Functional roles of MCP-1 in Propionibacterium acnes-induced, T cell-mediated pulmonary granulomatosis in rabbits.

The immunological manifestation of granuloma formations in humans largely depends on the delayed-type hypersensitivity response. We investigated the involvement of monocyte chemoattractant protein-1 (MCP-1) in a rabbit model of T cell-mediated pulmonary granulomatosis. Intravenous injection of Propionibacterium acnes (P. acnes) into sensitized rabbits induced massive and diffuse pulmonary granulomas. Levels of MCP-1 in sera and bronchoalveolar lavage fluids (BALF) peaked before the granuloma formation reached the peak (on days 1 and 3 after challenge, respectively). Chemotactic activities toward monocytes and T cells in BALF were inhibited by anti-MCP-1 IgG by 80 and 36%, respectively. The phenotypic analysis of the migrating T cells revealed that activated and memory T cells rather than naive cells were preferentially attracted to the BALF. Administration of anti-MCP-1 antiserum inhibited the development of granuloma formation in both size and number, the numbers of infiltrating leukocytes in BALF, the expression of adhesion molecules on peripheral monocytes/T cells, and on macrophages/T cells in BALF, and the production of TNF-alpha in the lung. Anti-MCP-1 resulted in a trend toward decreased level of IL-1beta in the lung. The inhibition of the production of these cytokines appeared to be induced indirectly through the inhibition of the recruitment of macrophages that produce these cytokines. The results suggest important roles of MCP-1 in the development of granuloma formation in this model through the attraction and activation of specific types of cells.

New echocardiographic observations in a patient with dissimilar atrial rhythms.

A patient with an impure flutter was found to have dissimilar atrial rhythms that were confirmed by direct ECG recordings. Echocardiographic studies disclosed that the a waves on the mitral echocardiogram occurred synchronously with the a waves on the esophageal ECG that, in turn, showed atrial flutter at a rate of 300 beats per minute. However, the a waves on the tricuspid echocardiogram coincided closely with the P waves on a surface ECG (lead V) that disclosed a chaotic atrial tachyarrhythmia. These results suggest that echocardiographic study, in conjunction with an esophageal ECG, may be a useful, noninvasive technique for the diagnosis of dissimilar atrial rhythms.

Novel chloride channel gene mutations in two unrelated Japanese families with Becker's autosomal recessive generalized myotonia.

We investigated the skeletal muscle voltage-gated chloride channel gene (CLCN1) in two unrelated Japanese patients with Becker's myotonia congenita. The non-myotonic parents of each patient were consanguineous. The proband of each family shares generalized myotonia, transient weakness after rest, and leg muscle hypertrophy. However, the disease severity related to the degree of myotonia differed, even in view of the response to long train nerve stimulation tests. CLCN1 gene analysis revealed a novel Ala659Val missense mutation identified to be homozygous in the more severe patient, while a novel Gln445Stop nonsense mutation was present in the other patient. Both mutations were absent in 90 Japanese normal controls. This is the first report of Japanese cases of Becker's myotonia congenita with CLCN1 gene mutations.

Role of monocyte chemoattractant protein-1 in Propionibacterium acnes-induced pulmonary granulomatosis.

