Latent pulmonary involvement in Crohn's disease: biological, functional, bronchoalveolar lavage and scintigraphic studies

Activity related increase of exhaled nitric oxide in Crohn's disease and ulcerative colitis: a manifestation of systemic involvement?

Nitric oxide (NO) is an important mediator of inflammation in several pathological conditions. Patients with lung diseases, like asthma, have higher levels of exhaled NO (eNO) in active disease in comparison with healthy volunteers. Aspirated colonic gas in patients with ulcerative colitis (UC) showed more than 100 times higher levels of NO in comparison with normal subjects. Crohn's disease (CD) and UC are associated with a variety of systemic manifestations, although lung diseases as an extra-intestinal expression of inflammatory bowel disease (IBD) are not well investigated. In some studies, clinical and subclinical pulmonary abnormalities are described in active IBD as well as in the stable situation. The aim of the present study is to evaluate whether eNO is increased in patients with active IBD and to investigate whether there exists a correlation between (1) the eNO levels and the disease activity, and (2) the spirometry and the disease activity in a subgroup of patients. In 31 patients with CD (mean age 36.8 +/- 12.9 years) and 24 patients with UC (mean age 38.0 +/- 14.7 years) the Crohn's Disease Activity Index (CDAI) and Colitis Activity Index (CAI) were measured, respectively. Exhaled NO was measured with a chemiluminescence analyzer, according to standardized criteria. In a subgroup of CD patients, spirometry was also performed according to standardized criteria. The mean CDAI in CD patients was 192.4 +/- 94.3 and their mean eNO value was 13.5 +/- 4.6 ppb. For UC the mean CAI was 6.2 +/- 4.8 and the mean eNO value was 15.8 +/- 6.2 ppb. In a matched control group of 27 healthy, non-smoking volunteers (mean age of 33.7 +/- 13.2 years) the eNO was 10.2 +/- 2.5 ppb (P < 0.05 compared to CD and P < 0.01 compared to UC). There was a disease-activity-related increase of the eNO level in patients with IBD. For patients with UC the correlation coefficient (r = 0.63, P < 0.001) was more pronounced than for CD (r = 0.39, P < 0.05). In 17 patients with CD, spirometry was available at the time of the eNO measurement. We found a significant negative correlation between the CDAI and the FEV1 and FVC in these patients (r = -0.559, P = 0.02 and r = -0.634, P = 0.006, respectively). We conclude that eNO is increased in active IBD and correlates with the activity of the disease; furthermore, we found a negative correlation between spirometry and disease activity in patients with CD. These observations strengthen the arguments that IBD is a systemic disease. Further research is needed to try to explain the significance of an increased eNO in IBD.

Alterations in pulmonary function in inflammatory bowel disease are frequent and persist during remission

OBJECTIVES

Information on the occurrence and frequency of pulmonary involvement in patients with inflammatory bowel disease (IBD) is inconsistent. The aim of this prospective study was to determine the frequency and type of pulmonary dysfunction in patients with IBD.

METHODS

Sixty-six patients with IBD (35 with Crohn's disease [CD] and 31 with ulcerative colitis [UC]) and 30 control patients were investigated with respect to the following pulmonary function tests: forced expiratory volume in 1 s (FEV1), inspiratory vital capacity (IVC), Tiffeneau value (FEV1/IVC), and lung CO transfer capacity (D(LCO)). Disease activity in IBD patients was assessed by the CD activity index for CD and the Truelove index for UC, respectively. Smoking habits and medication were documented in every patient.

RESULTS

Fourteen of 36 CD patients (39%) and 14 of 31 UC patients (45%) but only one of the controls exhibited at least one pathological (<80% of predicted value) pulmonary function test. In both CD and UC lung function tests were significantly decreased in comparison to the control group. This could be shown for FEV1 (-14% of predicted value in CD and -17% in UC, p < 0.01), IVC (-10% in CD and -12% in UC, p < 0.05), and DLCO (-20% in CD and -31% in UC, p < 0.01) without significant differences between both disease entities. The impairment of pulmonary function tests was more pronounced in patients with active disease than in those with inactive disease (FEV1, 81.4% vs 93.4% predicted, p < 0.02; IVC, 84.4% vs 93.7%, p < 0.05; DLCO, 80.4% vs 95.8%, ns).

CONCLUSIONS

IBD patients show significantly decreased lung function tests in comparison to healthy controls. The impairment in active disease exceeded that during remission.

Tracheobronchial involvement with Crohn's disease

We report the case of a young woman with Crohn's disease of the bowel who presented with a purulent tracheobronchitis and life-threatening upper airway obstruction. Fibreoptic bronchoscopy demonstrated severe tracheal and upper bronchial pseudotumours and stenosis. The role of recent discontinuation of corticosteroids, for quiescent inflammatory bowel disease, in the development of endobronchial disease and the dramatic response in airway patency after reintroduction of prednisolone in this rare complication of Crohn's disease are discussed.

Early bronchopulmonary involvement in Crohn disease: a case report

BACKGROUND

Bronchopulmonary manifestations of Crohn disease have been rarely described in children, including both subclinical pulmonary involvement and severe lung disease.

CASE PRESENTATION

A 6.5-year-old girl is described with early recurrent bronchopulmonary symptoms both at presentation and in the quiescent phase of Crohn disease. Pulmonary function tests (lung volumes and flows, bronchial reactivity and carbon monoxide diffusing capacity) were normal. Bronchoalveolar cytology showed increased (30%) lymphocyte counts and bronchial biopsy revealed thickening of basal membrane and active chronic inflammation.

