Cathelicidin LL-37 in bronchoalveolar lavage and epithelial lining fluids from healthy individuals and sarcoidosis patients.

Sarcoidosis is a granulomatous disease of unknown etiology most often characterized by pulmonary manifestations. Changes in an innate immune system, involving antimicrobial peptides, have been noted during the course of pulmonary sarcoidosis. This study focuses on the level of LL-37 peptide, the only human cathelicidin, additionally characterized by a wide range of pleiotropic activities, in pulmonary sarcoidosis. A cross-sectional study was conducted in groups of 32 patients with sarcoidosis and 12 healthy individuals. Bronchoalveolar lavage fluid (BALF) sampling, followed by LL-37 measurements by mass spectrometry combined with previous immunoaffinity purification, was performed. Based on urea levels, concentrations of LL-37 in epithelial lining fluid (ELF) were calculated. The levels of LL-37 peptide in BALF samples derived from patients with pulmonary sarcoidosis (median: 17.45 pg/ml, 25th-75th percentile: 8.05-28.33 pg/ml) were significantly higher compared to the healthy group (median: 6.38 pg/ml, 25th-75th percentile: 4.90-11.55 pg/ml) (U Mann-Whitney test, p=0.04). Assessment of LL-37 in ELF confirmed the differences across the groups that were observed in BALF. The level of LL-37 in patients with sarcoidosis (median: 2.25 ng/ml, 25th-75th percentile: 1.03-5.06 ng/ml) was again higher compared to healthy individuals (median: 0.62 ng/ml, 25th-75th percentile: 0.43-2.17 ng/ml) (p=0.06, Mann-Whitney U test). The results of this study demonstrate that the level of LL-37 peptide is elevated in pulmonary compartment affected by sarcoidosis. This might have a meaning in the pathomechanism of the disease, especially taking into consideration versatile activity of human cathelicidin revealed in numerous experimental studies during the last years.

Cathelicidin LL-37 in bronchoalveolar lavage and epithelial lining fluids from COPD patients and healthy individuals.

Innate immunity is currently under scope of interest concerning its role in the development of chronic obstructive pulmonary disease (COPD). Antimicrobial peptides constitute a potent part of this fast response system. Here, we focus on the role of a specific antimicrobial peptide, the only human cathelicidin, the pleiotropic LL-37 peptide, in the development of COPD under clinical conditions. A cross-sectional study was conducted in groups of 43 patients with COPD (previously classified according to GOLD) and 12 healthy individuals. Bronchoalveolar lavage fluid (BALF) sampling, followed by LL-37 measurements by mass spectrometry combined with previous immunoaffinity purification, was performed. Based on urea levels, concentrations of LL-37 in epithelial lining fluid (ELF) were calculated. Additionally, an antimicrobial assay of growth inhibition of two bacterial species, often involved in COPD development mechanisms, by purchased LL-37 was conducted. Altogether, 55 BALF samples were analyzed. LL-37 levels were significantly higher in BALF from patients in early stages of COPD (GOLD I-II) compared to BALFs from healthy individuals. The same was true for ELF. Cathelicidin’s concentration was significantly lower in both BALF and ELF from patients in advanced COPD (GOLD III-IV). The significantly elevated LL-37 levels both in BALF and ELF in patients with COPD at stage GOLD I-II together with reduced levels in advanced (COPD stage III-IV) further supports the innate immunity involvement in COPD pathology and suggests a profound change in non-specific immunity during the disease progression.

Unusual microbes in asthma exacerbation: Alcaligenes xylosoxidans and Leishmania.

Asthma is a chronic inflammatory condition characterised by a variable degree of airflow limitation. Exacerbations during the course of asthma often occur due to environmental factors or infectious, mostly viral, aetiology. The present study reports the case of a 61-yr-old male with severe asthma hospitalised due to increasing respiratory distress. Since recovery was delayed despite anti-obstructive/anti-inflammatory and antibiotic therapy, further diagnostic procedures, including bronchoscopy, were performed in order to attempt to identify the cause of the worsening respiratory condition. The surprising finding consisted of a rare coincidence of concomitant infection with the bacterial pathogen Alcaligenes xylosoxidans, grown from bronchoalveolar lavage fluid, and the protozoan parasite Leishmania spp., revealed by histopathological examination of bronchial mucosal biopsy specimens. This is the first report of an isolated bronchial mucosal involvement of Leishmania in an HIV-negative asthma patient following brief exposure in Leishmania-endemic regions. Further, to the best of the present authors' knowledge, this represents the first description of A. xylosoxidans in asthma, although it is questionable whether it was an infection or colonisation. The present observation identifies previously unreported microbial pathogens associated with asthma exacerbation. Further, the report highlights the importance of obtaining a thorough travel history and applying invasive diagnostic procedures in circumstances of treatment failure, even under unfavourable conditions.

