Epidemiology of sarcoidosis in Japan.

The present study was designed to identify recent clinical phenotypes using the National Epidemiological Survey and to compare findings with those of previous surveys in Japan. Pathologically confirmed sarcoidosis cases newly diagnosed in 2004 were eligible for the present study. Disease parameters were recorded and compared. A total of 1,027 patients were enrolled from a cluster encompassing 79.4% of the entire Japanese population. The study participants consisted of 364 males and 663 females, providing an average incidence rate of 1.01 per 100,000 inhabitants (0.73 for males and 1.28 for females). The age-specific incidence rate displayed a biphasic pattern in the whole patient population and in the females. The male incidence rates peaked in the 20-34-yr-old group. A second peak for 50-60-yr-old females showed a higher incidence than the first younger peak. Patients with abnormalities in eyes, skin and cardiac laboratory findings accounted for 54.8, 35.4 and 23.0% of cases, respectively. The female/male incidence ratio was increased, and the frequency of eye and skin involvement and cardiac abnormality was higher than in previous surveys conducted in Japan. In conclusion, the data obtained in the present study differ from those of other countries and showed changes in sarcoidosis clinical phenotypes compared with previous studies in Japan.

Acquired C1-esterase inhibitor deficiency and positive lupus anticoagulant accompanied by splenic marginal zone B-cell lymphoma.

A 70-year-old woman complained of mild shortness of breath. Laboratory findings revealed pancytopenia, positive lupus anticoagulant and severe hypocomplementemia without anti-nuclear or anti-DNA antibodies. After the failure of prednisolone treatment, an acquired C1-esterase inhibitor (C1-INH) deficiency was diagnosed. There were no episodes of angioedema or deep vein thrombosis. Three months later, extreme splenomegaly was detected. Lymph node biopsy suggested splenic marginal zone B-cell lymphoma. Acquired C1-INH deficiency due to a lymphoproliferative disorder should be considered as a possible diagnosis for patients with severe hypocomplementemia.

Effects of gene dosage on the expression of human growth hormone cDNA in Escherichia coli.

Gene dosage effects on the foreign protein production in Escherichia coli have been analyzed with the expression vectors containing one, two and four tandemly arranged human growth hormone cDNAs under various culture conditions. In a limited synthetic culture medium, a proportional relationship was observed between the number of the integrated cDNA and the amount of human growth hormone produced. With a culture medium rich in the nutrients, however, no such relationship was observed. These results suggest that, under the limited culture conditions, high-level expression of a foreign gene can be achieved by tandemly joined multiple copies of cDNA.

Rabbit vascular endothelial adhesion molecules: ELAM-1 is most elevated in acute inflammation, whereas VCAM-1 and ICAM-1 predominate in chronic inflammation.

Activation of the microvasculature is a major component of the inflammatory response. During inflammation the vascular endothelium not only becomes more permeable to plasma proteins but also develops adhesion molecules that initiate the local immigration of leukocytes. We describe herein the in vivo changes in the three major vascular adhesion molecules during the development and healing of two types of rabbit dermal inflammatory lesions: (1) acute lesions produced in rabbits by the topical application of 1% sulfur mustard (SM, the military irritant/toxicant); and (2) chronic (immune-mediated) lesions produced in rabbits by intradermal injections of Mycobacterium bovis (BCG), the vaccine strain of tubercle bacillus. In each case, frozen tissue sections were made from lesions of various ages and stained immunohistochemically for von Willebrand (vW) factor to measure the total functional microvasculature. The sections were also stained immunohistochemically for the vascular endothelial adhesion molecules ICAM-1, ELAM-1 (E-selectin), and VCAM-1, and for the leukocyte ligands for ICAM-1: LFA-1 (CD11a/CD18) and Mac-1 (CD11b/CD18). Infiltrating monocytes and lymphocytes expressed the LFA-1 ligand and infiltrating PMN expressed the MAC-1 ligand. The area of stained microvasculature per square millimeter of tissue section was determined with the use of a computerized image analyzer. Edema and cell infiltration spread apart the microvessels, changing the number of microvessels per square millimeter of tissue section. Three methods of assessing such changes are presented. In SM lesions, endothelial ICAM levels were decreased from normal by about 50% at 1 and 2 days (when the lesions reached their peak size) and returned to normal at 3 and 6 days (during the healing process). ELAM rose in peak SM lesions and remained high during healing. VCAM levels, however, were only elevated in the 6-day (almost healed) lesions. In BCG lesions the levels of endothelial ICAM and VCAM (and to a lesser extent ELAM) were increased at 9 days and remained so as the size of the lesions peaked at 23 days. During the healing phase at 37 days, the elevated ICAM and VCAM levels decreased but the slightly increased ELAM levels persisted. These findings indicate that ELAM plays a major role in acute inflammation and that VCAM and ICAM play major roles in chronic inflammation. VCAM is known to be monocyte and lymphocyte selective.

