Modulation of allergic responses by mitochondrial STAT3 inhibitors.

BACKGROUND: Recently, we have shown that mast cell mitochondrial STAT3 could serve as a new target for the regulation of the allergic response as it plays an essential role in immunologically mediated degranulation of mast cells. In the present work, we explored how two recently developed mitochondrial STAT3 inhibitors (Mitocur-1 and Mitocur-3) modulate the allergic response. METHODS: Experiments were performed both in vitro in cultured human/mouse mast cells and with rat basophilic leukemia (RBL) cells and also in vivo in mice. The effect of mitochondrial STAT3 inhibition on mast cell function was determined via checking degranulation and several cytokines secretion levels. RESULTS: Here, we show that treatment of rodent and human cultured mast cells with low concentrations of mitochondrial STAT3 inhibitors had no effect on STAT3 target gene expression. However, these inhibitors caused a significant reduction in mast cell exocytosis and cytokine release, due to a decrease in OXPHOS activity and STAT3 serine 727 phosphorylation. It was also observed in an OVA mouse model of allergic asthma that one of the inhibitors used significantly reduced eosinophilia and neutrophilia compared to the control mice group. Furthermore, it was observed that treatment with this inhibitor resulted in a significant reduction in blood histamine levels in mice after IgE-Ag challenge. CONCLUSION: The present data strongly suggest that the development of mitochondrial STAT3 inhibitors could serve as a potential treatment for allergy-associated diseases.

CD48 on blood leukocytes and in serum of asthma patients varies with severity.

BACKGROUND: CD48 is a membrane receptor (mCD48) on eosinophils and mast cells and exists in a soluble form (sCD48). CD48 has a pivotal role in murine asthma and in the proinflammatory interactions of mast cells with eosinophils via its ligand CD244. Thus, CD48 might be important in human asthma. METHODS: Therefore, two separate cohorts (IL and UK) comprising mild, moderate, and severe asthma and healthy volunteers were evaluated for blood leukocyte mCD48 expression and sCD48 in serum. Asthmatic bronchial biopsies were immunostained for CD48. sCD48 effect on CD244-dependent eosinophil activation was evaluated. RESULTS: Eosinophil mCD48 expression was significantly elevated in moderate while downregulated in severe asthma. mCD48 expression on B, T, and NK cells and monocytes in severe asthma was significantly increased. sCD48 levels were significantly higher in mild while reduced in severe asthma. sCD48 optimal cutoff values for differentiating asthma from health were identified as >1482 pg/ml (IL) and >1619 pg/ml (UK). In asthmatic bronchial biopsies, mCD48 was expressed predominantly by eosinophils. sCD48 inhibited anti-CD244-induced eosinophil activation. CONCLUSIONS: mCD48 and sCD48 are differentially expressed in the peripheral blood of asthma patients of varying severity. sCD48 inhibits CD244-mediated eosinophil activation. These findings suggest that CD48 may play an important role in human asthma.

Osteopontin is expressed and functional in human eosinophils.

BACKGROUND: Eosinophils are critically involved in allergic inflammation and tissue remodeling. Osteopontin (OPN) is a glycoprotein molecule which exhibits pro-fibrogenic and pro-angiogenic properties and has recently also been implicated in allergic diseases. In this study, we investigated the expression and function of OPN in human eosinophils. METHODS: Osteopontin mRNA (RT-PCR) and protein (immunofluorescence) expression in peripheral blood eosinophils from atopic human subjects were evaluated. Soluble OPN release was determined in resting and activated eosinophils. The contribution of OPN to eosinophil-induced angiogenesis was determined using the chick embryo chorio- allantoic membrane (CAM) assay and OPN-induced eosinophil chemotaxis was determined (ChemoTx System microplate wells). Finally, OPN expression in bronchoalveolar lavage (BAL) fluids from mild asthmatic and normal control subjects was determined. RESULTS: Osteopontin is expressed in human eosinophils and is increased following GM-CSF and IL-5 activation. Eosinophil-derived OPN contributes to eosinophil-induced angiogenesis. Recombinant OPN promotes eosinophil chemotaxis in vitro and this effect is mediated by alpha(4)beta(1) integrin binding. Soluble OPN is increased in the bronchoalveolar lavage fluid from mild asthmatic subjects and correlates with eosinophil counts. CONCLUSIONS: We therefore conclude that OPN is likely to contribute to the process of angiogenesis observed in the airways in asthma.

