditis is a rare complication that is universally fatal if untreated. Five days prior to this admission, he was admitted for fever, had a positive rapid test for influenza A, a sputum culture positive for H. influenza that was thought to be colonization, and was discharged home with a 5 day course of oseltamivir. He was readmitted for worsening respiratory distress and a chest X-ray showing complete opacification of left hemithorax. Ultrasound confirmed a left pleural effusion and a moderate pericardial effusion. The patient was subsequently intubated and had a chest tube and pericardial drain placed. The purulent pericardial fluid grew H influenzae, as did the pleural fluid. An extensive pericardial window was performed on hospital day 2 due to concerns for the development of restrictive pericarditis. He suffered multi-organ failure requiring prolonged mechanical ventilation, inotropic support, and renal replacement therapy. After 6 weeks of aggressive care in the ICU, patient was discharged to the floor and subsequently home without any major sequelae. This is the first report of non-typeable H. influenzae causing purulent pericarditis in a patient with cystic fibrosis patient. This patient's respiratory tract was likely colonized by H. influenzae that became pathogenic secondary to an altered immune response following his recent influenza A infection. Typically, isolation of H influenzae does not warrant antibiotic therapy in a patient with CF, but this case adds to the debate surrounding the pathogenic potential of non-typeable H. influenzae in CF.

Acute Renal Injury in a 14-year-old With HIV/AIDS and Tuberculosis

A 14-year-old male, who had immigrated to the United States from sub-Saharan Africa 7 years ago and was recently diagnosed with HIV/AIDS and disseminated tuberculosis, presented with a rapidly rising serum creatinine of unknown etiology. He had initially presented to our institution approximately 1 month before with 2 months of fever, general malaise, abdominal pain, a 23-pound weight loss and 4 months of cough. He was diagnosed with HIV/ AIDS and found to have an initial absolute CD4+ T-lymphocyte count of 227 cells/μL (16.8%) and an HIV RNA level of 734,709 copies/mL. At that time, computed tomography scan of his chest, abdomen and pelvis demonstrated extensive necrotic adenopathy in his bilateral neck and axilla, as well as multiple sites within his thorax and abdomen, along with diffuse miliary pulmonary nodules with ground glass opacification and several small, hypodense splenic lesions. Biopsies of a left neck lymph node and a right lower lung pulmonary nodule showed extensive granulomatous lymphadenitis and a granulomatous pneumonia, respectively, both with rare acid-fast bacilli. In addition, several sputum samples and a broncheoalveolar lavage sample grew Mycobacterium tuberculosis. Consequently, the patient was started on tuberculosis therapy consisting of rifampin, isoniazid, pyrazinamide and ethambutol. Two weeks after initiating tuberculosis therapy and 2 weeks before the current presentation, antiretroviral therapy with lamivudine, zidovudine and efavirenz was also initiated, but 4 days later, the regimen was transitioned to efavirenz, emtricitabine and tenofovir (as 1 pill daily; Atripla) for ease of administration. Of note, before the start of antiretroviral therapy, a renal ultrasound revealed normal kidney size and echogenicity with no signs of renal abnormalities, and the patient had a normal serum creatinine (0.4 mg/dL) and urinalysis. At the time of initial discharge from our hospital, the patient was afebrile without abdominal pain and was noted to have a marked decrease in his peripheral lymphadenopathy. Approximately 2 weeks after initiating antiretroviral therapy, he developed daily low-grade fevers, diffuse abdominal pain and increasing peripheral lymphadenopathy. Screening laboratory studies were suggestive of acute kidney injury with a blood urea nitrogen of 62 mg/dL (7–18 mg/ dL), creatinine of 4.9 mg/dL (0.3–0.8 mg/ dL), bicarbonate of 15 mmol/L (20–26 mmol/L) and phosphorus of 6.5 mg/dL (2.4–5.4 mg/dL), but normal potassium of 4.3 mmol/L (3.8–5.4 mmol/L). Other laboratory findings showed systemic inflammation with a C-reactive protein of 8.1 mg/dL (0–0.9 mg/dL), erythrocyte sedimentation rate of 137 mm/hr (0–2 mm/hr) and a lactate dehydrogenase of 1131 U/L (360–730 U/L). His absolute CD4+ T-lymphocyte count had increased to 812 cells/μL, and his HIV RNA level had decreased to 269 copies/mL. The patient was admitted to the nephrology service of our hospital for further evaluation of his acute kidney injury. He reported ongoing fevers, nonbloody, nonbilious emesis and diffuse abdominal pain, but denied diarrhea, respiratory distress or urinary complaints and reported a normal urine output. He and his family denied use of any nonprescription medicines or herbal remedies. He had a temperature of 36.7°C, heart rate of 92 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 106/72 mm Hg and oxygen saturation of 99% breathing room air. His examination was significant for a thin male in no acute distress with oral thrush, a distended abdomen with diffuse tenderness greatest in the right upper quadrant, and mild hepatomegaly. The remainder of his physical and neurological examination was normal. An abdominal ultrasound showed bilateral kidney enlargement (12 cm on the right and 12.6 cm on the left) with increased cortical echogenicity but no hydronephrosis and relative preservation of the corticomedullary differentiation. Renal doppler studies were normal. Abdominal ultrasound also demonstrated hepatosplenomegaly and diffuse lymphadenopathy, particularly within the porta hepatis, in the retroperitoneum around the aorta, and adjacent to the right and left renal hilum. A renal biopsy was performed on the second day of admission.

