Multiple brushings with immediate Riu's stain via flexible fibreoptic bronchoscopy without fluoroscopic guidance in the diagnosis of peripheral pulmonary tumours

BACKGROUND

Accurate diagnosis of peripheral pulmonary lesions usually relies on fluoroscopic guided procedures. As fluoroscopy is not routinely available in many respiratory units, an approach not using fluoroscopy but with a high diagnostic yield is highly desirable.

METHODS

Immediate cytological examination of multiple brushings using Riu's stain, a modified Wright's stain, was performed in 38 patients with peripheral pulmonary lesions not visible at bronchoscopy. The results were compared with the final diagnoses determined by histological examination or subsequent Papanicolaou staining of cytological specimens and clinical course.

RESULTS

Of the 38 patients 29 were subsequently confirmed to have a malignant tumour. Our method provided a diagnosis of malignancy in 86% of these lesions. The accuracy (91%) and sensitivity (88%) were higher for lesions > 3 cm in diameter than for those of diameter < or = 3 cm (87% and 83%). There were no false positive results. The 29 lesions correctly diagnosed as malignant by Riu's stain required significantly fewer brushings (mean (SD) 3 (2)) than the nine benign lesions (5 (4)).

CONCLUSIONS

This technique provides a high diagnostic yield, avoids the need for fluoroscopy, and is probably safer than percutaneous biopsy.

Hypodense eosinophil number relates to clinical severity, airway hyperresponsiveness and response to inhaled corticosteroids in asthmatic subjects

The phenotypically distinct low-density eosinophil, with its greater inflammatory potential, is increased in asthma. However, the role of hypodense eosinophils in the development of asthma is still unclear. We conducted a double-blind, placebo-controlled study to examine the effect of inhaled corticosteroids on the number of hypodense eosinophils in 27 asthmatic subjects and its relationship with clinical severity. The density profile of eosinophils in the peripheral blood was determined using Percoll density gradient fractionation. Eosinophils recovered from asthmatics were mainly in the lower density fractions (< 1.095 g.ml-1) (63 +/- 3%; n = 27), significantly different from those of normal subjects (27 +/- 2%; n = 7). The proportion of hypodense eosinophils was inversely related to the provocative concentration of methacholine producing a 20% fall in forced expiratory volume in one second (PC20) value (r = -0.75). Patients with mild asthma had a lower percentage of hypodense eosinophils (45 +/- 4%; n = 14) than those with moderate asthma (67 +/- 3%; n = 13). Inhalation of budesonide (800 micrograms.day-1) (n = 15) for 4 weeks, but not placebo, significantly improved the PC20 values by 0.97 doubling dose, forced expiratory volume in one second (FEV1) % predicted by 17%, and peak expiratory flow rate (PEFR) by 15%, and decreased PEFR diurnal variability by 5.4%. The percentage of hypodense eosinophils was significantly decreased from 68 +/- 4 to 47 +/- 4% in the budesonide group (n = 15), but not in the placebo group (n = 12) (63 +/- 4 to 65 +/- 4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Vagal stimulation induces increased pulmonary vascular permeability in guinea pig

The effects of vagal stimulation on pulmonary vascular permeability were studied in guinea pigs in vivo using 125I-labeled albumin as a marker of plasma extravasation. Bilateral vagus nerve stimulation (NS) significantly increased the plasma leakage index in both parenchyma and tracheobronchial tissues. The NS-induced plasma leakage in the parenchyma was unaffected by the alpha-adrenoceptor antagonist phentolamine, the muscarinic receptor antagonist atropine, the ganglionic blocker hexamethonium, or pretreatment with 6-hydroxydopamine or capsaicin, but it was significantly potentiated by the beta-adrenoceptor antagonist propranolol. NS-induced tracheobronchial vascular leakage was markedly inhibited by pretreatment with atropine, hexamethonium, or capsaicin, although it was unaffected by pretreatment with phentolamine, propranolol, or 6-hydroxydopamine. By itself, NG-nitro L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide (NO) synthase, had no effect on pulmonary vascular leakage, but it significantly enhanced the NS-induced plasma leakage to parenchyma in a dose-related and L-arginine-reversible manner. Elevation of blood pressure to a similar extent as that induced by L-NAME by a phenylephrine infusion had no significant effect on the increased plasma leakage induced by NS. These results suggest that vagal stimulation increases plasma extravasation in lung parenchyma through the release of unidentified transmitter(s) in a process that is modulated by endogenous NO and catecholamines (via activation of beta-adrenoceptors), and that different mechanisms are involved in the vagally induced plasma extravasation in the pulmonary and tracheobronchial vascular beds.

