Effective treatment of steroid-resistant immune checkpoint inhibitor pneumonitis with mycophenolate mofetil.

Insufficient evidence is available for treating steroid-resistant immune checkpoint inhibitor pneumonitis (CIP). Although guidelines recommend the use of immunosuppressants, the efficacy of mycophenolate mofetil (MMF) has not been sufficiently verified. We report two cases of steroid-resistant CIP treated with MMF. Both patients responded to initial treatment with prednisolone (PSL), but the CIP flared up repeatedly as the steroids were gradually tapered off. Upon receiving MMF in addition to PSL, their subjective symptoms improved, and the shadows gradually disappeared, allowing for a reduction in the steroid dose. Ultimately, no CIP recurrence was observed despite discontinuing PSL and MMF. Both cases were completely resolved by treatment with MMF. This indicates that MMF may be effective in treating steroid-resistant CIP. In the future, the effects and safety of MMF should be investigated in large-scale clinical trials targeting patients with steroid-resistant CIP.

Finger sweating levels evaluated by video capillaroscopy system are increased in patients with systemic sclerosis compared to pre-clinical stage patients.

New strategies for early diagnosis and careful follow-up of systemic sclerosis are urgently needed. We unconventionally used a video capillaroscopy system to measure the amount of sweating on finger pads, and investigated its clinical significance. Thirty-three Japanese patients who were diagnosed with typical or pre-clinical stage patients of systemic sclerosis were included in this study. Five healthy subjects were also included. Among twenty-one patients with typical systemic sclerosis that fulfilled ACR/EULAR 2013 classification criteria, seven had increased sweating levels. On the other hand, among twelve pre-clinical stage patients that did not fulfill the classification criteria, no patient showed increase in finger sweating. We found that there was statistically significant difference. The ratio of diffuse cutaneous systemic sclerosis was also found to be significantly higher in subjects with increased amounts of sweating than in subjects with normal levels. Furthermore, the positivity of topoisomerase I antibody was statistically higher in patients with increased sweating levels than in those without. These results indicated that measurement of finger sweating levels may be a useful tool for early diagnosis and clarification of pathogenesis in this disease.

Residual salivary secretion ability may be a useful marker for differential diagnosis in autoimmune diseases.

BACKGROUND: We have elucidated decreased resting salivary flow in approximately 60% of patients with autoimmune diseases not complicated by Sjögren syndrome (SjS). In this study, salivary stimulation tests using capsaicin were performed to examine residual salivary secretion ability in patients with autoimmune diseases. MATERIALS AND METHODS: Fifty-eight patients were divided into three groups: patients with primary or secondary SjS (SjS group), patients with systemic sclerosis not complicated by SjS (SSc group), and patients with other autoimmune diseases (non-SjS/non-SSc group). Simple filter paper and filter paper containing capsaicin were used to evaluate salivary flow rates. RESULTS: Resting salivary flow rates were significantly lower in the SjS and SSc groups than in the non-SjS/non-SSc group but did not differ significantly between the SjS and SSc groups. Capsaicin-stimulated salivary flow rates were significantly lower in the SjS and SSc groups than in the non-SjS/non-SSc group, but not significantly different between the SjS and SSc groups. In the non-SjS/non-SSc group, salivary flow rates increased after capsaicin stimulation to the threshold level for determination of salivary gland dysfunction, whereas no improvement was observed in the SjS and SSc groups. CONCLUSION: Residual salivary secretion ability may be a useful marker for differential diagnosis in autoimmune diseases.

Relationship between alveolar nitric oxide concentration in exhaled air and small airway function in COPD.