CONCLUSIONS

Clinical and histological findings in our young patient suggest involvement of both distal and central airways in an early phase of lung disease. The pathogenesis of Crohn disease-associated lung disorders is discussed with reference to the available literature. A low threshold for pulmonary evaluation seems to be advisable in all children with CD.

Granulomatous lung masses in an elderly patient with inactive Crohn's disease

This is a case report of a 77-year-old female with Crohn's disease manifested by recurrent bowel obstructions, who required surgical resections on two occasions but no further medical treatment. She presented 2 years later with pulmonary infiltrates, hilar adenopathy, and multiple lung masses. Biopsies of the masses demonstrated noncaseating granulomatous inflammation and fibrosis similar to the pathology from her bowel resection. Six months later, these pulmonary lesions partially resolved without therapy. This case illustrates significant pulmonary manifestations of Crohn's disease in the absence of active gastrointestinal disease.

The use of induced sputum in the assessment of pulmonary involvement in Crohn's disease

OBJECTIVE

Our aim was to evaluate lung involvement in Crohn's disease (CRD) patients by induced sputum (IS). Extraintestinal manifestations are frequent in CRD, but lung involvement is rare. Induced sputum is a reliable noninvasive method of investigating the pathogenesis, pathophysiology, and treatment of lung disease.

METHODS

Twenty-four CRD patients and nine control subjects (all nonsmokers) without respiratory symptoms were tested. Sputum was induced by 20' inhalation of 3.5% saline using ultrasonic nebulizer. Samples were studied by differential counts of 200 cells on cytopreps stained by Giemsa. T-lymphocyte subset analyses were done by FACS using three monoclonal antibodies: CD3 = total T cells, CD4 = T helper cells, and CD8 = T suppressor-cytotoxic cells. CD4/CD8 >2.5 was considered abnormal.

RESULTS

Four patients did not produce sputum. Of the remaining 20 patients, seven had active CRD and 13 were in remission. They were divided into two groups: Group A patients had abnormal CD4/CD8 ratio of 6.7 +/- 2.5; Group B (seven patients) had normal CD4/CD8 ratio of 1.7 +/- 0.52 (p = 0.0001). The differential counts of IS samples were similar in both groups, but lymphocyte count was significantly higher in CRD patients than in the control group (13.2 +/- 11.2 vs 4.8 +/- 3.6, p = 0.036). There were no differences in spirometry, treatment, extent, or activity of CRD.

CONCLUSION

Using a simple noninvasive method, we found that among CRD patients without respiratory symptoms there was a high (65%) incidence of lung involvement.

Bronchial hyperresponsiveness in children and adolescents with Crohn's disease

Pulmonary manifestations have been described in Crohn's disease (CD). Bronchial responsiveness to methacholine (MCh) was evaluated in 14 children with CD with no evidence of airway disease, 10 asthmatics, and 10 healthy subjects. In patients with CD total blood eosinophils and serum IgE were 0.20 x 10(9) x L(-1) (95% CI -1.68 to 2.08) and 138.4 kU x L(-)(1) (95% CI 18.84 to 257.96), respectively. Three patients with CD had positive prick tests. Bronchial hyperresponsiveness (BHR) was demonstrated in 10 patients with CD (71%) and in the asthmatics, but not in control subjects. In patients with CD PD(20) appeared significantly greater than in asthmatics (699 microg [95% CI 238 to 1,115] versus 104 microg [95% CI 37.35 to 293]; p < 0.05), and was not related either to baseline FEV(1) or IgE or eosinophils (r = 0.32; r = -0.5; r = -0.15, p = NS, respectively). Neither activity nor treatment or duration of CD affected BHR. Five nonatopic CD patients underwent a second MCh challenge over a 25-mo period: the PD(20) appeared significantly greater than basal PD(20) (1,941 microg versus 575 microg, p < 0.05, respectively), in the absence of significant changes of disease activity. BHR might be the expression of subclinical airway inflammation, a phenomenon which can be responsible for the development of various pulmonary manifestations in CD.

Bronchial eosinophilic infiltration in Crohn's disease in the absence of pulmonary disease

BACKGROUND

Immunological and functional bronchopulmonary abnormalities may be present in up to two-thirds of patients with Crohn's disease. Having recently described a mild increase in methacholine airways responsiveness in these patients, we investigated whether this physiological abnormality is associated with bronchial inflammation since it has previously been described in asthma.

METHODS

Eighteen patients with Crohn's disease and 15 healthy controls matched for age, atopy and smoking habit, were studied. All the subjects underwent a bronchial methacholine challenge (1, 4 and 16 mg/mL) and a sputum induction by inhalation of hypertonic saline (NaCl 4.5%). The sputum samples were analysed for their cellular composition as well as for the levels of several mediators and proteins in the fluid phase, including eosinophil cationic protein (ECP), myeloperoxydase, albumin, alpha2-macroglobulin, interleukin-8 (IL-8), IgA and IL-8/immunoglobulin A complexes.

RESULTS

When compared to control subjects, patients with Crohn's disease had significantly higher sputum eosinophil counts (14.5% [0-79.9%] vs 0.2% [0-2.3%]; P < 0. 001) and ECP levels (26.2 microg/L [4-124.2 microg/L] vs 9.8 microg/L [0-94.2 microg/L]; P < 0.05). However, patients with Crohn's disease had no sign of increased plasma exudation as reflected by sputum levels of albumin and alpha2-macroglobulin similar to those seen in control subjects. Furthermore the sputum levels of IL-8, IgA and IL-8/IgA complexes were not significantly different between the two groups. The magnitude of the fall in forced expiratory volume in 1 s after methacholine inhalation was significantly increased in Crohn's disease patients although it did not correlate with the extent of sputum eosinophilia or with the sputum ECP levels.

