[Diffuse alveolar hemorrhage arising after use of a waterproofing spray].

A 33-year-old woman used waterproofing spray and subsequently developed cough, sputum and chest pain about 8 hours later accompanied by dyspnea, fever and general fatigue. She was admitted to our hospital 4 days after the symptoms appeared. A chest CT scan on the first visit revealed diffuse mild centrilobular nodular opacities and ground-glass opacities in both lung fields. Hemosiderin-laden macrophages accounted for 11% of the histiocytes found in her bronchoalveolar lavage fluid, which also contained blood. Based on these findings, the patient was given a diagnosis of diffuse alveolar hemorrhage. This is the first report in Japan of diffuse alveolar hemorrhage occurring after the use of a waterproofing spray.

[Efficacy of leukotriene receptor antagonists in asthma treatment and analysis of background factors evaluated by a questionnaire survey among physicians].

The efficacy of leukotriene receptor antagonists (LTRAs) in the treatment of asthma and the involvement of various patient background factors were investigated. A questionnaire was used to survey the physicians of 1,600 asthma patients regarding the use of LTRAs, whether treatment was being continued or had been discontinued, and reasons for continuation or discontinuation. The results showed that 797 patients had used an LTRA, with 468 having used pranlukast (P), 294 having used montelukast (M) and 25 having used zafirlukast. For the remaining 10 patients, either the drug name was unknown or multiple LTRAs had been used. The P Group was slightly younger in age (median: P, 55 years, M, 57 years) and had a higher frequency of mild, intermittent disease (P: 20.3%; M:11.2%). The P Group also had a higher percentage of patients who continued taking an LTRA because the drug was "clearly effective" (P: 34.6%; M: 17.3%), and a lower percentage of patients who discontinued the drug because the drug was "ineffective" (P: 2.6%; M:19.0%). Logistic regression analysis showed the following as independent factors contributing to efficacy of the LTRA in the treatment of the asthma (R2 = 0.19): P as the drug used (p < 0.01); allergic rhinitis not present as a complication (p < 0.01); and mild severity of asthma (p = 0.02). Further, the present findings indicate that LTRAs are highly effective for patients who have mild asthma without complication by allergic rhinitis. Further investigation is necessary to determine differences in efficacy among different LTRAs.

[The realities of clinical asthma diagnosis from questionnaire results].

We investigated the basis on which respiratory physicians establish a diagnosis of asthma in clinical practice. A questionnaire survey was conducted on physicians in charge of 1,600 asthma patients receiving outpatient treatment at the Hokkaido University General Hospital or its affiliated hospitals or clinics. The bases for diagnosis were ranked as follows: 1) recurrent paroxysmal dyspnea or symptoms such as wheezing and cough (86%); 2) detection of wheezing on auscultation (78%); 3) improvement in symptoms or auscultation findings after using bronchodilators (56%); 4) improvement in symptoms or auscultation findings after using inhaled corticosteroids (55%); 5) diagnosis of asthma by another physician (46%); and 6) spirometry findings (31%). The performance rates of each examination were as follows. Spirometry at initial visit, 47%; sputum eosinophils, 25%; improvements in FEV1 measured after inhalation of bronchodilator or after treatment as asthma, 12%; measurements of airway responsiveness, 5% and variability in peak expiratory flow, 2%. Asthma is often diagnosed by respiratory physicians based on symptoms, physical examinations and improvement in symptoms or physical findings after treatment for asthma in medical practice. The performance rates of tests used to diagnose asthma were low.

Association between nonspecific airway hyperresponsiveness and Arg16Gly beta2-adrenergic receptor gene polymorphism in asymptomatic healthy Japanese subjects.