Controlled prospective randomised trial on the effects on pulmonary haemodynamics of the ambulatory long term use of nitric oxide and oxygen in patients with severe COPD.

BACKGROUND: Pulmonary hypertension is a frequent complication of severe chronic obstructive pulmonary disease (COPD) and a major cause of morbidity and mortality in this condition. Based on the improved survival of these patients due to long term oxygen therapy and the potent and selective pulmonary vasodilation by inhaled nitric oxide, the safety and effectiveness of the combined inhalation of these two gases over a 3 month period was assessed. METHODS: Forty patients with secondary pulmonary hypertension due to COPD were randomly assigned to receive either oxygen alone or "pulsed" inhalation of nitric oxide with oxygen over a period of 3 months. "Pulsed" inhalation of nitric oxide was used to reduce pulmonary ventilation-perfusion mismatch and formation of toxic reaction products of nitric oxide and oxygen. RESULTS: Compared with oxygen alone, the combined inhalation of nitric oxide and oxygen caused a significant decrease in mean (SE) pulmonary artery pressure (from 27.6 (4.4) mm Hg to 20.6 (4.9) mm Hg, p<0.001) and pulmonary vascular resistance index (from 569.7 (208.1) to 351.3 (159.9) dyne x s(-1) x cm(-5) x m(-2), p<0.001) without decreasing arterial oxygenation. Cardiac output increased by 0.5 litres (from 5.6 (1.3) l/min to 6.1 (1.0) l/min, p=0.025). Systemic haemodynamics and left heart function remained unchanged during this period and no increase in toxic reaction products of nitric oxide was observed. CONCLUSIONS: This is the first controlled trial indicating that the "pulsed" inhalation of nitric oxide together with oxygen may be safely and effectively used for the long term treatment of severe COPD.

Aerosolised iloprost improves pulmonary haemodynamics in patients with primary pulmonary hypertension receiving continuous epoprostenol treatment.

BACKGROUND: Continuous intravenous treatment with epoprostenol significantly improves pulmonary haemodynamics and survival in patients with primary pulmonary hypertension (PPH). Its beneficial effect, however, may be blunted due to adverse effects such as catheter sepsis and systemic hypotension. Recent investigations have shown that inhaled iloprost is effective in the treatment of PPH. Based on their different pharmacokinetics, we hypothesised that the combination of intravenous epoprostenol and inhaled iloprost would be more efficacious than epoprostenol alone during acute testing in patients with PPH. METHODS: The effect of a single dose of inhaled iloprost (30 microg total over 15 minutes) on pulmonary haemodynamics was examined in eight patients with PPH (initial non-responders to nitric oxide) who had considerable adverse effects during treatment with epoprostenol. RESULTS: The combination of inhaled iloprost and intravenous epoprostenol significantly improved mean pulmonary artery pressure (MPAP), cardiac index (CI), mixed venous oxygen saturation (SvO2), and systemic arterial oxygen pressure (PaO2) compared with epoprostenol treatment alone. Mean systemic arterial pressure (MSAP) and pulmonary capillary wedge pressure (PCWP) remained unchanged. CONCLUSIONS: The pulmonary vasoreactivity shown by additional iloprost inhalation during effective epoprostenol treatment suggests that an improvement of treatment for pulmonary hypertension may be possible by combining vasoactive substances.

Aerosolized iloprost therapy could not replace long-term IV epoprostenol (prostacyclin) administration in severe pulmonary hypertension.