Nitrative stress is thought to be involved in the inflammatory process in COPD airways, and the alveolar nitric oxide concentration (CAlv) has been reported to be increased. However, the CAlv levels are also regulated by gas diffusion at alveolar sites. The aim of the study was to assess the relationship between the CAlv and pulmonary function in COPD patients, while taking into account the lung diffusion capacity. Twenty stable COPD patients (GOLD stage1/2/3/4 = 6/8/6/0) and 16 healthy subjects took part in this cross-sectional study. Fractional exhaled nitric oxide (FE(NO)), CAlv, and pulmonary functions were measured. Pulmonary function, including single nitrogen washout curve (dN2) and diffusion capacity for carbon monoxide (DL(CO)), was also evaluated in patients with COPD. The mean FE(NO) levels (20.7 ppb versus 16.3 ppb, p < 0.05) and the mean CAlv levels (6.4 ppb versus 4.2 ppb, p < 0.01) in COPD patients were significantly increased compared to those in HS. The CAlv level in COPD was significantly correlated with dN2, %DL(CO)/alveolar volume (VA). Using the standard entry method of multivariate analysis to adjust for dN2 and %DL(CO)/VA, dN2 (ß = 0.54, p = 0.005) and %DL(CO)/VA (ß = -0.44, p = 0.018) still showed significant correlations with the CAlv levels. These results suggest that the CAlv could be a useful marker for the small airway dysfunction in COPD. Airway inflammation, including excess nitric oxide generation in the peripheral airways, might be related to the pathophysiology of COPD.

Persistent elevation of exhaled nitric oxide and modification of corticosteroid therapy in asthma.

BACKGROUND: Persistent airway inflammation, detected by fractional exhaled nitric oxide (FENO), is occasionally observed in asthmatic patients, even in those treated with inhaled corticosteroids (ICS). However, improvement in residual airway inflammation and pulmonary function through modification of corticosteroid therapy has not been proven. METHODS: Thirteen asthmatic patients whose FENO levels were over 40 parts per billion (ppb), despite dry-powder ICS therapy, were enrolled. A 3-step change in steroid treatment was undertaken until FENO was less than 40ppb. In the first step, the powder formula was changed to an ultra-fine particle compound as an equipotent ICS dose. In the second step, the ICS dose was doubled. In the third step, oral corticosteroids were added. We measured pulmonary function and FENO and alveolar NO concentrations (CAlvNO). RESULTS: Doubling the ICS dose and changing the ICS formula significantly improved FVC (p<0.001), FEV1 (p<0.05), the slope of the single nitrogen washout curve (dN2) (p<0.01), FENO (p<0.001), and CAlvNO (p<0.05), relative to baseline. The reductions in FENO were significantly associated with the improvement in airflow limitation assessed by dN2 (r=0.73, p=0.007). The remaining FENO elevation, even after doubling the ICS dose, did not decrease after oral corticosteroid administration. CONCLUSIONS: These results suggest that modification of ICS therapy can suppress residual FENO elevation, and that reduction in FENO levels is associated with improvement in airflow limitation. However, steroid-resistance mechanisms may exist in some asthmatic patients with sustained FENO elevations.

[Case of successful pregnancy and childbirth in a rheumatoid arthritis patient treated with etanercept].

The patient was a 34-year-old woman who, at age 23, was diagnosed with rheumatoid arthritis (RA) presenting with morning stiffness, swelling and tenderness of bilateral knee joints and metacarpophalangeal (MP) joints of the right second and third fingers, increased C-reactive protein (CRP) levels, and a high level of rheumatoid factor (RF). The patient was maintaining remission with oral dose of bucillamine (BUC; 300 mg/day); however, due to the deterioration of arthralgia at age 26, she was additionally administered 8 mg/week of methotrexate (MTX), which improved the symptoms. Thereafter, the prescription of BUC was discontinued. At age 31, she experienced onsets of swelling and tenderness in both the knee joints and wrists and in MP joints of the right second and third fingers; further, CRP levels increased to 5.44 mg/dL, resulting in increased RA activity. The concomitant administration of infliximab was started at a dose of 3 mg/kg, which helped achieve favorable RA control. At age 32, approximately 2 years before childbirth, the prescription of infliximab was changed to 25 mg/dose of etanercept administered twice a week because the patient wished to conceive. Remission was maintained even after the drug change; therefore, MTX was discontinued and the patient was treated with etanercept alone. After she was confirmed to be pregnant in March of the following year, administration of etanercept was continued for treating of RA even during pregnancy. During that time, RA was favorably controlled, and the patient gave birth to a baby boy weighing 3192 g in October of the same year. The Apgar score of the baby was favorable. This case is considered important because, to the best of our knowledge, this may be the first report of a planned pregnancy and childbirth in a patient under administration of a biological preparation.