CONCLUSIONS

Crohn's disease patients without any clinical respiratory involvement have airway eosinophilia without local increased plasma exudation. However, bronchial eosinophilia in Crohn's disease per se is not sufficient to induce clinically significant airway hyperresponsiveness, suggesting that other factors than bronchial eosinophilic infiltration are required for the clinical expression of an airway instability.

Sarcoidosis presenting as granulomatous colitis

Sarcoidosis presenting solely as a granulomatous colitis is rare and appears identical to Crohn's disease. A 56-yr-old woman developed a Crohn's-like illness, which remitted after 5-ASA therapy. Two months later, she developed fever, adenopathy, muscle weakness, and peripheral neuropathy. A diagnosis of sarcoidosis was made after an extensive search for an infectious or rheumatological cause. This case illustrates the utility of serum angiotensin converting enzyme level in differentiating sarcoidosis from Crohn's disease.

Lung function in patients with inflammatory bowel disease

Previous studies on baseline pulmonary function testing (PFT) abnormalities in patients with inflammatory bowel disease (IBD) are conflicting because most of them have incorporated patients suffering from both ulcerative colitis (UC) and Crohn's disease (CD). The aim of the study is to investigate whether any PFT abnormalities could be detected in a large group of IBD patients and whether there are differences between the two IBD entities. A total of 132 patients, 47 with CD (mean age 35 years) and 85 with UC (mean age 40 years) were studied. Pulmonary function tests (PFTs), lung transfer factor for carbon monoxide (TLCO) were examined and compared with those of 36 healthy controls. No significant difference of mean values of spirometric indices, TLCO and ABG was found between the two groups of patients and controls, or between patients with CD and UC. However, nine (19%) patients with CD and 15 (17.6%) with UC had a reduction in TLCO, a percentage significantly higher than in controls (P < 0.05). The majority of the patients with TLCO reduction were in an active phase of disease (P < 0.05). Our results suggest that there is no difference in routine PFTs between UC and CD patients, as well as between both these groups and normal controls. However, TLCO abnormalities related to the degree of disease activity are found in patients with both UC and CD.

Small airways function in patients with inflammatory bowel disease

It has been reported that in patients with inflammatory bowel disease (IBD), the airways are involved, and a number of clinical manifestations have been described. The aim of this study was to investigate the function of the small airways in IBD. Thirty patients with IBD (mean age, 47 yr), 12 with Crohn's disease and 18 with ulcerative colitis, were studied and compared with a control group of 16 normal subjects. Maximal expiratory flow-volume curves were performed breathing room air and a mixture of 80% helium, 20% oxygen. The differences of flows at 50% of FVC (delta Vmax50) and the volume of equal flows (Visov) were calculated as indices of small airways function. In addition, spirometry, lung volumes, and diffusing capacity were measured. Visov was statistically significantly greater in patients with either CD or UC than in control subjects (x +/- SD) (24.99 +/- 1.35 and 25.95 +/- 1.5 versus 20.1 +/- 1.39), (p < 0.01 and p < 0.001, respectively). A reduction in TL(CO) was noticed in the active stage of the disease in both groups of patients (p < 0.05). This may indicate that lung parenchyma is also involved in active IBD. Our results suggest that the function of the small airways and diffusion capacity of the lungs are affected in patients with IBD.

[Bronchopulmonary manifestations of gastroenterologic and hepatic diseases]

Topics of this review are the bronchopulmonary manifestations of gastroesophageal reflux disease, cirrhosis of the liver and chronic inflammatory bowel diseases. About 20% of patients with chronic obstructive airway disease show evidence of gastroesophageal reflux disease. Reflux bronchoconstriction seems to be of greater importance than microaspiration. First studies show the positive effects of acid inhibition by proton pump inhibitors on pulmonary symptoms. Hepatorenal syndrome is characterized by arterial hypoxemia with PaO2-values < 70 mm Hg. Different mediators (endotoxins, amines, polypeptides or allergens) are discussed. Furthermore, elevated levels of prostacycline, atrial natriuretic factor and platelet activating factor have been described. Recently published studies focused on the role of nitric oxide (NO). Patients with cirrhosis of the liver show a higher rate of a pathologically elevated airway resistance which might be induced by a reduced histamine clearance. Ascites leads to reversible restrictive airway disease. Bronchopulmonary manifestations in chronic inflammatory bowel diseases include obstructive and restrictive airway diseases, vascular or serosal changes and show low clinical evidence. In contrast, pathological changes of the common function tests were found in 30 to 50%. These findings may be induced by circulating immune complexes, vasculitis, increased permeability or a combined immune reaction of both, the bronchial and intestinal mucosa. Undesired effects of salicylates should be taken into account. This review shows that bronchopulmonary manifestations in diseases of the Gl-tract or the liver are more common than usually known and should be taken into clinical consideration.

Biochemical changes in sarcoidosis

Biochemical markers in sarcoidosis are closely related to the immunological events and the activity of inflammatory effector cells at sites of granuloma formation. The markers can be measured in serum, then reflecting whole body concentration, or in BAL fluid, then indicating activity in the lung. Only calcium and ACE serum levels have gained a proven value in the clinical field.