Follow-up for cervical abnormalities in a managed care plan, 1999-2004.

OBJECTIVE: The objective of this study was to determine the follow-up for women after receiving an abnormal Pap test before and after the updated American Society of Colposcopic and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology. METHODS: In 1999 and 2004, women who had been enrolled in a US health care plan for at least 21 months and were between 18 and 70 years of age were included. We calculated differences in type of follow-up between the time periods before and after ASCCP guideline changes in 2002. RESULTS: Overall, 1.7 million women met study criteria and received at least one Pap test. Overall, 227,802 (14%) women received additional follow-up. Of these women, 73% had a repeat Pap test within 9 months as their first follow-up, 13% received colposcopy, and 7% had other events. The proportion of women receiving a repeat Pap test decreased significantly during the post-guideline time period. The odds of a woman receiving a colposcopy versus a repeat Pap test were 41% higher in the post-guideline period, after controlling for other variables. CONCLUSIONS: Our findings indicate that for the time period after the ASCCP guidelines changed, more colposcopies and fewer repeat Pap tests were performed as a follow-up of abnormal Pap test.

The role of eosinophil major basic protein in angiogenesis.

BACKGROUND: Eosinophil-derived major basic protein (MBP) plays an active role in allergic inflammation and tissue remodelling. However, its role in angiogenesis has not been established as yet. Therefore our objective was to investigate whether MBP exhibits any direct pro-angiogenic effects. METHODS: Rat aortic endothelial cells and human umbilical vascular endothelial cells were cultured with different concentrations of MBP and their viability (Trypan blue exclusion test), proliferation (thymidine incorporation) and capillary-like structure formation (matrigel assay) were investigated in vitro. The angiogenic activity of MBP was then tested in vivo using the chick chorio allantoic membrane (CAM) assay. RESULTS: Subcytotoxic concentrations of MBP induce endothelial cell proliferation and enhance the pro-mitogenic effect of vascular endothelial growth factor (VEGF), but do not affect their VEGF release. MBP promotes capillarogenesis by endothelial cells seeded on matrigel and sprouting formation in the CAM assay. Furthermore, we have shown that the pro-angiogenic effect of MBP is not due to its cationic charge since stimulation of the CAMs with the synthetic polycation, poly-L-arginine does not induce any angiogenic effects. CONCLUSIONS: These data demonstrate that MBP has pro-angiogenic effects in vitro and in vivo, providing a novel mechanism whereby MBP can participate in tissue inflammation and remodelling in atopic diseases.

Frameshift and splice-junction mutations in the sterol 27-hydroxylase gene cause cerebrotendinous xanthomatosis in Jews or Moroccan origin.

The sterol 27-hydroxylase (EC 1.14.13.15) catalyzes steps in the oxidation of sterol intermediates that form bile acids. Mutations in this gene give rise to the autosomal recessive disease cerebrotendinous xanthomatosis (CTX). CTX is characterized by tendon xanthomas, cataracts, a multitude of neurological manifestations, and premature atherosclerosis. A relatively high prevalence of the disease has been noted in Jews originating from Morocco. The major objectives of the present investigation were to determine the gene structure and characterize the common mutant alleles that cause CTX in Moroccan Jews. The gene contains nine exons and eight introns and encompasses at least 18.6 kb of DNA. The putative promoter region is rich in guanidine and cytosine residues and contains potential binding sites for the transcription factor Sp1 and the liver transcription factor, LF-B1. Blotting analysis revealed that the mutant alleles do not produce any detectable sterol 27-hydroxylase mRNA. No major gene rearrangements were found and single-strand conformational polymorphism followed by sequence analysis identified two underlying mutations: deletion of thymidine in exon 4 and a guanosine to adenosine substitution at the 3' splice acceptor site of intron 4 of the gene. The molecular characterization of CTX in Jews of Moroccan origin provides a definitive diagnosis of this treatable disease.

