Efficacy and safety of transbronchial lung biopsy for the diagnosis of lymphangioleiomyomatosis: A report of 24 consecutive patients

BACKGROUND AND OBJECTIVE

Lymphangioleiomyomatosis (LAM) is a diffuse cystic lung disease that occurs in women of childbearing age. LAM can be diagnosed on a clinical basis in patients with typical high-resolution computed tomography (HRCT) patterns and at least one other corroborating disease feature, such as chylothorax, angiomyolipoma, tuberous sclerosis complex or elevated serum vascular endothelial growth factor (VEGF)-D. However, patients who do not meet these criteria require tissue confirmation for a definitive diagnosis, and the utility of methods that are less invasive than surgical lung biopsy, such as transbronchial lung biopsy (TBLB), are not well studied. We retrospectively studied the efficacy and safety of TBLB for the diagnosis of LAM.

METHODS

From January 1991 to August 2015, 131 consecutive LAM patients were prospectively registered in our study, and a TBLB was conducted for 24 patients. We retrospectively studied the yield and safety of TBLB in this cohort.

RESULTS

All 24 patients were women; the median age was 42 years. HRCT showed multiple round thin-walled cysts diffusely scattered throughout the lungs. The median level of serum VEGF-D was 2109 pg/mL. Characteristic pathological findings for LAM were identified in 17 patients (70.8%) by two expert pathologists. The %predicted value for diffusing capacity of carbon monoxide was significantly lower in the 17 TBLB-positive LAM patients compared to the seven TBLB-negative LAM patients (P = 0.046). There were no serious adverse events such as pneumothorax or uncontrollable bleeding due to TBLB.

CONCLUSION

TBLB is a safe and effective method for the pathological diagnosis of LAM.

Risk factors for stomatitis in patients with lymphangioleiomyomatosis during treatment with sirolimus: A multicenter investigator-initiated prospective study

PURPOSE

Lymphangioleiomyomatosis is a rare lung disease caused by proliferation of abnormal smooth muscle-like cells and typically occurs in premenopausal women. Sirolimus is now the first-line drug for the treatment of lymphangioleiomyomatosis. Sirolimus-induced stomatitis is the most frequent adverse event experienced during treatment. To identify risk factors, we investigated the association of stomatitis incidence with patient background data and treatment parameters, using data from the multicenter long-term sirolimus trial.

METHODS

Subjects received sirolimus for 2 years at doses adjusted to maintain a trough blood level of 5 to 15 ng/mL. The incidence of stomatitis was correlated with baseline demographics, clinical characteristics, and changes in the longitudinal data. Risk factors at baseline were assessed by using univariate and multivariate analyses.

RESULTS

The most frequent adverse event was stomatitis, with the cumulative rate reaching 88.9% by 9 months, higher than that reported in postrenal transplant patients. The repetition, the duration, and the severity of stomatitis events were variable among patients. We found that patients with low hemoglobin (Hb) (<14.5 g/dL) showed significantly higher incidence than those with high Hb (≥14.5 g/dL, P < .01). The cumulative rate for stomatitis incidence was significantly associated with a decrease in the mean corpuscular volume, while the Hb level was constant; thus, red blood cell count in patients increased during the study.

CONCLUSIONS

Baseline Hb levels and a decrease in mean corpuscular volume during treatment were correlated with the incidence of stomatitis.

Combination of virtual bronchoscopic navigation, endobronchial ultrasound, and rapid on-site evaluation for diagnosing small peripheral pulmonary lesions: a prospective phase II study

BACKGROUND

The diagnostic yield of peripheral pulmonary lesions (PPLs) by flexible bronchoscopy (FB) is still insufficient. To improve the diagnostic yield of bronchoscopy, several techniques such as endobronchial ultrasound (EBUS), virtual bronchoscopic navigation (VBN), and rapid on-site evaluation (ROSE) have been examined. The primary purpose of the present study was to evaluate the usefulness of combining EBUS, VBN, and ROSE for diagnosing small PPLs.

METHODS

Patients with PPLs 30 mm or less on chest computed tomography (CT) were prospectively enrolled. We determined the responsible bronchus for the target lesions using VBN before bronchoscopy was performed. EBUS and ROSE were performed during the examination to determine whether the bronchus and specimen were adequate. On the basis of previous studies, we assumed that the diagnostic yield of 85% among eligible patients would indicate potential usefulness, whereas, the diagnostic yield of 75% would indicate the lower limit of interest. The required number of patients was estimated as 45 for a one-sided α value of 0.2 and a β value of 0.8. The primary study endpoint was the diagnostic yield.