Mucosal allergy: role of mast cells and eosinophil granulocytes in the gut

Despite the progress made in understanding the mechanisms of allergic disease, the pathophysiology and clinical significance of intestinal allergic reactions is largely unclear. The intestinal mucosa is pre-destined for allergic reactions against food proteins and other antigens, and a number of studies indicate that allergic reactions occur in the GI tract. However, only a few epidemiological data are available, and the mechanisms are poorly understood. Intestinal allergic reactions may be different to classical IgE-mediated reactions because patients with intestinal allergy often have negative skin tests and low levels of serum IgE. There is increasing evidence that, as with the findings in the skin and lung, mast cells and eosinophils play a central role in mediating intestinal allergic reactions. Furthermore, both types of cell are found to be activated in a number of other GI inflammatory diseases such as inflammatory bowel disease, celiac disease and eosinophilic gastroenteritis. However, the relationship between these pathologies and intestinal allergy is largely unclear. A major clinical problem is the lack of appropriate means for confirming the diagnosis of intestinal allergy. However, new test systems have been developed--such as the measurement of eosinophil mediators in stool samples or endoscopic provocation tests performed locally at the intestinal mucosa, which may improve the possibility of identifying afflicted patients on an objective basis. Since symptoms of intestinal allergic reactions are variable and non-specific, the diagnosis requires the use of multiple tests and the exclusion of other pathologies such as infectious disease or non-immunological intolerance reactions. The preferred therapeutic option is avoidance of the allergens of relevance; however, this approach can be realized only in some patients, whereas others require additional treatment, for example, with oral cromoglycate or corticosteroids. Although we do not yet know to what extent intestinal allergic reactions may be an aetiological factor in GI diseases, such reactions should be considered in the differential diagnosis of unclear intestinal inflammation and irritable bowel syndrome.

Increased intestinal permeability in bronchial asthma

T lymphocytes are a major component of bronchial inflammatory processes in asthma. Because lymphocytes have the ability to migrate from one mucosal site to another, we initiated this prospective study to demonstrate mucosal abnormalities of the digestive barrier in asthma. To establish this we studied intestinal permeability in a group of 37 patients with asthma (21 allergic and 16 nonallergic) by measuring chromium 51-labeled ethylenediaminetetraacetatic acid (CrEDTA) urinary recovery. The results were compared with those obtained in a group of 13 nonasthmatic patients with chronic obstructive pulmonary disease and 26 healthy control subjects. Urinary recovery of CrEDTA was significantly higher in patients with asthma (2.5% +/- 1.95%) than in patients with chronic obstructive pulmonary disease (1.16% +/- 0.48%) and healthy control subjects (1.36% +/- 0.14%). There was no significant difference in intestinal permeability between patients with allergic asthma (2.94% +/- 2.4%) and those with nonallergic asthma (1.92% +/- 0.9%). Intestinal permeability was not correlated with the severity of asthma as measured by FEV1. Similarly, intestinal permeability did not significantly vary according to Aas score or steroid treatment. Serum IgE values and eosinophil blood count were not correlated with intestinal permeability. Intestinal permeability was evaluated sequentially in seven patients with asthma (4 allergic and 3 nonallergic) with a mean interval of 7.6 months (range, 2 to 13 months) and did not significantly change. Our results support the hypothesis that a general defect of the whole mucosal system is present as a cause or a consequence of bronchial asthma.

[Sarcoidosis in children with digestive manifestations]

BACKGROUND

Gastric involvement is the least rare among digestive localizations of sarcoidosis, as well in adults as in children. When it is to be seen at the beginning of the disease, it may cause difficulties in the diagnostic, especially with Crohn's disease.

CASE REPORT

Gastric ulcers were detected in a 12 year-old girl, of African origin, who complained about epigastric pain. Eighteen months later, diarrhea, poor growing, uveitis and inflammatory biological signs led to a probable diagnostic of Crohn's disease. Endoscopy seemed to confirm this diagnostic with granulomatous lesions on gastric biopsies. The absence of radiological anomalies of the digestive tract and the poor efficiency of the medical treatment led to question this diagnosis and to assert that of sarcoidosis.

CONCLUSIONS

This case allows to emphasize the rare involvement of the digestive tract in sarcoidosis and the aspects common both to Crohn's disease and sarcoidosis.

Association between inflammatory bowel disease and sarcoidosis. Report of two cases and review of the literature

BACKGROUND

Common etiopathogenic factors may explain the association of systemic sarcoidosis with inflammatory bowel disease.

METHODS

We report two cases of such an association: one of sarcoidosis that developed 2 years after proctocolectomy for ulcerative colitis and one of sarcoidosis and Crohn's colitis. Factors like increased cellular immunity or circulating immunocomplexes or autoantibodies may have a role. Exogenous agents or familiarity may also be involved.

CONCLUSIONS

It is postulated that the association between sarcoidosis and inflammatory bowel disease (both ulcerative colitis and Crohn's disease) does not occur by chance alone and that the two conditions may share some genetic or immunologic alterations. The two diseases, however, follow an independent clinical course.

Increased frequency of bronchial hyperresponsiveness in patients with inflammatory bowel disease

Although bronchopulmonary manifestations are rare in inflammatory bowel disease (IBD), subclinical abnormalities have been described in up to 50% of cases. The pathophysiology of these abnormalities remains unknown. However, a latent inflammation of the bronchial mucosa secondary to the inflammation of the intestinal mucosa has been suggested. This subclinical inflammation may lead to increased bronchial responsiveness. We studied the bronchial responsiveness in 38 inflammatory bowel disease (IBD) patients, using the methacholine test. Bronchial hyperresponsiveness was defined by a PC20M < 16 mg/ml. Twenty-four healthy controls were also studied. There was no significant difference in baseline FEV1 between IBD patients and controls. However, there was a significantly greater fall in FEV1 in the IBD patients at the concentrations of methacholine tested. The frequency of bronchial hyperresponsiveness was significantly higher in the IBD population (45%) than in controls (17%; P < 0.03). Atopy, defined by skin test, was more common in IBD patients (42%) than in controls (21%). Even when only nonatopic subjects were considered, the frequency of bronchial hyperresponsiveness was significantly higher in IBD patients (41%) than in controls (5%; P < 0.02). Thus, subclinical bronchial hyperresponsiveness is common in IBD, and may be considered a further extraintestinal manifestation.

