Mycobacterium avium complex with a distinct clinical and iconographic presentation: the Lady Windermere syndrome.

Clinically significant pulmonary disease caused by non-tuberculous mycobacteria such as Mycobacterium avium Complex (MAC) usually occurs upon pre-existing lung diseases or immune-deficiency. In 1992, a particular presentation of pulmonary MAC, occuring in otherwise healthy middle-aged women, was described with pulmonary consolidations localized in lingula and middle lobe. For this specific, rare condition, the term Lady Windermere syndrome was introduced. We report a particular case of this syndrome, in which an otherwise healthy individual developed clinically significant disease upon MAC (subtype: Mycobacterium avium) infection of the right middle lobe and lingula of the lung. The patient did not have the classical risk factors for developing this syndrome (e.g. habitual cough suppression, long and narrow bronchi) indicating their modest contribution in the pathogenesis. In our case, guideline based therapy was found to be inadequate because of multi-drug resistance, so an alternative treatment regime was given with good clinical result.

Sensitization to inhaled antigen by intratracheal instillation of dendritic cells.

BACKGROUND: Airway dendritic cells (DCs) capture and present inhaled antigen. It is not known whether antigen presentation by DCs in the airways is sufficient to induce sensitization to inhaled antigen in vivo. METHODS: Rats were immunized by intratracheal instillation of ovalbumin (OVA) -pulsed bone marrow-derived DCs or macrophages and exposed 10 days later to a 30-min aerosol of OVA on 3 consecutive days. Total and differential cell counts and flow cytometry on bronchoalveolar lavage (BAL) fluid, airway histology and serum OVA-immunoglobulin (Ig) E levels were analysed 24 h after the last exposure. RESULTS: As few as 2 x 104 OVA-DC induced sensitization to inhaled OVA. The secondary response to OVA-aerosol consisted of an antigen-specific increase in the number of bronchoalveolar mononuclear cells, activated CD4-positive alphabeta-TCR T lymphocytes, neutrophils and few eosinophils. Peribronchial and perivascular mononuclear cell infiltrates were seen on histological analysis. There was no production of systemic OVA-IgE. Bone marrow-derived macrophages did not induce sensitization. CONCLUSION: Delivering antigen to the respiratory tract via professional antigen-presenting DCs sensitizes for a secondary response to inhaled antigen leading to airway inflammation. This model will prove very useful for studying the early events of sensitization to inhaled antigen using the respiratory route.

Trovafloxacin concentrations in airway fluids of patients with severe community-acquired pneumonia.

The penetration of trovafloxacin (TVA), 200 mg once daily, into the airways of 17 patients with severe pneumonia was studied. The mean (standard deviations are given in parentheses) steady-state TVA concentrations, 2 h after the last intake, were 3.1 (0.3) mg/liter in induced sputum (n = 8), 3.2 (1.1) mg/liter in bronchial secretions (n = 9), 3.2 (0.9) mg/liter in bronchoalveolar lavage fluid (n = 10), and 4.9 (1.4) mg/liter in epithelial lining fluid (n = 11).

The cellular composition of induced sputum in chronic obstructive pulmonary disease.

Asthma and chronic obstructive pulmonary disease are characterized by airway inflammation, which can be assessed by bronchoscopic techniques as well as by the analysis of induced sputum. A method to induce sputum with inhaled hypertonic saline was adapted for use in 21 chronic obstructive pulmonary disease (COPD) patients (mean baseline forced expiratory volume in one second (FEV1) 1.60 L, or 54% predicted) and in 16 healthy volunteers. The success rate and safety of the method, were investigated along with the reproducibility of cell counts and differences in cell counts between both groups. All subjects produced adequate samples and the procedure did not alter spirometric values. A marked sputum neutrophilia was noted in patients with COPD (74.9+/-4.7%), whereas mainly macrophages were seen in healthy volunteers (74.0+/-4.0%). Reliability of the cell counts was high, both within investigators (r=0.99 neutrophils, r=0.99 macrophages) and between investigators (r=0.95 neutrophils, r=0.77 macrophages). In patients with COPD, an inverse correlation was noted between percentage of neutrophils and FEV1 (r(s)=-0.48, p<0.05). Immunostaining revealed a large proportion of activated macrophages in both groups. It was concluded that induction of sputum is a safe and reproducible method to study the composition of airway secretions in patients with chronic obstructive pulmonary disease.