Nonspecific and immune-specific up-regulation of cytokines in rabbit dermal tuberculous (BCG) lesions.

To our knowledge, this is the first sequential study of cytokines in tissue sections of developing and healing tuberculous (BCG) lesions. In situ hybridization, immunohistochemical, and RT-PCR techniques were used. Cytokine mRNAs showed a biphasic pattern. The percentage of mononuclear cells (MN) containing IL-1beta, TNF-alpha, MCP-1, and IL-8 mRNAs was highest in 1- to 3-day lesions, apparently because of the nonspecific inflammatory response caused by the tubercle bacilli in the BCG vaccine. At 5 days, this percentage was significantly reduced. With IFN-gamma, the peak and trough were delayed by 2 days. By 9 days, the percentage of MN containing the mRNAs of all five cytokines had again increased and the rabbits had become tuberculin-positive. In general, MCP-1 and TNF-alpha proteins and the vascular adhesion molecules, ICAM, VCAM, and perhaps ELAM, peaked at about 3 days. Many mononuclear cells surrounding the central areas of solid and liquefied caseous necrosis contained chemokine IL-8 mRNA. IL-8 is known to attract PMN, and PMN were present nearby. In contrast, MN containing chemokine MCP-1 mRNA were present more peripherally in areas rich in macrophages and lymphocytes. The early nonspecific cytokine response seems to be an adjuvant effect of the mycobacteria in BCG vaccine in that it causes a rapid entry of macrophages, lymphocytes, granulocytes, and probably dendritic cells into local sites of antigen deposition. This effect should be considered in developing improved vaccines for the prevention of tuberculosis, because BCG vaccines producing a strong early cytokine response should be more immunogenic than BCG vaccines with similar antigens producing a weak response.

Purification, characterization, and distribution of enolase isozymes in chicken.

Chicken brain enolase was found to show multiple forms (I, II and III) separable by DEAE-cellulose column chromatography, whereas enolase from chicken skeletal muscle showed a single form. Brain enolase I, enolase III and muscle enolase were purified to electrophoretic homogeneity. These three isozymes were dimeric enzymes, each being composed of two identical subunits, alpha, gamma and beta, having molecular weight of 51,000 +/- 600, 52,000 +/- 550 and 51,500 +/- 650, respectively, as determined by SDS-polyacrylamide gel electrophoresis analysis. Brain enolases I, II and III and muscle enolase had similar catalytic parameters, including almost the same Km values and pH optima. Specific antibodies against brain enolase I, enolase III and muscle enolase, raised in rabbit, showed no cross-reactivity with each other. Antibodies for brain enolases I and III also reacted with brain enolase II, indicating that brain enolase II was the hybrid form (alpha gamma) of brain enolases I (alpha alpha) and III (gamma gamma). Enolases from chicken liver, kidney and heart reacted with the antisera for brain enolase I, but not with those for brain enolase III or muscle enolase. Developmental changes in enolase isozyme distribution were observed in chicken brain and skeletal muscle. In brain, the alpha gamma and gamma gamma forms were not detected in the early embryonic stage and increased gradually during the development of the brain, whereas the alpha alpha form existed at an almost constant level during development. In skeletal muscle, complete switching from alpha alpha enolase to beta beta was observed during the period around hatching.

Clinicopathologic characteristics of the lungs of patients with human T cell lymphotropic virus type 1-associated myelopathy.

Lung autopsy specimens were evaluated histologically in the six patients with human T cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy (HAM). The results revealed two histologic changes. First, lymphoid infiltrates were distributed widely in peribronchiolar and perivascular regions, subpleural regions, and the alveolus. Lymphoid infiltrates were also observed in bronchial mucosal glands in relatively large bronchi, in which the acinar epithelium was sometimes degenerated. Second, chronic inflammatory changes, such as smooth muscle hypertrophy, fibrosis, or squamous cell metaplasia, were increased significantly in the membranous bronchioles of HAM patients compared with specimens from lung cancer control patients. Such histologic changes were subclinical in most cases, but one case had an abnormal chest shadow, and two cases had recurrent pneumonia. In HAM patients, high levels of HTLV-1-specific cytotoxic T lymphocytes are believed to attack the HTLV-1-bearing cells in the lung, resulting in inflammatory reactions.

A case of sarcoidosis presenting as multiple pulmonary nodules, nasopharyngeal and cerebellopontine tumors.

