Role of the Hla-Dp Glu 69 and the Tnf-α Tnfa-α2 Gene Markers in Susceptibility to Beryllium Hypersensitivity

Berylliosis is an environmental chronic inflammatory disorder of the lung caused by inhalation of beryllium dusts, characterized by the accumulation of CD4+ T cells and macrophages in the lower respiratory tract. Beryllium presentation to CD4(+) T cells from patients with berylliosis results in T cell activation, and these Be-specific CD4(+) T cells undergo clonal proliferation and Th1-type cytokine production such as interleukin-2, interferon-gamma and tumor necrosis factor-alpha. In exposed workers, genetic susceptibility to this granulomatous disorder is associated with major histocompatibility gene and the TNF-α gene. The HLA-DP glutamic 69 residue was shown to be the MHC genetic marker associated with disease susceptibility; furthermore the TNF-α TNFA-308*2 allele was found to be independently associated with HLA-DP GIu69 in the determination of berylliosis risk.

Posterior mediastinal extramedullary hematopoiesis secondary to hypoxia

Two mediastinal masses were incidentally detected at high resolution computed tomography (HRCT) of a 72 year-old male patient, former smoker, affected by chronic obstructive pulmonary disease with worsening dyspnea and 2-year medical history of polycythemia secondary to hypoxia. Integration with a multidetector computed tomography (MDCT) scan after administration of intravenous injection contrast medium showed slightly inhomogeneous increase of enhancement of masses, suggesting in the first case potential malignancy. Diagnosis of extramedullary hematopoiesis was achieved by fine needle aspiration citology (FNAC). Extramedullary hematopoiesis must be considered in differential diagnosis in patients with medical history of polycythemia and severe hypoxia.

Indications to Hospital Admission and Isolation of Children With Possible or Defined Tuberculosis: Systematic Review and Proposed Recommendations for Pediatric Patients Living in Developed Countries. [Corrected]

Tuberculosis (TB) is a re-emerging health problem in developed countries. This paper is part of large guidelines on the global management of TB in children, by a group of scientific societies. It describes the indications to hospitalization of children with suspected or diagnosed TB, the isolation measures, hospital discharge, and re-admission into the community. Using the Consensus Conference method, relevant publications in English were identified by means of a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception until 31 December 2014. Available data on indications to hospitalization were mainly indirect and largely derived from observational studies. They include: (1) host-related risk factors, the main being age <12 months, immune deficiencies, and malnutrition; (2) TB-related clinical conditions that resemble those of pneumonia but also include drug-resistance; and (3) social and logistic conditions. The latter are based on opinion and depend on local conditions. Analysis of the literature showed that patients hospitalized with suspected pulmonary TB should be put in precautionary respiratory isolation regardless of their age while they await diagnosis. The general conditions for re-admission into the community are at least 14 days of effective treatment and negative microscopic tests of 3 consecutive samples in previously microscopically positive patients. This is the first paper that provides indications to hospitalization of children with TB. Most recommendations are generally applicable in all developed countries. Some might need an adaptation to local setting, epidemiological, parameters, and availability of specific health-care facilities.

Levels of circulating endothelial cells are low in idiopathic pulmonary fibrosis and are further reduced by anti-fibrotic treatments

BACKGROUND

It has been suggested that circulating fibrocytes and endothelial cells actively participate in the intense remodelling of the pulmonary vasculature in patients with idiopathic pulmonary fibrosis (IPF). Indeed, fibrotic areas exist that have fewer blood vessels, whereas adjacent non-fibrotic tissue is highly vascularized. The number of circulating endothelial cells (CEC) and endothelial progenitor cells (EPC) might reflect the balance between vascular injury and repair. Thus, fibrocytes as well as endothelial cells could potentially be used as biomarkers of disease progression and treatment outcome.