Alveolar macrophage subpopulations in patients with active pulmonary tuberculosis

Alveolar macrophages are a heterogeneous cell population. The heterogeneity of alveolar macrophages recovered by bronchoalveolar lavage (BAL) from 12 patients with active pulmonary tuberculosis (TB) and 10 normal subjects was studied using Percoll density fractionation. The numbers and subsets (on the basis of CD3, CD4, and CD8 monoclonal antibodies) of lymphocytes in BAL were measured by flow cytometry. Alveolar macrophages recovered from patients with TB were mainly in the lower-density fractions (< 1.030 and 1.030 to 1.040 g/ml), whereas alveolar macrophages from normal subjects were in the higher-density fractions (1.050 to 1.070 and > 1.070 g/ml). There were no significant differences in alveolar macrophages' repartition between smokers and nonsmokers in either patients with TB or normal subjects. The significant changes in the proportions of the lowest fraction and the higher fractions of alveolar macrophages in patients with TB were not altered after division of our patients into smoker and nonsmoker subgroups when compared with corresponding subgroups in normal subjects. The proportion of the alveolar macrophages in the lowest fraction was inversely related to the bacterial load of sputum and the disease extent on chest radiography in TB patients. The CD4/CD8 ratio was significantly higher in patients with TB. This study shows that alveolar macrophages from TB patients are heterogeneous with hypodense cells predominant probably by interaction with T lymphocytes. Changes in the proportions of alveolar macrophages within subpopulations may be of critical importance in determining the overall response of the lung to TB infection.

Relationship between increased hypodense eosinophils in the peripheral blood and bronchial hyperresponsiveness in patients with bronchial asthma

Eosinophils are the most prominent inflammatory cells involved in the development of bronchial hyperresponsiveness in bronchial asthma. There is evidence that eosinophils in the peripheral blood are a heterogeneous cell population. The heterogeneity of eosinophils in the peripheral blood from 16 patients with mild to moderate bronchial asthma and seven normal subjects was studied using Percoll density fractionation. Eosinophils recovered from patients with bronchial asthma were mainly in the lower density fractions (< 1.095 g/mL), whereas eosinophils from normal subjects were in the higher density fractions (> 1.095 g/mL). The total cell count and the proportion of hypodense eosinophils were highly correlated with the provoking concentration (PC20) of methacholine, which caused a 20% decrease in FEV1 but not in the baseline spirometry. Disease severity, determined on the grounds of clinical history and the peak expiratory flow rate as well as its variability, showed that patients with moderate bronchial asthma had a higher count of hypodense eosinophils than those with mild bronchial asthma. This study shows that eosinophils from asthmatics, when compared with those from control subjects, are heterogeneous and predominantly hypodense cells. Changes in the repartition of the eosinophil subpopulations may be of critical importance in determining the magnitude of the inflammatory response of the airways in bronchial asthma.

The effect of endogenous nitric oxide on neurogenic plasma exudation in guinea-pig airways

We studied the effect of endogenous nitric oxide (NO) on vagally induced plasma exudation into guinea-pig trachea and main bronchi using 125I-albumin as a plasma marker. NG-Nitro-L-arginine methyl ester (L-NAME, 1-10 mg/kg) dose dependently inhibited neurogenic plasma exudation. Intravenous phenylephrine which simulated the vasopressor effect as L-NAME (10 mg/kg) was without effect. The effect of L-NAME (5 mg/kg) was reversed by L-arginine (50 mg/kg). These results suggest that endogenous NO may contribute to neurogenic inflammation in the airways.