A 64-year-old woman presented with multiple pulmonary nodules, and after spontaneous regression of the pulmonary lesions in six months, nasopharyngeal and right cerebellopontine tumors developed. Noncaseous epithelioid cell granulomas were demonstrated histologically in both resected pulmonary and nasopharyngeal tumors. She complained of hearing loss and tinnitus probably due to the cerebellopontine tumors. Corticosteroid therapy resulted in the improvement of these symptoms and the gradual decrease of tumor size. Although histological probe of the cerebellopontine tumors was not diagnostic, this patient was finally diagnosed as having sarcoidosis, based on the clinicopathological features, including systemic granulomatous lesions, MRI findings, and good response to corticosteroid therapy. The diagnosis of sarcoidosis is sometimes difficult when its clinical manifestations are uncommon.

Distribution of endogenous and exogenous carnitine in rats with sepsis and acute liver failure.

The distribution of carnitine was investigated in male Wistar rats with sepsis or acute liver failure. Sepsis was produced by cecal ligation and puncture, while acute liver failure was induced by intraperitoneal injection of carbon tetrachloride. Then 14C-carnitine or L-carnitine was injected intravenously. In healthy control rats and rats with sepsis, both 14C-radioactivity and carnitine were increased in the liver and kidneys. When the carnitine fractions were investigated, it was found that free carnitine and short-chain acylcarnitine were increased. In the rats with acute liver failure, 14C-radioactivity decreased in the liver, but carnitine increased, with free carnitine and short-chain acylcarnitine levels rising. These findings suggested that exogenous free carnitine accumulated directly in the organs with carnitine deficiency in rats with sepsis and acute liver failure. In addition, there was differential regulation of the fractions of both exogenous and endogenous carnitine (free carnitine, short-chain acylcarnitine, and long-chain acylcarnitine). Furthermore, the distribution of exogenous carnitine differed between sepsis and acute liver failure.

The cytokines NAP-1 (IL-8), MCP-1, IL-1 beta, and GRO in rabbit inflammatory skin lesions produced by the chemical irritant sulfur mustard.

Developing and healing dermal inflammatory lesions were produced in rabbits by the topical application of dilute sulfur mustard (SM), the military vesicant. In tissue sections of such lesions, cells containing the mRNA of important cytokines were identified with in situ hybridization techniques. These cytokines were neutrophil attractant/activation protein-1 (NAP-1 (also called IL-8), monocyte chemoattractant (activating) protein 1 (MCP-1), interleukin 1 (beta) (IL-1 (beta)), and GRO (a growth factor and chemokine). Mononuclear cells (mainly macrophages and activated fibroblasts) contained the mRNA of all four of these cytokines. A higher percentage of cytokine-producing mononuclear cells (macrophages and activated fibroblasts) was present in lesions at 2 days (their peak size) than at 6 days, when they were almost healed. Granulocytes emigrated from the bloodstream, passed through the lesions, and were the major constituent of the protective crust. This sequence correlated with the distribution of cells able to produce NAP-1: At 2 days and 6 days, the mononuclears that contained messenger RNA for this granulocyte chemoattractant were found mainly in the upper part of the dermis. At 2 days and 6 days, cells containing the mRNA of IL-1, a primary cytokine, were also found predominantly in the upper dermis, i.e., nearest the site of injury. In contrast, mononuclears containing the mRNA of MCP-1 (a monocyte chemoattractant), and the mRNA of GRO (a granulocyte chemoattractant) were more equally distributed throughout the dermis. SM stimulated hair follicle epithelial cells to up-regulate GRO mRNA and, to a lesser degree, NAP-1 mRNA. Apparently, the irritation produced by SM directly or indirectly induces such epithelial cells to manufacture these growth factors. In the rabbit, hair follicles are known to be the main source of new epithelial cells after the covering epithelium has been destroyed. Therefore, GRO is probably a major autocrine-paracrine stimulus for such repair. A brief review of the role of cytokines in dermal inflammation is presented.

Characterization of distribution of T lymphocyte subsets and activated T lymphocytes infiltrating into sarcoid lesions.

We studied the relationship between various T lymphocyte functions and granuloma formation in 5 lung tissue and 4 lymph node tissue samples from patients with sarcoidosis by immunohistological methods. In the lesion of sarcoidosis, T cells were positive for alpha beta TCR, but gamma delta TCR-positive T cells were rarely observed. The results of analysis of functional subsets showed that T cells in the internal area of granuloma were predominantly helper/inducer subset (CD4+CD45RA-). On the other hand, cytotoxic T cells (CD8+CD45RA-CD11b-) were present in abundance in the outer boundaries of granuloma. In addition, suppressor-inducer T cells (CD4+CD45RA+) were present in the surrounding areas. However, T cells of various subsets were present sporadically outside the granulomas. We also studied the distribution of T cells expressing activation-related antigens. The results showed that T lymphocytes in the internal area of granulomas more frequently had these antigens than did T lymphocytes in the external area. These findings suggested that T cells infiltrating into the sarcoidosis lesion demonstrated a layer-like distribution based on functional subsets. These findings also confirm that activated T cells were more abundantly distributed in the internal area of sarcoid granuloma than in the external area.