The inflammatory process in granulomatous disorders such as sarcoidosis is mainly the consequence of delayed hypersensitivity induced by causative antigens. Propionibacterial DNA was isolated recently by PCR from human sarcoidosis tissue. Hence, we developed a model using sensitized rabbits for T cell-mediated pulmonary granulomatosis induced by Propionibacterium acnes (P. acnes) and investigated the role of monocyte chemoattractant protein-1 (MCP-1) in the pathogenesis of the granuloma formation in vivo. Intravenous injection of P. acnes into sensitized rabbits induced massive pulmonary granulomas on day 3. Maximum levels of MCP-1 in sera and bronchoalveolar lavage fluid (BALF) were detected on day 1 and preceded recruitment of monocyte/macrophages and T cells. In BALF, monocyte chemotaxis peaked 1 day after P. acnes challenge, and T cell chemotaxis peaked 3 days after P. acnes challenge. Anti-MCP-1 IgG inhibited monocyte chemotaxis by 80.2% and T cell chemotaxis by 35.7%. Phenotypic analysis of migrating T cells revealed that activated and memory T cells (CD26(+)/CD45RO(+)) but not naive cells were preferentially attracted to BALF. Administration of MCP-1 antiserum in vivo inhibited the development of granulomas in both size 59.9% reduction and number 28.6% reduction, the number of infiltrating leukocytes in BALF, and the expression of adhesion molecules on leukocytes in peripheral blood and BALF. Our data indicate that MCP-1 plays important roles in granuloma formation by attracting and activating specific types of cells in this model. Furthermore, results suggest that the rabbit model resembles human angiocentric granulomatosis and would be useful for investigating the immunopathogenesis of human pulmonary granulomatosis.

Measurement of serum monocyte chemoattractant protein-1 and its clinical application for estimating the activity of granuloma formation in sarcoidosis.

BACKGROUND AND AIM OF THE WORK: The role of monocyte chemoattractant protein-1 (MCP-1) in bronchoalveolar lavage fluids from sarcoidosis patients was previously reported. To study the role of MCP-1, we evaluated the serum MCP-1 and its clinical significance in sarcoidosis. METHODS: The serum MCP-1 level was measured in 47 patients with sarcoidosis and 10 normal healthy controls with the use of an enzyme-linked immunosorbent assay. The localization and mRNA expression of MCP-1 in sarcoid lymph nodes were evaluated by an immunohistochemical method using an anti-MCP-1 monoclonal antibody and an in situ hybridization technique to determine the cellular source(s) of MCP-1. RESULTS: Serum MCP-1 levels were significantly elevated in the sarcoidosis patients compared with the healthy controls (698.3 +/- 101.9 vs. less than 39 pg/ml, p < 0.001). A comparison of the patients' serum MCP-1 levels among standard radiographic stages revealed that the serum MCP-1 was significantly higher in early stages: stage 0 vs. III, and stage I vs. II. In addition, the serum MCP-1 levels were significantly correlated with the serum angiotensin converting enzyme levels (r = 0.539, p = 0.0006). MCP-1 expression was detected in macrophages peripheral to the epithelioid granuloma in sarcoid lymph nodes, by both immunohistochemistry and in situ hybridization. CONCLUSIONS: These data suggest that MCP-1 may be expressed by the macrophages in the granuloma throughout the body, and that the measurement of serum MCP-1 levels may have clinical value as an indicator in estimating the activity of granuloma formation throughout the body in sarcoidosis.

Left ventricular outflow tract obstruction due to mitral annulus calcification in patient with mild concentric left ventricular hypertrophy.

The combination of the systolic anterior motion of the anterior leaflet of the mitral valve and/or the mitral annular calcification in the case of asymmetrical septal hypertrophy has been fully recognized. However, in concentric left ventricular hypertrophy the systolic anterior motion of the anterior mitral valve and the massive posterior submitral calcification have not been commonly reported. We present a case with mild concentric left ventricular hypertrophy and massive posterior submitral calcification which displace the entire mitral ring anteriorly, namely, toward the left ventricular outflow tract. In this case, typical left ventricular outflow obstruction with systolic anterior motion of the anterior mitral valve was seen. Thus, we considered that this rare condition may have contributed to the formation of the systolic anterior motion of the anterior mitral leaflet in this case. We have provided additional information regarding the possible causes of systolic outflow obstruction in hypertrophic obstructive cardiomyopathy.

Use of tacrolimus, a potent antifibrotic agent, in bleomycin-induced lung fibrosis.