RESULTS

Between June 2014 and July 2015, we enrolled 50 patients in the present study, and we excluded 5 patients. The total diagnostic yield of 45 PPLs was 77.7%. In cases of lung cancer, the diagnostic yield was 84.2%. The sensitivity, specificity, positive predictive value, and negative predictive value of ROSE were 90.6%, 92.3%, 96.7%, and 80.0%, respectively. The diagnostic yield of PPLs from 20 to 30 mm was 87.5%, and the diagnostic yield of PPLs less than 20 mm was 66.7%. PPLs for which the probe was located within the lesion had the highest diagnostic yield.

CONCLUSIONS

We could not demonstrate usefulness for diagnosing small PPLs by combining EBUS, VBN, and ROSE. However, combining these techniques may be useful for diagnosing lung cancer.

Prevalence and risk factors of bovine trypanosomosis in Kilwa district, Lindi region of southern Tanzania

African animal trypanosomosis (AAT) and human African trypanosomosis (HAT) are complex chronic, debilitating, emaciating and often fatal diseases of animals and humans, respectively. This cross-sectional study was conducted to determine the prevalence and risk factors associated with bovine trypanosomosis in tsetse-infested Kilwa district, Lindi region, southern Tanzania. Blood samples were collected from 420 cattle randomly selected from 86 herds from ten villages. A maximum of ten herds per village and at most six animals from each herd were selected for sampling. At the same time, a questionnaire was administered. Individual animal samples were analysed using microscopy and pooled sample at herd level were analysed by loop mediated isothermal amplification (LAMP). A herd was considered positive if at least one animal in the herd was positive for AAT. A prevalence of 9.3% (95% CI: 2.9-14.9) was recorded for AAT by microscopy, mainly caused by Trypanosoma congolense (5.8%, 95% CI=0.9-10.7), Trypanosoma brucei species (5.8%, 95%, CI=0.9-10.7) and Trypanosoma vivax (3.5%, 95% CI=0-7.4). Loop mediated isothermal amplification (LAMP) recorded a heard prevalence of 41.9% (95% CI: 30.0-51.4%), mainly caused by T. congolense (30.2%, 95% CI: 20.5-39.9), T. brucei species (25.6%, 95% CI: 16.4-34.8) and T. vivax (20.9%, 95% CI: 12.3-29.7). Most of the cattle herds had mixed infections of these parasites. According to LAMP, Miteja and Matandu villages had the highest AAT herd prevalence of 57% (95% CI: 20.3-93.7) while Mavuji had the lowest prevalence of 14% (95% CI: 0-39.7). Data from the present study suggest that district of origin, grazing in game reserve, water source and form of watering point are risk factors associated with AAT in Kilwa district, southern Tanzania. Continuous surveillance and monitoring of AAT using more sensitive are recommended.

Low-Dose Morphine for Dyspnea in Terminally Ill Patients with Idiopathic Interstitial Pneumonias

BACKGROUND

Dyspnea is highly prevalent in patients with idiopathic interstitial pneumonias (IIPs).

OBJECTIVE

The objective of this study is to examine the effectiveness and safety of continuous subcutaneous morphine for dyspnea in terminally ill IIP patients.

SETTING/SUBJECTS

We retrospectively reviewed cases of terminally ill IIP patients who received continuous subcutaneous morphine for dyspnea.

MEASUREMENTS

We reviewed dyspnea severity measured using numerical rating scale (NRS) and respiratory rate (RR) before and two and four hours after morphine initiation. We conducted subgroup analyses of patients with and without noninvasive positive pressure ventilation (NPPV).

RESULTS

Twenty-five patients were included in this study. Median morphine dose at morphine initiation and two and four hours after treatment was 0.25, 0.25, and 0.5 mg/hour, respectively. Dyspnea NRS decreased significantly four hours after (mean ± standard deviation: 5.32 ± 2.58, p = 0.04) but not two hours (5.52 ± 2.43, p = 0.11) after morphine initiation compared with baseline (7.08 ± 2.33). RR did not change significantly either two or four hours after treatment compared with baseline. The median survival after morphine initiation was 47 hours. Patients who were not using NPPV showed significantly improved dyspnea both two and four hours after treatment compared with baseline, although patients who used NPPV showed no significant improvement with morphine. RR did not significantly change in either subgroup.

