Airway inflammation accelerates pulmonary exacerbations in cystic fibrosis.

Airway inflammation underlies cystic fibrosis (CF) pulmonary exacerbations. In a prospective multicenter study of randomly selected, clinically stable adolescents and adults, we assessed relationships between 24 inflammation-associated molecules and the future occurrence of CF pulmonary exacerbation using proportional hazards models. We explored relationships for potential confounding or mediation by clinical factors and assessed sensitivities to treatments including CF transmembrane regulator (CFTR) protein synthesis modulators. Results from 114 participants, including seven on ivacaftor or lumacaftor-ivacaftor, representative of the US CF population during the study period, identified 10 biomarkers associated with future exacerbations mediated by percent predicted forced expiratory volume in 1 s. The findings were not sensitive to anti-inflammatory, antibiotic, and CFTR modulator treatments. The analyses suggest that combination treatments addressing RAGE-axis inflammation, protease-mediated injury, and oxidative stress might prevent pulmonary exacerbations. Our work may apply to other airway inflammatory diseases such as bronchiectasis and the acute respiratory distress syndrome.

Prospective multicenter randomized patient recruitment and sample collection to enable future measurements of sputum biomarkers of inflammation in an observational study of cystic fibrosis.

BACKGROUND: Biomarkers of inflammation predictive of cystic fibrosis (CF) disease outcomes would increase the power of clinical trials and contribute to better personalization of clinical assessments. A representative patient cohort would improve searching for believable, generalizable, reproducible and accurate biomarkers. METHODS: We recruited patients from Mountain West CF Consortium (MWCFC) care centers for prospective observational study of sputum biomarkers of inflammation. After informed consent, centers enrolled randomly selected patients with CF who were clinically stable sputum producers, 12 years of age and older, without previous organ transplantation. RESULTS: From December 8, 2014 through January 16, 2016, we enrolled 114 patients (53 male) with CF with continuing data collection. Baseline characteristics included mean age 27 years (SD = 12), 80% predicted forced expiratory volume in 1 s (SD = 23%), 1.0 prior year pulmonary exacerbations (SD = 1.2), home elevation 328 m (SD = 112) above sea level. Compared with other patients in the US CF Foundation Patient Registry (CFFPR) in 2014, MWCFC patients had similar distribution of sex, age, lung function, weight and rates of exacerbations, diabetes, pancreatic insufficiency, CF-related arthropathy and airway infections including methicillin-sensitive or -resistant Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia complex, fungal and non-tuberculous Mycobacteria infections. They received CF-specific treatments at similar frequencies. CONCLUSIONS: Randomly-selected, sputum-producing patients within the MWCFC represent sputum-producing patients in the CFFPR. They have similar characteristics, lung function and frequencies of pulmonary exacerbations, microbial infections and use of CF-specific treatments. These findings will plausibly make future interpretations of quantitative measurements of inflammatory biomarkers generalizable to sputum-producing patients in the CFFPR.

Pulmonary mucormycosis in an adolescent female with type 1 diabetes mellitus.

Mucormycosis is a relatively rare, life-threatening and opportunistic infection that affects immunocompromised patients. We present the unusual case of pulmonary mucormycosis in a 13-year-old Caucasian female that had recently been diagnosed with type 1 diabetes. Our case serves as an example to healthcare providers treating immunosuppressed patients with pneumonia to have a high clinical suspicion for fungal infections, as delay in diagnosis and treatment can result in disseminated disease and higher patient mortality risk.

Recurrent cutaneous tuberculosis in an immunocompetent 7-year-old male.

Cutaneous tuberculosis (TB) makes up a small proportion of the 10.4 million cases around the world. Although it is more commonly found in the developing world, cutaneous TB is rarely reported in the developed countries. It is fairly challenging to diagnose without histological examination. In this report, we present an immunocompetent 7-year-old male with a complex medical history diagnosed with cutaneous Mycobacterium tuberculosis after multiple ventriculoperitoneal shunt (VPS) revisions. This case of cutaneous TB in an immunocompetent patient is remarkable in its uncharacteristic presentation with no obvious source of TB infected contacts or travel history.

Simultaneous Streptococcus pneumoniae empyema in fraternal twins.

Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia. The current trend in Streptococcus pneumoniae infections has been the rise of multi-drug resistance in the last two decades. We present the case of a pair of 16-month old African-American fraternal twins who presented to the emergency room on the same day for symptoms consistent with pneumonia. Upon further examination, the twins showed remarkably similar symptoms, and cultures revealed penicillin-resistant Streptococcus pneumoniae in both twins. The pneumonia affected both twins in the same way, but a tomography scan did not reveal any shared anatomical abnormalities to account for this near-identical progression. In a review of literature and case reports, there are no reported cases of fraternal twins with simultaneous or non-simultaneous pneumococcal pneumonia or effusions. This case suggests that there may be possible anatomical abnormalities in the fraternal twins which were not evident in routine testing that may have led to near-identical illnesses. The pathophysiology of the simultaneous and near identical infections is not clear but may reflect subtle genetic factors in the siblings.

Correlation between digital clubbing and pulmonary function in cystic fibrosis.

The correlation between digital clubbing and certain pulmonary function derangements (hypoxemia and FEV(1)) was previously described. However, the relationship between digital clubbing and other measures of pulmonary function or the presence of liver disease in patients with cystic fibrosis (CF) is poorly defined. Hence we compared the digital clubbing index (CI: ratio of distal phalangeal depth to interphalangeal depth) of 100 patients with CF (43 males, 57 females; mean age, 15.7 +/- 7.3 years) with that of 100 age- and gender-matched healthy controls. Digital clubbing was defined as a CI > or = 1.00 (mean + 2.6 SD; 99% of normal subjects). The CI and its relationship to pulmonary function and to liver disease was then evaluated in the CF patients. Digital clubbing was present in 75/100 (75%) of CF patients but was absent in all controls (P < 0.0001). In CF patients, CI was inversely correlated with PaO(2) (r = -0.555; P < 0.001), FEV(1) (r = -0.499; P < 0.001), and FEF(25-75%) (r = -0.404; P < 0.001), and was positively correlated with RV (r = 0.285; P < 0.05) and the slope of phase 3 of single-breath nitrogen washout (SP3N(2)) (r = 0.532; P < 0.01). There was no significant correlation between CI and age (r = 0.020; P = 0.84), TLC (r = -0.097; P = 0.34), PaCO(2) (r = 0.167; P = 0.10), or history of liver disease (P = 0.08). We conclude that in CF, the degree of digital clubbing is related to degree of hypoxemia, airways obstruction, hyperinflation, and nonuniformity of ventilation.

Evidence of the involvement of biogenic amines in the antinociceptive effect of a vouacapan extracted from Pterodon polygalaeflorus Benth.

In view of the extensive use of Pterodon species in Brazilian folk medicine, the present investigation was performed to examine the involvement of biogenic amines in antinociceptive by a vouacapan (6 alpha-7 beta-dihydroxy vouacapan-17 beta-oate), extracted from seeds of Pterodon polygalaeflorus Benth), using acetic acid writhing test in mice. The alpha 2-adrenergic (yohimbine) and D2-dopaminergic (domperidone) antagonists and the pretreatment with the peripheral noradrenergic depletor, guanethidine partially inhibited the antinociceptive effect of vouacapan. Dopamine and D2 dopaminergic agonist (Ly 17155) caused antinociceptive that was not antagonized by naloxone but by domperidone, whereas noradrenaline induce pain. A synergistic analgesic effect was obtained when vouacapan was associated with clonidine or dopamine. These results indicate that vouacapan acts, at least in part, through activation of the catecholaminergic system.

Effect of lamotrigine in the acute and chronic hyperalgesia induced by PGE2 and in the chronic hyperalgesia in rats with streptozotocin-induced diabetes.

There is still a need for a new analgesic devoid of the side effects presented by opioids or non-steroidal anti-inflammatory drugs, for the treatment of some acute and chronic pain conditions. Lamotrigine (Lamictal1, 10-100 mg/kg), a new anticonvulsant, showed analgesic effects in the acute model of prostaglandin E2 (PGE2)-induced hyperalgesia when given orally before or after the subplantar injection of PGE2 in the rat. It also inhibited the development of sustained hyperalgesia induced by multiple subplantar injections of PGE2 when administered orally prior to the PGE2 injections. Furthermore, lamotrigine induced analgesia in the model of chronic hyperalgesia in streptozotocin-induced diabetic rats. The effects of carbamazepine and phenytoin are compared to the effects of lamotrigine in this model. The results suggest that lamotrigine could be used in pain conditions where neuronal sensitization may be present and possibly also where it could inhibit the development of this sensitization.

