An inhibitor of tumor necrosis factor found in pleural effusions

Tumor necrosis factor (TNF) has significant biologic effects. Inhibitors of TNF have been isolated from urine and blood. We studied pleural fluid from 22 patients with benign or malignant effusions. Pleural macrophages from these effusions were capable of releasing TNF, especially when stimulated with lipopolysaccharide. The cell-free supernatant from some of these pleural effusions contained an inhibitor of TNF. Fluid from 12 malignant effusions contained an inhibitor of 17% +/- 15.4% (mean +/- SD) of 500 U/ml of TNF activity, whereas the mean inhibition in 10 benign effusions was 2% +/- 5.6% (p less than 0.05). Only one of 10 benign effusions had more than 10% inhibitory activity. This inhibitor was found to be heat sensitive and unaffected by dialysis, and the molecular weight of at least one of the inhibitors was 60 to 80,000 daltons. Enzyme digestion studies were consistent with a protein portion being the major determinant of activity. We conclude that some malignant effusions contain an inhibitor of TNF activity.

Crackles in interstitial lung disease. Comparison of sarcoidosis and fibrosing alveolitis

STUDY OBJECTIVE

Determine why crackles on chest auscultation are characteristic of most interstitial lung diseases, but may not be heard in sarcoidosis.

DESIGN

All patients with sarcoidosis or cryptogenic fibrosing alveolitis seen during a four-week period were studied. In a second study to relate ausculatory findings to anatomy, patients with fibrotic changes on their chest roentgenogram were studied.

SETTING

Patients were recruited from outpatient clinics.

PATIENTS

In the first part, all patients seen over the course of one month were studied. In the second study, patients with pulmonary fibrosis seen on chest roentgenograms were studied.

INTERVENTIONS

For the first study, two independent observers performed auscultation on five sites for crackles and reviewed four roentgenogram quadrants for changes. For the second study, patients underwent VC measurements, auscultation, and high resolution computer tomography scans.

MEASUREMENTS AND RESULTS

For the first study, crackles were noted at greater than 2 sites in all 11 CFA patients, but only one of 17 SARC patients (p less than 0.001). Roentgenogram changes were seen in greater than 2 quadrants in nine of 11 CFA patients and eight of 17 SARC patients (p = ns). In the second study, the VC was similar in the two groups: SARC: 1.96 +/- .90 L (means +/- SD), 58 +/- 20.4 percent predicted; CFA: 1.81 +/- .33 L, 59 +/- 9.2 percent predicted). Only two of 14 SARC patients had crackles in greater than 1 area, while all 14 CFA patients had crackles at greater than 2 sites. The HRCT studies were read by a radiologist unaware of the diagnosis. The presence and degree (0 to 3 scale) of subpleural and peribronchial fibrosis were scored. Twelve SARC patients had peribronchial changes (mean score 1.9 +/- 1.08), while only eight had subpleural fibrosis (mean score .6 +/- .52). There was a significantly different pattern in the CFA patients, where eight had peribronchial fibrosis (mean score = .9 +/- .78, p less than 0.05) and all 14 had subpleural fibrosis (mean score = 1.6 +/- .73, p less than 0.01).

CONCLUSIONS

We conclude that crackles are more frequent in fibrosing alveolitis than in sarcoidosis; this difference may be due to the distribution of parenchymal fibrosis.

The effect of corticosteroid or methotrexate therapy on lung lymphocytes and macrophages in sarcoidosis

Methotrexate appears to be an effective alternative to corticosteroid therapy for some patients with sarcoidosis. The mechanism of action of methotrexate as an immunosuppressive is unknown. Patients with symptomatic pulmonary sarcoidosis underwent pulmonary function tests and bronchoscopy with bronchoalveolar lavage. Patients were treated with 10 mg methotrexate or prednisone weekly for at least 6 months and repeat studies were performed. A comparison was made between those patients receiving methotrexate (12 patients) and those receiving prednisone (12 patients). For both groups, there was a significant improvement in the vital capacity with therapy (Prednisone: Pre = 2.5 +/- 0.14 L (Mean +/- SEM); Post = 3.1 +/- 0.18 L, p less than 0.01; Methotrexate: Pre = 2.4 +/- 0.14 L; Post = 2.8 +/- 0.18 L, p less than 0.01). In addition, the percentage of lymphocytes in the lavage fell significantly for both the prednisone (Pre: 30 +/- 3.5%; Post: 16 +/- 2.7%, p less than 0.001) and methotrexate (Pre: 37 +/- 3.4%; Post: 13 +/- 2.9%, p less than 0.001) groups. Alveolar macrophages from the symptomatic sarcoid patients were found to be spontaneously releasing hydrogen peroxide and tumor necrosis factor. After treatment with either prednisone or methotrexate, alveolar macrophages retrieved by lavage spontaneously released less of either macrophage product. We found that effective doses of methotrexate for sarcoidosis led to significant changes in lymphocyte and macrophages retrieved by lavage.

