Pulmonary pseudallescherioma associated with systemic lupus erythematosus

We report a case of fungus ball due to Pseudallescheria boydii (pseudallescherioma) associated with systemic lupus erythematosus. Direct microscopical examination revealed a fungus with broad septate hyphae resembling Aspergillus and the fungus was identified as P. boydii on culture. Surgical resection was required to control episodes of hemoptysis. Cases of pulmonary pseudallescheriasis are rare, especially in Japan. However, some cases previously diagnosed as pulmonary aspergillosis may have been found to be caused by P. boydii, if adequate culture studies had been conducted. Unlike Aspergillus, P. boydii is resistant to amphotericin B. Therefore, we emphasize the importance of a correct diagnosis based on culture examination.

Colorimetric determination of citrulline residues in proteins

A method is described for the direct colorimetric determination of citrulline residues in proteins based on the reaction with diacetylmonoxime in the presence of lower concentrations of sulfuric acid. The reduced sensitivity due to the lower acid concentration was overcome by the addition of ferric chloride which also contributed to the color stabilization. Insoluble proteins or proteins resulting in turbidity can be analyzed following partial hydrolysis of those with enzyme or acid. The molar absorption coefficient (epsilon) for citrulline at 464 nm was 2.8 x 10(4). The method enabled us to determine low levels of protein-bound citrulline which are beyond the limitations of conventional methods using an amino acid analyzer. We determined the citrulline contents in the cornified cells of the epidermis of newborn rats, as well as soybean trypsin inhibitor.

First report of Trichosporon ovoides isolated from the home of a summer-type hypersensitivity pneumonitis patient

Trichosporon species have been known to cause summer-type hypersensitivity pneumonitis (SHP). During the isolation of yeasts from an SHP patient's house, we recovered a strain belonging to the genus Trichosporon. Morphologically, the isolate produced rectangular arthroconidia when grown on corn meal agar. DNA-DNA hybridization experiments identified the isolate as T. ovoides. A slide agglutination test using specific factor sera demonstrated that the serotype of the strain was type II. Previously, T. asahii, a serotype II species, was considered to be the major antigen of SHP, but it is possible that T. ovoides may also be responsible for SHP. This is the first report of T. ovoides isolated from an SHP patient's home environment.

Endoscopic sphincterotomy and laparoscopic cholecystectomy in an infant with cholecysto-choledocholithiasis

Laparoscopic cholecystectomy (LC) and endoscopic sphincterotomy (EST) are widely accepted procedures for cholecysto-choledocholithiasis in adults. However, their use in infants has not been reported. An 8-month-old girl presented with high fever and obstructive jaundice. Ultrasound scan showed acute cholecystitis with stones in the bile duct. After 2-week-long antibiotic therapy the acute cholecystitis and hepatic impairment resolved. An endoscopic retrograde cholangiopancreatography (ERCP) confirmed choledocholithiasis and cholecystolithiasis. Risk factors for the development of biliary calculi were not detected. One month after the restoration of her liver function, she underwent EST using a side-viewing endoscope with a small sphincterotome. A common bile duct stone was extracted using a basket catheter. LC was then carried out. The time interval between the EST and LC was 34 days. No complications have been noted for 6 months.

[Chronic hypersensitivity pneumonitis due to isocyanate in a patient presenting with acute symptoms 1 month after environmental exposure]

