Muscle Biopsy-proven Drug-induced Microscopic Polyangiitis in a Patient with Tuberculosis.

We herein report a case of muscle biopsy-proven microscopic polyangiitis (MPA) in a patient with tuberculosis. The patient had developed a persistent fever after the initiation of treatment for tuberculosis and was positive for myeloperoxidase-antineutrophil cytoplasmic antibody (ANCA). However, because conventional symptoms were lacking, determination of the biopsy site was difficult. Based on the findings of a biopsy of the biceps femoris, which confirmed small vessel vasculitis, the patient was diagnosed with MPA. The fever was alleviated by glucocorticoids. Tuberculosis and antituberculosis drugs can cause ANCA-associated vasculitis (AAV). A muscle biopsy is useful for the diagnosis of AAV.

Fibroblast-epithelial cell interactions drive epithelial-mesenchymal transition differently in cells from normal and COPD patients.

BACKGROUND: Epithelial-to-mesenchymal transition (EMT), which involves changes in cellular morphology of highly polarized epithelial cells and the gain of mesenchymal cell phenotype with migratory and invasive capacities, is implicated in smoking-related chronic obstructive pulmonary disease (COPD). However, the interactions of fibroblasts and epithelial cells and the participation of fibroblasts in the EMT processes in COPD are poorly understood. Here, we investigated the hypothesis that EMT is active in human bronchial epithelial (HBE) cells of COPD patients, and that mediators secreted by lung fibroblasts from COPD patients induce EMT. METHODS: Primary HBE cells from normal subjects and COPD patients were purchased from LONZA. HLFs were derived from resected lung obtained from normal (N) and COPD (D) subjects and their conditioned medium (CM) was collected after 2-day culture in serum-free medium. The expression of epithelial and mesenchymal markers as well as EMT-related transcription factors in lung biopsies, and in HBE cells following stimulation with CM from both normal human lung fibroblasts (NHLF) and COPD human lung fibroblasts (DHLF) was evaluated by immunohistochemistry, qRT-PCR and western blot. RESULTS: Basal mRNA expression of mesenchymal markers and EMT-related transcription factors were increased in DHBE cells compared to normal human bronchial epithelial cells (NHBE) cells as well as in COPD lungs. CM from NHLF significantly induced vimentin expression in both NHBE and COPD human bronchial epithelial cells (DHBE) cells, but only increased N-cadherin expression in DHBE cells. CM from NHLF significantly induced Twist1 and Twist2 expression in NHBE cells and increased Snai2 (Slug) expression in DHBE cells. While CM from NHLF had no effect on such EMT markers, CM from DHLF significantly increased the protein expression of E-cadherin and vimentin in NHBE cells compared to control. N-cadherin expression was upregulated to a greater degree in NHBE cells than DHBE cells. Only CM from DHLF significantly increased E-/N-cadherin ratio in DHBE cells. CONCLUSIONS: Our results suggest that DHBE cells have partially undergone EMT under baseline conditions. DHLF-CM promoted EMT in NHBE, suggesting that interactions between fibroblast and epithelial cells may play an important role in the EMT process in COPD.

Potential role of pentosidine on susceptibility to small airway closure in elderly and smoking asthma.

BACKGROUND: Small airway closure in asthma is determined by a complex interaction of structural and functional characteristics including lung elastic recoil. Recently, we determined that loss of elastic recoil might be attributable to pentosidine level in the airways. This study was designed to investigate the influences of aging and smoking on small airway closure in asthma. METHODS: Sixty-one patients with asthma (20 non-smoking young adult, 23 non-smoking elderly, and 18 smoking young adult) and 36 control subjects (12 non-smoking young adult, 11 non-smoking elderly, and 13 smoking young adult) were included. We assessed airway responses during methacholine provocation and calculated the closing index. In addition, we measured pentosidine levels in induced sputum from all study subjects. RESULTS: Pentosidine levels in induced sputum were markedly higher in asthmatic patients than in controls. In control subjects, the intergroup differences in pentosidine level among 3 subgroups were significant. Similarly, pentosidine levels were significantly higher in non-smoking elderly and smoking young adult asthmatics than in non-smoking young adult asthmatics. There was no significant difference in pentosidine levels between non-smoking elderly and smoking young adult asthmatics. The closing index was also significantly higher in non-smoking elderly and smoking young adult asthmatics than in non-smoking young adult asthmatics. Moreover, pentosidine levels in non-smoking elderly and smoking young adult asthmatics were closely correlated with closing index. CONCLUSIONS: We determined the correlation of pentosidine level with susceptibility to small airway closure in elderly and smoking asthmatics. Our results might facilitate the understanding of elderly and smoking asthma.

