Pulmonary hypertension in idiopathic pulmonary fibrosis: prevalence and clinical progress.

The aims of the present study are to define the prevalence of pulmonary hypertension (PH) in a cohort of idiopathic pulmonary fibrosis (IPF) patients, to investigate any correlations between systolic pulmonary artery pressure (PAPs) and functional data, to evaluate clinical progress and to compare long-term survival in IPF patients with and without PH. A population of 126 IPF patients was recruited. A high prevalence of PH (39.7%, 50/126), evaluated by echocardiography on the basis of PAPs greater than 36 mmHg, was mainly observed in smokers and female patients. Regression analysis revealed a significant correlation between PAPs greater than 50 mmHg and DLCO/VA (p = 0.0294). Mean PAPs was significantly greater one year after onset of PH (p = 0.01). 11/21 patients with FVC less than 50% had a significant increase in PAPs one year after onset of PH (p = 0.02). There was a highly significant difference between survival of IPF patients with and without PH (p = 0.0001; hazard ratio = 3.56). This study revealed that PH has a high prevalence in patients with IPF and is associated with increased risk of mortality. Early diagnosis of IPF patients with pulmonary hypertension is important, so that they can be enrolled in waiting lists for lung transplant as soon as possible.

Defining the clinical outcome status (COS) in sarcoidosis: results of WASOG Task Force.

The clinical outcome of sarcoidosis is quite variable. Several scoring systems have been used to assess the level of disease and clinical outcome. The definition of clinical phenotypes has become an important goal as genetic studies have identified distinct genotypes associated with different clinical phenotypes. In addition, treatment strategies have been developed for patients with resolving versus non resolving disease. A task force was established by the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) to define clinical phenotypes of the disease based on the clinical outcome status (COS). The committee chose to examine patients five years after diagnosis to determine the COS. Several features of the disease were incorporated into the final nine categories of the disease. These included the current or past need for systemic therapy, the resolution of the disease, and current status of the condition. Sarcoidosis patients who were African American or older were likely to have a higher COS, indicating more chronic disease. The COS may be useful in future studies of sarcoidosis.

Cytokine modulators in the treatment of sarcoidosis.

Sarcoidosis is a granulomatous lung disease in which several cytokines play a pivotal pathogenetic role. Steroid-resistant disease can be treated with immunosuppressive drugs, antimalarial therapies and recently with anti-TNFα agents. The use of biological agents for the treatment of sarcoidosis springs from research into the pathogenesis of the disease and also from the experience of rheumatologists with other chronic inflammatory diseases. Rituximab, golimumab and ustekinumab are cytokine modulators, useful in the treatment of immunoinflammatory disorders, for which randomized trials to evaluate safety and efficacy in sarcoidosis are not yet available. Novel anticytokine drugs administered alone or in association may offer a new approach to treatment of the disease. This review focuses on recent advances in anti-TNFα agents and cytokine modulators for the treatment of sarcoidosis and their therapeutic prospects.

Rare localizations of bone sarcoidosis: two case reports and review of the literature.

Sarcoidosis is a multisystem disease of unknown origin. Granulomatous bone involvement has an overall incidence of 1-13%. This incidence is probably underestimated in certain patient series because bone involvement is often asymptomatic. The small bones of hands and feet are the most common localizations, while skull, knee, rib, pelvic and sternal localizations are rarely reported. Here we describe some interesting cases of chronic sarcoidosis with unusual bone localizations observed at our regional referral centre for sarcoidosis. We also review the literature to underline the complexity of the disease, the problem of differential diagnosis with respect to malignancies and the need for appropriate and effective therapy of this rare localization.

Exhaled carbon monoxide in sarcoidosis.

BACKGROUND: Exhaled Carbon monoxide has been proposed as a non-invasive marker in several inflammatory diseases of the lung, but no data are available in patients with sarcoidosis. METHODS: We evaluated the levels of exhaled CO in 78 nonsmoker patients with sarcoidosis and we compared the results with 25 healthy non smoker controls, of 25 patients with a variety of interstitial lung diseases, and 77 smokers. RESULTS: Mean value of exhaled CO in sarcoidosis was 3.3 (2.9-3.8) ppm (GM with 95% CI in parenthesis), resulting significantly higher than both normal controls, 1.4 (1.2-1.7) ppm (p<0.001), and clinical controls, 2.1 (1.7-2.7) ppm (p<0.02). All these levels, however, were markedly lower than those observed in smokers, 14.6 (12.7-16.9) ppm. No correlation was found with radiological stage, steroid therapy, respiratory function, or serum ACE activity. Using an upper normal value of 4 ppm, an increased level of exhaled CO was found in 50% of patients with sarcoidosis, in 24% of clinical controls, and in 97% of smokers. CONCLUSIONS: Our data indicate that significant release of endogenous CO occurs in sarcoidosis. It is unlikely that the measurement of exhaled CO could be of diagnostic usefulness, due to its low specificity and to the possible influence by occasional or passive smoke.