Particle-induced pulmonary acute phase response correlates with neutrophil influx linking inhaled particles and cardiovascular risk.

BackgroundParticulate air pollution is associated with cardiovascular disease. Acute phase response is causally linked to cardiovascular disease. Here, we propose that particle-induced pulmonary acute phase response provides an underlying mechanism for particle-induced cardiovascular risk.MethodsWe analysed the mRNA expression of Serum Amyloid A (Saa3) in lung tissue from female C57BL/6J mice exposed to different particles including nanomaterials (carbon black and titanium dioxide nanoparticles, multi- and single walled carbon nanotubes), diesel exhaust particles and airborne dust collected at a biofuel plant. Mice were exposed to single or multiple doses of particles by inhalation or intratracheal instillation and pulmonary mRNA expression of Saa3 was determined at different time points of up to 4 weeks after exposure. Also hepatic mRNA expression of Saa3, SAA3 protein levels in broncheoalveolar lavage fluid and in plasma and high density lipoprotein levels in plasma were determined in mice exposed to multiwalled carbon nanotubes.ResultsPulmonary exposure to particles strongly increased Saa3 mRNA levels in lung tissue and elevated SAA3 protein levels in broncheoalveolar lavage fluid and plasma, whereas hepatic Saa3 levels were much less affected. Pulmonary Saa3 expression correlated with the number of neutrophils in BAL across different dosing regimens, doses and time points.ConclusionsPulmonary acute phase response may constitute a direct link between particle inhalation and risk of cardiovascular disease. We propose that the particle-induced pulmonary acute phase response may predict risk for cardiovascular disease.

Airway epithelial cells initiate the allergen response through transglutaminase 2 by inducing IL-33 expression and a subsequent Th2 response