Organizing pneumonia following treatment with pembrolizumab for metastatic malignant melanoma - A case report.

Pembrolizumab is a monoclonal antibody against the programmed cell death 1 (PD-1) receptor, and is widely used for the treatment of various malignancies, most commonly malignant melanoma. Here we report the first documented and pathology proven case of Organizing Pneumonia complicating treatment with Pembrolizumab. This was a man who presented with a dense lung consolidation four months following treatment with Pembrolizumab. A thorough microbiological workup was negative and his findings did not improve with broad spectrum anti-microbial treatment. Transbronchial biopsy revealed organizing pneumonia, and treatment with cortico-steroids resulted in complete resolution of clinical and radiological disease. This report highlights the importance of recognizing immune related adverse events, specifically pulmonary inflammation, in patients receiving treatment with novel immune-modulating agents.

Acute gastric dilatation causing respiratory failure and "tension pneumothorax" in an elderly women with a diaphragmatic hernia.

The occurrence of respiratory failure as a result of a large diaphragmatic hernia is a well-described entity in infants with congenital hernias. On reviewing the literature, the authors did not find a similar clinical presentation in the adult population. They report the case of an elderly patient with a large hiatus hernia who developed recurrent episodes of life-threatening respiratory failure and hemodynamic compromise due to recurrent gastric dilatation. Decompression with nasogastric suction resulted in dramatic and immediate relief of the respiratory distress. One should keep in mind the possibility of intrathoracic gastric dilatation as a cause of acute respiratory insufficiency in patients with hiatal hernia.

Successful talc slurry pleurodesis in patients with nonmalignant pleural effusion.

BACKGROUND: Chemical pleurodesis is an effective treatment for malignant pleural effusion and pneumothorax. This mode of therapy is, however, less widely accepted in the treatment of patients with refractory benign or undiagnosed pleural effusion. STUDY OBJECTIVES: To analyze the outcome of talc slurry pleurodesis in patients with nonmalignant pleural effusions. DESIGN: Retrospective and partly prospective analysis of clinical outcome. SETTING: Hadassah University Hospital, Jerusalem, Israel. PATIENTS AND PARTICIPANTS: Between 1992 and 1997, we treated 16 patients with nonmalignant pleural effusion using talc slurry pleurodesis. The cause of effusion was congestive heart failure in 6 patients, liver cirrhosis in 4 patients, yellow nail syndrome in 1 patient, systemic lupus erythematosus in 1 patient, chylothorax in 1 patient, and undiagnosed in 3 patients. INTERVENTIONS: Nine patients were hospitalized, and seven patients received treatment in a day-care setting. Follow-up ranged from 2 months to 3 years. RESULTS: Complete success was observed in 12 cases (75%), partial success in 3 cases (19%), and pleurodesis was ineffectual in 1 case (6%). There were no significant complications after the procedure in any of our patients. A review of the English-language medical literature revealed an additional 110 reported cases of nonmalignant pleural effusion that were treated with chemical pleurodesis. Of these cases, talc was used in 65% with a success rate of nearly 100%. CONCLUSIONS: Chemical pleurodesis, and specifically talc slurry, is an effective treatment for recurrent benign or undiagnosed pleural effusion. This procedure is safe and easily performed and, in selected cases, can be performed in an outpatient day-care setting.

Amiodarone pulmonary toxicity presenting as a solitary lung mass.