Calgranulin B (S100A9) levels in bronchoalveolar lavage fluid of patients with interstitial lung diseases.

Calgranulins are small calcium-binding proteins with several immunological functions involved in inflammatory processes. Calgranulin A is reported to be mainly associated with acute inflammation while calgranulin B seems to play a role in chronic inflammatory disorders. In this study we used a proteomic approach to analyse calgranulin B expression in bronchoalveolar lavage (BAL) from a group of patients with different interstitial lung diseases. Two dimensional electrophoresis analysis of BAL was performed in 11 idiopathic pulmonary fibrosis patients, nine sarcoidosis patients, 11 with systemic sclerosis patients and five healthy controls. Significantly higher (p<0.001) calgranulin B percentage volumes were observed in BAL from IPF patients than controls and other ILD patients. This result sustains the hypothesis that calgranulin B could be involved in chronic lung diseases, probably through increased expression and enhanced activation of alveolar polymorphonuclear cells related to idiopathic pulmonary fibrosis. Quantitative analysis by an easier method applied to a larger population will be necessary to determine whether calgranulin B could be a good marker of disease severity.

Analysis of trace elements in bronchoalveolar lavage of patients with diffuse lung diseases.

Airborne trace elements are implicated in the etio-pathogenesis of a large number of pulmonary diseases. The aim of this study was to evaluate the reliability and effectiveness of direct determination of Cd, Cr, Cu, Fe, Mn, Ni, Pb, V, and Zn concentrations in bronchoalveolar lavage (BAL) samples from patients with sarcoidosis, idiopathic pulmonary fibrosis, and Langerhans cell histiocytosis and healthy (smoking and non-smoking) controls. A total of 44 individuals were recruited among sarcoidosis, idiopathic pulmonary fibrosis, and Langerhans cell histiocytosis patients and healthy (smoking and non-smoking) controls. Average Mn concentrations in BAL from patients were 45% lower than in controls (p < 0.01) and remarkable decreases in average concentrations of Cr, Ni and Zn were also found in BAL from patients with idiopathic pulmonary fibrosis and Langerhans cell histiocytosis. As these diseases are characterized by the enhanced activation of certain immunomodulatory cells and by generation of free radicals, the depressed Mn, Zn, Cr and Ni concentrations in BAL from patients may be due to oxidative stress. These preliminary results indicate that assessment of the elemental composition of BAL is a promising approach to study the pathogenesis of diffuse lung diseases and Langerhans cell histiocytosis.

Comparative proteomic analysis of bronchoalveolar lavage of familial and sporadic cases of idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive deterioration of the alveolar integrity. Among IPF identified phenotypes, that of familial (f-)IPF is usually associated with several gene mutations which are seldom observed in sporadic (s-)IPF. This study aimed at investigating the molecular patterns and variability in f-IPF and s-IPF patients through a differential proteomic analysis. Protein patterns of bronchoalveolar lavage fluid (BALF) samples from 10 familial and 17 sporadic IPF patients were compared using 2D electrophoresis and mass spectrometry. Principal component analysis (PCA) was applied to proteomic data and an enrichment analysis was also performed to characterize specific pathogenic mechanisms and to identify potential biomarkers. BALF samples from f-IPF showed 87 protein spots differentially expressed than those from s-IPF samples; once identified, these spots revealed 22 unique proteins. The functional analysis showed that the endothelial reticulum stress probably plays a central pathogenetic role in f-IPF with an up-regulation of proteins involved in wounding and immune responses, coagulation system, and ion homeostasis. Up-regulated proteins in the s-IPF group were those involved in the oxidative stress response. PCA analysis of differentially expressed proteins clearly distinguished f-IPF from s-IPF patients, and in agreement with radiological and histological patterns, pointed out a higher heterogeneity in f-IPF than s-IPF samples. The 'Slit/Robo signaling', 'clathrin-coated vesicle' and 'cytoskeleton remodelling', were extrapolated by 'pathways analysis' and the results of 'diseases (by biomarkers)' highlighted a 'connective tissue and autoimmune disease', two aspects of increasing interest in IPF.