Cigarette smoke-induced airway goblet cell secretion: dose-dependent differential nerve activation

We studied the effect of acute inhalation of middle-tar cigarette smoke on airway goblet cell secretion in anesthetized guinea pigs. Secretion induced by a low dose of smoke (10 breaths diluted 1:10 in air) was blocked by either hexamethonium or by filtering out the particulate phase of the smoke. The response was partially inhibited by atropine but was not inhibited by propranolol, phentolamine, or capsaicin pretreatment. Cutting the nerve supply to the airways did not inhibit the response to low-dose smoke. In contrast, goblet cell secretion induced by a high dose of cigarette smoke (20 breaths undiluted) was inhibited by capsaicin pretreatment but not by autonomic receptor blockade nor by filtering out the particulate phase. Secretion induced by the vapor phase of the high dose of cigarette smoke was blocked by capsaicin pretreatment but was not inhibited by hexamethonium. We conclude that in guinea pig airways the particulate phase of low doses of smoke activates cholinergic nerves via stimulation of parasympathetic ganglia, whereas the vapor phase of high doses of smoke activates capsaicin-sensitive sensory nerves.

K+ channel activator inhibition of neurogenic goblet cell secretion in guinea pig trachea

A potassium (K+) channel activator, BRL 38227, inhibited goblet cell secretion in guinea-pig trachea induced by either electrical stimulation of the vagus nerves or acute inhalation of cigarette smoke, two stimuli which activate both cholinergic nerves and capsaicin-sensitive sensory nerves. BRL 38227 failed to inhibit methacholine- or substance P-induced goblet cell secretion which suggests that K+ channel activators inhibit neurogenic goblet cell secretion via a prejunctional effect on cholinergic and sensory nerves.

Differential inhibitory effects of opioids on cigarette smoke, capsaicin and electrically-induced goblet cell secretion in guinea-pig trachea

1. Goblet cell secretion in guinea-pig airways is under neural control. Opioids have previously been shown to inhibit neurogenic plasma exudation and bronchoconstriction in guinea-pig airways. We have now examined the effects of morphine and opioid peptides on tracheal goblet cell secretion induced by either electrical stimulation of the cervical vagus nerves, exogenous capsaicin, or acute inhalation of cigarette smoke. The degree of goblet cell secretion was determined by a morphometric method and expressed as a mucus score which is inversely related to mucus discharge. 2. Morphine, 1 mg kg-1, completely blocked goblet cell secretion induced by electrical stimulation of the vagus nerves. Morphine also inhibited the response to cigarette smoke given either at a low dose (10 breaths of 1:10 diluted in air), which principally activates cholinergic nerves, or at a high dose (20 breaths of undiluted), which activates capsaicin-sensitive sensory nerves, by 100% and 73% respectively. In contrast, morphine had no significant inhibitory effect on capsaicin-induced goblet cell secretion. The inhibitory effect of morphine was reversed by naloxone. 3. Selective mu- or delta-opioid receptor agonists, [D-Ala2, NMePhe4, Glyol5]enkephalin (DAMGO) or [D-Pen2, D-Pen5]enkephalin (DPDPE) respectively, caused a dose-related inhibition of low dose cigarette smoke-induced goblet cell discharge, with DPDPE more potent than DAMGO. A kappa-receptor agonist, trans-3,4-dichloro-N-methyl-N-(2-(1-pyrollidinyl)cyclohexyl) benzeneacetamine (U-50,488H), had no inhibitory effect. DPDPE had no inhibitory effect on goblet cell secretion induced by exogenous methacholine. 4. DAMGO dose-dependently blocked the response to high dose cigarette smoke with a maximal inhibition of 95% at 2 x 10(-7) mol kg-1. Neither DPDPE nor U-50,488H had any significant inhibitory effect. The increase in goblet cell secretion induced by exogenous substance P was not affected by DAMGO.5. We conclude that opioids inhibit neurally-mediated goblet cell secretion via actions at prejunctional delta and mu-receptors on cholinergic nerves and at mu-receptors on sensory nerve endings, and that capsaicin activation of sensory nerves is via a different mechanism from that of electrical or cigarette smoke activation.

Capsaicin and sensory neuropeptide stimulation of goblet cell secretion in guinea-pig trachea