METHODS

Peripheral blood samples were collected from 67 patients with a multidisciplinary diagnosis of IPF and from 45 age-matched and sex-matched healthy volunteers. Buffy coat was isolated according to standard procedures and at least 20 million cells were stained with different monoclonal antibodies for the detection of CEC, EPC and circulating fibrocytes. For the detection of CEC and EPC, cells were stained with anti-CD45, anti-CD34, anti-CD133, anti-CD14, anti-CD309 and with the viability probe Far-Red LIVE/DEAD. For the detection of circulating fibrocytes, cells were first stained with LIVE/DEAD and the following monoclonal antibodies: anti-CD3, anti-CD19, anti-CD45, anti-CD34 and anti-CD14, then cells were fixed, permeabilized and stained with fluorochrome-conjugated anti-collagen I monoclonal antibodies.

RESULTS

Patients with IPF displayed almost undetectable levels of circulating fibrocytes, low levels of CEC, and normal levels of EPC. Patients treated with nintedanib displayed higher levels of CEC, but lower levels of endothelial cells expressing CD309 (the type II receptor for vascular endothelial growth factor). Treatment with both nintedanib and pirfenidone reduced the percentage of CEC and circulating fibrocytes.

CONCLUSIONS

Levels of CEC were reduced in patients with IPF as compared to healthy individuals. The anti-fibrotic treatments nintedanib and pirfenidone further reduced CEC levels. These findings might help explain the mechanism of action of these drugs and should be explored as predictive biomarkers in IPF.

Asthma is associated with increased susceptibility to infection

Asthma is a chronic inflammatory disorder of the airways characterized by airway hyperresponsiveness and airflow limitation. Despite respiratory symptoms may be episodic, progressive changes occur in the structure of the airway, leading to its irreversible remodeling. Changes include mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, sub-basement membrane fibrosis and angiogenesis. The risk factors for developing asthma are a combination of genetic predisposition along with environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways, such as in- and out-door allergens, tobacco smoke, chemical irritants in the workplace and air pollution. Asthma is a clinically heterogeneous entity due to the complexity of its pathogenetic substrate. Recent evidence suggests asthma to be associated with a sort of immunodeficiency accounting for an increased susceptibility to infection in asthmatic patients. The role of infections as triggers and promoters of disease progression is well established. Conversely, the impact of asthma as a predisposing condition to infection has not clearly been addressed. Such a topic will be the focus of the present review.

Increased liver stiffness in idiopathic pulmonary fibrosis: a pilot study

PURPOSE

There is evidence that pulmonary, hepatic and renal fibrosis may share common pathogenetic pathways. Aim of our study was to measure liver stiffness in patients affected by clinically stable idiopathic pulmonary fibrosis (IPF).

METHODS

Twenty-nine cases (24 M; mean age±SD: 67±8.3 yrs; 19 ex-smokers) along with fifteen age- and sex-matched healthy volunteers were enrolled. Liver conventional ultrasound examination and transient ultrasound elastography (TUE) were realized by two independent operators.

RESULTS

Mild/moderate steatosis was identified in 1 control and 8 IPF cases (6.6% and 27.5%); severe steatosis in 2 IPF patients (7%). Mean TUE measurements were increased in 11 IPF cases (38%) as compared to controls (6.4±2.2 kPa vs 5.2±0.4 kPa; p=0.02).

CONCLUSIONS

To our knowledge, this is the first report suggesting that liver stiffness is increased in more than one-third of IPF patients. Application of novel methodologies should be encouraged for investigating further IPF.

Which factors affect the choice of the inhaler in chronic obstructive respiratory diseases?

Inhalation is the preferred route of drug administration in chronic respiratory diseases because it optimises delivery of the active compounds to the targeted site and minimises side effects from systemic distribution. The choice of a device should be made after careful evaluation of the patient's clinical condition (degree of airway obstruction, comorbidities), as well as their ability to coordinate the inhalation manoeuvre and to generate sufficient inspiratory flow. These patient factors must be aligned with the specific advantages and limitations of each inhaler when making this important choice. Finally, adherence to treatment is not the responsibility of the patient alone, but should be shared also by clinicians. Clinicians have access to a wide selection of pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) that can be used effectively when matched to the needs of individual patients; this should be perceived as an opportunity rather than a limitation.