Association of extrahepatic manifestations with HLA class II alleles and with virus genotype in HCV infected patients.

It has been postulated that host factors, such as the human leucocyte antigen (HLA) system, may play a predominant role in the pathogenesis of HCV-related extra-hepatic manifestations. This study was performed to investigate the role of HLA- DR and DQ alleles in a group of Italian patients, with HCV infection and associated extrahepatic manifestations and to test whether an association between HCV genotype, HLA locus and clinical or serological manifestations can be demonstrated. Thirty unrelated patients affected by HCV infection with extra-hepatic manifestations were consecutively included in the study. One hundred and sixty-three HCV patients without extrahepatic manifestations were tested as controls for the prevalence of HCV genotypes, and 283 healthy donors were used as controls for HLA class II alleles distribution. HCV-RNA was quantified by an reverse transcription-PCR. HLA class II alleles typing was performed using a standard microlymphocytotoxicity assay on B lymphocyte purified. HCV 2c genotype was found in 53.3% compared to 18.4% of controls (p=0.00001; OR=5.1). Cryoglobulins were detected in 72.7% DR6+ patients and in 31.6% DR6- patients (p=0.05; OR=3.21). Rheumatoid factor was found in 90.9% of DR6+ patients and in 42.1% DR6- patients (p=0.018; OR 13.7). Only two DR5+ patients (20%) had cryoglobulinemia, while 6 patients (30%) in the DR5- group had cryoglobulinemia (p=0.02; OR=0.07). Associations were found between DR7 and ANA (OR=1.74) and between DQ2 and ANA (OR=1.97). According to our findings HLA-DR6 might play an important role in developing extra-hepatic manifestations and genotype 2c could be considered as a risk factor for their onset.

[Retrospective study of tuberculosis in the Province of Siena]. / Studio retrospettivo sui ricoveri per tubercolosi nella Provincia di Siena.

We report here the results of a retrospective study carried out on 200 tuberculosis cases admitted to the Hospital of Siena during the period 1994-2003. For each case, epidemiological, clinical and microbiological data were collected in order to analyze the trend of tuberculosis over the years and to compare our experience with similar studies. Indigenous patients were significantly older than immigrants (60.1 vs 34.2 yrs) more frequently affected by underlying chronic diseases. Overcrowding and HIV infection were predisposing conditions in 30 subjects (15% of cases) recently arrived from high endemicity countries. Pulmonary tuberculosis (TB) was diagnosed in 71% of cases, irrespective of origin. The death rate was 5%. Microbiological investigation was positive in 74.4% of examined subjects; 9.8% of isolates were resistant to one or more antituberculous drugs. The number of cases admitted to the Hospital seems to have slowly decreased in the last few years; factors that may influence this trend are discussed. Our results confirm a distinct epidemiological pattern of the disease between indigenous patients and immigrants, which is typical of low-endemicity countries. The delay in the diagnosis and management of the disease observed in this case-series report underlines the need to improve information on TB and skill in treatment, and to maintain specialized centres.

A functional proteomics approach to the comprehension of sarcoidosis.

Pulmonary sarcoidosis (Sar) is an idiopathic disease histologically typified by non-caseating epitheliod cell sarcoid granulomas. A cohort of 37 Sar patients with chronic persistent pulmonary disease was described in this study. BAL protein profiles from 9 of these Sar patients were compared with those from 8 smoker (SC) and 10 no-smoker controls (NSC) by proteomic approach. Principal Component Analysis was performed to clusterize the samples in the corresponding conditions highlighting a differential pattern profiles primarily in Sar than SC. Spot identification reveals thirty-four unique proteins involved in lipid, mineral, and vitamin Dmetabolism, and immuneregulation of macrophage function. Enrichment analysis has been elaborated by MetaCore, revealing 14-3-3ε, α1-antitrypsin, GSTP1, and ApoA1 as "central hubs". Process Network as well as Pathway Maps underline proteins involved in immune response and inflammation induced by complement system, innate inflammatory response and IL-6signalling. Disease Biomarker Network highlights Tuberculosis and COPD as pathologies that share biomarkers with sarcoidosis. In conclusion, Sar protein expression profile seems more similar to that of NSC than SC, conversely to other ILDs. Moreover, Disease Biomarker Network revealed several common features between Sar and TB, exhorting to orientate the future proteomics investigations also in comparative BALF analysis of Sar and TB.