Prevention of pneumococcal disease: an update on the Belgian Consensus Report.

An ad hoc working party on pneumococcal vaccine with representatives of the Belgian Society for Infectiology and Clinical Microbiology, the Belgian Society of Pulmonology and Scientific Societies of General Practitioners reviewed new data on the epidemiology of S. pneumoniae infections in Belgium, on the efficacy and the cost-effectiveness of the 23-valent capsular polysaccharide vaccine. We discuss recent data on vaccination with a new conjugate pneumococcal vaccine, shown to be highly effective in children. The Working Group of the Belgian Scientific Societies endorses the recommendations issued by the Hoge Gezondheidsraad in 1993 and described in a consensus report in 1996.

The role of theophylline in asthma management.

Views on the appropriate use of theophylline in asthma management have varied substantially over the past decades. The recent emphasis on potential anti-inflammatory effects of theophylline has only added to the debate. In current guidelines, theophylline has been positioned mainly as a form of "add-on" therapy in moderate to severe persistent asthma. The purpose of this review is to analyze whether recent developments have been made that allow for a further positioning of theophylline in the treatment of asthma.

Therapeutic activities of theophylline in chronic obstructive pulmonary disease.

Recent observations in asthmatics demonstrated anti-inflammatory and immunomodulatory activities of theophylline besides the bronchodilating effect. Theophylline inhibits the mediator release from mast cells, peripheral blood monocytes and alveolar macrophages. The proliferative response of T-cells as well as the influx of eosinophils in BAL fluid is inhibited by treatment with theophylline. The production and release of pro-inflammatory cytokines are affected by theophylline showing a potent inhibitory effect on the production of IL-1beta, TNF-alpha and IFN-gamma. The production of the anti-inflammatory cytokine IL-10 is increased. Evidence is mounting that the anti-inflammatory effects and immunomodulating actions are exerted at lower plasma concentrations than those required for bronchodilation. These activities are of relevance in the treatment of chronic obstructive pulmonary disease (COPD), a disease in which the inflammatory component is considered to be more important than previously thought.

Methods of examining induced sputum: do differences matter?

Analysis of induced sputum has been proposed as a direct, relatively noninvasive method for the evaluation of airway inflammation in diseases such as asthma or chronic obstructive pulmonary disease (COPD). An important question in the validation of this technique concerns the potential influence of differences in the methods of examining sputum. Up to the present time, two basic techniques for processing sputum have been described. The first approach consists of selecting all viscid portions from the expectorated sample, whereas the second approach processes the whole expectorate, containing sputum plus saliva. Both processing techniques have been shown to provide valid and reliable data on the composition of the cellular and soluble fraction of induced sputum. From the data currently available, it would therefore appear that the usefulness of induced sputum as a method for assessing airway inflammation is not influenced by differences in the methods currently used for examining sputum.

Role of IFN-gamma in the inhibition of the allergic airway inflammation caused by IL-12.