A 51-year-old man who had been working for 10 years with polyurethane paint containing isocyanate (MDI) was admitted to our hospital with complaints of fever and exertional dyspnea. Fine crackles were heard in both bases, and the patient had clubbed fingers. A chest X-ray film and computed tomograms of the lungs revealed patchy infiltrative shadows in both lung fields and subpleural honeycombing associated with irregular linear areas. Examination of bronchoalveolar lavage fluid showed increased T lymphocytes and a decreased CD 4/8 ratio. Specimens obtained by transbronchial lung biopsy revealed lymphoplasmacytic infiltration into the thickened alveolar walls, macrophage accumulation, and micro-epithelioid cell granulomas in the alveolar sacs. Hypersensitivity pneumonitis was suspected although the causative antigen was not identified because the results of short-term environmental provocation tests were negative in the patient's home and workplace. After discharge, the patient continued working as a paint sprayer. His acute symptoms recurred 1 month after exposure to isocyanate. Similar episodes occurred on two separate occasions. In addition, the patient tested positive for antibody to MDI-HSA in bronchoalveolar fluid. From the above observations, the patient was given a diagnosis of chronic hypersensitivity pneumonitis due to isocyanate (MDI). This condition is extremely rare. Furthermore, it is interesting that acute symptoms recurred 1 month after environmental exposure to the causative antigen.

[Procainamide-induced lupus in a patient with bilateral pleural effusion]

A 70-year-old physician was admitted to our hospital because of bilateral pleural effusion and left-sided chest pain on deep inspiration. On admission, the APTT was prolonged and was not corrected with a 1:1 mixture of normal plasma. Results of serological examinations included a positive lupus-anticoagulant test and a positive ANA test at a titer of 1:1,280 in a homogeneous pattern. The patient's age, sex, symptoms, signs, and laboratory results all argued against the diagnosis of SLE except for ANA and lupus anticoagulant test. Because procainamide had been prescribed (250 mg every 6 h) for premature ventricular contractions for eight years before admission, procainamide-induced lupus was suspected. Procainamide was discontinued. Chest pain persisted and tests for c-reactive protein were positive. Prednisolone was administered. Procainamide induced lupus was diagnosed, because anti-histone H 2 A-H 2 B complex antibodies were high by enzyme-linked immunosorbent assay, and IgM-class anti-histone antibodies were found in response to H1, H 2 B and H 2 A-H 2 B complex (immunoblotting), which suggested the drug induced lupus. There are only a few reports of drug induced lupus in which the lupus-anticoagulant test was positive and prednisolone was indicated. The measurements of anti-histone antibodies and of expression of anti-histone antibodies were useful in distinguishing drug-induced lupus from SLE.

Sarcoid reactions scattered in the tumor-bearing lung parenchyma and regional lymph nodes associated with pulmonary carcinoid

A 77-year-old woman was admitted to our hospital because of a mass lesion in the left lung. The tumor was pulmonary carcinoid associated with sarcoid reactions in the regional lymph nodes and scattered in the resected lung parenchyma. Pulmonary carcinoid with sarcoid reactions is extremely rare. This appears to be the first case report in which tumor-related sarcoid reactions were studded within the tumor-existing lung parenchyma and confirmed not to be within the uninvolved right lung.

Effects of a neutrophil elastase inhibitor (ONO-5046) on acute pulmonary injury induced by tumor necrosis factor alpha (TNFalpha) and activated neutrophils in isolated perfused rabbit lungs