An unusual perilobular pattern of pulmonary interstitial fibrosis associated with Crohn's disease

Pulmonary pathology associated with inflammatory bowel disease is rare, and seldom biopsied. In this report, we describe a case of pulmonary interstitial fibrosis associated with Crohn's disease. Biopsy showed a unique pattern, with cellular fibroblastic proliferation and fibrosis affecting interlobular septa, spreading into the parenchymal interstitium from the periphery, with associated lymphoid aggregates and thickening of arterial adventitia.

Crohn's disease with pulmonary involvement in a 3 year old boy

Extra-intestinal or metastatic Crohn's disease is being recognised increasingly, most commonly in the skin and genitourinary system. Only very rarely has it been reported in the lung. A 3 year old boy who presented with swollen gums and a persistent abnormality on his chest x ray is reported. Lung biopsy specimens showed multiple non-caseating epithelioid granulomas. Subsequent investigation showed the presence of intestinal Crohn's disease. The evidence for abnormal lung function in Crohn's disease and the possible pathogenesis of metastatic pulmonary Crohn's disease are discussed.

Early pulmonary physiologic abnormalities in beryllium disease

By using the beryllium-specific blood lymphocyte transformation test (BeLT) as a screening tool, it is possible to identify beryllium disease before clinical symptoms or radiographic abnormalities develop. Little is known about the early pulmonary physiologic abnormalities in granulomatous lung diseases. We compared two groups: (1) "surveillance-identified" early beryllium disease patients, detected using the blood BeLT in workplace screening projects (n = 21), and (2) "clinically identified" beryllium disease patients who presented with symptoms or radiographic abnormalities (n = 15). We measured spirometry, lung volumes, diffusing capacity for carbon monoxide, arterial blood gases, and maximal exercise capacity. Physiologic abnormalities occurred in 12 of 21 (57%) surveillance-identified patients. The most common derangement was a rise in the dead space to tidal volume ratio (VD/VT) during exercise, suggesting a pulmonary vascular abnormality. None of the surveillance-identified patients had pure restriction, and only one of 21 had an abnormal diffusing capacity. In comparison, 93% of clinically identified beryllium disease patients had one or more abnormalities, the most sensitive indicator being the exercise capacity. One-third had airflow limitation. Resting arterial blood gas analysis was abnormal in seven of 15 (47%), whereas diffusing capacity was low in only five of 15 (33%). Clinically identified patients performed less work, had more severe gas exchange abnormalities, and had higher VD/VT at maximal exercise than did surveillance-identified patients. We conclude that alterations in gas exchange and the pulmonary vascular bed occur early in beryllium disease.

Increased pulmonary and intestinal permeability in Crohn's disease

We tested the hypothesis that an increased epithelial permeability may affect sites other than the intestine in patients with Crohn's disease by simultaneously evaluating their pulmonary and intestinal permeability. Pulmonary and intestinal permeability were measured by clearance of inhaled technetium-99m diethylene triamine pentacetate (99mTc-DTPA) and by urinary recovery of chromium-51 ethylene diamine tetracetate respectively in 22 patients with Crohn's disease. The half time clearance of 99mTc-DTPA from lung to blood (t1/2LB) was decreased--that is pulmonary permeability increased--in the whole group of patients with Crohn's disease as compared with 13 controls (median 45.5 minutes (8-160) v 85 minutes (34-130) (p less than 0.003)). When analysed separately only patients with active Crohn's disease (n = 15) had a decreased t1/2 lung to blood v controls (42 minutes (8-160) v 85 minutes (34-130) (p less than 0.0025)). Among patients with active Crohn's disease, six were studied again when their disease was quiescent and their t1/2 lung to blood did not differ significantly. The intestinal permeability was increased in the whole group of Crohn's disease patients as compared with 15 controls (5.25% (1.2-24) v 1.7% (0.65-5.75) (p less than 0.0002)). When analysed separately both patients with active and inactive Crohn's disease had increased intestinal permeability v controls (8.1% (1.6-24) and 3.5% (1.2.9.2) v 1.7% (0.65-5.75)) (p less than 0.0001, p = 0.05 respectively). Six patients with active Crohn's disease were studied again when their disease was quiescent and their intestinal permeability decreased significantly p less than 0.04). Pulmonary permeability was increased in patients with Crohn's disease but was not greatly influenced by Crohn's disease activity as opposed to intestinal permeability. The mechanism of this increase is unknown, but may be related in some patients to the presence of an alveolitis.

Bronchoalveolar lavage in alcoholic liver cirrhosis. T-lymphocyte subsets and immunoglobulin concentrations

The purpose of this study was to determine the phenotype profiles of immune effector cells and the concentrations of immunoglobulins in the lower respiratory tract of non-smoking patients with alcoholic liver cirrhosis (ALC). Nine nonsmoking patients with liver biopsy-proved ALC (grade B or C cirrhosis in Child's classification), free of clinical pulmonary symptoms, and with normal chest roentgenogram were included in the study. The control group included 12 healthy nonsmokers. Each patient had fiberoptic bronchoscopy with bronchoalveolar lavage (BAL). The number of T cells and of lymphocyte subpopulations was determined by immunofluorescence studies using monoclonal antibodies that were specific for CD3, CD4, and CD8 markers. Patients with ALC exhibited a dramatically increased percentage of CD8+ cells in BAL that induced a low CD4/CD8 ratio (0.96 +/- 0.15 vs 1.8 +/- 0.12 in healthy controls). Further characterization of lymphocyte subsets' dual immunofluorescence analysis demonstrated that most of the CD8+ alveolar lymphocytes had a phenotype of cytotoxic cells (CD8+ CD11b-; 48 percent +/- 13 in ALC vs 10 percent +/- 5 in controls). ALC was associated with an appreciable alveolar-capillary "leak" as demonstrated by a significant increase in BAL fluid albumin. In addition, the concentrations of immunoglobulins in BAL fluid were significantly greater in ALC than in controls. However, the relative (to albumin) coefficient of excretion of IgG, A, and M in and alpha 2-macroglobulin BAL fluid was not significantly different between controls and ALC. Our results indicate that increased proportions of CB8+ and especially of CD8+ CD11b- cells are a common feature in the lower respiratory tract of nonsmoking patients with ALC. These changes may be of potential functional importance in the regulation of the local pulmonary immune response in ALC.