Following treatment with amiodarone, a patient developed weight loss, fatigue and severe myopathy, without respiratory symptoms. A solitary lung infiltrate, impaired thyroid and liver function tests, and leukocytosis were evident. Biopsies from the lung lesion, liver, and bone marrow revealed foam cells. All these signs and symptoms subsided following cessation of amiodarone therapy. It is demonstrated that amiodarone may induce a localized lung lesion rather than diffuse pulmonary disease.

Fatal Haemophilus influenzae septicemia following bronchoscopy in a splenectomized patient.

We describe a 46-year-old splenectomized patient who died of Haemophilus influenzae septicemia 16 h following bronchoscopy. Although rare, postsplenectomy overwhelming sepsis is always a danger in splenectomized patients undergoing invasive procedures. Chemoprophylaxis should be considered in asplenic patients peribronchoscopy.

Rehabilitation of hypoxemic patients with COPD at low altitude at the Dead Sea, the lowest place on earth.

BACKGROUND: In patients with COPD, oxygen therapy has been shown to improve exercise capacity and survival. Increase in barometric pressure at low altitude can serve as a simple way to improve arterial oxygenation in hypoxemic patients. We have tried to evaluate the effect of staying at low altitude on arterial oxygenation and exercise performance in patients with COPD. PATIENTS AND METHOD: Eleven patients with COPD (9 male, 2 female) aged 38 to 79 years (mean FEV1, 0.96 L; 36% predicted) with hypoxemia (mean PaO2, 54.2+/-8.9 mm Hg) at Jerusalem (altitude 800 m above sea level) were taken down to the Dead Sea area (altitude 402 m below sea level) for 3 weeks. At both locations we tested arterial blood gases, spirometry, progressive exercise, 6-minute walking distance, and sleep oximetry. The study was repeated 2 weeks after returning to Jerusalem. RESULTS: Spirometry results were unchanged. Mean arterial PaO2 rose from 54.2+/-8.9 mm Hg to 69.5+/-11 at the first week and to 66.6+/-11 at the third week of stay (p<0.001). PaCO2 rose from 43.5+/-9.8 mm Hg to 47.7+/-9 and 49.5+/-8.4 (p<0.006). Six-minute walking distance rose from 337+/-107 m to 449+/-73 and 507+/-91 in the third week (p<0.005). Maximum oxygen consumption (VO2max) rose from 901+/-257 mL/min to 1,099+/-255 and 1,063+/-250 mL/min (p=0.01). Sleep oximetry showed an increase in mean sleep arterial oxygen saturation from 86.0+/-4.3% to 89.9+/-4.2% and 88.3+/-3.0 at 1 and 3 weeks, respectively (p<0.05). Following the return to Jerusalem, arterial gases returned to their baseline levels (PaO2, 52.9+/-9.4 mm Hg) but 6-min walking distance remained significantly high, 453+/-47 (p<0.02), and VO2max remained high as well (1,102+/-357 mL/min), although it did not reach statistical significance. CONCLUSIONS: Decline to low altitude or staving at high oxygen environment improves arterial oxygenation and exercise capacity in hypoxemic patients residing in moderate or high altitude. Low altitude (or pressurized wards) can improve pulmonary rehabilitation of hypoxemic patients with COPD.

The role of BAL in the diagnosis of pulmonary mucormycosis.

Five patients with pulmonary mucormycosis diagnosed during life are described. All had underlying predisposing conditions: either posttransplant or hematologic malignancies. In all cases, the diagnosis was made using fiberoptic bronchoscopy. In three patients, BAL was diagnostic. In two of these patients, the diagnosis was made by identifying the typical hyphae of mucormycosis in the BAL fluid alone. Transbronchial biopsy was diagnostic in three patients. Treatment was based on IV antifungal chemotherapy together with surgical removal of involved lung tissue whenever feasible. The clinical outcome of these patients was dismal and was determined primarily by the underlying condition.