T-helper 2 (Th2)-like cells are thought to play a crucial role in the pathogenesis of the eosinophilic airway inflammation observed in asthma. In a murine model of allergen-induced airway eosinophilia and bronchial hyperresponsiveness (BHR), we have shown that interleukin (IL)-12 can suppress antigen-induced airway changes despite the presence of circulating specific IgE. In the present study, we investigated the role of interferon-gamma (IFN-gamma) in the inhibitory effects of IL-12 on allergic airway inflammation. Repeated daily exposure of actively immunized mice to aerosolized ovalbumin (OVA), as compared with aerosolized saline (SAL), induced a significant increase in bronchoalveolar lavage fluid (BALF) eosinophilia and OVA-specific serum IgE in both IFN-gamma-receptor-deficient (IFN-gammaR KO) and wild-type mice. As compared with placebo (PLAC), administration of recombinant murine IL-12 (rmIL-12) during the daily aerosol exposure (but not at the time of immunization) significantly inhibited BALF eosinophilia in both IFN-gammaR KO mice and wild-type controls, without influencing the production of specific IgE. In contrast, administration of rmIL-12 during the active immunization inhibited both BALF eosinophilia and specific IgE in wild-type mice as compared with littermates given PLAC; however, treatment with rmIL-12 during immunization, in comparison with PLAC, caused a significant increase in BALF eosinophilia and specific IgE in IFN-gammaR KO mice. These results demonstrate that inhibition of the allergen-induced eosinophil influx in murine airways by IL-12 is IFN-gamma-dependent during the initial sensitization, but becomes IFN-gamma-independent during the secondary response.

Interleukin-12 inhibits antigen-induced airway hyperresponsiveness in mice.

The airway inflammation observed in allergic asthma is thought to be orchestrated by an antigen-driven T-helper-2 (Th2) lymphocyte response. In vitro data indicate that the presence of interleukin-12 (IL-12) during the primary stimulation of T-lymphocytes with antigen favors the development of Th1 cells. The aim of the present study was to examine the effect of IL-12 in vivo on antigen-induced airway changes in a murine model. C57BL/6 mice were actively sensitized to ovalbumin; 14 d later, they were exposed daily for 7 d to aerosolized ovalbumin. This resulted in airway eosinophilia, production of ovalbumin-specific IgE, and airway hyperresponsiveness to carbachol. Administration of recombinant murine IL-12 (rmIL-12) during the active immunization prevented these antigen-induced changes. In contrast, administration of rmIL-12 to actively immunized mice during the daily aerosol exposure (but not at the time of immunization) abolished airway eosinophilia and hyperresponsiveness without influencing the production of specific IgE. These results suggest that IL-12 can suppress antigen-induced airway changes despite the presence of circulating specific IgE.

Importance of interleukin-4 and interleukin-12 in allergen-induced airway changes in mice.

T helper 2 (Th2)-like cells are thought to play a crucial role in the pathogenesis of atopic asthma. In this study, we attempted to evaluate the in vivo effect of suppressing Th2 cell development on allergen-induced airway changes. Repeated exposure of actively sensitized C57Bl/6 mice to aerosolized ovalbumin (OA) causes, in comparison to saline-exposed control animals, synthesis of specific IgE, increase of eosinophils in bronchoalveolar lavage fluid and airway hyperresponsiveness. These effects are not observed in OA-exposed, sensitized IL-4-knockout mice. Likewise, these effects are inhibited in OA-exposed C57Bl/6 mice treated with IL-12 during initial antigen exposure. These results suggest that suppressing Th2 cell development in vivo might have profound inhibitory effects on allergen-induced airway changes.

The effect of a nitric oxide synthase inhibitor on the modulation of airway responsiveness in rats.

The possible role of nitric oxide (NO) in the regulation of airway tone remains to be fully explored. In the present study we examined the effect of NG-nitro-L-arginine methyl ester (L-NAME), an inhibitor of NO synthase, on airway responsiveness in rats. The effect of L-NAME on endotoxin (lipopolysaccharide; LPS)-induced changes in airway responsiveness was also evaluated. L-NAME (1 mg/kg given intravenously) caused a 33.3 +/- 6.9% increase in blood pressure, but did not influence baseline airway tone or the provocative dose of carbachol causing a 50% increase in pulmonary resistance (RL)(PD50RL). Exposure of F344 rats to LPS induced a transient increase in airway responsiveness at 90 min after exposure, followed by a significant hyporesponsiveness between 9 and 12 h after exposure. L-NAME (1 mg/kg intravenously) did not influence the increase in responsiveness but inhibited the LPS-induced hyporesponsiveness; in LPS-exposed, L-NAME-treated animals, the PD50RL for carbachol was 3.0 +/- 0.1, versus 4.8 +/- 0.3 micrograms/kg in the LPS-exposed, placebo-pretreated group (p < 0.05). The effect of L-NAME was abolished by pretreatment with L-arginine but not with D-arginine. L-NAME did not influence the LPS-induced increase of neutrophils in bronchoalveolar lavage fluid (BALF). These results suggest that in rats, consitutive NO synthesis does not contribute either to basal airway tone or to the basal degree of airway responsiveness, but that inducible NO synthesis mediates endotoxin-induced hyporesponsiveness.

