A physiologic differentiation between delayed and immediate hypersensitivity.

Studies have been made of movement of various macromolecules into and out of the pleural space of guinea pigs during the course of a delayed hypersensitivity reaction to purified protein derivative (PPD), and a passively transferred immediate hypersensitivity reaction to ovalbumin. While the immediate hypersensitivity reaction transiently alters vascular permeability as shown by increased movement of macromolecules into the chest, the delayed hypersensitivity reaction is marked by a decreased capacity to resorb macromolecules from the pleural space. The data suggest that the two hypersensitivity reactions may be distinguished by these physiologic differences. Additional data from studies of a chemically induced pleural effusion in these animals suggest that some type of outflow obstruction is necessary for the development of effusion, but that the outflow defect caused by the irritating chemical is based on a different mechanism than that seen during the delayed hypersensitivity reaction.

Orosomucoid content of pleural and peritoneal effusions.

22 nonneoplastic, noninflammatory effusions (cirrhosis and congestive heart failure), 12 non-neoplastic inflammatory effusions (tuberculosis, lupus erythematosus, rheumatoid arthritis, and idiopathic pleuropericarditis), and 58 neoplastic effusions (cancer of lung, breast, ovary, and pancreas, and lymphoma) were analyzed by radial immunodiffusion for orosomucoid concentration. The average concentration +/-SE was 35+/-4, 65+/-17, and 130+/-13 mg/100 ml in the three types of effusion, respectively. By gel filtration and ion exchange chromatography, orosomucoid was isolated from 12 nonmalignant and 14 malignant fluids. The orosomucoid preparations reacted as single components in acrylamide gel electrophoresis at pH 9.0, and in immunodiffusion and immunoelectrophoresis against antisera to human serum and to human plasma orosomucoid. In radial immunodiffusion, the slope of the line relating concentration to the square of the diameter of the precipitate area was identical for orosomucoid isolated from normal human plasma and from nonneoplastic effusions, but was subnormal for orosomucoid isolated from neoplastic fluids. All orosomucoid preparations had normal amino acid composition. Orosomucoid from the nonmalignant effusions had normal carbohydrate content. 11 of 14 samples of orosomucoid isolated from neoplastic fluids had abnormalities in carbohydrate composition, consisting of subnormal content of sialic acid (11 of 14), hexose (10 of 14), and hexosamine (3 of 14), and abnormally high content of hexosamine (4 of 14). Discriminant analysis showed that concentration of orosomucoid distinguished between neoplastic and nonneoplastic noninflammatory effusions more effectively than concentration of total protein, albumin, alpha(1), alpha(2), beta, or gamma-globulin.

The relationship between right duct lymph flow and extravascular lung water in dogs given alpha-naphthylthiourea.

The relationship between right duct lymph flow and extravascular lung water was studied in 3 normal dogs and 15 dogs with pulmonary edema induced by alpha-naphthylthiourea (ANTU). Right duct lymph was collected in a pouch created by ligating jugular, subclavian, and brachiocephalic veins. Extravascular lung water was measured in vivo by double indicator dilution and post-mortem by weighting lungs before and after drying. Cardiac output, pulmonary artery and pulmonary artery wedge pressures, and the concentration of protein and electrolytes in plasma and right duct lymph were determined. Eight lungs were examined by light and electron microscopy. There was a direct relationship between right duct lymph flow (RDLF in milliters per hour per gram dry lung) and extravascular lung water (Qwl in milliliters per gram dry lung) which was best described by the equation RDLF=0.75-0.26 Qwl+0.03 (Qwl).2 Dogs with severe ANTU-induced edema had extensive lung capillary endothelial destruction but only mild interstitial swelling and no visible damage to type I alveolar epithelial cells. Cardiac output, pulmonary artery and wedge pressures, and protein and electrolyte concentrations did not correlate with either extravascular water or right duct flow. Thus, in ANTU-induced pulmonary edema right duct lymph flow was directly related to extravascular lung water with the highest flows occurring with severe edema. The absence of a rapid increase in lymph flow with small increases in extravascular water may be due to early sequestration of fluid in the alveolar space. Hemodynamic changes did not account for changes in lung water or lymph flow. The pulmonary interstitial factors relating increased extravascular water to lymph drainage remain to be determined.

Purification and characterization of alpha 1-antichymotrypsin from human pleural fluid and human serum.