Dose escalation and feasibility study of amrubicin combined with cisplatin in previously untreated patients with advanced non-small cell lung cancer.

OBJECTIVES: Cisplatin is a key drug used in the treatment of non-small cell lung cancer (NSCLC), and amrubicin is one of the new active agents for NSCLC. The objective of this study was to determine the recommended dose (RD) of amrubicin in combination with a fixed dose of cisplatin, and to assess the toxicity profile and feasibility of this regimen. METHODS: We conducted a dose escalation study of amrubicin and cisplatin in previously untreated patients with stage IIIB or IV NSCLC. Dose level 1 of amrubicin was 30 mg/m on days 1 to 3 and level 2 was 35 mg/m. Cisplatin was administered at a fixed dose of 80 mg/m on day 1. Chemotherapy was given in a 3-week cycle. RESULTS: Twenty patients were enrolled. Dose-limiting toxicities were neutropenia, febrile neutropenia, thrombocytopenia, and creatinine elevation. Level 1 (30 mg/m) was determined to be the RD, and 35 mg/m exceeded the RD. In 17 patients treated with the RD, the overall response rate was 41.2% (95% confidence interval, 17.7-64.7) and the median survival time was 16.4 months (95% confidence interval, 13.1-19.5). CONCLUSIONS: This amrubicin and cisplatin regimen may be feasible and promising against advanced NSCLC. The efficacy and safety of this regimen should be confirmed in a phase II study.

Measurement of soluble perforin, a marker of CD8+ T lymphocyte activation in epithelial lining fluid.

BACKGROUND: CD8(+) T lymphocytes in the peripheral airways have been suggested to be involved in the pathogenesis of COPD. However, the significance of CD8(+) T lymphocyte activation in COPD is not well understood. A biomarker of CD8(+) T lymphocyte activation in patients with COPD is required. METHODS: Thirty COPD patients and twenty-one healthy controls (eleven ex-smokers and ten who had never smoked or were light ex-smokers) were included in this study. We separately obtained epithelial lining fluid (ELF) from central and peripheral airways using a bronchoscopic microsampling technique. Levels of perforin in ELF were measured and we examined correlations between its values and patients characteristics including pulmonary function. RESULTS: Perforin levels in both the central and peripheral airways in COPD patients were significantly higher than those in the healthy control groups. In the healthy control groups, there was no significant difference in perforin levels between central and peripheral airways. However, in COPD patients, perforin levels in peripheral airways were significantly higher than those in central airways. Perforin levels in peripheral airways were significantly correlated with FEV(1) (percent predicted), FEV(1)/FVC, and DLco (percent predicted) in COPD patients. CONCLUSION: The microsampling technique is safe and useful for separately obtaining ELF from central and peripheral airways. Levels of perforin in ELF from peripheral airways were significantly increased and correlated with the degree of pulmonary dysfunction. Perforin might reflect inflammation involving CD8(+) T-lymphocytes. This novel biomarker might enable better understanding of the pathogenesis of COPD.

Comparison of alveolar nitric oxide concentrations using two different methods for assessing small airways obstruction in asthma.

BACKGROUND AND OBJECTIVE: Fractional exhaled nitric oxide (F(E) NO) is considered a potentially useful biomarker for airway inflammation. A two-compartment model (2CM) of pulmonary NO dynamics has been used for the evaluation of bronchial NO flux (J'awNO) and alveolar NO concentration (C(A) NO) in asthmatic patients. Recently, the trumpet shape of the airway tree and axial diffusion (TMAD) model has been reported as a modification of the 2CM. This study was designed to determine the validity of C(A) NO measurement using the TMAD model for assessing small airways inflammation in asthma. METHODS: A total of 52 asthmatic patients and 12 normal control subjects were included in the study. Methacholine inhalation challenge and pulmonary function tests, sputum induction, and exhaled NO measurements at several flow rates were performed. J'awNO and C(A) NO were calculated using both the 2CM (C(A) NO( 2CM) , J'awNO( 2CM) ) and TMAD models (C(A) NO( TMAD) , J'awNO( TMAD) ). RESULTS: Both J'awNO (J'awNO( 2CM) and J'awNO( TMAD) ) and C(A) NO (C(A) NO( 2CM) and C(A) NO( TMAD) ) were significantly higher in asthmatic patients than in control subjects. C(A) NO( 2CM) was significantly correlated with FEV(1) /FVC (r = -0.35, P = 0.01), FEF(25-75) (r = -0.45, P < 0.001) and sputum eosinophils (r = 0.32, P = 0.02). In contrast, C(A) NO( TMAD) was significantly correlated with FEF(25-75) (r = -0.42, P = 0.002) but not with FEV(1) /FVC or sputum eosinophils. CONCLUSIONS: C(A) NO( TMAD) is more specific as an indicator of small airways obstruction than C(A) NO( 2CM) . Assessment of small airways obstruction using the TMAD model may clarify the role of the small airways in the pathogenesis of asthma.