The use of low dose methotrexate in refractory sarcoidosis

Symptomatic sarcoidosis is usually treated with glucocorticoids; however, glucocorticoids are associated with significant morbidity. Because low dose methotrexate has been successful in treating other inflammatory diseases, methotrexate was used in patients with persistent, symptomatic sarcoidosis. Fifteen patients with either progressive advancing disease or severe side effects with prednisone were treated with methotrexate for at least 6 months. In 13 of 14 evaluable cases there was symptomatic improvement. In 12 of 14 patients there was significant improvement in objective parameters, including a greater than 15% increase in the vital capacity (5 patients), improvement in chest roentgenogram (6 patients), or a greater than 50% reduction in skin lesions (4 patients) or liver function tests (2 patients). In five patients the disease relapsed as methotrexate was being withdrawn; all patients responded to reinstitution of the drug.

The effect of cancer and chemotherapy on monocyte function

Defective monocyte function has been described in human malignancies. This report assessed adherence and the production of hydrogen peroxide by peripheral blood monocytes in breast and lung cancer patients receiving cyclic chemotherapy. Monocyte adherence was similar in cancer patients and normal controls, and adherence was unchanged with chemotherapy. Release of hydrogen peroxide by adherent monocytes was measured before and after chemotherapy in 15 breast and 7 lung cancer patients and compared to cells from 15 normal controls. Monocytes from untreated breast cancer patients released significantly less hydrogen peroxide than controls (Breast = 75 +/- 17.7 nmol/10(6) monocytes; Controls = 150 +/- 19.2, p less than 0.05). Hydrogen peroxide release by monocytes decreased two weeks after chemotherapy in breast and lung cancer patients (Breast Post = 67 +/- 18.3; Lung Pre = 168 +/- 45.9; Post = 77 +/- 16.0, p less than 0.01). This effect was reversible as hydrogen peroxide release prior to the fourth chemotherapy cycle was greater than pre-chemotherapy levels. These findings suggest that chemotherapy causes a reversible impairment of monocyte function.

Release of tumor necrosis factor by alveolar macrophages of patients with sarcoidosis

Tumor necrosis factor (TNF) is a monokine released by macrophages and is important in the inflammatory response. We compared the spontaneous release of TNF by alveolar macrophages (AMs) from patients with symptomatic pulmonary sarcoidosis, some of whom were receiving corticosteroid therapy, with AMs from control smokers. TNF was released from AMs of sarcoidosis patients at significantly higher levels than was released by control AM subjects (sarcoids, 15 U/ml [0 to 1140 U (median [range]]); controls, all less than 5 U/ml, p less than 0.01). By using a specific polyclonal antibody, the detected TNF was found to be TNF-alpha. Among the sarcoidosis patients, the amount of TNF released was significantly lower for those patients given treatment with corticosteroids (5 U/ml [0 to 15 U/ml]) compared with untreated persons (50 U/ml [0 to 1140 U/ml], p less than 0.05). In vitro studies demonstrated that incubation of peripheral blood monocytes or AMs with dexamethasone for 42 hours suppressed subsequent release of TNF. We conclude that AMs from sarcoidosis patients often spontaneously release TNF and this release is suppressed by prolonged corticosteroid therapy.

Isolation of functionally active pleural macrophages

Pleural fluid provides an easily accessible source of tissue macrophages (MACS). We established a method for retrieval and isolation of these cells. Thirty thoracenteses were performed on patients with the clinical diagnosis of congestive heart failure or malignancy. Within 4 hr of thoracentesis, the specimen was placed on a Ficoll-Hypaque gradient, centrifuged, and the mononuclear cells were isolated. Assessment for total cell count, cell viability, and percentage of cells which were MACS as determined by nonspecific esterase staining was recorded. Pleural MACS were separated by glass adherence. In 24 cases, sufficient cells were available to measure the release of hydrogen peroxide spontaneously and with phorbol myristate acetate (PMA) stimulation. Nine of 24 specimens had spontaneous hydrogen peroxide release. In all cases, stimulation of pleural MACS resulted in a significant increase in the amount of hydrogen peroxide released. We report a simple method for retrieving viable and functionally active pleural macrophages.