BACKGROUND: Nonspecific airway hyperresponsiveness (AHR), a cardinal feature of asthma, is thought to result from several genetic and environmental factors. Asymptomatic AHR in nonasthmatic healthy subjects might be a risk factor for the development of asthma. Genetic variations in codons 16 and 27 of the human beta(2)-adrenergic receptor (beta(2)-AR) alter receptor function in vitro and are associated with various asthma-related phenotypes, including asthma severity and AHR. To date, however, few reports have examined the impact of beta(2)-AR gene polymorphism on AHR in asymptomatic healthy subjects. OBJECTIVE: To determine whether polymorphism of the beta(2)-AR gene (Arg16Gly and Gln27Glu) might influence nonspecific AHR in asymptomatic healthy Japanese subjects. DESIGN AND PARTICIPANTS: A cohort of 120 asymptomatic healthy subjects was analyzed using a stepwise linear regression model. Nonspecific airway responsiveness was measured using a continuous methacholine inhalation method (Astograph; Chest; Tokyo, Japan). We used values of the cumulative dose of inhaled methacholine measured at the inflection point at which respiratory conductance starts to decrease (Dmin) as an index of AHR. Genotyping to identify polymorphisms at codons 16 and 27 was conducted using an assay combining kinetic real-time quantitative polymerase chain reaction with allele-specific amplification. RESULTS: The Gly16Gly genotype was associated with lower Dmin values. The log Dmin value of asymptomatic healthy subjects carrying the Arg16 allele (Arg16/Arg or Arg16/Gly, n = 90) was 1.09 +/- 0.56 (mean +/- SD), while those homozygous for the Gly16 allele (n = 30) yielded a log Dmin value of 0.85 +/- 0.56 (p < 0.05). CONCLUSION: This study indicates that a specific beta(2)-AR polymorphism at codon 16 might be a genetic determinant of AHR, as judged by methacholine-induced bronchoconstriction in asymptomatic healthy subjects.

[Total serum IgE levels in eosinophilic lung diseases].

BACKGROUND: We previously reported elevated levels of total serum IgE in patients with asthma, regardless of their atopic status. We hypothesized that certain factors inherent to asthma may contribute to this non-specific elevation of total serum IgE. In the current study, to evaluate the role of eosinophils in the regulation of total serum IgE, we examined whether peripheral blood eosinophil count is associated with total serum IgE level in patients with eosinophilic lung diseases. METHODS: Ninety-nine healthy controls, 277 patients with asthma, 15 patients with acute eosinophilic pneumonia, 21 patients with chronic eosinophilic pneumonia were studied for total serum IgE levels and peripheral blood eosinophil counts. RESULTS: Patients with acute or chronic eosinophilic pneumonia had significantly increased total serum IgE levels compared with healthy controls regardless as atopic status (p<0.001). In non-atopic subjects with eosinophilic lung diseases, total serum IgE level was significantly correlated with peripheral blood eosinophil count (r=0.42, p<0.001, n=57). CONCLUSION: Our findings suggest that, in addition to antigen-specific IgE production, non-specific IgE production may contribute to elevated levels of total serum IgE in patients with asthma or eosinophilic pneumonia. An increased number of activated eosinophils may underlie an increased total serum IgE level in these conditions.

Enhanced expression of interleukin-18 receptor alpha chain by CD4+ T cells in sarcoidosis.

STUDY OBJECTIVES: To investigate the expression of interleukin-18 receptor alpha chain (IL-18Ralpha) in BAL and peripheral blood (PB) T cells in patients with sarcoidosis compared with control subjects, to evaluate the relationship between the expression and clinical manifestations, and to clarify the mechanisms of altered expression. SUBJECTS AND METHODS: The study subjects consisted of 21 patients with sarcoidosis and 8 normal control subjects. The expression of IL-18Ralpha was examined by flow cytometry. RESULTS: The proportions of BAL CD4+ and PB CD4+ T cells expressing IL-18Ralpha were significantly increased in patients with sarcoidosis compared to control subjects. BAL CD4+ T cells expressed IL-18Ralpha in a higher proportion than did paired CD8+ T cells in patients with sarcoidosis but not in control subjects. Greater proportions of BAL CD4+ T cells and BAL CD8+ T cells than of their PB counterparts expressed IL-18Ralpha in both patients and control subjects. CD4+ T cells were more sensitive to the induction of IL-18Ralpha by cytokines in vitro, such as interleukin (IL)-2, IL-12, and tumor necrosis factor-alpha than were CD8+ T cells. Increased expression of IL-18Ralpha by BAL T cells commonly observed in patients and control subjects was associated with the expansion of CD45RO+ cells in BAL T cells. However, there were no significant correlations between the expression of IL-18Ralpha by any cell populations and BAL findings, serum angiotensin-converting enzyme activities, radiograph stages, or clinical courses. CONCLUSION: The overexpression of IL-18Ralpha predominantly by CD4+ T cells in sarcoidosis emphasizes crucial roles played by T-helper type 1 cells in the IL-18/IL-18Ralpha system in sarcoidosis.