Radiation-induced pulmonary veno-occlusive disease.

Late occurrence of radiation-induced pulmonary pneumonitis and fibrosis is well documented. We report an unusual case of radiation induced veno-occlusive disease (VOD) occurring six years following mantle irradiation for Hodgkin's lymphoma. The patient developed severe pulmonary hypertension and cor pulmonale. A left lung transplantation was performed successfully and pathologic examination of the explanted lung showed severe changes compatible with VOD. In the absence of exposure to alternate therapeutic or toxic agents that may cause VOD, it is likely that radiation caused damage to the venular endothelium and caused progressive obliteration of the pulmonary vessels. Review of the literature reveals only a few similar reports of VOD mostly following radiation for bone marrow transplantation. We conclude that previous irradiation (even several years earlier) should be considered as a possible cause of pulmonary VOD.

The role of open lung biopsy in the management and outcome of patients with diffuse lung disease.

BACKGROUND: Open lung biopsy (OLB) has long been considered the gold standard for the diagnosis of parenchymal lung disease. With recent advances in computed tomographic imaging and diagnostic techniques (eg, bronchoscopy), we thought it necessary to reevaluate the role of OLB in the management of patients with interstitial lung disease. METHODS: We carried out a retrospective analysis of 103 OLBs performed at Hadassah University Hospital, Jerusalem, and Carmel Medical Center, Haifa, between 1980 and 1994. Data gathered included demographic information, underlying condition, indications for biopsy, diagnosis before biopsy, final diagnosis, change in therapy, and mortality. "Benefit" was defined as a change in therapy resulting in survival. RESULTS: There were 45 immunocompetent patients (group 1), 39 immunocompromised patients (group 2), and 26 children (group 3), 7 of whom were included in group 2 for analysis. Overall, a diagnosis was reached after OLB in 85% of patients. An unexpected diagnosis was reached in 52%, and a change in therapy was instituted in 46%. The overall mortality rate was 20%. In group 1, the mortality rate was 13%, and "benefit" from OLB was reached in only 18%. In group 2, the mortality rate was 39%, and "benefit" was achieved in 46%, and in group 3, the mortality rate was 12% and "benefit", 50%. CONCLUSIONS: Open lung biopsy is an excellent diagnostic technique. In immunocompetent patients, the "benefit" is relatively low, as therapy (corticosteroids) is frequently used after biopsy. In immunocompromised patients, therapy changes substantially after OLB, but mortality is high. Therefore, OLB should be reserved for patients in whom the diagnosis is likely to lead to a change in therapy and in patients in whom the underlying condition has a reasonable prognosis according to the clinical impression by the attending physician.

Obstructive solitary bronchial non-Hodgkin's lymphoma--a rare presentation of primary extranodal disease.

Endobronchial involvement by non-Hodgkin's lymphoma (NHL) is uncommon and usually occurs in the presence of more generalised disease. Solitary endobronchial lymphoma in the absence of disease elsewhere is extremely rare. In this report we describe a patient with an obstructing endobronchial mass which was the initial manifestation of NHL. The patient was treated initially with radiotherapy followed by cyclic combination chemotherapy with initial complete resolution of the endobronchial disease. However, he subsequently developed widespread lymphoma. This unusual presentation of NHL is discussed and the relevant literature is reviewed.

Pulmonary involvement as the major manifestation of chronic lymphocytic leukemia.

Respiratory symptoms and abnormal findings on chest X-ray are frequently noted in patients with chronic lymphocytic leukemia (CLL). However, most of these represent pulmonary infections or mediastinal lymphadenopathy, and leukemic involvement of the lung is seldom diagnosed during life. In this report we describe three patients with non-progressive, responsive CLL who developed biopsy proven pulmonary infiltration with CLL. In one case, pulmonary involvement was the sole manifestation of recurrent disease and a second case had little disease elsewhere with minimal CLL in the blood at the time pulmonary involvement appeared. In all three cases, transbronchial biopsy and bronchoalveolar lavage performed during fibreoptic bronchoscopy provided adequate tissue for diagnosis. We conclude that CLL may involve the lung even in the presence of a low peripheral white blood cell count with responsive disease elsewhere, and can readily be diagnosed by transbronchial biopsy and bronchoalveolar lavage.