Sarcoidosis presenting as bilateral hydronephrosis.

We report an unusual case of sarcoidosis associated with bilateral hydronephrosis. The patient was a 53-year-old Japanese woman who presented with dysuria and urinary incontinence. Computed tomography of the abdomen showed bilateral hydronephrosis caused by a retroperitoneal mass, surrounded by enlarged retroperitoneal lymph nodes. Histological examination of the mass demonstrated noncaseating epithelioid cell granulomas involving the retroperitoneal lymph nodes. Corticosteroid therapy led to complete resolution of the retroperitoneal mass and hydronephrosis. This case emphasizes that sarcoidosis should be included in the differential diagnosis of a retroperitoneal mass.

[Misoprostol-induced pneumonitis].

A 76-year-old woman presented with non-productive cough and progressive dyspnea, and was admitted to Oita Medical University Hospital. Arterial blood gas values obtained on admission indicated severe hypoxemia. Chest roentgenograms and computed tomography disclosed diffuse interstitial infiltrates in both lungs. Transbronchial lung biopsy specimens demonstrated thickened alveolar walls with lymphocyte infiltration and swollen type II pneumocyte proliferation. Eosinophils were observed mainly around bronchioles. For approximately 6 months prior to hospitalization, the patient had been given misoprostol, sodium aurothiomalate, prednisolone, and loxoprofen sodium for the treatment of rheumatoid arthritis. Based on the clinical history and findings, drug-induced interstitial pneumonia was suspected. All medications were discontinued, and the patient was then placed on corticosteroids. After treatment, arterial blood gas values improved and the findings on chest roentgenograms cleared up. Positive lymphocyte stimulation tests and positive dermal reaction patch tests implicated misoprostol as an etiologic factor in the patient's interstitial pneumonia. High serum levels of KL-6 and cytokeratin subunit 19 fragment had been detected on admission. These values returned to normal after the interstitial infiltrates had disappeared. To our knowledge, this is the first reported case of misoprostol-induced interstitial pneumonia.

[A case of chronic hypersensitivity pneumonitis due to wild pigeons].

A 61-year-old woman was admitted to the Oita Medical University Hospital because of a nonproductive cough and exertional dyspnea. Interstitial changes had been seen on her chest radiograph 5 years previously, but no respiratory symptoms were identified at that time. On admission, chest radiography revealed linear and ground-glass opacities in the middle and lower lung fields. Computed tomography provided evidence of bronchiectasis and micro-honeycombing of the lungs, while lymphocyte and neutrophil counts in the bronchoalveolar lavage fluid were increased. Transbronchial lung biopsy demonstrated alveolitis and Masson's bodies. The patient was not a pigeon breeder, but she could have been exposed to pigeons at her workplace. Indeed, she had specific antibodies against pigeon serum and droppings, and her peripheral lymphocytes showed proliferation in response to pigeon serum. A positive provocation test involving inhalation of pigeon serum confirmed that she had chronic hypersensitivity pneumonitis caused by allergy to pigeons. This is a rare case of chronic hypersensitivity pneumonitis associated with wild pigeons, that progressed to pulmonary fibrosis. Antigen provocation testing proved to be of great value.

[Nutritional support in critically ill patients; with special reference to fat emulsion and carnitine].

Energy metabolism of fat emulsion was studied in rats with septic condition. The results indicate that fat emulsion was rapidly eliminated from the blood stream and metabolized readily even in such condition. Based on these findings, we have actively employed fat emulsion clinically as an energy source of septic patients. In septic rats, it was demonstrated that levels of carnitine decreased and that this decrease was based upon a decrease of synthesis. When carnitine was administered together with fat emulsion, the energy metabolism returned to approximately normal level. This reports also describes the absorption and utilization of orally administered fat in septic rats.

[Nutritional support in surgery: with special reference to fat emulsion and carnitine].

Energy metabolism of fat emulsion has been studied in rats with various conditions including postoperative catabolism, chronic and acute hepatic dysfunction, diabetes and sepsis. The results indicate that fat emulsion is rapidly eliminated from the blood stream and metabolized readily even in such conditions. Based on these findings, we have actively employed fat emulsion clinically as energy source. In septic rats, it was demonstrated that levels of carnitine decreased and that this decrease was based upon a decrease of synthesis. When carnitine was administrated together with fat emulsion, the energy metabolism returned to approximately normal level. This report also describes the tissue concentrations of carnitine in diabetic rats and the blood and urine concentrations of carnitine in postoperative patients.