BackgroundTransglutaminase 2 (TG2) is a post-translational protein-modifying enzyme that catalyzes the transamidation reaction, producing crosslinked or polyaminated proteins. Increased TG2 expression and activity have been reported in various inflammatory conditions, such as rheumatoid arthritis, inflammation-associated pulmonary fibrosis, and autoimmune encephalitis. In particular, TG2 from epithelial cells is important during the initial inflammatory response in the lung. In this study, we evaluated the role of TG2 in the pathogenesis of allergic asthma, particularly whether TG2 affects initial activation signaling leading to Th2 differentiation against antigens.MethodsWe induced allergic asthma by ovalbumin sensitization and intranasal challenge in wild-type (WT) BALB/c and TG2-deficient mice. Broncheoalveolar lavage fluid cells and intracellular cytokine production were analyzed by flow cytometry. Interleukin (IL)-33 and TG2 expression in lung epithelial cells was detected by confocal microscopy.ResultsAirway responsiveness was attenuated in TG2-deficient mice compared to that in the WT control. In addition, recruitment of eosinophils and Th2 and Th17 differentiation decreased in TG2-deficient mice. Treatment with cysteamine, a transglutaminase inhibitor, also reduced airway hypersensitivity, inflammatory cell recruitment, and T helper cell differentiation. TG2-deficient mice showed reduced IL-33 expression following induction of allergic asthma compared to those in the WT control.ConclusionsWe found that pulmonary epithelial cells damaged by allergens triggered TG2-mediated IL-33 expression leading to type 2 responses by recruiting both innate and adaptive arms of the immune system.

Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients

We aimed to establish that a bronchoscopic view can be as reliable as microbiology, and support an empirical tracheobronchial fungal infection (TBFI) treatment decision. We retrospectively studied 95 respiratory failure patients with suspected TBFI admitted to the intensive-care unit (ICU) in 2008 with sticky secretions, hyperaemic mucosa, and whitish plaques on bronchoscopic view. Patients not suspected of having TBFI were chosen as a control group (n = 151). Broncheoalveolar lavage (BAL) fluid was cultured, and biopsy samples were taken from the lesions. Biopsy samples positive for fungi were defined as ‘proven', only BAL-positive (+ fungi) cases were ‘probable TBFI', and BAL-negative (– fungi) cases were ‘possible TBFI'. BAL (+ fungi) and BAL (– fungi) in the control group were defined as ‘colonization' and ‘no TBFI', respectively. The sensitivity, specificity and positive and negative predictive values of BAL (+ fungi) were 85.1% (63/74), 81.4% (140/172), 66.3% (63/95), and 92.7% (140/151), respectively. Biopsies were performed in 78 of 95 patients, and 28 were proven TBFI with fungal elements, and 100% were BAL (+ fungi). Probable TBFI was seen in 30 of 95 patients with BAL (+ fungi), and possible TBFI (BAL(– fungi)) in 25 of 95. Among the 95 patients, microbiology revealed fungi (90.5% Candida species; 9.5% Aspergillus) in 63 (66.3%). In the controls, the colonization and no TBFI rates were 11 of 151 and 140 of 151, respectively. Observing sticky secretions, hyperaemic mucosa and whitish plaques by bronchoscopy is faster than and may be as reliable as microbiology for diagnosing TBFI. These findings are relevant for empirical antifungal therapy in suspected TBFI patients in the ICU.

Effect of Treatment Media on the Agglomeration of Titanium Dioxide Nanoparticles: Impact on Genotoxicity, Cellular Interaction, and Cell Cycle

The widespread use of titanium dioxide (TiO2) nanoparticles in consumer products increases the probability of exposure to humans and the environment. Although TiO2 nanoparticles have been shown to induce DNA damage (comet assay) and chromosome damage (micronucleus assay, MN) in vitro, no study has systematically assessed the influence of medium composition on the physicochemical characteristics and genotoxicity of TiO2 nanoparticles. We assessed TiO2 nanoparticle agglomeration, cellular interaction, induction of genotoxicity, and influence on cell cycle in human lung epithelial cells using three different nanoparticle-treatment media: keratinocyte growth medium (KGM) plus 0.1% bovine serum albumin (KB); a synthetic broncheoalveolar lavage fluid containing PBS, 0.6% bovine serum albumin and 0.001% surfactant (DM); or KGM with 10% fetal bovine serum (KF). The comet assay showed that TiO2 nanoparticles induced similar amounts of DNA damage in all three media, independent of the amount of agglomeration, cellular interaction, or cell-cycle changes measured by flow cytometry. In contrast, TiO2 nanoparticles induced MN only in KF, which is the medium that facilitated the lowest amount of agglomeration, the greatest amount of nanoparticle cellular interaction, and the highest population of cells accumulating in S phase. These results with TiO2 nanoparticles in KF demonstrate an association between medium composition, particle uptake, and nanoparticle interaction with cells, leading to chromosomal damage as measured by the MN assay.