CONCLUSIONS

Morphine might improve dyspnea in terminally ill IIP patients without decrease in RR.

A Cryptogenic Case of Fulminant Fibrosing Organizing Pneumonia

Cryptogenic organizing pneumonia (COP) generally responds well to corticosteroids with a favorable outcome. Rare cases of organizing pneumonia are rapidly progressive. Yousem et al. studied pathologic predictors of idiopathic bronchiolitis obliterans organizing pneumonia/COP with an unfavorable prognosis. Beardsley and Rassl proposed the name fibrosing organizing pneumonia (FOP). A 74-year-old female non-smoker presented with a 2-week history of dry cough followed by dyspnea and a fever. The clinical course was fulminant, but we successfully performed bronchoscopy. After the diagnosis of FOP, we treated the patient with mechanical ventilation and high-doses of steroids/immunosuppressants, which improved the disease.

Temporary remission of autoimmune pulmonary alveolar proteinosis after infectious episodes

Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown aetiology. Although resolution occurs in about 30% of autoimmune PAP (APAP) cases, its pathogenesis is not yet sufficiently understood. Two APAP cases at our institute showed remission following infectious episodes. Case 1: a 40-year-old female APAP patient suffered from herpes encephalitis and was treated with an antiviral drug. Her symptoms and radiological results resolved within two months of her recovery from the encephalitis. Case 2: A 53-year-old male current-smoker APAP patient was admitted for pneumonia. After treatment with antibiotics, his radiological results and symptoms improved. He experienced a similar resolution of APAP after another infectious episode two years later. Remission of APAP may occur following viral or bacterial infection. We hypothesise that remission of APAP is triggered by the induction of granulocyte-macrophage colony-stimulating factor (GM-CSF) following viral or bacterial infection. Further studies of APAP remission, and especially of the effects of GM-CSF induction, are needed. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 85-90).

Clinical Impact of Emphysema Evaluated by High-Resolution Computed Tomography on Idiopathic Pulmonary Fibrosis Diagnosed by Surgical Lung Biopsy

BACKGROUND

The prognosis of combined cases of pulmonary fibrosis and emphysema is unresolved partially because radiological differentiation between usual interstitial pneumonia and nonspecific interstitial pneumonia is difficult in coexisting emphysema cases.

OBJECTIVE

The purpose of this study was to clarify the clinical impact of emphysema on the survival of patients with idiopathic pulmonary fibrosis (IPF).

METHODS

One hundred and seven patients with interstitial lung diseases were diagnosed by surgical lung biopsies between 2006 and 2012, and 47 patients were diagnosed with IPF through multidisciplinary discussion. Emphysema on high-resolution computed tomography scans was evaluated semiquantitatively by visual scoring.

RESULTS

Eight out of the 47 IPF patients showed a higher emphysema score (>3) and were diagnosed to have IPF-emphysema. The median survival time of patients with IPF-emphysema (1,734 days) from the initial diagnosis was significantly shorter than that of patients with IPF alone (2,229 days) by Kaplan-Meier analysis (p = 0.007, log-rank test). Univariate Cox proportional hazard regression analyses revealed that a higher total emphysema score (>3.0) was a significantly poor prognostic factor in addition to Krebs von den Lungen-6, surfactant protein-D, arterial oxygen tension, percent forced vital capacity, and percent diffusing capacity of carbon monoxide (%DLCO). Multivariate Cox proportional hazard regression analyses with the stepwise method showed that higher total emphysema score (>3) and %DLCO were significantly poor prognostic factors.

CONCLUSIONS

The prognosis of IPF-emphysema was significantly worse than that of IPF alone.

Heterogeneity of incidence and outcome of acute exacerbation in idiopathic interstitial pneumonia

BACKGROUND AND OBJECTIVE

Acute exacerbations (AEs) of idiopathic pulmonary fibrosis (IPF) and other idiopathic interstitial pneumonia (IIP) have a poor prognosis. This study aims to clarify the incidence and prognosis of AE in IPF and the other IIP.