[Evaluation of antigen specific IgE responses in Japanese asthmatics and non-asthmatics].

BACKGROUND: An increase in the prevalence of asthma does not seem to be comparable to the dramatic increase of atopy for the last two decades in Japan. Atopy is considered an important risk factor for asthma. It is, however, suggested that asthma itself may be responsible for the increased overall IgE responsiveness. We examined the significance of IgE responsiveness in asthma. METHODS: We studied 265 healthy controls and 275 patients with asthma. Total serum IgE levels and levels of antigen-specific IgE antibody to mite (D. farinae), cat, dog, timothy, and Candida spp. were determined. We defined atopy by positive RAST (>0.35UA/ml) or MAST scores (>1.0 lumicount) to at least one inhaled allergen. Frequencies of atopic subjects and frequencies of subjects sensitized to each allergen in atopic subjects were compared between the asthmatics and controls. All comparisons were made in younger (<41 yrs) and older (> = 41 yrs) groups, separately. RESULTS: In younger non-asthmatics, 76.5% (104/136) were atopic. The frequency of atopy was significantly higher in asthmatic subjects compared to non-asthmatics in both younger and older groups. In atopic subjects, older asthmatics were sensitized to animals more frequently than older controls. Although the frequency of subjects sensitized to mite did not differ between asthmatics and controls both in younger and older atopic subjects, asthmatics sensitized to mite had higher titers of specific IgE antibody to mite compared to those of controls sensitized to mite. Even non-atopic asthmatics had higher levels of total IgE compared to non-atopic controls. CONCLUSION: Our data may indicate that sensitization to animals and severer sensitizations to mite are risk factors for asthma. However, given the high prevalence of atopy in younger healthy controls, and increased levels of total serum IgE even in non-atopic asthmatics, our findings may reflect the increased overall IgE responsiveness that is inherent in asthma.

[Case of drug-induced pneumonia followed by sequential bronchoalveolar lavage].

A 30-year-old woman who had been receiving minocycline for 11 days to treat a skin burn presented with high fever and progressive dyspnea. Chest radiography demonstrated bilateral pulmonary infiltrates with ground glass opacities. She was admitted to our hospital under a tentative diagnosis of minocycline-induced pneumonia. Minocycline therapy was discontinued at hospital admission, which led to dramatic clinical and radiographic improvement. Bronchoalveolar lavage fluid (BALF) analysis three days after the onset of the pneumonia showed increased numbers of total cells (7.68 x 10(5)/ml), neutrophils (33%) and eosinophils (14%). An increased number of peripheral blood neutrophils was also noted at the time of hospital admission. Follow-up evaluations of BALF 10 days and 34 days after the onset showed rapidly declining numbers of neutrophils and eosinophils. We also measured the levels of several cytokines in BALF, suggesting that TNF-alpha and IL-8 contributed to the accumulation of neutrophils, whereas IL-5 contributed to the accumulation of eosinophils. In summary, we report here the temporal change in the inflammatory cell and cytokine profile in BALF, serum, or both, in a case of drug-induced pneumonia.

[Concentrations of carcinoembryonic antigen in serum and bronchoalveolar lavage fluid of asthmatic patients with mucoid impaction].