Tachykinin antagonists and the airways.

There is now convincing evidence for the presence of substance P (SP) and neurokinin A (NKA) in human airway nerves. Studies on autopsy tissue, on bronchoalveolar lavage fluid and on sputum suggest that SP may be present in increased amounts in the asthmatic airway. Substance P and NKA are potent bronchoconstrictors of human airways, asthmatics being more sensitive than normal persons. The major enzyme responsible for the degradation of the tachykinins, the neutral endopeptidase, is present in the airways and is involved in the breakdown of exogenously administered SP and NKA, both in normal and asthmatic persons. Other, less well documented airway effects of SP and NKA include mucus secretion, vasodilation and plasma extravasation, as well as the chemoattraction and stimulation of various cells presumed to be involved in asthmatic airway inflammation. NK2 receptors and, to a lesser extent, NK1 receptors have been shown to be involved in bronchoconstriction, whereas NK1 receptors were found to be involved in mucus secretion, microvascular leakage and vasodilatation, and in most of the effects on inflammatory cells. The first clinical trial with FK224, a peptide NK1 and NK2 receptor antagonist, and CP99994, a nonpeptide NK1 receptor antagonist, are negative. However, FK224 failed to block the bronchoconstrictor effect of NKA in asthmatics and the dose of CP99994, needed to antagonize tachykinin effects in man, remains to be determined.

Sensory neuropeptides and the human lower airways: present state and future directions.

The sensory neuropeptides, substance P and neurokinin A, are present in human airway nerves, beneath and within the epithelium, around blood vessels and submucosal glands, and within the bronchial smooth muscle layer. Studies on autopsy tissue, bronchoalveolar lavage and sputum suggest that in asthma the substance P content of the airways may be increased. Neurokinin A is a more potent bronchoconstrictor than substance P. Asthmatics are hyperresponsive to neurokinin A and substance P. The neuropeptide degrading enzyme, neutral endopeptidase is present in the airways and is involved in the degradation of endogenously released and exogenously administered substance P and neurokinin A, both in normal and asthmatic subjects. As for other indirect bronchoconstrictor stimuli, the effect of neurokinin A on airway calibre in asthmatics can be inhibited by pretreatment with nedocromil sodium. Evidence is accumulating, not only from studies in animals but also from experiments on human airways, that tachykinins may also cause mucus secretion and plasma extravasation. They also have important proinflammatory effects, such as the chemoattraction of eosinophils and neutrophils, the adhesion of neutrophils, and the stimulation of lymphocytes, macrophages and mast cells. The tachykinins interact with the targets on the airways by specific tachykinin receptors. The NK1 and the NK2 receptor have been characterized in human airways, both pharmacologically and by cloning. The NK2 receptor is responsible for the in vitro contraction of normal airways, whilst the NK1 receptor is responsible for most of the other airway effects. Because of their presence in the airways and because of their ability to mimic the various pathophysiological features of asthma, substance P and neurokinin A are presently considered as possible mediators of asthma. The present development of potent and selective tachykinin antagonists will allow us to further define the role of tachykinins in the pathogenesis of asthma.

The effect of zardaverine, an inhibitor of phosphodiesterase isoenzymes III and IV, on endotoxin-induced airway changes in rats.