METHODS

A total of 229 patients were enrolled, of whom 92 had IPF and 137 had 'IIP other than IPF' based on the American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association (ATS/ERS/JRS/ALAT) 2011 IPF Guidelines. IIP other than IPF included 11 patients with a surgical lung biopsy (SLB) and the remainder without such a biopsy. IIP other than IPF was further classified into IIP with a 'possible usual interstitial pneumonia (UIP)' pattern on HRCT (n = 75) and IIP with 'inconsistent with UIP' pattern (n = 62) based on published guidelines. Predictors of AE and the prognosis after AE were examined in these groups.

RESULTS

The 1-year incidence of AE in IPF, IIP with possible UIP HRCT patterns and IIP with inconsistent with UIP HRCT patterns was 16.5%, 8.9% and 4.0%, respectively. AE occurred significantly more frequently in IPF than in IIP with possible UIP and inconsistent with UIP HRCT patterns after adjustment for BMI, modified Medical Research Council score and %forced vital capacity. Prognosis of AE-IIP with possible UIP HRCT pattern was significantly worse than that of AE-IPF.

CONCLUSION

Although AE occurred significantly less frequently in IIP with possible UIP and inconsistent with UIP HRCT patterns than in IPF, the prognosis of AE-IIP with possible UIP HRCT patterns might be worse than that of AE-IPF.

Molecular screening for Rickettsia, Anaplasmataceae and Coxiella burnetii in Rhipicephalus sanguineus ticks from Malaysia

A total of 44 Rhipicephalus sanguineus ticks collected from 23 dogs from Malaysia were screened for Rickettsia, Anaplasmataceae and Coxiella burnetii. Coxiella burnetii was detected in 59% (26/44) of ticks however Rickettsia and Anaplasmataceae were not detected in any of the ticks. In order to genotype the strains of C. burnetii, multispacer sequence typing (MST) was carried out using three different spacers. One of the spacers; Cox2 successfully amplified a fragment for which the full length sequence of 397 bp was obtained. The sequenced product revealed only a single nucleotide difference with the Cox2.3 type sequence.

Pulmonary macrophage alterations associated with aging and SIV infection in rhesus macaques (VIR9P.1155)

Accelerated aging occurs in HIV-infected persons HIV, despite ART, as seen by earlier onset of chronic inflammatory diseases and HIV-associated non-AIDS (HANA) conditions than in non-HIV-infected individuals. In the rhesus macaque SIV model, we reported earlier that increasing monocyte turnover associated with tissue macrophage death predicted onset of terminal disease progression. Here, we hypothesize that macrophage dysregulation contributes to accelerated aging that occurs during SIV infection. We compared macrophage populations of the lung in older and younger uninfected and SIV-infected rhesus macaques. We observed that the ratio of alveolar macrophages (AM) to interstitial macrophages (IM) was significantly lower in chronic SIV-infected younger macaques and older uninfected monkeys compared to uninfected young macaques. The mechanisms differed, however, because the lower ratio in the older uninfected monkeys was due to lower numbers of AM while the shift during SIV infection of younger adults was due to increasing numbers of IM. Functionally, AM of older vs younger uninfected animals exhibited higher levels of pro-inflammatory cytokine secretion (TNFα, IL12) during incubation in medium yet produced lower levels of cytokines after induction with LPS ex vivo. During the acute phase of SIV infection, we observed a higher turnover of monocytes and IM in older compared to younger macaques. This suggests that AM become dysregulated during aging and SIV/HIV infection.

Distinct impact of SIV infection in interstitial and alveolar lung macrophages on the pathogenesis of lung disease in rhesus macaques (VIR9P.1147)

Declining CD4+ T cells during HIV infection contributes to immunodeficiency, but we recently reported that increasing monocyte turnover better predicted onset of terminal disease progression to AIDS in SIV-infected rhesus macaques. Here we describe the kinetics of SIV infection on distinct lung macrophage subsets and on monocyte/macrophage turnover rates in relation to pulmonary disease progression in rhesus macaques. Monocyte and tissue macrophage turnover were monitored by in vivo BrdU injection and cell uptake. Cell-associated SIV DNA in lung tissue was quantified by qPCR and in situ hybridization. Massive SIV infection was associated with increasing death rate of shorter-lived lung interstitial macrophages (IM) with elevated monocyte turnover and progression to AIDS. Conversely, the turnover of alveolar macrophages (AM) and decreasing numbers of CD4+ T cells in lung tissue did not directly correlate with disease progression. SIV DNA levels within IM and AM of the lung increased as monocyte turnover increased, but did not change within lung CD4+ T cells regardless of the stage of disease. These data suggest that SIV infection and concurrent destruction of lung IM contribute to pulmonary pathogenesis during AIDS progression while the longer-lived AM that become infected may contribute to establishing a virus reservoir. Also, bronchoalveolar lavage (BAL) specimens contain AM but not IM, so may be insufficient for fully evaluating macrophage-mediated responses in the lung.