Tracheo-bronchitis as a complication of Crohn's disease--a case report

A case of Crohn's enterocolitis associated with diffuse tracheo-bronchitis is presented herein. Although respiratory tract involvement in Crohn's disease is extremely rare, our review of the world literature revealed several common clinical pathologic features. These features include a productive cough with chest X-ray films which are normal except for some peripheral involvement. Bronchoscopy, however, shows diffuse inflammation of the trachea and bronchi with widely scattered whitish lesions while biopsy reveals a granulomatous infiltration of inflammatory cells. This tracheobronchitis typically responds well to treatment with prednisone.

Subclinical alveolitis in immunologic systemic disorders

Subclinical alveolitis is a frequent finding in immunologic systemic disorders. However the significance of subclinical alveolar inflammation does not seem to be univocal and varies according to the disease. The fact that pulmonary involvement is rare during the course of extrathoracic granulomatosis like Crohn's disease or primary cirrhosis and that subclinical alveolitis is frequent suggests that alveolar inflammation may be the expression in the lung of a systemic immune disorder. In contrast subclinical alveolitis in collagen-vascular diseases, particularly progressive systemic sclerosis, is frequently associated with abnormalities of lung parenchyma as assessed by CT scan supporting the hypothesis that subclinical alveolitis is associated with development of ILD. Close follow-up of these patients is needed to better determine whether subclinical alveolitis precedes ILD and whether early detection of subclinical alveolitis in immunologic systemic disorders may identify those patients that are at risk for the development of ILD in the future.

Crohn's disease of the lung

Two years after developing colonic Crohn's disease, a 17 year old boy presented with focal pulmonary consolidation. A lung biopsy specimen showed areas of non-caseating epithelioid granuloma. Although some respiratory abnormalities appear to be associated with inflammatory bowel disease, granulomatous disease affecting the lung has not previously been reported in a child.

Are there characteristic alterations in lung tissue associated with Crohn's disease?

Two male patients aged 12 and 31 years suffered from Crohn's disease for more than six years and were treated with Cortison for more than four years. Surgical excision of parts of the terminal ileum was performed in both patients. They suffered from pulmonary symptoms as dyspnoea, shortness of breath and ventilation disturbances two years after operation. Wedge biopsies of the lungs revealed the following histomorphological findings: 1. Granulomatous interstitial lymphocyte infiltrates 2. Acute alveolitis with severe dysplasia of pneumocytes 3. Moderate interstitial fibrosis. Immunohistology performed in one case showed predominantly lambda chains expressed by lymphocytes associated with IgA and IgM. IgG was missing, furthermore kappa chains could not be detected. Macrophages contained endogenous lectins (sugar receptors) for fucose, maltose, and N-acetyl-D-glucosamine (glcNAc). No receptors specific for mannose, lactose, and heparin could be found. Pneumocytes did not bind the neoglycoproteins but were found to express HLA-DR receptors detectable by the monoclonal antibody LN 3 in dysplastic pneumocytes only. The histomorphological and immunohistochemical findings suggest that the analyzed alterations of lung tissue are related to the underlying disease of enteritis regionalis.

Enhanced local production of complement components in the small intestines of patients with Crohn's disease

There is evidence that complement components may be formed locally in inflammatory lesions containing monocytes and macrophages. To investigate the role of complement in Crohn's disease we measured jejunal-fluid concentrations of the complement components C4, C3, and factor B by perfusion of a closed segment of the jejunum in 22 patients with Crohn's disease thought to be limited to the terminal ileum. The mean (+/- SEM) jejunal-fluid C4 concentration was 2.0 +/- 0.3 mg per liter, significantly higher than the mean level in 35 healthy controls (0.7 +/- 0.1 mg per liter; P less than 0.001). The mean C3 concentration was 1.0 +/- 0.1 mg per liter in the patients and 0.7 +/- 0.1 mg per liter in the controls (P less than 0.05). The factor B levels were similar in the two groups. Calculated rates of intestinal secretion of these components showed differences of the same magnitude. Leakage of protein from plasma was not increased. The jejunal-fluid:serum ratios of these complement proteins indicated that their appearance in the lumen of the jejunum was due to at least in part to local mucosal synthesis. The increased jejunal secretion of C4, but not C3 or factor B, paralleled the clinical activity of Crohn's disease. Values were normal in first-degree relatives of the patients (n = 13), patients with celiac disease (n = 8), and patients with ulcerative colitis (n = 4). We conclude that increased secretion of complement by clinically unaffected jejunal tissue in patients with Crohn's disease reflects the systemic nature of this disorder and may be due to the stimulated synthesis of complement by activated intestinal monocytes and macrophages.