Severe Bacterial Superinfection Based on Influenza A (H1N1) Pneumonia in a Heart-Lung Transplant Recipient

A 47-year-old heart-lung transplant recipient presented to our outpatient transplant clinic with respiratory infection. Her nose and throat swabs for influenza A (H1N1) infection were negative. Broncheoalveolar lavage showed a positive result for H1N1 infection. Antiviral therapy was initiated. Because of superinfection with Pseudomonas aeruginosa and Aspergillus terreus, her clinical condition worsened. The clinical condition of the patient improved with antibiotic and antifungal treatment. Negative nose and throat swab results cannot rule out H1N1 infection safely. We therefore advocate to routinely perform broncheoalveolar lavage.

Tamoxifen a new therapeutic approach for allergy airway disease

Event Abstract Back to Event Tamoxifen a new therapeutic approach for allergy airway disease Gabriel Moran1*, Hugo Folch1, Barbara Perez1, Natalia Morales1, Jose Sarmiento1, Claudio Henriquez1 and Juan Galecio1 1 Universidad Austral de Chile, Chile Recurrent airway obstruction (RAO) is an asthma-like condition that develops in mature horses following stabling and exposure to dusty hay and straw. The hallmark of this disease is that hay/straw exposure induces clinical airway obstruction, airway neutrophilia and increased airway mucous production. Our previous study indicated that tamoxifen has the ability to induce apoptosis in vitro in granulocytic cells from peripheral blood and broncheoalveolar lavage fluid (BALF). Therefore, we propose that tamoxifen, when used as a treatment in RAO-affected horses, induces a resolution of allergy airway inflammation through action on polymorphonuclear neutrophils. For this purpose, nine RAO-susceptible horses sensitized to Aspergillus fumigatus (RAO herd) will be selected for use in this study. The animals will be exposed to dusty/moldy hay, and once the signs of the disease appear. Later, the horses will be treated with 100 mg PO of tamoxifen every other day in a remission environment. During treatment and after drug administration has ended, periodical evolution of RAO clinical signs will be conducted to evaluate the effect of tamoxifen on airway inflammation (clinical score, mucus score, endoscopic examination and BALF for apoptosis evaluation). Our results indicate that RAO-affected horses treated with tamoxifen displayed a significant reduction of neutrophils in BALF and a concomitant improvement in their clinical status. This reduction in neutrophils BALF is related to the percentage of cells positive Anexin-V. These results indicate that the apoptotic mechanisms under these experimental conditions would affect blood and BALF granulocytic cells, particularly in early apoptosis (positive Anexin–V). Acknowledgements FONDECYT 1130355 Keywords: Tamoxifen, allergy, Airway Obstruction, Inflammation, Neutrophils Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Immune-mediated disease pathogenesis Citation: Moran G, Folch H, Perez B, Morales N, Sarmiento J, Henriquez C and Galecio J (2013). Tamoxifen a new therapeutic approach for allergy airway disease. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.00082 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 08 Mar 2013; Published Online: 22 Aug 2013. * Correspondence: Dr. Gabriel Moran, Universidad Austral de Chile, Valdivia, Chile, gmoran@uach.cl Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Gabriel Moran Hugo Folch Barbara Perez Natalia Morales Jose Sarmiento Claudio Henriquez Juan Galecio Google Gabriel Moran Hugo Folch Barbara Perez Natalia Morales Jose Sarmiento Claudio Henriquez Juan Galecio Google Scholar Gabriel Moran Hugo Folch Barbara Perez Natalia Morales Jose Sarmiento Claudio Henriquez Juan Galecio PubMed Gabriel Moran Hugo Folch Barbara Perez Natalia Morales Jose Sarmiento Claudio Henriquez Juan Galecio Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.