OBJECTIVES: To switch patients with severe pulmonary hypertension and previous life-threatening catheter-related complications from long-term IV epoprostenol therapy to aerosolized iloprost therapy. DESIGN: Open, uncontrolled trial. SETTING: Medical ICU of a university hospital. PATIENTS: Two patients with primary pulmonary hypertension and one patient with pulmonary hypertension after surgical closure of atrial septal defect (mean pulmonary artery pressure > or =50 mm Hg). All were classified as New York Heart Association class II under treatment with continuous IV epoprostenol for 4 years. INTERVENTIONS: Stepwise reduction of IV epoprostenol (1 ng/kg/min steps every 3 to 10 h) during repeated inhalations of aerosolized iloprost (150 to 300 microg/d with 6 to 18 inhalations/d). Continuous pulmonary and systemic arterial monitoring were performed. RESULTS: Aerosolized iloprost reduced pulmonary artery pressure by 49%, 49%, and 45%, respectively, and increased cardiac output by 70%, 75%, and 41% in the three patients. The effect lasted for 20 min and was similar at different doses of IV epoprostenol. Persistent treatment change to inhaled iloprost could not be achieved because all patients developed signs of right heart failure. After termination of iloprost inhalations, return to standard epoprostenol therapy led to clinical and hemodynamic restoration. CONCLUSIONS: Although aerosolized iloprost demonstrated short-term hemodynamic effects, it could not be utilized as alternative chronic vasodilator in patients with severe pulmonary hypertension.

Mechanisms of antifibrotic action of interferon gamma-1b in pulmonary fibrosis.

The pathology of progressive pulmonary fibrosis combines injury, chronic inflammation and exaggerated, but futile organ repair. Models of experimental organ fibrosis such as bleomycin- or irradiation-induced lung fibrosis indicate that the continuous overexpression of major growth factors such as transforming growth factor beta 1 plays a major role in the tissue reorganization process and the modulation of the accompanying immune response. Moreover, this process is combined with a reorganization of the extracellular matrix that is likely to allow for the secondary loss of transcription of the interferon gamma gene. As a result, the cytokine pattern of the evolving chronic cellular immune response shifts to the so-called T helper 2 type. Recent investigations have demonstrated that this poorly balanced immune response is a characteristic feature of human progressive lung fibrosis such as idiopathic pulmonary fibrosis. Based on the strong antifibrotic properties of interferon gamma, we combined low-dose glucocorticoids with interferon gamma-1b for the treatment of idiopathic pulmonary fibrosis, a relentlessly progressive form of human pulmonary fibrosis. This pilot investigation demonstrated that interferon gamma is able to improve pulmonary function in patients with idiopathic pulmonary fibrosis while at the same time counterbalancing mechanisms of exaggerated wound repair, such as the overinduction of transforming growth factor beta 1.

Treatment with epoprostenol reverts nitric oxide non-responsiveness in patients with primary pulmonary hypertension.

OBJECTIVE: To assess whether long term treatment with epoprostenol might restore primary non-responsiveness to nitric oxide (NO) in patients with primary pulmonary hypertension. METHODS: Seven patients with primary pulmonary hypertension receiving intravenous epoprostenol continuously because of failure of NO to influence pulmonary haemodynamics during initial testing were followed over a period of 13-29 months. Afterwards, acute vascular reactivity towards NO was tested again during right heart catheterisation. RESULTS: Administration of NO after continuous epoprostenol treatment for a mean period of 18 months improved arterial oxygen saturation (p < 0.01) and cardiac index (p < 0.05), and decreased mean pulmonary artery pressure (p < 0.01) and total pulmonary vascular resistance (p < 0.01) in patients previously unresponsive to NO. CONCLUSIONS: Long term treatment with epoprostenol reverts initial refractoriness to NO in patients with primary pulmonary hypertension. Thus the addition of NO to epoprostenol treatment might cause further improvement in the course of the disease.

Cytokine expression in bronchial biopsies of cystic fibrosis patients with and without acute exacerbation.

In patients with cystic fibrosis (CF), the progression of pulmonary disease differs considerably, even in identical cystic fibrosis transmembrane conductance regulator-genotypes which could reflect an additional influence of the host's immune response. This study therefore measured cytokine expression patterns in CF patients with different clinical presentation. Expression of interleukin (IL)-8, interferon gamma (IFN-gamma), IL-4, IL-10, and transforming growth factor (TGF)beta(I) was assessed in bronchial mucosal biopsies of eight CF patients with acute exacerbation (age 6.0-14.2 yrs), eight CF patients with chronic stable disease (age 7.3-17.4 yrs), and in five normal control subjects by semiquantitative and quantitative reverse transcriptase polymerase chain reaction combined with histopathological assessment and immunohistochemical staining. All CF patients expressed IL-8. In acute exacerbation, expression of TGF-beta1 and IFN-gamma was either absent or extremely low. In contrast, all patients with stable disease strongly expressed TGF-beta1. The highest expression of TGF-beta1 and IFN-gamma was found in CF patients with mild disease and a history of infrequent exacerbations. No correlation was found between the expression of IL-4 and IL-10 and patient history. In normal control subjects, only a weak expression of TGF-beta1 was observed. These results show a remarkable correlation between cytokine pattern and the clinical course of cystic fibrosis. High expression of transforming growth factor-beta1 and interferon gamma was associated with mild disease, whereas no or very weak expression of these cytokines was typical for patients with acute disease and frequent exacerbations suggesting a contribution of the immune response to the progression of pulmonary disease in cystic fibrosis.