An intractable case of Hermansky-Pudlak syndrome

A 52-year-old Japanese man with congenital amblyopia and oculocutaneous albinism was admitted to our hospital. Chest CT showed reticular opacities and traction bronchiectasis without honeycombing. Specimens obtained by a video-assisted thoracoscopic surgery showed patchy chronic fibrotic lesions. We diagnosed him with Hermansky-Pudlak syndrome (HPS). A mutation in the HPS1 gene was detected, and the diagnosis was confirmed. The patient was treated with prednisolone, pirfenidone, and azathioprine, but he nevertheless died within four months. Autopsy lung specimens showed diffuse alveolar damage suggesting comparatively rapid deterioration, although this presentation was not typical of an acute exacerbation. These pathological changes may be a possible progression pattern in HPS patients.

CYFRA 21-1 as a disease severity marker for autoimmune pulmonary alveolar proteinosis

BACKGROUND AND OBJECTIVE

Serum markers, including Krebs von den Lungen (KL-6), surfactant protein (SP)-D, SP-A and carcinoembryonic antigen (CEA), are reported to reflect autoimmune pulmonary alveolar proteinosis (APAP) disease severity. We evaluated serum CYFRA21-1 levels as a marker of APAP.

METHODS

In addition to KL-6, SP-D and CEA, we prospectively measured serum CYFRA 21-1 levels in 48 patients with APAP, consecutively diagnosed between 2002 and 2010. Diagnostic usefulness of CYFRA 21-1 was determined from 68 patients with interstitial lung diseases by receiver operator characteristic curve analysis. We evaluated the association between these serum markers and other disease severity markers, including pulmonary function parameters, alveolar-arterial oxygen gradient, British Medical Research Council score reflecting shortness of breath, and disease severity score. CYFRA 21-1 localization in the lung was examined by immunohistochemistry.

RESULTS

Receiver operator characteristic curve demonstrated that CYFRA 21-1 effectively identified APAP. Serum CYFRA 21-1 levels at diagnosis were significantly associated with the measured disease severity parameters. Following whole lung lavage (n = 10) and granulocyte-macrophage colony-stimulating factor (GM-CSF) inhalation (n = 20), serum CYFRA 21-1 levels were significantly decreased. Responders (n = 11) to GM-CSF inhalation revealed significantly higher serum CYFRA 21-1 levels than non-responders (n = 9). Serum CYFRA 21-1 appeared to be a significant predictor of effectiveness of GM-CSF based on regression analysis. Immunohistochemistry showed that CYFRA 21-1 was localized on hyperplastic alveolar type II cells and lipoproteinaceous substances in alveoli.

CONCLUSIONS

Serum CYFRA 21-1 is a sensitive and useful serum marker for diagnosis and evaluation of disease severity of APAP, and may predict the response to GM-CSF inhalation.

Predictors of the clinical effects of pirfenidone on idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with a poor prognosis. Recently, pirfenidone was reported to slow the rate of decline in vital capacity and improve progression-free survival in IPF. The purpose of this study was to clarify the factors that predicted a good response to pirfenidone, as well as its adverse effects.

METHODS

Forty-one IPF cases, treated with pirfenidone from January 2009 to January 2011, were enrolled in this investigation. Disease severity was classified into grades I-IV, as defined by the Japanese Respiratory Society (JRS). Short-term responsiveness to pirfenidone was evaluated by the modified criteria of the JRS. Predictors of nausea, anorexia, or both that represented important adverse effects were examined by multivariate Cox proportional hazard analyses. Predictors of short-time responsiveness were examined by multivariate logistic regression analyses.

RESULTS

Diagnosed by a surgical lung biopsy (SLB), the mild cases of grade I/II were predictors of good, short-term responsiveness. Patients taking acid-secretion inhibitors, including proton pump inhibitors and histamine H2-receptor antagonists, showed less anorexia, nausea, or both. Only 1 case was administered drugs to activate gastrointestinal motility.