Exhaled nitric oxide and carbon monoxide in lung transplanted patients.

BACKGROUND: Exhaled nitric oxide (eNO) and carbon monoxide (eCO) are markers of pulmonary inflammation associated with acute graft rejection and lung infections in lung transplant (LTX) recipients. Regarding eNO and eCO levels in LTX patients affected by bronchiolitis obliterans syndrome (BOS), published data are discordant. OBJECTIVES: We aim to evaluate eNO at multiple flows, alveolar concentration of nitric oxide (CalvNO), maximum conducting airway wall flux (J'awNO) and eCO levels in LTX patients to assess the potential role of these parameters in BOS evaluation. METHODS: Fractional exhaled nitric oxide (FeNO), CalvNO and J'awNO were analysed in 30 healthy subjects and 27 stable LTX patients (12 BOS patients). Pulmonary function tests were performed after eNO and eCO assessment. Receiver operating characteristic (ROC) curves were conducted to evaluate diagnostic accuracy for BOS of eNO parameters. RESULTS: LTX patients reported higher values of FeNO at flow rates of 50 (p < 0.01), 150 (p < 0.05), 350 ml/s (p < 0.001), and CalvNO (p < 0.0001) than healthy controls. BOS patients showed higher FeNO at flow rates of 150 (p < 0.05) and 350 ml/s (p < 0.01) and CalvNO (p < 0.001) than non-BOS patients. CalvNO reported a remarkable diagnostic accuracy for BOS (AUC: 0.82). There were no significant differences of eCO levels between LTX patients and healthy controls. CONCLUSION: LTX patients affected by BOS showed higher levels of FeNO 150 and 350, and CalvNO than non-BOS LTX patients, probably due to chronic airway inflammation and fibrotic remodelling. CalvNO may be a potential biomarker of BOS in LTX patients.

CagA-positive Helicobacter pylori infection may increase the risk of food allergy development.

The aim of this study was to test whether patients with symptomatic food allergy and significant levels of immunoglobulin E (IgE) to alimentary antigens were more likely infected by H. pylori, especially by strains expressing the CagA protein, with respect to controls. A group of 38 patients with symptomatic food allergy and 53 age-matched controls were examined serologically for H. pylori infectious status, and for CagA seropositivity. IgE to alimentary allergens were measured by a commercial kit. The prevalence of H. pylori infection in patients with food allergy and controls was similar (42.1%, and 48.3%, respectively). However, anti-CagA antibodies in H. pylori-infected persons were detected in 62.5% of patients with food allergy, and 28% of controls (P = 0.030, odds ratio = 4.29). The mean level of IgE to the most common alimentary antigens in serum samples from infected patients with anti-CagA antibodies was significantly higher than in CagA-negative infected patients: 3.28 kU/L (SD 3.93), vs. 1.99 kU/L (SD 1.53), P = 0.002, 95% confidence interval = 0.61 to 2.53). Infection by CagA-positive H. pylori increases the risk of developing food allergy.

Asbestos exposure assessment by mineralogical analysis of bronchoalveolar lavage fluid.

Mineralogical analysis of bronchoalveolar lavage fluid (BALF) by electron microscopy can represent the most suitable method for assessing asbestos exposure. However, it has been claimed that no standardized or systematic approach to the subject of mineralogical analysis exists. This study aimed to evaluate BALF mineralogical analysis by transmission electron microscopy as biomarker of asbestos fiber load. BALF was examined in 108 exposed workers and 57 patients who underwent diagnostic fiberoptic bronchoscopy for various clinical purposes. Asbestos bodies in BALF were counted with a phase-contrast microscope. Fibers were counted and analyzed by transmission electron microscopy, which showed a significant difference between the two populations and positive results for all exposed subjects. Only 82.2% of the exposed population tested positive for asbestos bodies. Subjects with long-term exposure had higher concentrations of fibers than did those with more recent exposure, probably because of the higher workplace exposure levels in the past. The results of the study confirm that fiber concentration in BALF can be considered as a reliable biomarker of past asbestos exposure, even many years after the end of exposure.

Detection of specific antibodies in immune complexes of farmer's lung patients.