A preliminary study of long-term treatment with interferon gamma-1b and low-dose prednisolone in patients with idiopathic pulmonary fibrosis.

BACKGROUND AND METHODS: Patients with idiopathic pulmonary fibrosis have progressive scarring of the lung and usually die within four to five years after symptoms develop. Treatment with oral glucocorticoids is often ineffective. We conducted an open, randomized trial of treatment with a combination of interferon gamma-1b, which has antifibrotic properties, and an oral glucocorticoid. We studied 18 patients with idiopathic pulmonary fibrosis who had not had responses to glucocorticoids or other immunosuppressive agents. Nine patients were treated for 12 months with oral prednisolone alone (7.5 mg daily, which could be increased to 25 to 50 mg daily), and nine with a combination of 200 microg of interferon gamma-1b (given three times per week subcutaneously) and 7.5 mg of prednisolone (given once a day). RESULTS: All the patients completed the study. Lung function deteriorated in all nine patients in the group given prednisolone alone: total lung capacity decreased from a mean (+/-SD) of 66+/-8 percent of the predicted value at base line to 62+/-6 percent at 12 months. In contrast, in the group receiving interferon gamma-1b plus prednisolone, total lung capacity increased (from 70+/-6 percent of the predicted value at base line to 79+/-12 percent at 12 months, P<0.001 for the difference between the groups). In the group that received interferon gamma-1b plus prednisolone, the partial pressure of arterial oxygen at rest increased from 65+/-9 mm Hg at base line to 76+/-8 mm Hg at 12 months, whereas in the group that received prednisolone alone it decreased from 65+/-6 to 62+/-4 mm Hg (P<0.001 for the difference in the change from baseline values between the two groups); on maximal exertion, the value increased from 55+/-6 to 65+/-8 mm Hg in the group that received combined treatment and decreased from 55+/-6 mm Hg to 52+/-5 mm Hg in the group given prednisolone alone (P<0.001). The side effects of interferon gamma-1b, such as fever, chills, and muscle pain, subsided within the first 9 to 12 weeks. CONCLUSIONS: In a preliminary study, 12 months of treatment with interferon gamma-1b plus prednisolone was associated with substantial improvements in the condition of patients with idiopathic pulmonary fibrosis who had had no response to glucocorticoids.

[The lung as an immunologic organ]. / Die Lunge als immunologische Organ.

Immune response and restructuring of tissue during organ fibrosis mutually influence each other. It has become evident that the immunomodulatory properties of lining cells of the lung, such as bronchial or alveolar epithelial cells or pulmonary endothelial cells exert a major influence on the acute and chronic activation of the immune system. On the other hand, recent data obtained under in vivo conditions, suggest that the process of mesenchymal organ remodelling during inflammation not only causes organ fibrosis, but may actually perpetuate the process of chronic pulmonary inflammation due to its immunosuppressive effects. In this short review, two examples for this reciprocal influence are discussed.

Addition of nitric oxide to oxygen improves cardiopulmonary function in patients with severe COPD.

STUDY OBJECTIVE: To assess the effect of nitric oxide inhalation on pulmonary hemodynamics and oxygenation in patients with COPD receiving long-term oxygen therapy (LTOT). DESIGN: Prospective study. SETTING: ICU of a university medical center. PATIENTS: A total of 18 (6 female, 12 male) patients with COPD, spontaneously breathing with LTOT. INTERVENTIONS: Oxygenation and hemodynamic variables were measured and calculated at an inspired oxygen fraction (FIO2) adjusted to mimic LTOT conditions (control), and then 1 h after each sequential addition of 5, 10, and 20 ppm nitric oxide to the gas mixture. A newly developed device (Pulmonox) provided both the delivery and continuous analysis of nitric oxide and oxidative nitric oxide products. MEASUREMENTS AND RESULTS: There was a significant improvement in oxygenation at 5 ppm nitric oxide (PaO2/FIO2 ratio improved from 244+/-37 to 303+/-59, p<0.05), but no further improvement at higher doses (ceiling effect). There was a dose-dependent improvement in hemodynamic variables that was maximal at 20 ppm nitric oxide (mean pulmonary artery pressure decreased from 29+/-7 to 24+/-5 mm Hg, pulmonary vascular resistance index decreased from 565+/-321 to 392+/-215 dyne x s x cm(-5) x m(-2), and right ventricular ejection fraction improved from 34+/-6 to 39+/-7%, all p<0.05). CONCLUSION: Prior studies have demonstrated that inhaled nitric oxide may improve or worsen oxygenation in patients with COPD. Our data show an unequivocal improvement in oxygenation (albeit with a ceiling effect at 5 ppm) and pulmonary hemodynamics (dose dependent) in COPD patients receiving LTOT. Further studies are warranted to examine the usefulness of inhaled nitric oxide during acute exacerbations of COPD, or even the possibility of long-term application in patients receiving LTOT.