The aim of this study was to examine the effect of ONO-5046, a neutrophil elastase (NE) inhibitor, on a model of acute lung injury induced by tumor necrosis factor alpha (TNFalpha) and phorbol myristate acetate (PMA)-activated neutrophils in isolated perfused rabbit lungs. 120 min after TNFalpha (4,000 JRU/ml) was injected into the pulmonary artery (PA), 5 x 10(7) PMA-stimulated neutrophils were infused into the PA together with 1251-rabbit serum albumin (RSA). In the ONO-5046-treated group (ONO), ONO-5046 (20 mg/kg/h) was continuously infused during the experimental period from 30 min prior to neutrophil administration. Saline, the ONO-5046 vehicle, was infused instead of ONO-5046 in the positive control group (ALD) and nonactivated neutrophils were infused without TNFalpha in the negative control group (Cont). PA pressure was monitored over a 240 min period, and bronchoalveolar lavage (BAL) was performed at the end of the experiment. Lung tissues were examined immunohistochemically for the expression of thrombomodulin (TM). The levels of TM in the perfusate were also measured by ELISA and the radioactivities in the BAL fluid, lung tissue and perfusate were determined to calculate the permeability index (PI) as an indicator of alveolar septal or vascular endothelial damage. The rabbit lungs infused with ONO-5046 showed slower and less increases in PA pressure compared with ALD group. The PI was significantly higher in ALD group (PI[BAL] = 0.028 +/- 0.014, PI[LUNG] = 0.04 +/- 0.003) than Cont (PI[BAL] = 0.002 +/- 0.001, PI[LUNG] = 0.015 +/- 0.003) and ONO group (PI[BAL] = 0.004 +/- 0.003, PI[LUNG] = 0.028 +/- 0.003 (p < 0.05). ALD group had higher TM levels in the perfusate and showed decreased expression of TM on the vascular endothelium compared to Cont and ONO group, suggesting that there was shedding of TM on endothelium and ONO-5046 attenuated a shedding of TM. In conclusion, ONO-5046 attenuated acute lung injury by inhibiting the alveolar epithelial and vascular endothelial injury triggered by activated neutrophils. NE appears to play an important role in the neutrophil-induced increase of pulmonary epithelial and microvascular permeability observed in acute lung injury.

[An elderly woman with chronic pigeon-breeder's disease]

A 64-year-old woman had been feeding more than 60 pigeons in a coop in her back yard for 35 years. Diffuse reticulonodular shadows were found on a chest radiograph obtained as part of an annual check-up eight years before admission to the hospital. She was given a tentative diagnosis of idiopathic pulmonary fibrosis and was observed. She was admitted to our hospital because she noticed dry coughing and shortness of breath. A chest CT scan revealed segmentally distributed honeycombing and bronchi-bronchioloectasis. Tests for IgA and IgG antibodies to extracts of pigeon droppings in serum samples and in samples of bronchoalveolar lavage fluid were strongly positive, as were tests for lymphocyte blastogenic responses to samples of pigeon serum Examination of lung-biopsy specimens obtained by video-assisted thoracoscopic surgery revealed bronchiolitis, alveolitis, and honeycombing in a centrilobular distribution. The patient was given a diagnosis of pigeon-breeder's disease. Chronic hypersensitivity pneumonitis without acute episodes might be misdiagnosed as idiopathic interstitial pneumonia or bronchiectasis, as happened in this case. The possibility of chronic hypersensitivity pneumonitis should be considered when patients are suspected to have pulmonary fibrosis. It is important to obtain the detailed information on past or current avian contact, working history, and the home environment.

Non-Hodgkin's lymphoma with pulmonary infiltrates mimicking miliary tuberculosis

Miliary infiltrates observed on chest films in non-Hodgkin's lymphoma are extremely rare. We report a case with pulmonary infiltrates mimicking miliary tuberculosis associated with prominent eosinophilia and elevated IgE levels. The levels of circulating eosinophils correlated with disease activity as they transiently returned to normal after effective chemotherapy in a short period. However, the patient developed acute respiratory failure due to the rapid progression of the disease even with intensive chemotherapy. We emphasize that small nodular shadows appear to be a sign of the rapid progression of the disease and a poor prognosis.

Identification of the mouse calcium-binding proteins, MRP 8 and MRP 14, in Schistosoma mansoni-induced granulomas: biochemical and functional characterization

Granuloma initiation factor (GIF), which elicits a granulomatous reaction in naive murine skin, contains low-molecular-weight proteins partially purified from organized granulomas developed in livers of mice with schistosomiasis. In this study, we found that 10- and 14-kDa proteins in the GIF are highly homologous to mouse migration inhibitory factor-related protein (MRP) 8 and MRP 14. Compared with the N-terminal amino acid sequence deduced from each corresponding cDNA, the 10-kDa protein from the granuloma lacks the first methionine, whereas the 14 kDa misses methionine, alanine, and asparagine. Immunohistochemically, cells expressing MRP 8 and MRP 14 considerably increased in different murine tissues after Schistosoma mansoni infection and concentrated in liver around the dilated blood vessels and at the edge of granulomas. The staining of differentiated macrophages and epithelioid cells located in the center of the granulomas was negative. Immunoreactivity of peritoneal exudate cells also was found to gradually disappear with time in cell culture. Furthermore, in vivo effects of the recombinant proteins in murine skin were described histologically. Both MRPs caused severe infiltration of neutrophils and monocytes during 7-14 days. The reaction resulting from individual MRP implantation became minimal after 50 days but inoculation of the Ca2+-dependent heterodimers showed an extensive eosinophil accumulation.

