Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis.

The broadest pattern of tuberculosis (TB) drug resistance for which a consensus definition exists is extensively drug-resistant (XDR)-TB. It is not known if additional drug resistance portends worsened patient outcomes. This study compares treatment outcomes of XDR-TB patients with and without additional resistance in order to explore the need for a new definition. Individual patient data on XDR-TB outcomes were included in a meta-analysis comparing outcomes between XDR alone and three nonmutually exclusive XDR-TB patient groups: XDR plus resistance to all the second-line injectables (sli) and capreomycin and kanamycin/amikacin (XDR+2sli) XDR plus resistance to second-line injectables and to more than one group 4 drug, i.e. ethionamide/protionamide, cycloserine/terizidone or para-aminosalicylic acid (XDR+sliG4) and XDR+sliG4 plus resistance to ethambutol and/or pyrazinamide (XDR+sliG4EZ). Of 405 XDR-TB cases, 301 were XDR alone, 68 XDR+2sli, 48 XDR+sliG4 and 42 XDR+sliG4EZ. In multivariate analysis, the odds of cure were significantly lower in XDR+2sli (adjusted OR 0.4, 95% CI 0.2-0.8) compared to XDR alone, while odds of failure and death were higher in all XDR patients with additional resistance (adjusted OR 2.6-2.8). Patients with additional resistance beyond XDR-TB showed poorer outcomes. Limitations in availability, accuracy and reproducibility of current drug susceptibility testing methods preclude the adoption of a useful definition beyond the one currently used for XDR-TB.

Tumour necrosis factor gene polymorphisms are associated with COPD.

Tumour necrosis factor (TNF)-alpha has been shown to be an important factor in animal models of chronic obstructive pulmonary disease (COPD). However, human studies of TNF polymorphisms in COPD have been equivocal. Six TNF single nucleotide polymorphisms (-1031C/T, -863C/A, -857C/T, -237G/A, -308G/A and +487G/A) and their haplotypes were investigated in 423 Caucasian smokers (298 patients with spirometric evidence of COPD and 125 without airflow obstruction). The -308 minor allele (A) had a higher odds ratio (OR) of being associated with COPD in multivariate analysis (controlling for age, sex, pack-yrs; OR 1.9, 95% confidence interval (CI) 1.1-3.2) and was also associated with worse forced expiratory volume in one second/forced vital capacity. The -237 minor allele (A) had a lower OR of being associated with COPD (OR 0.40, 95% CI 0.19-0.86). In COPD patients, the -857 minor allele (T) had a lower OR of being associated with severe stages of COPD (Global Initiative for Obstructive Lung Disease stage III and IV versus stage I and II, OR 0.46, 95% CI 0.24-0.88). Other TNF single nucleotide polymorphisms were not associated with COPD but the -1031/-863 haplotype CC/TC had a lower OR in COPD patients versus smoking controls (OR 0.22, 95% CI 0.05-0.97). The present study adds further evidence that tumour necrosis factor genotypes play a role in susceptibility to cigarette smoke.

TNF-alpha-induced regulation and signalling in macrophages.

Tumor necrosis factor alpha (TNF-alpha) is a pleiotropic cytokine produced predominantly by macrophages. In addition, macrophages respond to TNF-alpha by differentiating to express different groups of gene products. Our laboratory recently showed that the context in which TNF-alpha is recognized by macrophages dramatically impacts the pattern of gene expression and hence investigating the mechanism of TNF-alpha signal transduction will be important in understanding how this molecule regulates macrophage differentiation. TNF-alpha is recognized by two cell surface receptors, CD120a (p55) and CD120b (p75) that belong to the TNF/NGF receptor family. Signalling is initiated by receptor multimerization in the plane of the plasma membrane. The initial signalling events activated by receptor cross-linking are unknown although activation of the mitogen-activated protein kinase (MAPK) cascade occurs shortly after ligand binding to CD120a (p55). We have investigated the upstream kinases that mediate the activation of p42mapk/erk2 following cross-linking of CD120a (p55) in mouse macrophages. Exposure of mouse macrophages to TNF-alpha stimulated a time-dependent increase in the activity of MEK1, that temporally preceded peak activation of p42mapk/erk2. MEKs, dual specificity T/Y kinases, act as a convergence point for several signalling pathways including Ras/Raf, MEKK and Mos. Incubation of macrophages with TNF-alpha was found to transiently stimulate an MEKK that peaked in activity within 30 sec of exposure and progressively declined towards basal levels by 5 min. By contrast, under these conditions, activation of either c-Raf-1 or Raf-B was not detected. These data suggest that the activation of the MAPK cascade in response to TNF-alpha is mediated by the sequential activation of an MEKK and MEK1 in a c-Raf-1 and Raf-B-independent fashion. The implications of these findings will be discussed in the context of the regulation of macrophage gene expression.