Idiopathic pulmonary fibrosis has a poor prognosis and few efficacious treatments. The immunosuppressant cyclosporin A has been shown to inhibit tumour growth factor (TGF)-beta-induced collagen deposition in vitro, and is widely used in Japan as a potent antifibrotic agent. Tacrolimus (FK506) is another attractive immunosuppressant, which may be useful in the treatment of pulmonary fibrosis. The aim of the present study was to elucidate the antifibrotic effect of FK506. The inhibitory effect of FK506 on collagen synthesis in cultured lung fibroblastic cells, TIG-3-20, and its antifibrotic effect on bleomycin (BLM)-induced pulmonary fibrosis in mice was investigated. FK506 inhibited TGF-beta-induced collagen synthesis, and suppressed the expression of TGF-beta type I receptor (TbetaR-I) in TIG-3-20 cells. Consistent with the in vitro findings, FK506 treatment starting on day 6 attenuated BLM-induced pulmonary fibrosis, in part, via reduced TbetaR-I expression. FK506 treatment in the acute BLM injury phase unexpectedly increased pro-inflammatory cytokine levels in bronchoalveolar lavage fluid and enhanced lung injury, resulting in poor survival. In conclusion, the present results suggest that FK506 has a potent antifibrotic effect and may be useful for the treatment of pulmonary fibrosis, although its use in the acute inflammatory phase may exacerbate lung injury.

Echocardiogram and phonocardiogram related to the movement of the pulmonary valve.

Pulmonary valve movement and the related acoustic phenomena were investigated using high speed strip-chart echo- and phonocardiographic recording. The opening of the pulmonary valve had no definite relationship to the acoustic phenomena, whereas the pulmonary ejection sound was closely related in time to the early systolic maximal opening of the valve. The concomitant pulmonary ejection systolic murmur faded away by the time of the mid-systolic semi-closure of the valve, where the tiny extrasound occurred in a half of cases. The pulmonary component of the second heart sound occurred after the valve closure, and the time lag maximally reached up to 50 msec. Pulmonary hypertension tended to minimize this delay, giving the so-called single loud second heart sound. Graham Steell murmur started with the pulmonary component of the second heart sound and reached up to the isometric contaction phase beyond the first heart sound.

Ruptured chordae tendineae in acromegaly. An autopsy case.

A 57-year-old woman with acromegaly associated with mitral chordal rupture is reported. She was noted to have abnormal development in the size of her hands and feet in childhood. She occasionally suffered from shortness of breath on exertion and nocturnal dyspnea for several years, and was diagnosed and treated as having congestive heart failure due to valvular heart disease. On admission to our hospital, chordal rupture was suspected on the basis of M-mode and two-dimensional echocardiography. Seven years after discharge, she died of congestive heart failure. On autopsy, the heart weight and ventricular wall thickness were increased. Rupture of the posterior chordae was confirmed, but evidence of an old myocardial infarction was not found. There was severe interstitial fibrosis in the left ventricular wall. A possible etiology of the chordal rupture in this case was thought to be the excessive stretching caused by the disproportional visceromegaly of the heart.

Clinical significance of MCP-1 levels in BALF and serum in patients with interstitial lung diseases.

It has previously been reported that the expression of monocyte chemoattractant protein-1 (MCP-1) in the lung tissues of patients with idiopathic pulmonary fibrosis (IPF) was different from that in the tissues of patients with other interstitial lung diseases (ILDs). The aim of this study was to determine whether this difference reflects the amount of MCP-1 in the bronchoalveolar lavage fluid (BALF) or serum of patients with ILD, and whether such a correlation, if it exists, is clinically useful. MCP-1 concentrations in the BALF and sera were evaluated in 86 patients with ILDs including IPF, acute interstitial pneumonia, interstitial pneumonia with collagen vascular disease (IP-CVD), chronic interstitial pneumonia (CIP), bronchiolitis obliterans-organizing pneumonia, sarcoidosis, hypersensitivity pneumonitis, and in 10 normal healthy volunteers who were controls (NC). BALF MCP-1 levels were significantly elevated in the IPF, IP-CVD, CIP and sarcoidosis groups compared with the NC group. The level in the IPF group was significantly higher than that in any other patient group. Serum MCP-1 levels in the IPF, IP-CVD, CIP and sarcoidosis groups were significantly higher than the NC group. No statistical difference was found in serum MCP-1 levels between the IPF, IP-CVD and CIP groups. BALF MCP-1 levels were significantly higher than serum MCP-1 levels in the IPF group and lower than in the IP-CVD and CIP groups. Serum MCP-1 levels correlated with the clinical course of ILD treated with corticosteroid therapy. These results show that measurement of monocyte chemoattractant protein-1 levels in both bronchoalveolar lavage fluid and serum may be helpful in discriminating idiopathic pulmonary fibrosis from other types of interstitial lung disease and that monitoring of serum monocyte chemoattractant protein-1 may be useful for predicting the clinical course of interstitial lung diseases.