CONCLUSIONS

We concluded that IPF patients with a mild disease, diagnosis by SLB, or both showed indications of a good response to pirfenidone. In addition, acid-secretion inhibitors may reduce the frequency of anorexia, nausea, or both from pirfenidone.

Comparison of the ontogeny of hunting behavior in pharaoh cuttlefish (Sepia pharaonis) and oval squid (Sepioteuthis lessoniana)

Animals adopt various forms of hunting according to their ecological, morphological, and cognitive features, and their specific hunting skills are acquired ontogenetically in relation to these features. It is noted that cuttlefish and squid hunt prey through the elongation of tentacles used specifically to capture prey. However, these two cephalopods have different lifestyles, leading to questions such as whether hunting skill is acquired similarly after birth and whether tentacle elongation is behaviorally identical. To address these questions, we observed and compared how captive pharaoh cuttlefish (Sepia pharaonis) and oval squid (Sepioteuthis lessoniana) attack prey during their early life stages. Like the adults, S. pharaonis hatchlings used the tentacular lunge attack, whereas S. lessoniana hatchlings used the arm-opening attack. S. lessoniana began to exhibit the tentacular strike attack after 30 days of age. In addition to timing of the emergence of a specific hunting mode, some differences were observed in the physical aspect of hunting behavior. For cuttlefish, maximum tentacle length and maximum speed of tentacle elongation increased from hatching to 30 days of age and then decreased. In contrast, for squid, maximum tentacle length increased from hatching to 30 days of age and then became constant. The distance to prey was positively correlated with maximum length and speed of tentacle elongation in S. pharaonis and with maximum swimming speed in S. lessoniana. These results show that cuttlefish mainly use an ambush strategy and that squid use a pursuit strategy. Possible causes for the ontogenetic differences in hunting behavior are discussed.

Identification of the plague reservoir in an endemic area of Zambia

Yersinia pestis, the bacterial agent of plague, is primarily a parasite of wild rodents that persists in permanent, discrete enzootic foci throughout the world. The disease is transmitted in humans by bites from fleas of wildlife rodent species. Therefore surveillance is the ultimate public health solution through plague detection in domestic dogs, other carnivores and wild rodents. The investigations of die-offs amongst plague-susceptible colonial rodents are also significant to determine the presence of Y. pestis in a susceptible population.This study details the identification of the plague reservoir in a suspected endemic area of Zambia. The study was undertaken through rodent investigation for the presence of Y. pestis. A total of 105 rodents were sampled routinely and during a suspected plague period. On dissection 4 (3.81%, 95% CI: 1.23−10.0) rodents sampled during an outbreak showed signs of spleen enlargement. The blood, liver, lymph nodes and spleen of each rodent were subjected to culture on 6% sheep blood agar and MaCconkey agar. Colonies obtained were identified as Y. pestis by colony morphologic features, biochemical profiles, mouse inoculation assay and polymerase chain reaction (PCR). The PCR primers used targeted the Y. pestis plasminogen activator gene, chromosomal ferric iron uptake regulation gene and the outer membrane protein B gene.The isolates were also subjected to antibiotic sensitivity tests using the disk diffusion method on Mueller-Hinton agar with sensitivity being observed with ampicillin, amoxicillin, chloramphenicol, gentamycin, streptomycin, tetracycline and trimethoprim-sulfamethoxazole. The findings, identifies a natural reservoir of Y. pestis in Zambia providing the public health officials with a definite host for the control strategy.

Polymyxin-B hemoperfusion for acute exacerbation of idiopathic pulmonary fibrosis: serum IL-7 as a prognostic marker

BACKGROUND

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) has an extremely poor prognosis. Direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) has been used to improve oxygenation for acute respiratory distress syndrome. The study aim was to retrospectively determine the predictive factors affecting the prognosis of AE of IPF treated with PMX-DHP.

METHODS

We studied patients suffering from AE of IPF, treated with PMX-DHP combined with high-dose corticosteroid therapy. Stored serum taken before and after PMX-DHP therapy was analyzed for 27 cytokines and chemokines.

