Pulmonary interstitial glycogenosis - A systematic analysis of new cases.

BACKGROUND: Pulmonary interstitial glycogenosis (PIG) is a rare paediatric interstitial lung disease of unknown cause. The diagnosis can only be made by lung biopsy. Less than 100 cases have been reported. Clinical features, treatment and outcomes have rarely been assessed systematically in decent cohorts of patients. METHODS: In this retrospective multicentre study, the clinical presentation, radiologic findings, pattern of lung biopsy, extrapulmonary comorbidities, treatment and outcome of eleven children with PIG were collected systematically. RESULTS: 10/11 children presented with respiratory distress immediatly after birth and 8/11 needed invasive ventilation. In 8/11 children extrapulmonary comorbidities were present, congenital heart defects being the most common. 7/11 children received systemic glucocorticoids and of these four showed a clear favorable response. During a median follow-up of 3.0 years (range 0.42-12.0) one child died, while 10 patients improved. Chest CT-scans showed ground-glass opacities (7/10), consolidations (6/10), linear opacities (5/10) and mosaic attenuation (4/10) without uniform pattern. Besides interstitial thickening related to undifferentiated glycogen positive mesenchymal cells all tissue samples showed growth abnormalities with reduced alveolarization. CONCLUSIONS: PIG is associated with alveolar growth abnormalities and has to be considered in all newborns with unexplained respiratory distress. Apparent treatment benefit of glucocorticosteroids needs to be evaluated systematically.

Respiratory disease in Niemann-Pick type C2 is caused by pulmonary alveolar proteinosis.

Niemann-Pick diseases are hereditary neurovisceral lysosomal lipid storage disorders, of which the rare type C2 almost uniformly presents with respiratory distress in early infancy. In the patient presented here, the NPC2 exon 4 frameshift mutation c.408_409delAA caused reduced NPC2 protein levels in serum and lung lavage fluid and the synthesis of an aberrant, larger sized protein of around 28 kDa. Protein expression was strongly reduced also in alveolar macrophages. The infant developed failure to thrive and tachypnea. Lung lavage, computer tomography, and histology showed typical signs of pulmonary alveolar proteinosis with an abnormal intraalveolar accumulation of surfactant as well as macrophages. An NPC2-hypomorph animal model also showed pulmonary alveolar proteinosis and accumulation of macrophages in the lung, liver, and spleen long before the mice died. Due to the elevation of cholesterol, the surfactant had an abnormal composition and function. Despite the removal of large amounts of surfactant from the lungs by therapeutic lung lavages, this treatment was only temporarily successful and the infant died of respiratory failure. Our data indicate that respiratory distress in NPC2 disease is associated with a loss of normal NPC2 protein expression in alveolar macrophages and the accumulation of functionally inactive surfactant rich in cholesterol.

Inhalation of alpha(1)-protease inhibitor in cystic fibrosis does not affect surfactant convertase and surface activity.

The inhalation of alpha(1)-protease inhibitor (alpha(1)-PI) was assessed in a pilot study to restore the protease-antiprotease balance in the lungs of cystic fibrosis (CF) patients. In addition, the effect of this treatment on the surface active properties of lung surfactant and the metabolic conversion of aggregate forms was studied. Eight young adults with CF inhaled 100 mg of alpha(1)-PI twice daily over 8 weeks and bronchoalveolar lavages (BAL) were obtained before and 12 h after the last inhalation. Large aggregate (LA) forms of surfactant were isolated from the in vivo material by ultracentrifugation and their conversion into small aggregates (SA) was assessed by an in vitro surface area cycling assay. Although alpha(1)-PI partially restored the protease-anti-protease imbalance and reduced BAL protein content, no effects were noted on the impaired minimal surface tension and on the in vivo and in vitro conversion of LA to SA. Antiserum against the specific carboxyl esterase ES-2, previously identified in mice and rats as the putative surfactant convertase, did not detect a protein of the appropriate size in CF BAL. Whereas short-term inhalation of alpha(1)-PI was beneficial for the proteolytic aspects of CF lung injury, this appeared not to be the case for surfactant conversion and surface activity.

Health effects of sulfur-related environmental air pollution: the pulmonary surfactant system is not disturbed by exposure to acidic sulfate and neutral sulfite aerosols.

The goal of this study was to assess the impact of long-term exposure to environmental sulfur-related aerosols on the biochemical and biophysical properties of lung surfactant. Eight Beagle dogs were housed under clean air conditions for 450 days, followed by an exposure period of 400 days to 0.36 mg/m3 of sulfite (16.5 h/d) and to 5.66 mg/m3 of sulfate (6 h/d) equivalent to a pulmonary hydrogen burden of 15 mumol/m3. Other dogs kept in clean air for the whole study period were additional controls. Serial bronchoalveolar lavages (BALs) were analyzed for total phospholipid concentration, content and ratio of a surfactant-rich large aggregate (LA) fraction and a small aggregate (SA) fraction, in vitro surface area cycling of LAs into SAs as a measure of alveolar extracellular pulmonary surfactant aggregate metabolism, and surface activity of native and lipid-extracted LA. No significant changes over time and no differences between the clean air period and the exposure period were observed. Thus, long-term environmental exposure of dogs to the sulfur-related air pollution tested does not lead to alterations in the amount, extracellular metabolism, or surface-active properties of pulmonary surfactant.