Cell-surface hydrophobicity and scum formation of Rhodococcus rhodochrous strains with different colonial morphologies

Rhodococcus rhodochrous has been reported to be one of the micro-organisms responsible for the formation of scum which is thick and viscous biological foam in activated sludge plants. The hydrophobicity of mycolic acids present on the cell surface and the long-branched shape of the hyphae have been thought to contribute to the scum formation. Cell surface hydrophobicity and scum formation of four R. rhodochrous strains with different colony morphologies were determined, and the results showed that the two rough strains had strong cell surface hydrophobicity and produced scum, whereas the weakly hydrophobic smooth strain and the hydrophilic mucoidal strain did not. All four strains displayed long, branched hyphae, and their electrophoretic mobilities were similar, between pH 4 and 9. These data suggest that changes in the cell surface hydrophobicity of the R. rhodochrous result in changes in the culture characteristics and the formation of scum.

In vivo macrophage-stimulation activity of the enzyme-degraded water-soluble polysaccharide fraction from a marine alga (Gracilaria verrucosa)

The water-soluble polysaccharide fraction from Gracilaria verrucosa (GWS) has been reported to increase the phagocytic activity of mice [Yoshizawa et al., Nippon Shokuhin Kogyo Gakkaishi, 41, 557-560 (1994)]. In this study, the macrophage-stimulation activity of enzyme-degraded GWS (GWS-E) was investigated by intraperitoneally and orally administering GWS-E to mice. The intraperitoneal administration of GWS-E increased the number of peritoneal exudate cells (PEC), and increased the phagocytic activity and oxygen radical-secreting activity (spontaneous chemiluminescence) of PEC. This administration could also stimulate splenic macrophages (SPM), increasing radical-secreting activity. When GWS-E was administered orally, the radical-secreting activity of PEC and SPM increased. In this case of oral administration, the activity of SPM increased in a dose-dependent manner, while that of PEC had an optimum dose. These results indicate that GWS-E had macrophage-stimulation activity in vivo and would be suitable as a source for a physiologically functional food with protective and immunopotentiating activity.

Primary diffuse alveolar septal amyloidosis with multiple cysts and calcification

We report an extremely rare case of primary diffuse alveolar septal amyloidosis associated with multiple cysts and calcification. Development of multiple cysts may have resulted from fragile alveolar walls, as a consequence of amyloid deposition both on alveolar walls and around capillaries.

Paraneoplastic pemphigus: report of a case

A 56-year-old male with chronic lymphocytic leukemia developed extensive erosive mucocutaneous lesions with histologic acantholysis. Immunopathologic studies showed IgG deposition at the intercellular space, C3 deposition at both the intercellular space and the dermo-epidermal junction, and reactivity of the serum to rat urinary bladder epithelium. Autoantibodies in the serum to human epidermal proteins of 210 kD and 190 kD were shown by Western blotting and to proteins of 250 kD, 210 kD, and 190 kD by immunoprecipitation. All these data suggest the diagnosis of paraneoplastic pemphigus. Repeated plasmapheresis resulted in re-epithelialization of the mucocutaneous lesions and reduction in antibody titer from 1:1280 to 1:20. Although this mucocutaneous disease was established as a new autoimmune bullous disease by Anhalt et al. (1990), cases have rarely been reported from Japan. The present patient demonstrates the major characteristics of paraneoplastic pemphigus.