Human alpha 1-antichymotrypsin was purified from human pleural fluid and from human serum. Four affinity chromatographic steps were required to obtain pure alpha 1-antichymotrypsin. Pleural and serum alpha 1-antichymotrypsin have the same molecular weight, which was estimated by SDS-polyacrylamide gel electrophoresis to be 58 000. The chemical composition of the two types of alpha 1-antichymotrypsin is the same. Using a technique for visualization of the chymotrypsin inhibitors, we showed that the pure alpha 1-antichymotrypsin obtained from the two physiological fluids had its inhibitory capacity preserved.

The glucose-pH relationship in parapneumonic effusions.

Both a low pleural fluid glucose concentration and pleural fluid acidosis are markers of severe pleural inflammation, but the relationship between these phenomena has not been defined clearly. Therefore, we measured simultaneous pleural fluid glucose concentrations and pH in 25 consecutive parapneumonic pleural fluids. Seventeen effusions had a glucose concentration greater than 60 mg/dl (group 1, 126 +/- 7 mg/dl, mean +/- SEM), while eight had a pleural fluid glucose less than 60 mg/dl (group 2, 15 +/- 3 mg/dl, P less than .01). Pleural fluid pH was 7.35 +/- 0.03 in group 1 compared with 6.83 +/- 0.09 in group 2 (P less than .01). A significant correlation between pleural fluid glucose and pH was found (r = .81, P less than .01). Low-glucose, low-pH effusions were complicated (either loculated or empyemas). Uncomplicated effusions had glucose concentrations greater than 60 mg/dl and a pleural fluid pH greater than 7.30. The concomitant occurrence of low pleural fluid glucose and pH suggests that the mechanisms leading to these phenomena are interrelated.

Biochemical features of urinothorax.

In three patients with obstructive uropathy and retroperitoneal urine collections, rapidly accumulating pleural effusions developed. The diagnosis of urinothorax was confirmed when chemical analysis of pleural fluid disclosed higher creatinine concentrations than found in simultaneously obtained serum samples. Similar determinations made in 71 specimens from control patients with pleural effusions showed that pleural creatinine concentration did not exceed the serum level in other conditions. We conclude that elevated pleural fluid creatinine level is specific for the diagnosis of urinothorax. Low pleural fluid glucose concentration may also be seen in these patients.

Isolation of human C-reactive protein and serum amyloid P component.

Procedures are described for the isolation in high yield of consistent, highly purified preparations of human C-reactive protein (CRP) and serum amyloid P component (SAP). CRP was obtained from malignant ascitic and pleural fluids by calcium-dependent affinity chromatography on pneumococcal C-polysaccharide covalently coupled to cyanogen bromide-activated Sepharose. It was then gel filtered on Ultrogel AcA44 (acrylamide-agarose beads) in the presence of calcium ions, combining molecular sieve chromatography with removal of contaminating SAP by its affinity of agarose. Residual trace contaminants were removed by immunoabsorption with anti-normal human serum and anti-SAP antibodies insolubilised on Sepharose and/or by absorption with Sepharose-Con A to remove glycoproteins and Blue-Sepharose to remove albumin. After a final gel filtration step on Sephacryl S-300 35-45% of the initial CRP was recovered in pure form according to biochemical and immunochemical criteria. SAP was isolated from normal serum by calcium-dependent affinity chromatography on unsubstituted Sepharose beads, followed by solid-phase immunoabsorption of contaminants and finally gel filtration on Sephacryl S-300. At least 50% of the SAP in the starting material was recovered in pure form according to biochemical and immunochemical criteria. Ready availability of such preparations facilitates biochemical, biophysical and particularly biological studies of these plasma proteins.

Hemophilus influenzae b pericarditis in children.

Recent experience in the diagnosis and management of Hemophilus influenzae b pericarditis is described in five children. Anterior pericardectomy appears to be the preferred method of surgical drainage because it was associated with a shorter hospitalization than pericardiocentesis or closed or open pericardotomy and removed the risk of recurrent cardiac tamponade and constrictive pericarditis. Countercurrent immunoelectrophoresis of sera and pericardial fluid was used to rapidly identify the etiology of pericarditis in four of four patients tested. The observation that three children appeared to develop pericarditis in the absence of a contiguous infectious focus suggests that bacteremic seeding of the pericardium may be important in the pathogenesis of this disease.

The value of cells in the pleural fluid in the differential diagnosis.