Metformin/glibenclamide-related interstitial lung disease: a case report

Interstitial lung disease (ILD) may be caused by a wide panel of recognized drugs. Despite the increasing number of reports in the literature, high-lightings of ILD related to oral hypoglycemic drugs are very infrequent.  Herein, we describe the case of a 78-yr-old Caucasian diabetic woman who developed mild dyspnoea at rest, asthenia and fever while on treatment with oral metformin (2000 mg/day) and glibenclamide (12.5 mg/day). On hospital admission, pulmonary function testing (PFT), chest x-ray and thorax high resolution computed tomography (HRCT) were consistent with a diagnosis of ILD. The patient's clinical conditions significantly improved soon after the initiation of insulin therapy instead of oral anti-diabetics due to poor glycemic control. After excluding other known etiologies, the significant improvement in PFT along with the complete resolution of the radiologic findings in the absence of any additional therapeutic effort at 3 months suggested the causal link between previous oral hypoglycemic therapy and lung toxicity. Clinicians should always consider the role of drugs as causative agent in the diagnostic work-up of patients with suspected ILD. To our knowledge, this is the second report in the literature of a case of ILD related to the treatment with high doses of anti-diabetic drugs in a poorly controlled diabetic woman.

Tuberculosis of the tongue in a patient with rheumatoid arthritis treated with methotrexate and adalimumab

In recent years Tumor Necrosis Factor alpha (TNF alfa) inhibitors have been highly effective in treating rheumatoid arthritis (RA). However, patients receiving these inhibitors have an increased risk of developing tuberculosis (TB). We describe a rare case of tuberculosis of the tongue in an RA patient treated with methotrexate (MTX) and the TNF alfa inhibitor adalimumab (ADA) for the previous six years. Pretreatment tuberculin skin test (TST) was negative. The patient was admitted to our division complaining of a sore throat for months. Clinical examination revealed a swollen non-healing ulcer at the base of the tongue, which was suspected to be a squamous cell carcinoma. Histopathological assessment unexpectedly revealed a chronic granulomatous inflammation compatible with tuberculosis. TST was strongly positive and the T Spot TB test was also reactive. MTX and ADA were discontinued and the patient received antituberculous treatment with complete healing of the lesion. After three months our patient had a worsening RA that was treated with MTX and rituximab with no TB related adverse events. This case highlights the importance of considering tuberculosis in the differential diagnosis of ulcerative lesions of the oral cavity, especially in immunocompromised patients treated with TNF alfa inhibitors. Rituximab can be a valid alternative therapy in such patients.

Current treatment options for latent tuberculosis infection

Treatment of latent tuberculosis infection (LTBI) is a key component in TB control strategies worldwide. However, as people with LTBI are neither symptomatic nor contagious, any screening decision should be weighed carefully against the potential benefit of preventing active disease in those who are known to be at higher risk and are willing to accept therapy for LTBI. This means that a targeted approach is desirable to maximize cost effectiveness and to guarantee patient adherence. We focus on LTBI treatment strategies in patient populations at increased risk of developing active TB, including candidates for treatment with tumor necrosis factor-α blockers. In the last 40 years, isoniazid (INH) has represented the keystone of LTBI therapy across the world. Although INH remains the first therapeutic option, alternative treatments that are effective and associated with increased adherence and economic savings are available. Current recommendations, toxicity, compliance, and cost issues are discussed in detail in this review. A balanced relationship between the patient and healthcare provider could increase adherence, while cost-saving treatment strategies with higher effectiveness, fewer side effects, and of shorter duration should be offered as preferred.