Potential roles of pentosidine in age-related and disease-related impairment of pulmonary functions in patients with asthma.

BACKGROUND: Pentosidine is well established as an intermolecular cross-linking type of advanced glycation end products, and it accumulates with aging in various connective tissues. OBJECTIVE: To determine whether pentosidine contributes to age-related and disease-related impairment of pulmonary functions in patients with asthma. METHODS: We measured pentosidine levels in induced sputum from young to elderly patients with asthma and assessed the slope of the nitrogen (N(2)) alveolar plateau (delta N(2)), closing volume (CV), and closing capacity (CC) from a nitrogen washout curve in a single breath. RESULTS: Pentosidine levels in induced sputum were significantly higher in patients with asthma than in normal controls (patients with asthma: median, 20.1, interquartile range, 16.7-26.5 ng/mL; normal controls: median, 3.0, interquartile range, 0.7-7.5 ng/mL; P < .001). The levels were closely correlated with age in both normal controls and patients with asthma. However, the slope of age-related increase in pentosidine levels was markedly steeper in patients with asthma than in normal controls. CV/vital capacity, CC/total lung capacity, and delta N(2) increased with aging in both normal controls and patients with asthma. Moreover, in each range of age (21-40, 41-60, 61-80 years), CV/vital capacity, CC/total lung capacity, and delta N(2) were significantly higher in patients with asthma than in normal controls. In addition, pentosidine levels in patients with asthma were closely correlated with each of these variables. CONCLUSION: Our results demonstrated the association between sputum levels of pentosidine and age-related small airways function in both normal controls and patients with asthma. Moreover, the age-related increase in pentosidine levels was more pronounced in patients with asthma. These findings will herald new era in the pathophysiology of elderly asthma.

Validity of measurement of two specific biomarkers for the assessment of small airways inflammation in asthma.

BACKGROUND: Small airways inflammation in asthma has been supposed to contribute to instability of the disease and therapy resistance. This study was designed to determine the validity of measurement of N(epsilon)-(carboxymethyl)lysine (CML) levels in induced sputum and alveolar concentrations of nitric oxide (NO) for the assessment of small airways inflammation in asthma. METHODS: The authors measured CML levels in induced sputum and the bronchial flux (Jno) and alveolar concentration (C(alv)) of NO in 37 asthmatic patients and 15 normal controls. After initial analysis, all asthmatics were randomly assigned to receive inhaled fluticasone propionate (FP; 400 microg/day, n = 21) or hydrofluoroalkane-beclomethasone dipropionate (HFA-BDP; 400 microg/day, n = 16) for 12 weeks. And then the determination of exhaled NO level and sputum induction was performed after the treatment period. RESULTS: CML levels in induced sputum were significantly higher in asthmatics than in normal controls (median [interquartile range], asthmatics: 53.0 [44.8-64.3] microg/ml, normal controls: 22.0 [14.8-28.3] microg/ml; p < .01). Similarly, Jno and C(alv) were also higher in asthmatics. Moreover, CML level was closely correlated with C(alv) but not with Jno in asthmatics (r = .47, p = .005). Jno was significantly correlated with forced expiratory volume in one second/forced vital capacity (FEV(1)/FVC), and CML level and C(alv) were correlated with forced expiratory flow between 25% and 75% of FVC (FEF(25-75)), an index of small airways obstruction. After FP treatment, the decrease in CML level and Calv were very small. In contrast, these levels were markedly decreased after HFA-BDP treatment. Moreover, even after FP or HFA-BDP treatment, CML level was significantly correlated with C(alv). CONCLUSIONS: This novel, noninvasive technique of measurement of CML levels in induced sputum and C(alv) may prove to be important not only in the evaluation of small airways inflammation but also in helping us move toward a better understanding of the roles of the small airways in the pathogenesis of asthma.

[Potential mechanisms of airway remodeling initiated by activated thrombin in asthma].