BACKGROUND: Concentration of carcinoembryonic antigen (CEA) is known as a marker of malignant transformation and chronic inflammation. We recently observed increased levels of serum CEA in a patient with asthma accompanied by mucoid impactions, which dramatically decreased after a sequence of bronchial washings. The present study evaluated relationships between levels of CEA, bronchial asthma and mucoid impactions. METHODS: Serum CEA concentrations were determined by chemiluminescent immunoassay (CLIA) or enzyme immunoassay in 44 subjects, comprising 9 asthmatic patients with mucoid impactions, 13 asthmatic patients without mucoid impactions, 12 patients with bronchiectasis, and 10 healthy volunteers. CEA concentrations in bronchoalveolar lavage fluid (BALF) were determined in 5 asthmatic patients with mucoid impactions and 10 healthy volunteers. RESULTS: Serum concentrations of CEA were significantly increased in asthmatic patients with mucoid impactions compared with patients without mucoid impactions, patients with bronchiectasis, or healthy volunteers (median [range], 17.3 ng/ml [2.8-28.8 ng/ml]; 3.0 ng/ml [1.5-7.1 ng/ml], 2.2 ng/ml [0.9-17.9 ng/ml], and 1.9 ng/ml [0.6-2.9 ng/ml], respectively). Concentrations of CEA in BALF were also significantly increased in asthmatic patients with mucoid impactions compared to healthy volunteers (3.2 ng/ml albumin [1.2-12.4 ng/ml albumin] vs. 0.4 ng/ml albumin [0.2-1.9 ng/ml albumin]). CONCLUSION: These findings suggest that bronchial asthma with mucoid impactions is among several pathogeneses that cause increased levels of CEA in serum and BALF.

[Studies on airway hyperresponsiveness by the Astograph(r) method in asthmatics and young adult non-asthmatic asymptomatics].

We investigated airway hyperresponsiveness (AHR) by the continuous inhalation method using an Astograph(R) in 105 asthmatics and 141 non-asthmatic asymptomatics. The range of Dmin (1 U=one minute inhalation of 1 mg/ml of methacholine) of asthmatics was 0.001 to 28.70 U, and that of adjusted Dmin of non-asthmatic asymptomatics was 0.28 to 190 U; thus, an apparent overlap was recognized in the distributions of Dmin. Ninety-five percent of asthmatics had a Dmin lower than 7 U, and 95% of non-asthmatic asymptomatics had a Dmin higher than 0.9 U. Presuming that almost all asthmatics had AHR, it was inferred that nearly half of non-asthmatic asymptomatics had AHR, too. Comparison with previous reports suggests that AHR in healthy people may be increasing generally. When Dmin is determined to be>7 U by the Astograph(R) method, it is likely that the patient does not have asthma. When a patient has a Dmin<0.9 U, it is highly probable that the patient has asthma.

Genetic impact of functional single nucleotide polymorphisms in the 3'-UTR region of the chemoattractant receptor expressed on Th2 cells (CRTH2) gene on asthma and atopy in a Japanese population.

BACKGROUND: The human chemoattractant receptor expressed on Th2 cells (CRTH2), the receptor for prostaglandin D2, induces cell migration in eosinophils, basophils, and Th2 cells. The gene encoding CRTH2 is located on chromosome 11q13. Several groups, including ours, have reported significant associations between this region and various traits associated with allergic diseases such as asthma and atopy. Two single nucleotide polymorphisms in the 3'-UTR of the CRTH2 gene (1544G-->C and 1651G-->A) are associated with the mRNA stability of the gene; they have also been associated with asthma in both African American and Chinese populations. METHODS: Because CRTH2 is a biologically important candidate gene on chromosome 11q13, we conducted a case-control analysis using 787 Japanese subjects (384 asthmatics and 403 controls) to evaluate the genetic impact of the CRTH2 gene on asthma and asthma-related traits. Four polymorphisms [1544G-->C (rs11571288), 1651G-->A (rs545659), 11336T-->C (rs2074422), and 12375G-->T (rs561285)] were studied. RESULTS: The allele, genotype, or haplotype frequencies for 2 functional polymorphisms in our Japanese population were significantly different from those in the Chinese or African American populations. No association was found between any polymorphisms or haplotypes in the CRTH2 gene and asthma, atopy, or total serum IgE levels in a Japanese population. CONCLUSIONS: Our data failed to support previous associations of functional polymorphisms at the 3'-UTR of the CRTH2 gene implicated in asthma. We did show a significant difference in the allele and genotype frequencies as well as different haplotype frequencies among African American, Chinese, and Japanese populations, suggesting that the genetic impacts of these functional polymorphisms on asthma and asthma-related phenotypes may vary in different populations.