Peripheral depletion of NK cells and imbalance of the Treg/Th17 axis in idiopathic pulmonary fibrosis patients

The immune response plays an unsettled role in the pathogenesis of idiopathic pulmonary fibrosis (IPF), the contribution of inflammation being controversial as well. Emerging novel T cell sub-populations including regulatory T lymphocytes (Treg) and interleukin (IL)-17 secreting T helper cells (Th17) may exert antithetical actions in this scenario. Phenotype and frequency of circulating immune cell subsets were assessed by multi-parametric flow cytometry in 29 clinically stable IPF patients and 17 healthy controls. The interplay between Treg lymphocytes expressing transforming growth factor (TGF)-β and Th17 cells was also investigated. Proportion and absolute number of natural killer (NK) cells were significantly reduced in IPF patients in comparison with controls (p<0.001). Conversely, the proportion and absolute number of CD3(+)CD4(+)CD25(high)Foxp-3(+) cells were significantly increased in IPF patients (p=0.000). As in controls, almost the totality of cells (>90%) expressed TGF-β upon stimulation. Interestingly, the frequency of Th17 cells was significantly compromised in IPF patients (p=0.000) leading to an increased TGF-β/IL-17 ratio (4.2±2.3 vs 0.5±0.3 in controls, p=0.000). Depletion of NK and Th17 cells along with a not compromised Treg compartment delineate the existence of an "immune profile" that argue against the recent hypothesis of IPF as an autoimmune disease. Our findings along with the imbalance of the Treg/Th17 axis more closely suggest these immune perturbations to be similar to those observed in cancer. Clinical relevance, limitations and perspectives for future research are discussed.

Screening and monitoring of latent tubercular infection in patients taking tumor necrosis factor-α blockers for psoriatic arthritis

Patients with arthritis who need treatment with biologics are carefully screened for possible previous exposure to tuberculosis to detect any latent tubercular infection (LTBI). The traditional method of screening for LTBI is not specific, because positivity could also depend on infection by atypical mycobacteria and bacillus Calmette-Guerin vaccination. In addition, the screening does not show high sensitivity, frequently presenting a false negativity because of immunosuppression caused by drugs used for arthritis. Recently, interferon-γ release assays (IGRA) have been used to screen LTBI with more sensitivity and specificity before treatment with anti-tumor necrosis factor-α drugs. Moreover, in our experience, IGRA are potentially useful in monitoring LTBI during biologic therapy.

The role of biomarkers in low respiratory tract infections

Low respiratory tract infections (LRTI) represent the leading infectious cause of death worldwide and account for substantial use of healthcare resources. Physicians must adopt practices focused on improving outcomes and serum biomarker can help them in the management of patients with LRTI. Several studies have been carried out or are currently ongoing to evaluate the role of various biomarkers for the differential diagnosis, definition of prognosis, treatment and duration of antibiotic therapy in respiratory infections. The objective of this position paper of the Italian Society of Respiratory Diseases (SIMER) is to provide evidence-based recommendations for the use of biomarkers in routine clinical practice in the management of adult patients with LRTI. These guidelines capture the use of biomarkers both outside and inside the hospital, focused on community-acquired pneumonia, acute exacerbations of chronic obstructive pulmonary disease, hospital-acquired and ventilator-acquired pneumonia.

Psoriatic disease and tuberculosis nowadays

Psoriasis is a chronic, relapsing and remitting inflammatory skin and joint disease that has a prevalence of 2-3% in the world's population, whereas of 1-2% in Europe. The traditional concept of psoriasis as the "healthy people's" disease has been recently revised because of ever-increasing reports of associations with various pathological conditions (hypertension, Crohn's disease, type II diabetes mellitus, obesity, dyslipidemia, metabolic syndrome, infectious conditions). Particularly, advances in psoriasis therapies have introduced biologic agents. All the tumor necrosis factor-alpha inhibitors are associated with an increased risk of developing active disease in patients with latent tuberculosis infection, because of TNF-α key role against Mycobacterium tuberculosis. For this reason, exclusion of active tuberculosis and treatment of latent tuberculosis infection are clinical imperatives prior to starting this therapy. Moreover active surveillance for a history of untreated or partially treated tuberculosis or latent form has already been shown to be effective in reducing the number of incident tuberculosis cases.