[Characteristics of radiopharmaceutical delivered from 99mTc-DTPA in the technegas generator]

99mTc-DTPA aerosol permeates the alveolar membrane by an intercellular pathway. Measurement of the clearance rate of 99mTc-DTPA aerosol is useful for assessing injury of the lung epithelium. Pertechnegas (P-gas) is also used to assess epithelial permeability, but its clearance is too rapid to evaluate lung epithelial permeability. The aims of this study were first to generate 99mTc-DTPA fine aerosol (D-gas), second to characterize D-gas by radiochromatography and an in vivo study in the rat, and third to investigate the clinical significance of D-gas in comparison with 99mTc-DTPA aerosol and P-gas. We generated D-gas in a chamber with an atmosphere of 3% oxygen and 97% argon inside the Technegas Generator. The clearance half-time of D-gas was 19.8 +/- 4.0 min in eight normal non-smoker subjects, 12.0 +/- 2.8 min in four smoker subjects, and 31 +/- 11.2 min in three with idiopathic interstitial pneumonia (IIP). In radiochromatography, the development of D-gas was the same as that of P-gas and different from that of 99mTc-DTPA solution. In the in vivo study using a rat, the distribution of intravenously injected D-gas solution was the same as that of 99mTcO4-, but different from that of 99mTc-DTPA solution. These results suggest that 99mTc-DTPA separates to free 99mTcO4- in the chamber of the Technegas Generator and that D-gas behaves in the same manner as P-gas. In conclusion, D-gas has no clinical significance for the assessment of epithelial permeability.

Macrophage stimulation activity of the polysaccharide fraction from a marine alga (Porphyra yezoensis): structure-function relationships and improved solubility

The polysaccharide fraction from Porphyra yezoensis (PASF) has already been shown to stimulate murine phagocytic functions in vivo and in vitro [Y. Yoshizawa et al., Biosci. Biotech. Biochem., 57, 1862-1866 (1993)]. In this study, various treatments were applied to PASF to assess its structure-function relationships. Desulfation of PASF decreased in vitro macrophage-stimulation activity, while further sulfation of PASF did not change the activity. Among 7 fractions obtained by anion-exchange chromatography of PASF, stronger activity was found in the fractions having a lower or higher sulfate content than in those having a medium sulfate content. Digests of PASF with beta-agarase showed higher activity and solubility, and lower viscosity, than undigested PASF. These results indicate that the sulfate groups in PASF, probably porphyran, contributed to the macrophage stimulating activity, although a larger number of sulfate groups did not always cause stronger activity.

A compartmentalized bias for T-cell receptor V beta usage in summer-type hypersensitivity pneumonitis

Several monoclonal antibodies specific to the human T-cell receptor (TCR) variable (V) region were used to examine whether T-cell oligoclonality plays a key role in the development of the T-cell-mediated lung disease, summer-type hypersensitivity pneumonitis (SHP). The usage of TCR V-regions was examined using bronchoalveolar lavage (BAL) and matched peripheral blood lymphocytes (PBL) in patients with SHP. In 18 SHP patients, the majority of lymphocytes in both BAL and PBL was CD3+ cells (94.2 vs. 63.9%, respectively), which was similar to that in normals (n = 7). Of CD3+ lymphocytes in a SHP patient, the percentage of CD4+ cells in BAL was reduced compared to those in paired PBL, whereas the percentage of CD8+ cells was significantly elevated. In contrast, the percentage of CD4+ cells was much higher than that of CD8+ cells in both BAL and PBL of normal subjects. While a majority of CD3+ T cells expressed TCR alpha/beta+ in BAL and PBL from both SHP patients and normal controls, a marked increase of the expression of TCR gamma/delta+ was observed in PBL in 4 out of 18 SHP patients. A markedly increased prevalence (> 3 SD) of specific TCR alpha/beta+ V-region families in BAL was detected in 5 of 18 patients with SHP as compared to normal controls, whereas no specific increase was found in PBL. Increased V beta 8 was detected in 3 cases; V beta 6 was observed in 1 patient, and V beta 5 in another patient.(ABSTRACT TRUNCATED AT 250 WORDS)