Lipopolysaccharide and interleukin 1 augment the effects of hypoxia and inflammation in human pulmonary arterial tissue.

The combined effects of hypoxia and interleukin 1, lipopolysaccharide, or tumor necrosis factor alpha on the expression of genes encoding endothelial constitutive and inducible nitric oxide synthases, endothelin 1, interleukin 6, and interleukin 8 were investigated in human primary pulmonary endothelial cells and whole pulmonary artery organoid cultures. Hypoxia decreased the expression of constitutive endothelial nitric oxide synthase (NOS-3) mRNA and NOS-3 protein as compared with normoxic conditions. The inhibition of expression of NOS-3 corresponded with a reduced production of NO. A combination of hypoxia with bacterial lipopolysaccharide, interleukin 1 beta, or tumor necrosis factor alpha augmented both effects. In contrast, the combination of hypoxia and the inflammatory mediators superinduced the expression of endothelin 1, interleukin 6, and interleukin 8. Here, we have shown that inflammatory mediators aggravate the effect of hypoxia on the down-regulation of NOS-3 and increase the expression of proinflammatory cytokines in human pulmonary endothelial cells and whole pulmonary artery organoid cultures.

Intracellular interleukin 6 mediates platelet-derived growth factor-induced proliferation of nontransformed cells.

The functional relevance of interleukin 6 (IL-6) in platelet-derived growth factor (PDGF)-induced cell growth was evaluated in cultures of human fibroblasts, vascular smooth muscle cells, and mesangial cells. The three isoforms of the PDGF--namely, PDGF-AA, -AB, and -BB--induced the expression of the IL-6 gene and proliferation of the nontransformed cells. PDGF-induced transcription, translation, and secretion of IL-6 were diminished in the presence of IL-6 antisense oligonucleotides. While neutralizing anti-IL-6 antibodies failed to affect the growth factor-dependent cell proliferation, IL-6 antisense oligonucleotides inhibited cell division. In addition, IL-6 antisense oligonucleotides abolished PDGF-induced transcription of the genes coding for the cell division cycle 2-related protein (CDC2) and proliferating cell nuclear antigen (PCNA), both of which are regulated in a cell cycle-dependent manner. It is concluded that PDGF-dependent proliferation of nontransformed cells involves the action of intracellular IL-6.

[Chronic thromboembolic pulmonary hypertension and its treatment with pulmonary thrombendarterectomy]. / Die chronisch-thromboembolische pulmonale Hypertension und ihre Behandlung mit der pulmonalen Thrombendarteriektomie.

Chronic recurrent pulmonary embolism can lead to extensive pulmonary hypertension by obstruction of the pulmonary vessels. Pulmonary thrombendarteriectomy is a new approach to normalizing the elevated pulmonary vascular resistance by removal of the adsorbed thrombi. Between 1992 and 1994 we have operated on 8 patients aged between 34 and 62 years. The first patient died due to extensive reperfusion edema, all others showed significant improvement in hemodynamic parameters (mean pulmonary artery pressure preop. 63 +/- 5 mmHg; postop. 30 +/- 9 mmHg; Cardiac Index preop. 2.0 +/- 0.2 l/min; postop. 3.5 +/- 0.5 l/min; pulmonary vascular resistance preop. 1169 +/- 75 dyn; postop. 228 +/- 55 dyn) and exercise performance (NYHA classification preop. III-IV, postop. I-II). Pulmonary thrombendarteriectomy represents an efficient method to normalize elevated pulmonary pressure and exercise performance of patients with far-advanced chronic thromboembolic pulmonary hypertension.