BACKGROUND: High expression of vascular endothelial growth factor (VEGF) induces subepithelial fibrosis associated with angiogenesis in asthma. Thrombin is recognized as a new candidate mediating airway remodeling. Therefore, this study was designed to determine the potential mechanisms of airway remodeling initiated by activated thrombin in asthma. METHODS: Levels of biochemical parameters in induced sputum were examined in 21 asthmatic patients and 11 normal controls. RESULTS: Thrombin activity in induced sputum was significantly higher in asthmatic patients than in normal controls (normal controls: median [range] 1.26 (0.93-2.42) U/mL; asthmatic patients: 3.67 (1.15-10.2) U/mL, p < 0.0001). VEGF level in induced sputum was positively correlated with thrombin activity in all study subjects. Levels of basic fibroblast growth factor (bFGF), which is a major profibrotic factor, were also significantly higher in asthmatic patients than in normal controls. Moreover, thrombin activity was significantly correlated with bFGF level in all study subjects. We also observed a significant correlation between bFGF and procollagen type III peptide level. CONCLUSION: Increase in VEGF level leads to up-regulation of thrombin activity in asthmatic airways, and this elevated thrombin activity induces elevation of bFGF level. It will become to be a new strategy of asthma therapy to attenuate thrombin activity for the regulation of airway remodeling.

Plasma concentration of amrubicinol in plateau phase in patients treated for 3 days with amrubicin is correlated with hematological toxicities.

Amrubicinol (AMR-OH) is an active metabolite of amrubicin (AMR), a novel synthetic 9-aminoanthracycline derivative. The time-concentration profile of AMR-OH exhibits a continuous long plateau slope in the terminal phase. To determine the relationships between the steady-state plasma concentration of AMR-OH and treatment effects and toxicities associated with AMR therapy, we carried out a pharmacokinetic/pharmacodynamic study in patients treated with AMR alone or the combination of AMR+cisplatin (CDDP). AMR was given at a dose of 30 or 40 mg/m(2) on days 1-3. Plasma samples were collected 24 h after the third injection (day 4). Plasma concentrations of AMR-OH or total CDDP were determined by a high-performance liquid chromatography or an atomic absorption spectrometry. Percent change in neutrophil count (dANC) and the plasma concentration of AMR-OH were evaluated using a sigmoid E(max) model. A total of 35 patients were enrolled. Significant relationships were observed between AMR-OH on day 4 and the toxicity grades of leukopenia, neutropenia, and anemia (P=0.018, P=0.012, and P=0.025, respectively). Thrombocytopenia grade exhibited a tendency toward relationship with AMR-OH on day 4 (P=0.081). The plasma concentration of AMR-OH on day 4 was positively correlated with dANC in the group of all patients, as well as in patients treated with AMR alone and in patients coadministered with CDDP. In conclusion, the plasma concentration of AMR-OH on day 4 was correlated with hematological toxicities in patients treated with AMR. The assessment of plasma concentration of AMR-OH at one timepoint might enable the prediction of hematological toxicities.

Phase II study of docetaxel and carboplatin in elderly patients with advanced non-small cell lung cancer.

BACKGROUND: Mainly single-agent chemotherapy has been considered as standard treatment for elderly patients with non-small cell lung cancer (NSCLC). Docetaxel monotherapy is regarded as a standard treatment for elderly patients with advanced NSCLC, and recent subset analyses have suggested that platinum-based chemotherapy can be safely used in the elderly. This phase II study was conducted to evaluate the efficacy and safety of docetaxel and carboplatin in elderly patients with advanced NSCLC. METHODS: Patients enrolled in this study had stage IIIB or IV NSCLC with measurable disease, no prior chemotherapy, Eastern Cooperative Oncology Group performance status of 0-2, and were 70 years or older. Treatment consisted of docetaxel at a dose of 60 mg/m(2) and carboplatin at area under the curve of 5 mg/ml/min on day 1 every 3 weeks. RESULTS: From October 2003 to April 2006, 30 patients were enrolled. One complete response and 13 partial responses were observed, for an overall response rate of 46.7% (95% confidence interval: 28.8-64.6%). Median progression-free survival and overall survival periods were 4.4 months and 9.9 months, respectively. One-year survival rate was 43.3%. Major grade 3 and 4 hematological toxicities included neutropenia (86.7%), leucopenia (80.0%) and febrile neutropenia (16.7%). Major grade 3 nonhematological toxicities were anorexia (30.0%) and diarrhea (13.3%). There were no grade 4 nonhematological toxicities or treatment-related deaths. CONCLUSIONS: Docetaxel combined with carboplatin was an active treatment with manageable toxicity for the treatment of elderly patients with chemotherapy-naive NSCLC.

A technological advance comparing epithelial lining fluid from different regions of the lung in smokers.