Hyposalivation in autoimmune diseases.

We have investigated the prevalence of dry mouth among patients with autoimmune diseases other than Sjögren's syndrome. One hundred and forty-four patients, excluding patients with primary Sjögren's syndrome, were enrolled in this study. The volume of saliva secreted was measured with the screening technique for estimation of salivary flow, which uses a filter paper for diagnosing dry mouth. Disturbed salivary secretion was observed in 84 (58.3 %) of the 144 patients. In the case of patients free of Sjögren's syndrome, the prevalence of disturbed salivary secretion differed significantly among the disease groups (P < 0.05), with the prevalence being over 50 % in all disease groups other than the rheumatoid arthritis group and the highest in the systemic sclerosis group. There was significant positive correlation between the number of colored spots and oral visual analog scale score (r = 0.45, P < 0.0001). Autoimmune diseases can be accompanied by salivary gland dysfunction, regardless of the presence/absence of complication by Sjögren's syndrome. In the present study, the screening technique for estimation of salivary flow, which uses a filter paper for diagnosing dry mouth, was shown to be a useful means of detecting salivary gland dysfunction.

A case of fibromyalgia syndrome with anaphylaxis induced by intradermal injection of purified protein derivative.

When a 36-year-old woman with fibromyalgia syndrome (FMS) underwent the tuberculin test, urticaria developed on her trunk at 30 min after intradermal injection of purified protein derivative. Although the urticaria resolved, fever, facial edema, and generalized urticaria occurred after 8 h. A patient with FMS who developed a systemic allergic reaction after an intradermal skin test has not been reported. We should pay attention to anaphylactic reactions after intradermal injection in patients with FMS.

25-Hydroxycholesterol enhances cytokine release and Toll-like receptor 3 response in airway epithelial cells.

BACKGROUND: 25-hydroxycholesterol (25-HC) is one of the oxysterols, which are oxidized derivatives of cholesterol, and has been reported to be involved in the pathogenesis of atherosclerosis and Alzheimer's disease. In lung, the possible involvement of 25-HC in airway diseases has been revealed. In the present study, we examined whether 25-HC affects the release of cytokines and also modulates the responses of toll-like receptor 3 (TLR3) in airway epithelial cells. METHODS: The effect of 25-HC on the release of cytokines from primary human bronchial epithelial cells after stimulation with or without polyinosine-polycytidylic acid [poly(I:C)], a ligand for TLR3, and the signal transduction were examined. RESULTS: 25-HC significantly potentiated the release of interleukin-8 (IL-8) and IL-6 from the cells. This effect was more potent compared with that of other oxysterols, 22-HC and 27-HC. GW3965 and TO901317, synthetic agonists of liver X receptors that are receptors for oxysterols, did not augment the IL-8 release. 25-HC enhanced the nuclear factor-kappa B (NF-κB) DNA binding activity and translocation of phosphorylated c-Jun into the nucleus. The release of IL-8 was inhibited by the NF-κB inhibitor, caffeic acid phenethyl ester (CAPE), an inhibitor of nuclear factor kappa-B alpha (IκBα) inhibitor, BAY 11-7085, and an inhibitor of nuclear factor kappa-B kinase-2 (IKK-2) inhibitor, SC-514, but not by a c-Jun N-terminal kinase (JNK) inhibitory peptide, L-JNKi1. 25-HC significantly potentiated IL-8 release in poly(I:C)-treated cells and the augmentation was inhibited by CAPE, BAY 11-7085, and SC-514. Furthermore, 25-HC potentiated the translocation of interferon regulatory factor 3 into the nucleus and the release of interferon-beta (IFN-ß) in poly(I:C)-treated cells. CONCLUSIONS: These data demonstrated that 25-HC augments the release of IL-8 and IL-6 via NF-κB signalling pathway and enhances the release of IL-8 and IFN-ß after stimulation of TLR3 in airway epithelial cells. 25-HC may be involved in the neutrophilic airway inflammation through the stimulant effect of IL-8 and IL-6 release and also potentiate the TLR3-mediated innate immunity in airway diseases.