Marrow granulomas in coal workers' pneumoconiosis. A histologic study with elemental analysis

The differential diagnosis of bone marrow granulomas is lengthy but has not previously included coal workers' pneumoconiosis. This report describes the first case in which noncaseating epithelioid granulomas containing anthracotic pigment and birefringent silica containing crystals were discovered in the marrow of a patient with progressive massive fibrosis of coal workers' pneumoconiosis. The silicotic nature of the crystals was confirmed using energy dispersive x-ray microanalysis. There was no evidence of a mycobacterial, fungal, or other etiology for the granulomas. This case demonstrates that coal workers' pneumoconiosis should be added to the differential diagnosis of bone marrow granulomas and that marrow examination may be a source of tissue for documentation of specific occupational exposures.

Spontaneous hydrogen peroxide release from alveolar macrophages of patients with active sarcoidosis: comparison with cigarette smokers

Alveolar macrophages from patients with active pulmonary sarcoidosis have been shown to secrete several factors, such as interleukin-1 and alveolar macrophage-derived growth factor. We examined alveolar macrophages from nonsmoking patients with sarcoidosis undergoing bronchoalveolar lavage (BAL) for evaluation of disease activity. We compared these cells with macrophages from smoking and nonsmoking control patients. The amount of hydrogen peroxide released by the macrophages either spontaneously or after stimulation by phorbol myristate acetate was measured. The alveolar macrophages from smokers spontaneously released hydrogen peroxide, as we previously observed. The macrophages from the patients with sarcoidosis also released detectable amounts of hydrogen peroxide, but the macrophages from the non-smokers did not. Alveolar macrophages from all three groups released hydrogen peroxide when stimulated with phorbol myristate acetate. The macrophages from all three groups were examined for the presence on the surface membrane of beta-galactosidase, an enzyme that appears on the surface of older, activated macrophages. The macrophages in the BAL fluid of the patients with sarcoidosis had less beta-galactosidase staining than did those from the smokers, although they released comparable amounts of hydrogen peroxide. These findings suggest that alveolar macrophages in the BAL fluid of patients with sarcoidosis are younger, more monocyte-like, and activated by various factors, including gamma-interferon.

The anemia of sarcoidosis

Anemia and leukopenia have been reported in sarcoidosis. In order to characterize the prevalence and association with disease activity, 75 patients with active pulmonary sarcoidosis were studied. One or more hematologic abnormalities were identified in 87% of patients studied. Anemia was present in 21 patients (28%), and bone marrow examination in 17 anemic patients revealed noncaseating granulomas in 9 patients and absent iron stores in 8 patients. The bone marrow aspirates did not show characteristics seen in other anemias of chronic disease, such as tuberculosis. In the majority of unexplained anemia cases, hemoglobin levels normalized with prednisone treatment. Forty-one of 75 patients (55%) had lymphopenia. Anemia found in patients with active sarcoidosis was associated with noncaseating granulomas in the bone marrow and an improvement with steroid therapy.

Bleomycin causes alveolar macrophages from cigarette smokers to release hydrogen peroxide

Alveolar macrophages (AM) were retrieved by bronchoalveolar lavage from 20 patients. Following AM purification by glass adherence, the effect of bleomycin on hydrogen peroxide and lactic dehydrogenase release was assessed by colorimetric methods. All AM from nine nonsmokers had no detectable spontaneous release of hydrogen peroxide. The AM did not release hydrogen peroxide when stimulated with bleomycin (25 mU/mL). AM from all eleven smokers spontaneously released hydrogen peroxide (36 +/- 5.3 nm/10(6) AM, mean +/- SEM). AM from eight of the eleven smokers released more hydrogen peroxide when incubated with bleomycin (smokers 55 +/- 6.8 nm/10(6) AM, p less than 0.05). There was no difference in the amount of lactic dehydrogenase released by AM spontaneously or when incubated with bleomycin at 25 mU/mL, suggesting that this dose of bleomycin was not directly toxic to the AM. Results from this study further support the premise that bleomycin pulmonary toxicity may result from the generation of reactive oxygen metabolites and that cigarette smoking may predispose to bleomycin pulmonary toxicity.