RESULTS

Nineteen patients with AE of IPF were studied. The median survival time after diagnosis of AE was 22 days. Survival rates after diagnosis of AE were 47.4% at 30 days, 31.6% at 60 days, and 26.3% at 90 days. Serum levels of Interleukin (IL)-7, an anti-fibrotic cytokine, in survivors at day 30 following PMX-DHP therapy ('Survivors') significantly increased after the treatment, compared to serum levels of non-survivors at day 30 after the therapy ('Nonsurvivors'), which did not demonstrate a significant change. Serum levels of IL-1beta, interferon-y and chemokine ligand (CCL) 2 levels were not significantly altered in 'Survivors', but were significantly changed in 'Nonsurvivors.' Multivariate Cox proportional-hazards analysis showed that an increase in IL-7 levels after PMX-DHP therapy and treatment without intubation (other than invasive positive-pressure ventilation) were significantly better prognostic factors.

CONCLUSION

The results suggest that serum IL-7 may be a useful prognostic factor for patients with AE of IPF treated with PMX-DHP, possibly reflecting underlying anti-fibrotic mechanisms.

[Multidisciplinary assessment of effects, safety and procedure of whole lung lavage for 8 patients with autoimmune pulmonary alveolar proteinosis]

We treated 8 cases of autoimmune pulmonary alveolar proteinosis (APAP) with whole lung lavage (WLL) in our hospital and evaluated the disease severity of APAP before and after WLL, adverse events (AEs) and recurrence-free survival in those cases who improved. In all cases, unilateral WLL was performed in both lungs. The median of total lavage volume in unilateral WLL was 17.9 L, and the median procedure time of unilateral WLL was 105 min. Fever was the most frequently observed AE (87.5% of all procedures). Pulmonary function tests (percentage of predicted value of VC, FEV1 and diffusing capacity of carbon monoxide), serum markers (KL-6, surfactant apoprotein (SP)-D, SP-A and carcinoembryonic antigens), arterial blood gas analyses (PaO2, AaDO2) and disease severity score all significantly improved after WLL. The serum levels of anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibody temporarily decreased after unilateral WLL, but returned to previous levels (before WLL) in 7 cases. The radiological findings improved in 6 cases. In the 7 improved cases in whom AaDO2 decreased more than 10 Torr, the median recurrence-free survival of APAP after WLL was 17.5 months. We concluded that WLL is an effective and safe method for the treatment of APAP, and all parameters except for anti GM-CSF antibody are useful to evaluate the effect of WLL.

Prevalence of Theileria equi and Babesia caballi infections in horses belonging to resource-poor farmers in the north-eastern Free State Province, South Africa

The prevalence of Theileria equi and Babesia caballi infections in the north-eastern Free State Province of South Africa was determined by examination of thin and thick Giemsa-stained blood smears, IFAT and PCR. No parasites were detected by microscopy from any blood samples collected at five study sites, Qwaqwa, Kestell, Harrismith, Vrede and Warden. Of the tested serum samples, 28/29 (96.5%), 20/21 (95.2%) and 42/42 (100%) were positive by IFAT for T. equi infections in Harrismith, Kestell and Qwaqwa, respectively, and 5/29 (17.2%), 13/21 (61.9%) and 30/42 (71.4%) were sero-positive for B. caballi infections in Harrismith, Kestell and Qwaqwa, respectively. All DNA samples from the study sites were negative for B. caballi infections by PCR, but five samples, two from each of Kestell and Warden and one from Vrede, were PCR positive for T. equi infections. The high prevalence of antibodies against T. equi and B. caballi in the sampled horses indicates that the animals had been exposed to T. equi and B. caballi infections but the absence of parasitaemia and very low number of positive PCR samples, however, imply that T. equi and B. caballi are endemically stable in the north-eastern Free State Province.

Preliminary application and evaluation of loop-mediated isothermal amplification (LAMP) for detection of bovine theileriosis and trypanosomosis in Tanzania : research communication

The sensitivity of LAMP, PCR and microscopy to detect Theileria spp. and Trypanosoma congolense in field-derived bovine blood samples from Tanzania was evaluated and compared. No parasites were detected by microscopy. Furthermore, no bovine Theileria spp. were detected by LAMP and PCR from all the 24 samples collected from Arusha. Four and one out of 24 samples were positive for Theileria congolense infection by LAMP and PCR respectively while, 18 and nine out of 40 samples from Dar es Salaam were positive by LAMP and PCR for Theileria spp. Infection, respectively. Although all samples from Dar es Salaam were negative for Trypanosoma congolense infections by PCR, 12 out of 40 samples were LAMP positive. Whilst PCR is an established gene amplification method for the detection of Theileria and trypanosome parasites, this study introduces LAMP as an alternative molecular diagnostic tool that could be used in large-scale epidemiological surveys.