Inhibitory effects of theophylline on the peroxynitrite-augmented release of matrix metalloproteinases by lung fibroblasts.

The anti-inflammatory effects of theophylline have been reported to include inhibition of the release of proinflammatory mediators from macrophages and neutrophils. Overproduction of reactive nitrogen species (RNS) has been reported in the airways of patients with chronic obstructive pulmonary disease (COPD), and this causes tissue inflammation and injury. We investigated whether peroxynitrite stimulated the release of matrix metalloproteinases 2 and 9 (MMP-2 and -9; gelatinases) from human fetal lung fibroblasts (HFL-1 cell line) and whether theophylline inhibited the peroxynitrite-augmented release of MMPs. HFL-1 cells and primary lung fibroblasts were treated with peroxynitrite (an RNS), and gelatinases levels were evaluated by gelatin zymography. The inhibitory effect of theophylline on the peroxynitrite-augmented release of MMP-2 and MMP-9 was also investigated. To explore the cell signaling pathways involved in the peroxynitrite-induced gelatinases release and the inhibitory effect of theophylline, transforming growth factor-ß(1) (TGF-ß(1)), nuclear factor-κB (NF-κB), and histone deacetylase (HDAC) were measured. Peroxynitrite significantly augmented the release of MMP-2 and MMP-9 by fibroblasts (P < 0.01), as well as TGF-ß(1) release (P < 0.01), NF-κB activation (P < 0.01), and HDAC2 inactivation (P < 0.01). An NF-κB inhibitor diminished the RNS-augmented release of MMPs and TGF-ß(1) (P < 0.01), and a neutralizing TGF-ß antibody also diminished MMP release (P < 0.01). Theophylline significantly inhibited the peroxynitrite-augmented release of MMP-2 and MMP-9 in HFL-1 cells and normal adult lung fibroblasts, and it also inhibited the peroxynitrite-mediated HDAC2 inactivation, NF-κB activation, and TGF-ß(1) release in HFL-1 cells (all P < 0.01). These results suggest that peroxynitrite can influence tissue remodeling by promoting gelatinases release, while theophylline suppresses peroxynitrite-induced tissue remodeling via pathways involving NF-κB/TGF-ß(1) and/or HDAC in the HFL-1 cell line.

Increase of 27-hydroxycholesterol in the airways of patients with COPD: possible role of 27-hydroxycholesterol in tissue fibrosis.