The authors examined 23 precipitin-positive symptomatic patients with Farmer's Lung(FL) and compared them to different groups of exposed asymptomatic precipitin-positive(EAPP) and precipitin- negative(EAPN) farmers. The sera were tested using several techniques (i.e., immunodiffusion and ELISA for specific antibodies; polyethylene glycol [PEG] for circulating immune complexes [CIC]) in an attempt to find an in vitro test correlated with the disease which could also provide an insight into the pathogenic mechanisms of Farmer's Lung. Circulating immune complexes formed by IgG were significantly higher in Farmer's Lung patients than in EAPP subjects. In polyethlyene glycol precipitates from Farmer's Lung patients, specific antibodies found by ELISA correlated well with serum positivity, but they were not found in EAPP subjects. The possibility that the circulating immune complexes found were Ig aggregates was ruled out, as was the possibility that the antibodies found in the polyethylene glycol precipitate were also due to an unspecific link. The authors suggest that the circulating immune complexes of Farmer's Lung patients contain specific specific antibodies and that since their composition is different in EAPP subjects, these circulating immune complexes may play a role in the pathogenesis of the disease.

Clinical, laboratory and radiological findings in pulmonary fibrosis with and without connective tissue disease.

Uncertainty exists over whether to consider "lone" idiopathic pulmonary fibrosis (LIPF) and pulmonary fibrosis associated with connective tissue disorders (PFCTD) as significantly different entities. We retrospectively analysed data collected at the time of first diagnosis in 17 patients with LIPF and in 14 patients with PFCTD and compared survival in the two groups. At first evaluation, the time from onset of respiratory symptoms, spirometric volumes and the diffusing capacity for carbon monoxide were not significantly different between the two groups. However, arterial oxygen tension was significantly lower in LIPF than in PFCTD (63 +/- 3 vs 88 +/- 3 mmHg, p < 0.001). The radiological profusion scores relative to the upper and middle lung fields were significantly higher in LIPF than in PFCTD (upper regions: 6.9 +/- 0.6 vs 3.4 +/- 0.6, p < 0.005 - middle regions: 7.1 +/- 0.5 vs 4.8 +/- 0.7, p < 0.025), whereas the scores relative to the lower fields were similar (7.4 +/- 0.4 in LIPF and 8.4 +/- 0.6 in PFCTD). Survival since onset of respiratory symptoms was significantly better in the PFCTD than in LIPF patients, with a hazard ratio of 4.16 (95% CI 1.12-15.58, p=0.034). Thus, in our series of patients, those with LIPF had a more severe disease than those with PFCTD as shown by the higher frequency of hypoxaemia, the more diffuse pulmonary involvement demonstrated by the chest X-ray and the decreased survival.

Concentrations of major elements and mercury in unstimulated human saliva.

The aim of this study was a preliminary assessment of a possible role of human saliva in the diagnosis of some physiological and pathological changes in oral and body functions. Reliable procedures for collection and analysis of samples were established in order to assess total concentrations of Ca, K, Mg, Na, P, and Hg in whole unstimulated saliva. Possible relationships between element concentrations and sex, age, smoking, illness conditions, or side effects resulting from the use of drugs were investigated. The effects of stimulated or unstimulated collection procedures, dental prosthesis, and amalgam fillings were also evaluated. Total concentrations of major cations and Hg in whole saliva from 33 healthy adults living in the Siena district showed a coefficient of variation ranging from 11% (P) to 53% (Na) and average values were in the same range of those previously reported for unstimulated saliva. Healthy males had significantly higher concentrations of K, Na, P, and Na/K, Na/Ca, Na/Mg, and Na/P values than females. Age, smoking, dental prosthesis, and amalgam fillings had no significant effects on the concentrations of major elements. On the contrary, concentrations of Hg were positively correlated to the number of amalgam fillings and increased at a rate of about 1.9 microg/L for each filling. No correlations were found between Hg concentrations and those of major elements. Comparisons with literature data showed a different composition (particularly for Na and Hg concentrations) between unstimulated and stimulated saliva. Samples from patients affected by idiopathic pulmonary fibrosis had significantly higher concentrations of K and the maximum value was measured in a patient affected by acute pulmonary edema. This increase was likely the result of pharmacological treatments with tricyclic antidepressants and/or saline solutions. Data reported in this study, although preliminary, contribute to the assessment of levels of major cations (some of them very little investigated) and Hg in whole unstimulated human saliva and provides consistent support for further research on the possible use of this easy accessible matrix as a diagnostic tool of body function changes.