Elevated bronchoalveolar concentrations of MCP-1 in patients with pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown aetiology characterized by accumulations of lipoproteinaceous material within the alveoli. The alveolar macrophages become increasingly foamy, and are thought to have a role in the pathogenesis of PAP. However, the mechanisms of macrophage recruitment are unclear. In the bronchoalveolar lavage fluid (BALF) of four patients with PAP and 20 normal control subjects, the following were examined: the monocyte chemotactic activity due to the chemokine monocyte chemoattractant protein (MCP)-1 with the use of a chemotactic chamber assay, the levels of MCP-1 by enzyme-linked immunosorbent assay, and the MCP-1 expression on lavage cells by immunocytochemistry and in situ hybridization. The monocyte chemotactic activity in the BALF of the PAP patients was markedly elevated, and the activity was completely absorbed by treatment with anti-MCP-1. The MCP-1 levels in the BALF were surprisingly high in the PAP group (25,100+/-472 pg x mL(-1)), whereas low levels of MCP-1 were detected in the normal control subjects (mean: never smokers 4.8; smokers 10.4 pg x mL(-1)). MCP-1 protein and messenger ribonucleic acid were expressed by macrophages from the PAP patients, and the expression was reduced according to foaming of the cells; there were monocyte-like macrophages with strong expression, small foamy cells with moderate expression, large foamy cells with a faint expression of MCP-1, and ghost cells with no expression. However, the increase of macrophage number in the PAP BALF was relatively small. These data suggest that monocyte chemoattractant protein(-1) expression by alveolar macrophages represents an amplification mechanism for the recruitment of additional macrophages to the alveoli in pulmonary alveolar proteinosis. It is possible that an ingestion of an excess of alveolar materials in pulmonary alveolar proteinosis may impair the macrophage function and the survival, resulting in the lack of a prominent increase in the macrophage number in bronchoalveolar lavage fluid.

Echocardiogram in pulsus paradoxus. Respiration dependent cyclic changes in mitral and aortic valve motion: a case report.

The mechanism of production of pulsus paradoxus was echocardiographically studied in a 74-year-old male with subacute effusive-constrictive pericarditis which developed to constrictive pericarditis under the observation. Echocardiography disclosed the following phenomena during inspiration: 1) mitral valve did not open until the atrial systole, probably because of the lack of antegrade mitral flow during rapid filling phase (the E wave was not observed), 2) concomitantly, aortic valve opening decreased markedly in its grade, and 3) left ventricular ejection time (LVET) decreased and pre-ejection period (PEP) increased, resulting in a higher PEP/LVET ratio (up to 1.32). The opposite was true during expiration (PEP/LVET ratio was 0.40). This is probably the first case, in which the mechanism of pulsus paradoxus was investigated by aortic and mitral valve echograms.

Genesis of the third heart sound. Phonoechocardiographic studies.

To clarify the genesis of the third heart sound (IIIS), phonoechocardiographic analysis was made in 31 cases with apparent IIIS. The mitral valve, either anterior or posterior, showed no definite movement coincided with the IIIS. At the time of IIIS, mitral valve is in the closing process, but it is still widely open, and there was no evidence of the stretch or tension of the valve apparatus. On the other hand, the endocardial echoes, either of interventricular septum or of posterior wall of the left ventricle, almost always showed definite check point (point of inflexion) during (or exactly at the end of) rapid ventricular filling as manifested by the sudden change in the diastolic dimension of the left ventricle near the apex. The IIIS seems likely to originate from the abruptly arrested momentum of the moving mass of blood at this check point and then the vibration of the relaxed cardiohemic system.