Cigarette smoking causes inflammatory responses in the airways. However, not all smokers exhibit the development of airflow limitation. This study was designed to determine the implications of small airways inflammation in the development of airflow limitation in smokers by our newly explored method. Twenty-eight smokers (15 smokers without airflow limitation and 13 with airflow limitation) were included in this study. Levels of interleukin-8 (IL-8) and 8-isoprostane were measured in epithelial lining fluid (ELF) from central and peripheral airways separately collected using a bronchoscopic microsampling technique. 8-isoprostane levels in ELF from central or peripheral airways did not significantly differ between the two groups. However, these levels were markedly higher in peripheral than in central airways. Similarly, IL-8 levels in ELF from central airways did not significantly differ between the two groups. In smokers without airflow limitation, IL-8 levels were not higher in peripheral than in central airways. In contrast, in smokers with airflow limitation, IL-8 levels were significantly higher in peripheral airways. Moreover, in smokers with airflow limitation, 8-isoprostane levels in central or peripheral airways were not significantly correlated with FEV(1). However, IL-8 levels in peripheral airways were inversely correlated with FEV(1), though those levels in central airways were not. Thus our technique provides a novel method for ELF sampling from central or peripheral airways separately, and the preliminary evidence that support differences in oxidative stress and neutrophil chemotactic stimulus in these two locations.

Comparison of N-epsilon-(Carboxymethyl)Lysine levels and percentage of eosinophils in induced sputum for assessment of small airway involvements in asthma.

BACKGROUND: N-epsilon-(Carboxymethyl)Lysine (CML), a major advanced glycation end product, is expressed in the lower respiratory tract. In this study, we compared the validity of measuring CML levels and percentage of eosinophils in induced sputum for assessment of airway functions, and evaluated the clinical implications of sputum CML levels in the asthmatic airways. MATERIAL/METHODS: We examined CML levels and percentage of eosinophils in induced sputum from 37 asthmatic patients and 15 normal controls, and evaluated the relationships between these parameters and clinical profiles of asthmatic patients. RESULTS: The percentage of eosinophils in induced sputum was significantly higher in asthmatic patients than in normal controls. Similarly, CML levels were also significantly higher in asthmatic patients than in normal controls (median (range): asthmatic patients 29.3 (18.4-64.7) microg/mL; normal controls 25.8 (14.0-47.0) microg/mL, p=0.02). However, there was no significant correlation between CML level and percentage of eosinophils. In asthmatic patients, percentage of eosinophils was significantly correlated with FEV1/FVC and degree of airway hyperreactivity to methacholine. However, CML level was correlated with FEV1/FVC, but not with methacholine reactivity. In contrast, CML level, but not percentage of eosinophils, was significantly correlated with degree of small airways dysfunction. CONCLUSIONS: Our novel, non-invasive technique of measurement of CML levels in induced sputum may prove to be important not only in the evaluation of small airway involvements, but also in helping us move toward a better understanding of the roles of the small airways in the pathogenesis of asthma.

Nepsilon-(carboxymethyl)lysine, a major advanced glycation end product in exhaled breath condensate as a biomarker of small airway involvement in asthma.

N(epsilon) -(carboxymethyl)lysine (CML) expression is selectively present in the lower respiratory tract. We compared CML levels in exhaled breath condensate (EBC) between 19 asthmatics and 10 normal control subjects and its levels before and after tiotropium therapy in 11 non-smoking asthmatics and 10 smoking asthmatics. CML levels were significantly lower in asthmatics than in normal control subjects. Moreover, low CML level was associated with small airway dysfunction. After tiotropium therapy, CML level in non-smoking asthmatics was unchanged, while that in smoking asthmatics was significantly increased. Therefore, CML level in EBC is a non-invasive biomarker for evaluating small airway involvements in asthma.

Role of vascular endothelial growth factor in pulmonary endothelial cell injury by exercise challenge in asthmatic patients.

This study was designed to examine the role of vascular endothelial growth factor (VEGF) in pulmonary endothelial cell injury by exercise in asthmatics. Post-exercise circulating thrombomodulin (TM) levels were significantly increased in asthmatics. Moreover, the increase in TM levels with exercise was significantly correlated with VEGF level in induced sputum from asthmatics (r = 0.80, p = 0.0007). After inhaled steroid therapy, post-exercise TM levels were significantly decreased, but the increase in TM levels with exercise was also correlated with VEGF level (r = 0.60, p = 0.01). Thus, pulmonary endothelial cells stimulated by VEGF in asthmatic airways may be sensitive to exercise challenge.