Pulmonary involvement in lymphoma.

Intrathoracic involvement is common in both Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). The most common manifestation is mediastinal lymphadenopathy. In HD, nodal involvement is by contiguity and usually involves the superior mediastinum, while the findings in NHL are more variable. Pulmonary parenchymal disease occurs in 38% of HD and 24% of NHL. In untreated HD, parenchymal involvement is invariably associated with mediastinal lymphadenopathy and often with widespread disease. Three distinct radiological patterns of pulmonary lymphoma are recognised: nodular, bronchovascular-lymphangitic and pneumonic-alveolar. Rarely lymphoma may be endobronchial. Pleural effusion occurs in 16% of lymphoma patients and is usually associated with disease elsewhere. It is frequently caused by lymphatic obstruction but may be due to direct pleural involvement by tumour. Chylothorax may occur in NHL but is unusual in HD. Diagnosis of intrathoracic lymphoma is by transbronchial or transthoracic biopsy or by needle aspiration of tissue or pleural fluid. The addition of immunostaining improves the diagnostic yield in equivocal cases. Treatment and prognosis vary depending on cell-type, location and extent of disease.

Primary non-Hodgkin's lymphoma of the lung presenting as bronchiolitis obliterans organizing pneumonia.

A 44-year-old man presented with fever, dyspnea, and bilateral cavitary lung lesions. Following percutaneous transthoracic CT guided needle biopsy of the lung, a diagnosis of bronchiolitis obliterans organizing pneumonia (BOOP) was made and the patient was treated with corticosteroids. Despite a good initial response he developed new lung lesions within six months, associated with a lack of response to corticosteroids. Due to further deterioration and the development of Guillian-Barre' syndrome an open lung biopsy was performed and revealed T-cell rich, B-cell non Hodgkin's lymphoma with BOOP. We suggest that BOOP may be the presenting manifestation of primary lung lymphoma. We recommend that when BOOP has an atypical course or does not respond to corticosteroids open lung biopsy should be performed in order to exclude pulmonary lymphoma.

Bleomycin-induced lung injury is enhanced by interferon-alpha.

We have evaluated the effect of intraperitoneal (I.P.) injection of human recombinant interferon-2alpha (IFN-alpha) on Bleomycin-induced pulmonary injury in hamsters. Pulmonary injury was induced by a single intratracheal (I.T.) instillation of Bleomycin (Bleo). Six groups of male Syrian hamsters were treated as follows: 1) I.T. Bleo and daily I.P. injections of low-dose interferon-alpha (2 x 10(4) U), 2) I.T. Bleo and daily I.P. injections of high-dose interferon-alpha (10(5) U), 3) I.T. Bleo and I.P. injections of saline, 4) I.T. saline and I.P. low-dose IFN-alpha, 5) I.T. saline and I.P. high-dose IFN-alpha, 6) I.T. saline and I.P. saline. Animals were sacrificed 28 days after I.T. treatment. Lung injury was evaluated histologically and biochemically. Treatment of hamsters with low-dose but not high-dose IFN-alpha significantly augmented the Bleo-induced lung injury, as determined by a semiquantitative morphological index. Lung hydroxyproline measurements were highest in Bleo-low-dose-IFN-alpha followed by Bleo-high-dose-IFN-alpha and Bleo-Sal as compared to Sal-Sal and Sal-IFN-alpha controls. These results suggest that IFN-alpha augments Bleo-induced lung injury but that this effect is complex and does not follow a simple-dose-response pattern.