Primary pleural haemangioendothelioma in an Italian female patient: a case report and review of the literature

Primary epithelioid haemangioendothelioma (EHE) of the pleura is a rare vascular tumour that occurs mainly in men. Pleural effusion and thickening are the most common clinical presentations. A 58 year old female, nonsmoking patient presented to us with dry cough, dyspnoea and left chest pain for several weeks (no asbestos exposure). Standard chest X-ray and contrast enhanced multislice computed tomography revealed a large-size lobulated mass originating from the pleura which was diagnosed as primary pleural haemangioendothelioma (PHE) by histology and immunohistochemistry (reactivity for vimentin, CD31, CD34, Factor VIII and ulex europeaus). No metastases were detected. The patient refused treatment and died three months later due to the onset of acute and progressive respiratory failure. Despite the lack of high-grade malignancy, primary PHE displays a poor prognosis while curative therapies are actually not available. To our knowledge, this is the first case of primary PHE in a female patient occurring in Italy and the third one to have been reported in English literature. Difficulties in diagnosis and treatment management are discussed below.

Role of the Quantiferon-TB Test in Ruling Out Pleural Tuberculosis: A Multi-Centre Study

Diagnosing pleural tuberculosis (plTB) might be difficult due to limited sensitivity of conventional microbiology tools. As M. tuberculosis (MTB)-specific T cells are recruited into pleural space in plTB, their detection may provide useful clinical information. To this aim, in addition to standard diagnostic tests, we used the QuantiFERON-TB Gold In-Tube (QFT-IT) test in blood and pleural effusion (PE) samples from 48 patients with clinical suspicion of plTB, 18 (37.5%) of whom had confirmed plTB. Four of them (22.2%) tested positive with a nucleic acid amplification test for MTB. The tuberculin skin test was positive in most confirmed plTB cases (88.9%). Positive QFT-IT tests were significantly more frequent in patients with confirmed plTB, as compared to patients with an alternative diagnosis, both in blood (77.7 vs 36.6%, p=0.006) and in PE samples (83.3% vs 46.6%, p=0.02). In addition, both blood and PE MTB-stimulated IFN-γ levels were significantly higher in plTB patients (p=0.03 and p=0.0049 vs non-plTB, respectively). In blood samples, QFT-IT had 77.8% sensitivity and 63.3% specificity, resulting in 56.0% positive (PPV) and 82.6% negative (NPV) predictive values. On PE, QFT-IT sensitivity was 83.3% and specificity 53.3% (PPV 51.7% and NPV 84.2%). The optimal AUC-derived cut-off for MTB-stimulated pleural IFN-γ level was 3.01 IU/mL (77.8% sensitivity, 80% specificity, PPV 68.4% and NPV 82.8%). These data suggest that QFT-IT might have a role in ruling out plTB in clinical practice.

Reactive oxygen species are required for maintenance and differentiation of primary lung fibroblasts in idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal illness whose pathogenesis remains poorly understood. Recent evidence suggests oxidative stress as a key player in the establishment/progression of lung fibrosis in animal models and possibly in human IPF. The aim of the present study was to characterize the cellular phenotype of fibroblasts derived from IPF patients and identify underlying molecular mechanisms.