Amphotericin B and pulmonary surfactant.

Targeted intrapulmonary delivery of drugs may reduce systemic toxicity, improve treatment efficacy, but inhaled drugs may also interfere with pulmonary surfactant function. We hypothesized that the lipophilic drug amphotericin B used to treat or prevent pulmonary infections with aspergillus species, might destroy surface activity of lung surfactant, as assessed in a pulsating bubble surfactometer. Pure amphotericin B had no effect on a natural surfactant preparation or on the lipid extracted surfactant SurvantaTM. However, amphotericin BTM (containing deoxycholic acid) or deoxycholic acid alone inhibited surfactant surface activity dose dependently and perturbed lipid organization. AmbisomeTM containing amphotericin B associated with liposomes, only marginally affected surfactant function. Intrapulmonary delivery of large amounts of amphotericin BTM has to consider the potential of interferences with lung surfactant function.

Tracheobronchial surface active material in cystic fibrosis.

Surface active material potentially present in the airway is difficult to analyse due to the tight binding of surfactant components to mucins. A surface active sol-fraction was obtained from sputum of patients with cystic fibrosis (CF), analysed and compared with the sol-fraction from sputum of tracheomized, non-CF patients. The release of phospholipids from CF sputum was relatively fast being completed within minutes, temperature dependent and averaged 5.6 +/- 2.2% of total phospholipid mass. In comparison to sputum, the phospholipid composition of the sol fraction was the same except for a lower percentage of phosphatidylethanolamine, which is usually found primarily cell membrane associated. The sol-fraction from the CF patient group had a lower percentage of phosphatidylcholine and about 3 times more surfactant protein A than that from the non-CF patients. Surface activity did not differ between CF and non-CF samples. Of interest, the adsorption rate (gamma ads, about 30-35 mN/m) and the minimal surface tension (gamma min, about 20-25 mN/m) were relatively low. These data support the hypothesis that surface active material can be released from sputum and that it might support its transport by reducing mucus adhesiveness to the airways.

Clinical evaluation of heat-pressed glass-ceramic inlays in vivo: 2-year results.

In the present study, the 2-year clinical and scanning electron microscope (SEM) results for heat-pressed ceramic inlays are reported. In a selected patient population, 51 cavities were restored with all-ceramic inlays. All margins were located within the enamel. The inlays were luted to the cavities with a high-viscosity, dual-cure luting composite. After 2 days, 1 year, and 2 years, the restorations were evaluated clinically, using the modified USPHS criteria. Quantitative margin analysis was performed in the SEM on the replicas fabricated at the recall times. The data were tested for significant differences, using the chi-square test for the clinical evaluation and the Mann-Whitney U-test for the margin analysis. After 2 years, the clinical evaluation of the margin adaptation revealed Bravo ratings for 14 restorations (27.5%); 37 restorations (72.5%) were rated Alfa. Compared to the baseline data, this difference was statistically significant (p < or = 0.5). SEM analysis revealed that the ceramic-composite interface exhibited significantly (p < or = 0.01) more gap formation than the enamel-composite interface at all times of evaluation. Wear of the luting composite could be determined along 50% of the restoration interface during the first year, 53% during the second year. The inlay restorations controlled in this study perform well after a period of 2 years.

Recombinant human DNase (rhDNase) influences phospholipid composition, surface activity, rheology and consecutively clearance indices of cystic fibrosis sputum.

Cystic fibrosis (CF) is caused by mutation in the gene for the CF transmembrane conductance regulator which leads to massive, abnormally viscous, purulent sputum, chronic destructive endobronchitis and early death. Purified recombinant human (rh) DNase can digest extracellular DNA and its inhalation in these patients significantly improves lung function. To evaluate the poorly understood mechanisms, saliva protected sputum from patients treated with and without rhDNase were evaluated. Therapy with rhDNase resulted in a soluble sputum fraction that had a higher percentage of phosphatidylethanolamine, a phospholipid present mainly in cellular membranes, a much lower percentage of phosphatidylcholine, but a higher surface activity. The rigidity was significantly lower and the ratio of viscosity in proportion to elasticity increased. All these data are consistent with an increased clearability of the sputum by coughing, but not by mucociliary activity. Thus the interaction of inhaled rhDNase with the purulent mucus and the endobronchial inflammatory processes may induce changes that result in rheological properties favoring clearance of sputum by cough.