BACKGROUND: 27-Hydroxycholesterol (27-OHC) is produced from cholesterol by sterol 27-hydroxylase as an intermediate in the biosynthesis pathway of bile acid. Recently, 27-OHC was reported to cause inflammation and apoptosis in various types of cells. The aim of this study was to assess the production of 27-OHC in the airways of patients with COPD and to elucidate the possible role of 27-OHC in the tissue fibrosis of COPD. METHODS: Lung tissues were obtained from six control subjects and six patients with COPD, and sputum samples were obtained from 11 healthy subjects and 15 patients with COPD. The expression of sterol 27-hydroxylase in the lung was investigated by immunohistochemistry. The amounts of 27-OHC in the sputum were quantified by the liquid chromatography-tandem mass spectrometry method. Because peribronchial fibrosis in peripheral airways is involved in the airflow limitation of COPD, we investigated the profibrotic effects of 27-OHC in vitro. RESULTS: The expression of sterol 27-hydroxylase was significantly enhanced in the lung tissues of patients with COPD compared with control subjects. The amounts of 27-OHC in the sputum were significantly increased in the patients with COPD (P < .01), and the degree of 27-OHC production was negatively correlated with lung function (P < .01). 27-OHC augmented the differentiation of lung fibroblasts into myofibroblasts and the production of extracellular matrix protein through activation of nuclear factor-κB and subsequent transforming growth factor-ß(1) upregulation. CONCLUSIONS: 27-OHC production is enhanced in the airways of patients with COPD and might be involved in the pathogenesis of COPD.

Increase of nitrosative stress in patients with eosinophilic pneumonia.

BACKGROUND: Exhaled nitric oxide (NO) production is increased in asthma and reflects the degree of airway inflammation. The alveolar NO concentration (Calv) in interstitial pneumonia is reported to be increased. However, it remains unknown whether NO production is increased and nitrosative stress occurs in eosinophilic pneumonia (EP). We hypothesized that nitrosative stress markers including Calv, inducible type of NO synthase (iNOS), and 3-nitrotyrosine (3-NT), are upregulated in EP. METHODS: Exhaled NO including fractional exhaled NO (FENO) and Calv was measured in ten healthy subjects, 13 patients with idiopathic pulmonary fibrosis (IPF), and 13 patients with EP. iNOS expression and 3-NT formation were assessed by immunocytochemistory in BALf cells. The exhaled NO, lung function, and systemic inflammatory markers of the EP patients were investigated after corticosteroid treatment for 4 weeks. RESULTS: The Calv levels in the EP group (14.4 ± 2.0 ppb) were significantly higher than those in the healthy subjects (5.1 ± 0.6 ppb, p < 0.01) and the IPF groups (6.3 ± 0.6 ppb, p < 0.01) as well as the FENO and the corrected Calv levels (all p < 0.01). More iNOS and 3-NT positive cells were observed in the EP group compared to the healthy subject and IPF patient. The Calv levels had significant positive correlations with both iNOS (r = 0.858, p < 0.05) and 3-NT positive cells (r = 0.924, p < 0.01). Corticosteroid treatment significantly reduced both the FENO (p < 0.05) and the Calv levels (p < 0.01). The magnitude of reduction in the Calv levels had a significant positive correlation with the peripheral blood eosinophil counts (r = 0.802, p < 0.05). CONCLUSIONS: These results suggested that excessive nitrosative stress occurred in EP and that Calv could be a marker of the disease activity.

Multiple symptoms of higher brain dysfunction caused by Marchiafava-Bignami disease in a patient with dermatomyositis.

A 65-year-old woman with dermatomyositis (DM) was admitted because of disorientation, mental dysfunction, and disturbance of consciousness. Prior to admission, she suffered from septic and hypovolemic shock. There was no evidence of active DM on physical examination and laboratory tests. Cerebrospinal fluid examination revealed no signs of meningitis. Because of clinical symptoms and findings on magnetic resonance images, such as the lesion in the splenium of the corpus callosum that was a low-intensity area on T1-weighted images and a high intensity on T2-weighted images; she was diagnosed as Marchiafava-Bignami disease (MBD). She received a combination of vitamin B, vitamin E, vitamin C, and nicotinic acid. Her symptoms improved gradually, and she was discharged at 1.5 months after admission. There has been no report of a case of DM with MBD. This report may provide useful data with regard to the mechanisms of central nervous system (CNS) disorders in patients with DM.

Peroxynitrite augments fibroblast-mediated tissue remodeling via myofibroblast differentiation.