Possible participation of endogenous opioid peptides on the mechanism involved in analgesia induced by vouacapan.

The involvement of opioid peptides in the mechanism of action of vouacapan, a new experimental compound extracted from seeds of Pterodon poligalaeflorus Benth, was investigated both in mice utilizing acetic acid writhing response and in rats utilizing inflammatory hyperalgesia induced by carrageenan and modified Randall-Selitto method. Vouacapan, in both models, caused a dose-dependent analgesia when injected p.o., s.c. and i.p. The analgesic effect was partially blocked by naloxone, nalorphine and n-methyl-nalorphine. Significant tolerance to analgesic effect was observed following repeated administration of vouacapan or morphine. On the last day of treatment, cross administration revealed symmetrical and asymmetrical cross-tolerance between vouacapan and morphine, in rats and mice, respectively. We conclude that a release of endorphins could be involved in the analgesic mechanism of vouacapan in both models tudied.

Effect of neurokinin A, substance P and calcitonin gene related peptide in peripheral hyperalgesia in the rat paw.

The effect of neurokinin A (NKA), substance P (SP) and calcitonin gene-related peptide (CGRP) in peripheral hyperalgesia was studied in rats using a modification of the Randall-Selitto paw test. NKA was 10 times more potent than SP which was 500 times more potent than CGRP in inducing hyperalgesia in the rat paw, suggesting that NKA and SP but not CGRP could have an important role in acute hyperalgesic conditions. Furthermore, sensitization induced by several injections of subthreshold doses of NKA or CGRP suggest that these neuropeptides along with SP could participate as mediators or modulators of chronic pain.

Inhibition by neuropeptides of interleukin-1 beta-induced, prostaglandin-independent hyperalgesia.

The cytokine interleukin-1 beta (IL-1 beta) is a potent hyperalgesic agent in the rat whereas IL-1 alpha is relatively inactive (Ferreira et al., 1988). IL-1 beta induced a dose-dependent increase in the sensitivity of rat paws to mechanical stimulation following intra-plantar injection but this effect was not reduced by indomethacin (1.0 mg kg-1, p.o.), at a dose known to inhibit completely prostaglandin synthesis in the rat (Salmon et al., 1983). Prostaglandin (PG)E2 enhanced sensitivity to both mechanical pressure and increased temperature but IL-1 beta enhanced only sensitivity to pressure. These observations indicate that IL-1 beta sensitized pressure-sensitive but not temperature-sensitive sensory neurones, through a prostaglandin-independent mechanism. Hyperalgesia induced by IL-1 beta but not PGE2, was inhibited by the neuropeptide melanocyte-stimulating hormone (alpha MSH) and its analogue [Nle4, D-Phe7] alpha MSH which are known to antagonize IL-1 responses in other systems (Holdeman & Lipton, 1985; Cannon et al., 1986). IL-1 beta-induced hyperalgesia was also reduced by the putative IL-1 beta antagonist Lys-D-Pro-Thr (Ferreira et al., 1988) but alpha MSH and its analogue were 10-50 times more potent.

Substance P and peripheral inflammatory hyperalgesia.

The hyperalgesic effect of substance P (SP) is usually described as presenting short latency. We now report that multiple injections of sub-threshold doses of SP into the foot pad of a hind paw of rats pre-treated with indomethacin induced a long-lasting hyperalgesia, sensitizing the paw to further challenges with small doses of SP, dopamine or prostacyclin. The sensitizing process also occurred after multiple injections of prostacyclin or prostaglandin E2. The sensitizing effect induced by SP, prostaglandin E2 or prostacyclin is inhibited by pre-treatment with the SP antagonist (D-Arg, D-Pro, D-Trp, Leu)-SP. We suggest that SP has an important role as a modulator in peripheral inflammatory pain by sensitizing nociceptors to its own action and to the action of different mediators. This sensitizing process could also be associated with chronic inflammatory pain.