Echocardiogram of the pulmonary valve. Variability of the pattern and the related technical problems.

In order to examine the variability of the pattern due to the location and direction of the ultrasonic transducer, echocardiograms of the pulmonary valve were obtained from different precordial areas in 28 patients with various diseases and in 3 normal subjects. By higher positioning of the transducer, the diastolic slope became slower or upward and the 'a' wave became indiscernible, giving the pattern of pulmonary hypertension even in the normotensives. The anterior cusp was also detected by tilting of the transducer in some cases. Systolic time intervals (STI) of the right ventricle, however, were not influenced by the beam angle. The present data strongly suggests that the echocardiogram of the pulmonary valve should be carefully evaluated in the light of the spatial relationship of the echo beam and the valve in order to give the diagnostic importance.

Giant T wave inversion as a manifestation of asymmetrical apical hypertrophy (AAH) of the left ventricle. Echocardiographic and ultrasono-cardiotomographic study.

Left ventricular scanning by echocardiography and ultrasono-cardiotomography was performed to search the possible muscular abnormality in 9 cases with giant T wave inversion without documented cause. The deeply inverted T wave was more than 1.2 mV (average was 1.63 mV) in the left precordial leads. All the cases had electrocardiographic left ventricular hypertrophy of obscure origin and ischemic episode was absent. Conventional echo beam direction to measure the short axis of the left ventricle disclosed almost normal thickness and movement of both interventricular septum (IVS) and the posterior wasll (PW), so that the report of these cases is frequently within normal limits. However, ultrasono-cardiotomography (sector B scan) disclosed the fairly localized hypertrophy near the left ventricular apex, and conventional echocardiography also revealed the same area of either IVS or PW or both below the insertion of the papillary muscles, when the scanning towards the apex was performed (asymmetrical apical hypertrophy: AAH). Control study of 9 cases with IHSS showed asymmetrical septal hypertrophy (ASH) with almost equally hypertrophied IVS from base to apex. All cases had inverted T waves, but these were of lesser degree. Three cases had relatively deep T wave compatible with those of AAH, and these cases also had the apical hypertrophy of considerable degree (unusual type of IHSS, i.e., intermediate type between AAH and ASH). The close relationship between the depth of the inverted T waves and the Apex/Mid wall thickness ratios suggests that the altered recovery process of the hypertrophied apical musculature is responsible for the giant T wave inversion of heretofore unsolved origin. Until the connective link of AAH to the other forms of hypertrophic cardiomyopathy is disclosed, the cases with such a T wave and the apical hypertrophy may be designated as asymmetrical apical hypertrophy (AAH).

[Continuous recordings of the echocardiogram and electrocardiogram through the night in patients with nocturnal angina: "All-night echocardiography"].

Continuous observation of the left ventricular (LV) wall motion through the night has not been reported yet. So we developed the long-term recording system of the echocardiogram through all of the night, which was proved useful in a clinical setting. In order to record a long-term echocardiogram, a superimposed echocardiogram of each cardiac cycle was developed on the monitor television by using QRS complex as its trigger. This monitor view has a capacity to display such an echocardiogram with 2-channel electrocardiogram (ECG). Sudden changes of the cardiac motion during the recording were easily detected on the monitor view. These pictures were also recorded on the video cassette recorder through the video camera. We call this system "All-night echocardiography". Complete review of the video tape for 10 hours was possible for only 50 minutes by changing the speed of the review tape (one-twelfth of real time). A probe (Monitoring Probe) was fixed on the chest wall during the recording. "All-night echocardiograms" were recorded in eight patients for 10 hours in total 10 nights. LV posterior wall (PW) monitoring was succeeded in 3 patients for 4 nights during the anginal attack. Systolic motion of LVPW was decreased with ST elevation in a VF in the simultaneous ECG during spontaneous attack (Fig. 5).