Immunological study of histologically non-involved jejunum during Crohn's disease: evidence for reduced in vivo secretion of secretory IgA

We studied the local humoral immunity of histologically non-involved jejunum in patients with Crohn's disease. Normal subjects and patients with ulcerative colitis served as controls. Jejunal fluid samples were collected during segmental jejunal perfusion, under an occluding balloon and the in vivo jejunal secretion of the following proteins was determined: albumin, orosomucoid, transferrin, alpha 2-macroglobulin, secretory component, monomeric and polymeric IgA, IgG, and IgM. The densities and number of IgA-, IgG-, and IgM-containing cells in the lamina propria of the jejunum were measured on perendoscopic biopsies. Jejunal secretion of polymeric IgA and the density of IgA-containing plasma cells in the lamina propria were significantly lower in patients with Crohn's disease than in both control groups. This abnormal intestinal immune response, which was not correlated to the activity of the disease, might be involved in its pathogenesis.

Toxic oxygen metabolite production by circulating phagocytic cells in inflammatory bowel disease

To investigate the possibility that the oxidative capacity of phagocytic cells may be defective in inflammatory bowel disease, toxic oxygen metabolite production by circulating neutrophils and monocytes has been measured by luminol dependent chemiluminescence. Neutrophils from patients with Crohn's disease and ulcerative colitis produced significantly lower chemiluminescent responses after chemotactic stimulation with formylmethionylleucylphenylalanine (fMLP) than neutrophils from control patients, p = 0.018 and 0.043 respectively. Chemiluminescent responses of neutrophils from patients with inflammatory bowel disease, however, were similar to control responses when cells were stimulated with latex beads or phorbol myristate acetate. Monocytes from patients with Crohn's disease produced significantly greater levels of chemiluminescence than control monocytes when stimulated with either fMLP (p less than 0.002), phorbol myristate acetate (p less than 0.0005) or latex beads (p less than 0.002). Monocytes from patients with ulcerative colitis also produced significantly greater levels of chemiluminescence than controls when stimulated with latex beads (p less than 0.5) or phorbol myristate acetate (p less than 0.0005), although there was no difference in the level of chemiluminescence in response to fMLP. These results exclude a generalised defect in phagocytic cell oxidase activity in inflammatory bowel disease and suggest that circulating monocytes are 'activated'.

Pulmonary abnormalities in Crohn's disease

Abnormalities of pulmonary function in Crohn's disease have been described, although the results are conflicting and anecdotal accounts of lung involvement are few. In this study we assessed the prevalence of lung function abnormalities in Crohn's disease, and the relative contributions of age, sex, smoking and past medical history, and Crohn's disease activity to the pulmonary abnormalities found. Twenty-nine patients with Crohn's disease and 29 age-, sex- and smoking-matched volunteer controls underwent detailed respiratory assessment. Airways obstruction due to chronic bronchitis and asthma was present in 13 patients with Crohn's disease, but was not more prevalent than in the control group. FEV1 was similar in both Crohn's disease and control subjects (84.2 +/- 21.2% predicted, mean +/- SD; 93.7 +/- 16.3%, respectively: n.s.). The vital capacity was significantly lower in the Crohn's disease patients than in controls (86.7 +/- 16.6%; 95.9 +/- 12.7%; P less than 0.01), but this may have been influenced by the higher prevalence of past or intercurrent medical illnesses affecting the chest in Crohn's disease patients. No patient had evidence of fibrosing alveolitis or bronchiectasis. The haemoglobin corrected transfer factor was significantly lower in the Crohn's disease patients than in controls (100.4 +/- 17.4%; 113.2 +/- 25.1: P less than 0.05) but the diffusing coefficient was not significantly different. There was a significant correlation (r = 0.44, P less than 0.05) between the residual volume and the Crohn's disease activity index but otherwise no close relationship was observed between Crohn's disease activity, extent or duration and the indices of lung function. These findings suggest that the lungs are relatively unaffected by Crohn's disease.

Pathologic and immunologic alterations in early stages of beryllium disease. Re-examination of disease definition and natural history

Beryllium lung disease is a chronic granulomatous disorder in which a beryllium-specific immune response plays a central role. By using a measure of cellular immune response to beryllium salts, bronchoalveolar lavage (BAL), and lung biopsy, we have identified 12 new cases of beryllium disease. Each of these individuals had pathologic changes on biopsy, lymphocytic alveolitis on BAL, and positive BAL lymphocyte transformation tests (LTT) in response to beryllium sulfate. This group of patients was remarkable for its paucity of clinical findings. At initial evaluation, seven had no respiratory symptoms, and four had normal physical examinations. Five had no increase in interstitial markings on chest radiograph. In eight cases, flow rates and lung volumes were normal. Diffusing capacity for carbon monoxide was low in only one case, and oxygen exchange during exercise was normal in six of nine subjects studied. In addition to the 12 cases, we evaluated eight beryllium-exposed workers who had other (nonberyllium) lung diseases; two of these eight demonstrated beryllium sensitization based on BAL LTT. We conclude that use of fiberoptic bronchoscopy with transbronchial biopsy and BAL facilitates diagnosis of beryllium workers who have histopathologic and immunologic alterations consistent with chronic beryllium disease. These findings may precede frank clinical illness and physiologic impairment, having important implications for our understanding of the natural history of beryllium disease.

Neutrophil and eosinophil involvement of the small bowel in patients with celiac disease and Crohn's disease: studies on the secretion rate and immunohistochemical localization of granulocyte granule constituents

PURPOSE

The concentrations of myeloperoxidase (MPO), a neutrophil granule constituent, and eosinophil cationic protein (ECP), a specific eosinophil granule protein, were measured in jejunal perfusion fluid in an attempt to elucidate the neutrophil and eosinophil involvement of the small bowel in health and disease.

PATIENTS AND METHODS

The control group consisted of 14 males and two females. Ten patients (seven males and three females) with Crohn's disease and seven patients (two males and five females) with celiac disease were also studied; in addition, one patient with relapsing giardiasis, one patient with giardiasis and complete absence of plasma cells in small intestinal lamina propria, and one patient with selective IgA deficiency and no IgA plasma cells in duodeno-jejunal lamina propria were evaluated. Segmental perfusion of the jejunum was performed according to a previously described method. MPO and ECP were measured by radioimmunoassays.