Polymorphisms in the muscarinic receptor 1 gene confer susceptibility to asthma in Japanese subjects.

RATIONALE: The human cholinergic receptor muscarinic-1 (CHRM1) is widely distributed in the lungs. In patients with asthma, CHRM1 may be involved in airway constriction, airway epithelial cell proliferation, and airway inflammation. The CHRM1 gene is located on chromosome 11q13, which is one of the candidate loci for asthma and atopy. OBJECTIVES: To determine the role of the CHRM1 gene polymorphisms in asthma. METHODS: We studied nine single-nucleotide polymorphisms (-18379G > A, -9697C > T, -6965T > C, -4953A > G, +267A > C, +1353C > T, +3970C > G, +5418C > G, and +5455G > T) in a case-control study using 326 patients with asthma and 333 healthy control subjects. We also examined functional consequences of the -9697C > T and -4953A > G polymorphisms at the regulatory region using an mRNA reporter assay. MEASUREMENTS AND MAIN RESULTS: Two common single-nucleotide polymorphisms (-9697C > T and -4953A > G) were associated with asthma. The odds ratio for the TT homozygotes at the -9697C > T polymorphism was 0.29 compared with the CC homozygotes (95% confidence interval, 0.12-0.73; p = 0.008), and the odds ratio for the GG homozygotes at the -4953A > G polymorphism was 1.86 compared with the AA homozygotes (95% confidence interval, 1.04-3.34; p = 0.038). Haplotype analysis showed that the -9697T/-6965T/-4953A haplotype was associated with a lower risk of asthma (p = 0.00055) and the -9697C/-6965T/-4953G haplotype was associated with an increased risk of asthma (p = 0.020). The -9697T/-4953A haplotype was also associated with lower luciferase activity in vitro compared with the -9697C/-4953G haplotype. CONCLUSIONS: This study, together with an in vitro functional study, suggests that the CHRM1 gene is an important susceptibility locus for asthma on chromosome11q13.

IL-17F sequence variant (His161Arg) is associated with protection against asthma and antagonizes wild-type IL-17F activity.

BACKGROUND: IL-17F is a recently discovered cytokine that plays a role in tissue inflammation by inducing release of proinflammatory and neutrophil-mobilizing cytokines. Upregulated IL17F gene expression has been observed at sites of allergen challenge in the airways of patients with asthma, suggesting that IL-17F is involved in the pathophysiology of asthma. OBJECTIVE: To investigate the role of IL-17F in asthma pathogenesis, we conducted genetic analyses of association of asthma with the common variants of IL17F, using 867 unrelated Japanese subjects. METHODS: Five polymorphisms were studied, including the coding-region sequence variant single nucleotide polymorphism rs763780 (7488T/C), which causes a His-to-Arg substitution at amino acid 161 (H161R). Functional consequences of the H161R substitution were examined by using recombinant wild-type and mutant IL-17F proteins. RESULTS: Homozygosity of the H161R variant was inversely associated with asthma; the odds ratio (95% CI) for asthma was 0.06 (0.01-0.43) for the H161R homozygote compared with the wild-type homozygote (P = .0039). This result remains significant (P = .0079) after adjustment for the presence of atopy using the Mantel-Haenszel chi2 test. In addition, in vitro functional experiments demonstrated that the H161R variant of IL-17F lacks the ability to activate the mitogen-activated protein kinase pathway, cytokine production, and chemokine production in bronchial epithelial cells, unlike wild-type IL-17F. Furthermore, the H161R variant blocked induction of IL-8 expression by wild-type IL-17F. CONCLUSION: The current findings indicate that the IL-17F H161R variant influences the risk of asthma and is a natural IL-17F antagonist, suggesting a potential role for IL-17F in the etiology of asthma.