The detection of collapsible airways contributing to airflow limitation.

The detection of collapsible airways, which may be a component of asthma and emphysema, has important therapeutic implications. We describe a patient with significant airways collapse contributing to his airflow limitation and discuss how collapsible airways can be assessed by the volume difference between what exits the lung as determined by a spirometer and the volume compressed as measured by the plethysmograph. More simply, a large volume difference between the slow and forced vital capacity (SVC-FVC), easily obtained from spirometry, may be used as a surrogate index of airway collapse.

Isolated pulmonary capillaritis and diffuse alveolar hemorrhage in rheumatoid arthritis and mixed connective tissue disease.

STUDY OBJECTIVES: To demonstrate that pulmonary capillaritis and diffuse alveolar hemorrhage (DAH) occur and are isolated to the lung and therefore not part of systemic vasculitis at the time of the DAH episode in rheumatoid arthritis (RA) and mixed connective tissue disease (MCTD). DESIGN: Lung biopsy specimens from patients with DAH were reviewed and those with the histologic features of pulmonary capillaritis were identified. SETTING: The patients were selected from seven Denver-area general hospitals. PATIENTS: Fifty-eight patients with biopsy specimen proved pulmonary capillaritis (1991 to 1997) were identified and classified according to disease. Three patients met the American Rheumatism Association criteria for RA and one patient fulfilled clinical and serologic criteria for MCTD. INTERVENTIONS: All clinical, laboratory, and radiographic data on initial presentation and at follow-up periods were extracted from the charts of the four study patients. Histologic slides were reviewed and immunofluorescent studies of lung tissue were performed. MEASUREMENTS AND RESULTS: All four patients had a connective tissue disease diagnosis prior to the DAH episode. Symptoms referable to pulmonary capillaritis were of short duration (2 to 14 days) and there was no clinical or serologic evidence for an accompanying systemic vasculitis, in particular glomeronephritis. Three patients, two with RA and one with MCTD, demonstrated pulmonary immune complex deposition. Three resolved their illness following IV methylprednisilone and cyclophosphamide therapy. One RA patient died following a myocardial infarction. In the three survivors, no further episodes of DAH have occurred after a mean of 24 months (range, 10 to 48 months). CONCLUSIONS: To our knowledge, these are the first cases of DAH due to pulmonary capillaritis documented to complicate RA and MCTD. The capillaritis was not part of a systemic vasculitis at the time of the DAH episode, but rather represented an isolated small-vessel vasculitis of the lungs in this group of patients. Immune complex deposition may be involved in the pathogenesis.

Mycoplasma pneumoniae-associated bronchiolitis causing severe restrictive lung disease in adults: report of three cases and literature review.