Fifty samples of pleural fluid, collected from consecutive patients in a thoracic clinic who had diagnostic thoracentesis, were studied prospectively. Pleural fluid protein was of value in differentiating transudates from exudates. Pleural fluid red cell counts, white blood cell counts, and differential white blood cell counts have no specificity and no usefulness in the differential diagnosis of the origin of the effusion. Pleural fluid cytology was positive in 60% of all the malignancies studied in this series; for the group with metastatic breast carcinoma, there was a 78% positive pleural fluid cytology. Differential white cell counts revealed tumor cells in 45% of malignant effusions. In our experience, the finding of tumor cells is the only useful finding in differential cell counts of the pleural fluid.

Falsely high refractometric readings for the specific gravity of pleural fluid.

For 128 pleural fluids, the relationship between the protein content and the reading for the specific gravity obtained from a refractometer calibrated for urinary specific gravity was analyzed. The refractometer gave falsely high levels for the specific gravity of the pleural fluid. A reading for 1.019 (rather than 1.016) corresponded to a concentration of protein of 3.0 gm/100 ml, and each deviation of 0.005 (rather than 0.003) coresponded to a concentration of 1 gm/100 ml; however, determinations of the concentration of protein in the pleural fluid directly from the refractometer's scale for protein (calibrated for serum) was rapid and accurate. Calculation of the protein content of the pleural fluid from the reading for specific gravity on the refractometer is erroneous and sometimes misleading.

Diagnostic value of carcinoembryonic antigen in exudative pleural effusions.

Elevated pleural fluid (PF) and plasma (PL) carcinoembryonic antigen (CEA) levels (ng/ml) were more frequently found with malignant than benign exudative effusions, but with a low true-positive rate for malignancy in general. Adenocarcinomatous effusions differed from other malignant and benign effusions in the frequency and degree of elevation of PF and PL CEA levels. A PF > 20 had a sensitivity of 91 percent and a specificity of 92 percent as a screening test for adenocarcinomatous effusions. A PF CEA > 55 or PL CEA > 10 were present only with malignancy and 98 percent specific for adenocarcinoma.

Pleural effusion associated with aortitis syndrome.

A patient with aortitis syndrome had a pleural effusion which subsided but reappeared with an exacerbation of aortitis symptoms while under antituberculosis treatment. The character of the fluid was that of an exudate, and the glucose concentration was normal. Clinical and laboratory features of the case suggest that the effusion was part of the aortitis syndrome per se.

The diagnostic value of pleural fluid pH.

One hundred eighty-three patients had simultaneous blood and pleural fluid pH determinations. Thirty-six effusions were transudates, and 147 were exudates. In 46 effusions, the pleural fluid pH was less than 7.30; all 46 were exudates. A pleural fluid pH less than 7.30 was associated with the following six diagnoses: (1) empyema; (2) malignancy; (3) collagen vascular disease; (4) tuberculosis; (5) esophageal rupture; and (6) hemothorax. The results of pleural fluid pH determination are immediately available, narrow the differential diagnosis of the exudate, and may expedite patient management. The pH of pleural fluid should be measured whenever a diagnostic thoracocentesis is performed.

In vitro pleural fluid clottability and fibrinogen content.

Twenty-three specimens of pleural fluid from 23 patients were examined for quantitative fibrinogen, total protein levels, and for clottability in vitro using the recalcification time. Of the 19 specimens of pleural fluid from patients without loculation, 11 (seven exudates) had no detectable fibrinogen; another 8 (six exudates) had a mean fibrinogen level of 55.0 +/- 10.2 mg percent, and a mean recalcification time of 19.4 +/- 2.6 minutes. The pleural fluids from the four patients with loculation had no detectable fibrinogen. The only fluids containing fibrinolytic activity were from the nonloculated non-fibrinogen-containing group. No correlation existed between pleural fluid/plasma total protein ratios and pleural fluid/plasma fibrinogen ratios. In vitro clottability in this study did not reflect the in vivo tendency for coagulation and loculation.

Direct immunofluorescence in the diagnosis of Legionnaires' disease.