RESULTS

In healthy control subjects, the concentrations of both granule proteins were in a narrow range and much higher than would have been anticipated from passive leakage from circulating blood. In patients with celiac disease, the perfusion fluid concentrations of MPO and ECP were on average 3.5 and eight times, respectively, higher than the values seen in the controls. The jejunal segment perfused in patients with Crohn's disease was endoscopically and histologically normal. The perfusion fluid concentrations of MPO and ECP were increased 3.5 and two times, respectively, compared with that in the control subjects. Both patient groups and the control group had similar perfusion fluid concentrations of albumin. Data on MPO and ECP expressed as jejunal secretion rates gave the same differences between patients and controls as just described for the jejunal fluid concentrations. Immunohistochemical studies of jejunal biopsy specimens from another group of patients with celiac disease demonstrated a prominent extracellular deposit of ECP in the lamina propria of the atrophic intestinal mucosa, whereas the release of neutrophil constituents (cathepsin G, MPO) was scarce. In Crohn's disease, an extracellular degranulation of ECP and, to a lesser extent, of cathepsin G was observed in relation to ulcerations only.

CONCLUSION

Data obtained indicate that the local release of neutrophil and eosinophil granule components is enhanced in the jejunal tissue from patients with celiac sprue and Crohn's disease. The prominent extracellular deposit of eosinophil granule constituents with cytotoxic properties at the site of inflammatory intestinal lesions in celiac sprue might reflect a pathophysiologic mechanism.(ABSTRACT TRUNCATED AT 400 WORDS)

Hyaluronic acid and type III procollagen peptide in jejunal perfusion fluid as markers of connective tissue turnover

Hyaluronic acid (hyaluronate, HA) and type III procollagen N-terminal peptide were measured in jejunal perfusion fluid in an attempt to elucidate the turnover of connective tissue components in the small bowel in health and disease. In healthy controls (n = 16) the average concentration of hyaluronic acid in jejunal perfusion fluid was 12.2 +/- 2 micrograms/L (mean +/- SEM); the mean serum concentration was 22 +/- 7 micrograms/L. The type III procollagen N-terminal peptide concentration in jejunal fluid was 0.12 +/- 0.02 micrograms/L; the mean serum concentration was 12 +/- 0.7 micrograms/L. The albumin concentration in perfusion fluid was, on average, 0.04% of the serum values. Patients with celiac disease (n = 7) and Crohn's disease (n = 10) had normal serum levels of HA and type III procollagen N-terminal peptide. The jejunal secretion rate of HA was significantly increased in both disease groups and on average about three times higher than that in controls. The secretion rate of type III procollagen N-terminal peptide was not altered in celiac disease but increased more than three times in Crohn's disease. Habitual alcoholics investigated after alcohol withdrawal also had significantly increased jejunal secretion of HA but not of type III procollagen N-terminal peptide. In contrast, patients with alcoholic liver cirrhosis and similar ethanol intake had normal secretion of both substances. The findings of the study indicate that the secretion of HA into the jejunal lumen in health is considerable, possibly reflecting the rapid turnover of the intestinal mucosa. The enhanced jejunal secretion of HA in patients with celiac disease and Crohn's disease may be indicative of enhanced connective tissue response due to inflammation, but signs compatible with enhanced jejunal synthesis of type III collagen are only found in Crohn's disease. The HA secretion data in alcoholics might reflect (a) the active regeneration of the intestinal mucosa when ethanol is discontinued and (b) a possible role of the liver in this activity.

Apical pulmonary fibrosis in psoriasis

Apical pulmonary fibrosis has been established as a non-articular complication of ankylosing spondylitis. Although psoriasis is frequently associated with arthropathy and spondylitis, there is only one previous report of apical fibrosis occurring in a patient with psoriasis. We report two patients with psoriasis complicated by apical pulmonary disease in whom extensive investigations were negative.

Immune status in healthy relatives of patients with familial Crohn's disease

Immune-mediated mechanisms and genetic factors are believed to be involved in the pathogenesis of Crohn's disease. We studied T- and B-cell subpopulation proportions and various functional assays, including proliferative responses to PHA and Con A, Con A-induced suppressive activity, and natural killer cell assay toward the K562 cell line, in the peripheral blood of 22 patients with inactive familial Crohn's disease and their 35 healthy relatives including nine families. HLA-A, -B, and -DR antigens were determined in all the subjects. With the exception of minor abnormalities of suppressor cell activity present in some relatives of two families, neither significant impairments of immunological parameters in patients or their relatives nor concordant segregation of HLA haplotypes and disease were observed. These data indicate that peripheral immune abnormalities previously described in patients with Crohn's disease do not constitute primary factors involved in the disease itself and that familial incidence in Crohn's disease cannot be linked to immunological markers presently studied.

Crohn's disease with respiratory tract involvement

Symptomatic respiratory tract involvement with granulomatous bronchial lesions has not yet been described in Crohn's disease. We report two patients with colonic Crohn's disease and severe respiratory symptoms (dyspnoea associated in one of the patients with voicelessness); erythema, aphthoid and superficial ulcerations were found in the colon and whitish granulations in the bronchi at endoscopy. Non-caseating tuberculoid granulomas were found in the colonic mucosa of both patients, as well as in the bronchial mucosa of one of them; in the second a diffuse inflammatory infiltrate including epithelioid cells was found underneath an erosion of bronchial epithelium. Both patients improved on oral prednisone. These two patients probably had bronchial involvement by Crohn's disease.