METHODOLOGY/PRINCIPAL FINDINGS

We first analyzed the baseline differentiation features and growth ability of primary lung fibroblasts derived from 7 histology proven IPF patients and 4 control subjects at different culture passages. Then, we focused on the redox state and related molecular pathways of IPF fibroblasts and investigated the impact of oxidative stress in the establishment of the IPF phenotype. IPF fibroblasts were differentiated into alpha-smooth muscle actin (SMA)-positive myofibroblasts, displayed a pro-fibrotic phenotype as expressing type-I collagen, and proliferated lower than controls cells. The IPF phenotype was inducible upon oxidative stress in control cells and was sensitive to ROS scavenging. IPF fibroblasts also contained large excess of reactive oxygen species (ROS) due to the activation of an NADPH oxidase-like system, displayed higher levels of tyrosine phosphorylated proteins and were more resistant to oxidative-stress induced cell death. Interestingly, the IPF traits disappeared with time in culture, indicating a transient effect of the initial trigger.

CONCLUSIONS/SIGNIFICANCE

Robust expression of α-SMA and type-I collagen, high and uniformly-distributed ROS levels, resistance to oxidative-stress induced cell death and constitutive activation of tyrosine kinase(s) signalling are distinctive features of the IPF phenotype. We suggest that this phenotype can be used as a model to identify the initial trigger of IPF.

Usefulness of Ifn-Gamma Release Assays in Clinical Management of Difficult TB Cases: Evidence from Clinical Practice

Performance of T-SPOT.TB™ (TS-TB) and QuantiFERON TB Gold- In tube (QFT-IT) assays was evaluated for detection of M. tuberculosis (Mtb) infection in patients with suspected extra-pulmonary or smear-negative pulmonary tuberculosis (TB) in a low prevalence country. Twenty-one out of 35 patients were affected by active TB. Mtb culture isolation was achieved in 76% of cases. Tuberculin skin testing (TST), TS-TB, and QFT-IT yielded a positive result in 67%, 95% and 81% of cases, respectively. Agreement of interferon-γ release assays and TST was 70% (κ=0.18 for TS-TB; κ=0.46 for QFT-IT). Increased sensitivity of blood assays (>80%) improved diagnostic evaluation of difficult TB cases.

Prevention of tuberculosis in patients taking tumor necrosis factor-alpha blockers

Treatment with tumor necrosis factor-alpha (TNF-alpha) inhibitors increases the risk of tuberculosis (TB) due to reactivation of latent Mycobacterium tuberculosis infection (LTBI). Screening for LTBI is based mainly on the tuberculin skin test (TST), which has several limitations in any patient who is immunosuppressed due to drugs or autoimmune disease. T cell interferon-gamma release assays (IGRA) have been shown to be more specific than TST in immunocompetent patients and potentially represent a new approach for the management of patients taking TNF-alpha blockers. Even if there is no evidence-based literature of IGRA superiority versus TST in this specific clinical setting, some studies suggest blood assays may be helpful in clinical management of these patients, in addition to currently recommended clinical screening for risk factors for LTBI.

IFN-gamma release assays in tuberculosis management in selected high-risk populations

Tuberculosis (TB) is the most deadly infectious disease in the world. TB control relies on passive case findings and targeted treatment of latently infected individuals at high risk of disease progression. Tuberculin skin testing (TST) is conventionally used for detection of TB infection. Recently, blood assays measuring the release of IFN-gamma by TB-specific effector memory T cells have been developed to overcome TST limitations. Overall, IFN-gamma release assays are more specific than TST, more sensitive in detecting active TB and correlate better with TB exposure in immune-competent patients, at least in low-burden settings. There are three US FDA-approved assays commercially available: the ELISpot-based assay T-SPOT.TB (Oxford Immunotech, UK) and two ELISA-based formats, QuantiFERON TB Gold (QFT) and QFT-in tube (Cellestis, Australia). Recent international guidelines and consensus statements recommend the use of IFN-gamma release assays at different levels in TB management. However, conclusive evidence-based information targeting populations at high TB risk, including HIV-infected individuals, children and patient candidates for biotherapy with TNF-alpha blockers, are lacking. The aim of this review is to focus our attention on studies addressing the performance of commercial IFN-gamma release assays in clinical management of TB infection in these highly selected settings to provide a more comprehensive picture of the actual scenario and to identify areas to be investigated further.