Over a 2 1/2 year period, 61 clinical specimens from 41 patients with pneumonia of uncertain etiology were evaluated for the presence of Legionella pneumophila (serogroups 1 to 4) by immunofluorescent antibody techniques. In 13 of 19 patients with Legionnaires' disease, the diagnosis was established by fluorescent antibody (FA) staining of lung biopsies, pleural fluids, or respiratory tract secretions. In the 19 patients with Legionnaires' disease, the diagnosis was confirmed by isolation of L pneumophila by in vitro culture techniques in five or by measurement of serum antibody titers in 17. Although the FA staining technique was of limited sensitivity (68 percent), it was highly specific: no patients with non-Legionnaires' pneumonia had a false-positive fluorescent stain. In addition, the FA staining of lung tissue was positive only when performed during the first nine days of antimicrobial therapy and when an acute bronchopneumonia was noted histologically. In cases of a nonspecific interstitial pneumonitis, FA stain was always negative, and the diagnosis could be confirmed only by serum antibody measurements. Tests for serogroups 1 to 4 with a polyvalent conjugate showed that L. pneumophila serogroup 1 was the predominant strain detected in pneumonia of uncertain etiology in the Detroit area.

Carcinoembryonic antigen levels in malignant pleural fluids obtained from patients with mammary cancer.

The clinical usefulness of the carcinoembryonic antigen test for defining the malignant origin of pleural fluids obtained from patients who have mammary cancer was evaluated. Of 57 malignant pleural fluids obtained from 51 patients who had mammary cancer, 31 (54.4%) demonstrated a significantly elevated carcinoembryonic antigen content: the ratio of pleural fluid to serum carcinoembryonic antigen values ranged from .24 to 3.55; whereas for 14 of 23 patients who had normal levels of both serum and pleural fluid carcinoembryonic antigen, the ratio ranged from 0.25 to 2.30. This study indicates that the pleural fluid carcinoembryonic antigen value may be significantly elevated in only 50-60% of mammary cancer patients having documented malignant pleural fluids, and that the pleural fluid to serum carcinoembryonic antigen ratio is of no value in defining the malignant origin of pleural fluids obtained from these patients.

Orosomucoid contents of pleural and peritoneal effusion of various etiologies.

Orosomucoid and the contents of seven other proteins were determined by radial immunodiffusion in sera and in pleural or peritoneal fluids of 66 patients. No significant difference between concentration of individual proteins in effusions of neoplastic origin and those of nonneoplastic inflammatory origin was found. In noninflammatory fluids, the protein concentrations were lower, but their distribution was similar to distributions in the other fluids tested. These findings support the view that the protein content of effusions reflects changes in vascular permeability.

Lysozyme (muramidase) in pleural effusions and serum.

The authors evaluated the usefulness of paired pleural fluid and serum lysozyme determination in the differential diagnosis of pleurisies in 118 patients. Lysozyme activity of tuberculous effusions was found significantly higher (P less than 0.001) than that of effusions due to malignancy or heart failure, but considerable overlap of the individual values was observed. All patients with tuberculous pleurisy or tuberculous empyema, as well as a group of patients with suspected tuberculous effusion, had pleural fluid to serum lysozyme ratio of 1.0 or greater. In the remaining groups, only three patients, one with malignancy, one with lupus erythematosus, and one with sarcoidosis, exceeded this value. Their results suggest that pleural fluid to serum lysozyme ratio can be applied effectively in the differential diagnosis of tuberculous pleurisy.

Orosomucoid, alpha 2-macroglobulin and immunoglobulins in serum and pleural effusions.

Serum and pleural fluid levels of orosomucoid, alpha 2-macroglobulin, IgG, IgA, and IgM were measured in 36, 29, and nine patients suffering from malignant, tuberculous, and non-malignant, non-inflammatory pleural disease, respectively. Pleural fluid concentrations of the studied proteins were higher in tuberculous effusions, but due to wide overlapping of the values, correlation with diagnosis could not be established. The ratio of the pleural fluid to the serum concentration of the studied proteins was below unity with the exception of three tuberculous and one cancer patient who showed higher values of orosomucoid in the pleural fluid. The rate of diffusion of the various proteins in the pleural fluid was inversely proportional to their molecular weight.

Cancer-associated proteins in effusion fluids.

Two cancer-associated proteins, carcinoembryonic antigen (CEA) and pregnancy-associated alpha2 glycoprotein (PAG), together with 13 normal serum proteins were measured in the serum and effusion fluid of patients with ascites and pleural effusions. The results indicate that CEA measurement in effusion fluid is more effective than serum measurement in distinguishing cancerous from congestive or inflammatory effusions. Comparisons with the results of cytological examination suggest that fluid CEA estimation may prove a useful clinical tool. Serum PAG levels were higher in patients with cancer, but fluid determination offers no advantage in separating the disease groups. Similarly, the estimation of individual normal serum proteins in effusion fluids is unlikely to be of diagnostic value.