Zardaverine is a novel phosphodiesterase III/IV inhibitor, developed as a potential therapeutic agent for asthma. In this study we evaluated the effect of zardaverine in an in vivo animal model of airway inflammation and hyperresponsiveness. Endotoxin exposure in rats causes a transient increase in airway responsiveness and a neutrophilic inflammation of the bronchi, which are both at least partly mediated through the secondary release of tumour necrosis factor alpha (TNF alpha). Groups of 10 animals each were pretreated with placebo or zardaverine (1, 10, 30 mumol/kg) i.p., 30 min prior to exposure to aerosolized endotoxin (LPS) or saline. Ninety minutes later, airway responsiveness to 5-HT was assessed and bronchoalveolar lavage (BAL) performed. Zardaverine did not influence baseline lung resistance (RL), but inhibited dose dependently the 5-HT induced increase in RL in control animals. In placebo pretreated animals LPS exposure caused a significant decrease in PC50RL5-HT (provocative concentration of 5-HT causing a 50% increase in RL), compared to the saline exposed control group (1.1 +/- 0.1 vs 2.7 +/- 0.4 micrograms/kg) (P < 0.01). This decrease in PC50RL5-HT was significantly inhibited by zardaverine 30 mumol/kg (5.4 +/- 1.8 vs 1.1 +/- 0.1 micrograms/kg) (P < 0.05). Compared to placebo pre-treated, LPS exposed animals, zardaverine 30 mumol/kg also significantly inhibited to LPS induced neutrophil increase (193.0 +/- 50.0 vs 915.6 +/- 181.3 x 10(3)) (P < 0.01), increase in elastase activity (23 +/- 11 vs 54 +/- 9 nmol substrate/h/ml) (P < 0.05) and TNF alpha release in BAL fluid (93.1 +/- 19.5 vs 229.5 +/- 24.8 U/ml BAL fluid) (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of Theophylline on Endotoxin and Tumor Necrosis Factor Induced Airway Changes in an in vivo Animal Model.

We have previously reported that exposure to aerosolized endotoxin causes bronchial hyperresponsiveness in rats. This is at least partly due to secondary release of tumor necrosis factor (TNF). In this study, we evaluated the effect of pretreatment with aminophylline on these lipopolysaccharide-induced airway changes. Compared to placebo-pretreated animals aminophylline (20 mg/kg i.p.) significantly inhibited the lipopolysaccharide-induced increase in responsiveness without influencing neutrophil counts or TNF levels in bronchoalveolar lavage fluid. In a second part of the study, aminophylline- or placebo-pretreated rats were exposed to aerosolized recombinant human TNF. Compared to saline-exposed animals, TNF caused a significant increase in 5-hydroxytryptamine responsiveness which was inhibited by pretreatment with aminophylline. We conclude that the attenuating effect of aminophylline on lipopolysaccharide-induced airway hyperresponsiveness is not due to inhibition of TNF release, but could be explained by its inhibitory effect on TNF-induced hyperresponsiveness.

The effect of endotoxin inhalation on airway responsiveness and cellular influx in rats.

Studies in humans suggests that airway inflammation may modulate nonspecific airway responsiveness. We studied in a rat model the effect of the inhalation of endotoxin on the cellular composition of the bronchoalveolar lavage (BAL) fluid and airway responsiveness. The exposure to an aerosol of endotoxin caused a rapid influx of neutrophils in the airways. The neutrophils persisted up to 24 h after exposure. Elastase activity in lavage fluid became detectable 30 min after the endotoxin exposure and peaked 9 h later. The exposure to the endotoxin aerosol was followed 1 to 2 h later by a significant increase in the airway responsiveness to 5-hydroxytryptamine (5HT). However, the increase in responsiveness disappeared, and 9 to 12 h following the end of the exposure a significant decrease in airway 5HT responsiveness was observed at the moment that more than 80% of the cells contained in the BAL fluid were neutrophils. The effect of endotoxin on airway responsiveness and inflammation was dose dependent. We also compared in three different inbred rat strains the effect of endotoxin inhalation. The aerosol exposure induced in all three strains a comparable neutrophil influx in the airways, but only two of the three strains became hyperresponsive to 5HT. We conclude that the inhalation of endotoxin causes a neutrophilic airway inflammation in rats. The relationship between this airway inflammation and airway responsiveness is dependent on the time following the exposure and the animal strain used.