Irreversible airflow limitation in asthma is associated with airway remodeling in which the differentiation of fibroblasts to myofibroblasts plays a pivotal role. In asthmatic airways, excessive production of reactive nitrogen species (RNS) has been observed. The aim of this study is to evaluate whether peroxynitrite, one of the RNS, can affect the differentiation of fibroblasts to myofibroblasts. Human fetal lung fibroblasts were treated with various concentrations of authentic peroxynitrite or a peroxynitrite donor 3-morpholinosydnonimine hydrochloride (SIN-1), and the expressions of alpha-smooth muscle actin (alpha-SMA) and desmin, markers of myofibroblast differentiation, were evaluated. The releases of transforming growth factor-beta(1) (TGF-beta(1)) and ECM proteins including fibronectin and collagen I were assessed. To clarify the mechanism in this differentiation, the effect of anti-TGF-beta antibody or NF-kappaB inhibitors on the alpha-SMA expression and ECM production was assessed. Peroxynitrite and SIN-1 significantly augmented the alpha-SMA expression compared with control in a concentration-dependent manner (P < 0.01 and P < 0.05, respectively). Peroxynitrite significantly increased desmin and TGF-beta(1) production (P < 0.01). Peroxynitrite enhanced the translocation of NF-kappaB into the nucleus confirmed by immunocytostaining and immunoblotting. Peroxynitrite-augmented alpha-SMA expression was blocked by NF-kappaB inhibitors, MG132 and caffeic acid phenethyl ester (CAPE), and anti-TGF-beta antibody. CAPE completely inhibited the peroxynitrite-augmented TGF-beta(1) release. The production of fibronectin and collagen I was significantly increased by peroxynitrite (P < 0.01) and inhibited by anti-TGF-beta antibody. These results suggest that RNS can affect the differentiation to myofibroblasts and excessive ECM production via a NF-kappaB-TGF-beta(1)-dependent pathway.

Infectious mononucleosis-like syndrome induced by salazosulfapyridine in a patient with rheumatoid arthritis.

We describe a 43-year-old woman with rheumatoid arthritis (RA), who developed severe infectious mononucleosis (IM)-like syndrome during treatment with salazosulfapyridine (SASP). She presented with fever, skin rash, lymphadenopathy, and hepatosplenomegaly. Laboratory tests revealed a marked increase of atypical lymphocytes in the peripheral blood and biphasic hepatic dysfunction. IM-like syndrome can be caused by various drugs, including SASP, and the concept of drug-induced hypersensitivity syndrome has been proposed recently. IM-like syndrome due to SASP has been reported in patients taking higher dosages for the treatment of inflammatory bowel disease, but has not been reported earlier in patients with RA. The results of the drug-induced lymphocyte stimulation test tests suggested that 5-aminosalicylic acid was a possible causative metabolite. This severe type of drug-induced hypersensitivity reaction mimicking IM due to SASP should be granted wider awareness in the field of rheumatology, because the drug is widely used for the treatment of RA.

A case of polymyositis with a significantly high level of KL-6 associated with pancreatic cancer.

A 53-year-old man was diagnosed with polymyositis (PM) in 1997 and treated with prednisolone. The subjective symptoms of pneumonitis were poor. However, the KL-6 values were elevated to 2230 IU/l in March 2001. Abdominal computer tomography findings revealed a pancreatic-tail tumor and multiple liver nodules, diagnosed as primary pancreatic adenocarcinoma with multiple liver metastasis. The stage of the pancreatic cancer was IV, and curative surgery of the tumor was not indicated. Chemotherapy and radiotherapy were administered for the liver metastasis. However, these therapies were ineffective against the tumors. The patient died on 12 September 2001. If a high level of KL-6 is found without the increasing activity of lung disease containing interstitial pneumonia in PM patients, examination for the internal malignancies including pancreatic cancer should be performed, although cases of PM with a significantly high level of KL-6 associated with pancreatic cancer are rare.