1. We studied the effect of capsaicin and sensory neuropeptides on tracheal goblet cell secretion in anaesthetized guinea-pigs using a semi-quantitative morphometric technique whereby the magnitude of discharge of stained intracellular mucus, expressed as a mucus score (MS), was related inversely to discharge. 2. Capsaicin (i.v.) induced goblet cell secretion: a decrease of 50% in MS below control (indicative of increased secretion) was maximal at 3.3 x 10(-9) mol/kg. 3. Capsaicin-induced secretion was unaffected either by prior vagus nerve section or by pre-treatment with atropine, propranolol and phentolamine which suggests that local axon reflexes with release of sensory neuropeptides are involved in the response. 4. Intravenous substance P (SP), neurokinin A (NKA), neurokinin B (NKB), and calcitonin gene-related peptide (CGRP) produced dose-related increases in goblet cell secretion, with SP the most potent. Doses (mol/kg) causing a 50% decrease in MS from control were 3.5 x 10(-12) for SP; 72 x 10(-10) for NKA; 1.6 x 10(-9) for NKB; and 1.2 x 10(-8) for CGRP. The maximal increase in goblet cell secretion was 75% of control and occurred with SP at 10(-10) mol/kg. 5. SP-induced mucus discharge was not inhibited by atropine or the histamine receptor antagonists mepyramine or cimetidine. 6. We conclude that in guinea-pig trachea, goblet cell secretion is under the control of capsaicin-sensitive sensory nerves and release of neuropeptides from these nerves may induce mucus discharge via tachykinin receptors of the NK-1 subtype (indicated by an order of potency of SP greater than NKA greater than NKB).

Neural control of goblet cell secretion in guinea pig airways

We studied the neural control of goblet cell secretion in the lower airways of anesthetized guinea pigs using a semiquantitative morphometric technique. The magnitude of discharge of intracellular mucus was determined in histological sections of the trachea and main bronchi stained for mucus glycoproteins. Bilateral electrical stimulation of the cervical vagus nerves induced goblet cell secretion. The magnitude of the effect was dependent on the frequency, voltage, and pulse width of the stimulus, and the duration of stimulation. At 10 Hz, 5 V, and 5 ms for 3 min, there was a 62% decrease in the amount of intracellular mucus below that with sham stimulation. The secretion was blocked either by atropine or by pretreatment with capsaicin but was not significantly inhibited by idazoxan, an alpha-adrenoceptor antagonist. The magnitude of goblet cell discharge in animals pretreated with propranolol was intermediate between that in controls and that with nerve stimulation, although not significant to either. These results demonstrate that goblet cell secretion is under neural control in guinea pig airways and suggest that cholinergic, nonadrenergic-noncholinergic, and possibly adrenergic neural pathways, may contribute to the secretion.

Pleural mesothelioma--analysis of 12 cases in Chang-Gung Memorial Hospital

Twelve cases of pathologically proved pleural mesothelioma collected from 1983 to 1987 were analyzed retrospectively. There were 9 males, and 3 females, aged 14-76 year-old (mean 54 year-old). Eight cases were malignant mesothelioma. Four cases were benign mesothelioma. The male to female ratio in malignant tumor was 1 to 7; in benign tumor it was 1 to 1. The mean age in malignant mesothelioma was 45 year-old, and in benign mesothelioma it was 58. Of the 8 cases with malignant mesothelioma, there were 2 cases (25%) of fibrous type, 1 case (12.5%) of epithelial type, and 5 cases (62.5%) of mixed type. Asbestos exposure history was not evident in our series. Definitive diagnosis was obtained in 10 cases by thoracotomy (83%). Two cases of malignant mesothelioma were verified by pleural biopsy. The diagnostic yield is 40% for pleural biopsy, and 100% for thoracotomy. Bronchoscopic examination, percutaneous biopsy, and pleural effusion analysis were useless in making a definitive diagnosis and distinguishing from metastatic adenocarcinoma in our opinions.

[Cytomegalovirus pneumonitis in renal transplantation--a case report]

Cytomegalovirus pneumonitis is a severe complication of renal transplantation. It usually occurs in the first 3-4 months after transplantation. Herein, we describe a 21 year-old male patient with chronic renal failure who received a successful cadaveric renal transplantation after regular hemodialysis three times per week for 3 years. Cyclosporin A and Methylprednisone were used for immunosuppressants after operation. The allograft kidney function improved gradually in two weeks. Serum BUN and creatinine were lowered to 25 mg/dl and 1.7 mg/dl respectively. Bacterial pneumonia developed on the 16th postoperative day. The control of pneumonia rapidly improved after the use of broad spectrum antibiotics. However, bilateral diffuse pulmonary infiltrations developed 21 days later. He received transbronchoscopic diagnostic procedures including TBLB without definite diagnosis. The final diagnosis was obtained by open lung biopsy, in which intranuclear inclusion body was found. The patient expired on the 55th postoperative day despite adjustment of immunosuppresant dosage and use of antiviral therapy.