STUDY OBJECTIVES: To characterize adult Mycoplasma pneumoniae-induced bronchiolitis requiring hospitalization. DESIGN: We encountered an adult patient with severe bronchiolitis in the absence of pneumonia due to M. pneumoniae. To determine the relative frequency of such a condition, we retrospectively reviewed the medical records of adults over a 4-year period with a hospital discharge diagnosis of "bronchiolitis" from a university hospital. SETTING: University Hospital of the University of Colorado Health Sciences Center, Denver, CO. STUDY SUBJECTS: From 1994 to 1998, 10 adult inpatients were identified with a diagnosis of bronchiolitis. There were two with respiratory bronchiolitis, one with panbronchiolitis, one patient with bronchiolitis obliterans organizing pneumonia (BOOP), and six with acute inflammatory bronchiolitis. Including the initial patient, three had a definitive clinical diagnosis of Mycoplasma-associated bronchiolitis. RESULTS: The three adult patients with bronchiolitis due to M. pneumoniae are unusual because they occurred in the absence of radiographic features of a lobar or patchy alveolar pneumonia. Hospital admission was occasioned by the severity of symptoms and gas exchange abnormalities. One patient had bronchiolitis as well as organizing pneumonia (BOOP) that responded favorably to corticosteroid treatment. The other two had high-resolution CT findings diagnostic of an acute inflammatory bronchiolitis. One of the patients with inflammatory bronchiolitis had an unusual pattern of marked ventilation and perfusion defects localized predominantly to the left lung. All three had restrictive ventilatory impairment on physiologic testing. CONCLUSIONS: In adults, Mycoplasma-associated bronchiolitis without pneumonia is rarely reported, but in hospitalized patients, it may be more common than expected and may be associated with severe physiologic disturbances.

Sarcoidosis presenting with prolonged fever in a patient with sickle cell anemia.

Although the leading causes of fever and pulmonary infiltrates in sickle cell patients are acute bacterial pneumonia and the acute chest syndrome, the former is usually responsive to antibiotics and not protracted, and the clinical course of the latter is short and self-limited. A patient with sickle cell anemia presented with fever and pulmonary infiltrates of several weeks duration that were unresponsive to antibiotics. Gross endobronchial abnormalities were noted on bronchoscopy, and the biopsies were consistent with sarcoidosis. The diagnosis of sarcoidosis can be difficult to establish in a patient with sickle cell anemia and protracted fever since both disorders are associated with chronic interstitial changes on the chest radiograph as well as restrictive physiology.

Reye's syndrome in a young adult.

Reye's syndrome (RS), originally known by the more descriptive name "encephalopathy with fatty degeneration of the viscera," was first described in children and is still seen mostly in them. However, there have been a few case reports of adult Reye's Syndrome (ARS) since the mid-1970s. The following report is a case of ARS in a previously healthy 26-year-old woman. Although the clinical description and the pathophysiology are well known in RS, the etiology and the pathogenesis are still far from clear. From available evidence a multifactorial cause seems likely, encompassing genetic susceptibility, environmental factors, and the convincing role of aspirin. Moreover, as there is increasing awareness of metabolic mimics, questions arise about the validity of some of the diagnoses of RS, even in Reye's original cases.

Potential role of the JNK/SAPK signal transduction pathway in the induction of iNOS by TNF-alpha.

Nitric oxide production by macrophages is principally regulated by the calcium-independent enzyme, inducible nitric oxide synthase (iNOS). Both lipopolysaccharide and TNF-alpha synergize with IFN-gamma in the expression of iNOS with subsequent production of nitric oxide. Previous work has shown that IL-4 downregulates iNOS and nitric oxide expression by macrophages stimulated with LPS and IFN-gamma. In this study, we found that IL-4 also downregulated iNOS and nitric oxide expression induced by IFN-gamma and TNF-alpha and in mouse macrophages. Because various members of the mitogen-activated protein kinases and their upstream kinases have been shown to directly or indirectly activate a number of transcription factors including AP-1 and NFkappaB, we examined the effects of IL-4 on TNF-alpha activation of the MAPKs. Our results show that IL-4 modestly inhibited JNK/SAPK and ERK activation by TNF-alpha. Previously, we showed that selective pharmacologic inhibition of the ERK and/or p38mapk pathway did not affect NO2- expression. Treatment of cells with the chloride channel blocker 5-nitro-2-(3-phenylpropylamino) benzoic acid (NPPB) showed a dose-response inhibition of NO2- expression. NPPB was also found to inhibit ERK and JNK/SAPK activation but not p38mapk with TNF-alpha stimulation. The discordance between the marked degree of inhibition of iNOS transcript by IL-4 and the modest inhibition of JNK/SAPK and ERK suggests that the mechanism by which IL-4 inhibits iNOS transcription appears more complex than a mere inhibition of these MAPKs.