A follow-up study of pulmonary function tests, bronchoalveolar lavage cells, and humoral and cellular immunity in bird fancier's lung

BACKGROUND AND OBJECTIVE

The long-term outcome of bird fancier's lung appears to be variable. The objective of this study is to clarify the sequelae of disease process in bird fancier's lung, with special reference to the humoral and cellular immune responses after avoidance of direct antigen exposure.

METHODS

Five patients with bird fancier's lung were studied for various parameters including pulmonary function tests, cellular profiles of bronchoalveolar lavage (BAL) fluids, determinations of antibodies in BAL fluids and sera, and antigen-induced proliferation of peripheral and bronchoalveolar lymphocytes during the 5 years of follow-up.

RESULTS

Four of five patients showed improvement in pulmonary function, and one showed marked deterioration. This patient's room was close to the pigeon coop where her son was breeding pigeons, resulting in low-grade antigenic stimulation. Three patients demonstrated an increase in CD8+ cells in BAL fluid, but the remaining two showed an increase in CD4+ cells. The levels of IgA antibodies remained unchanged, whereas IgG levels started declining after the first 3 years of follow-up. Antigen-induced proliferation of BAL lymphocytes from all five patients and blood lymphocytes from four of five patients became weaker and gradually approached normal levels. One patient had pulmonary fibrosis and showed significant reduction in pulmonary functions but elevated reactivity of BAL lymphocytes to pigeon antigens.

CONCLUSION

This follow-up study demonstrates persistence of sensitized lymphocytes and antibody production in the respiratory tract and warrants careful evaluation of patients with bird fancier's lung, even after antigen avoidance.

[Physicochemical characterization and lung clearance of pertechnegas]

Pertechnegas, which is a variant of technegas, is an ultrafine carbon aerosol formed inside a technegas generator in the presence of 3% oxygen and 97% argon. The easy extractability of the pertechnegas in the phosphate buffered saline (PBS), the distribution seen in rats after intravenous injection of the pertechnegas and the results of the radiochromatography showed that the pertechnegas behaved like pertechnetate (TcO4-). In vivo study, the clearance half time (T1/2) of inhaled pertechnegas has shown no significant difference to that of TcO4- aerosol in 7 normal subjects. T1/2 of the pertechnegas was considerably faster in comparison with T1/2 of DTPA aerosol. However, T1/2 of the pertechnegas was more rapid in 6 smokers compared with T1/2 in 4 nonsmokers (p < 0.01), and was also increased in the upper lung field compared with the lower lung field (p < 0.01); these results closely correlate with those obtained with DTPA aerosol. Further study of the clearance of the pertechnegas in pulmonary diseases is required to assess clinical usefulness.

Immune responsiveness to inhaled antigens: local antibody production in the respiratory tract in health and lung diseases

The pulmonary defence mechanism in summer type hypersensitivity pneumonitis induced by Trichosporon cutaneum was investigated. We have studied the antibody response to fungal antigens in sera and bronchoalveolar lavage (BAL) fluids from patients with summer type hypersensitivity pneumonitis, bird fancier's lung, interstitial pneumonia associated with collagen vascular disease (INT-PNE), and from normal volunteers. Antigens extracted from fungi frequently isolated from home environments were used in ELISA to detect IgG and IgA antibodies in sera and BAL fluids. The results of the present study show that antibody titre in the respiratory tract to a variety of fungi from home environments is modulated by ongoing pulmonary inflammation, and that antibody production against inhaled antigens is altered by pulmonary inflammation resulting from diverse pathogenesis. This study concludes that the preexisting pulmonary inflammatory disease alters antibody production in the respiratory tract in response to inhaled fungi, and that the type of alteration depends in part on the etiology of the preexisting disease.