Extrinsic allergic alveolitis from a proteolytic enzyme

Machine operator's lung outbreak due to Eikenella corrodens

BACKGROUND

Outbreaks of hypersensitivity pneumonitis (HP) are not uncommon in workplaces where metalworking fluids (MWFs) are used. The recirculation of MWFs leads to microbiological contamination, which is responsible for outbreaks. Most outbreak reports come from USA and the UK; however, no similar reports have been published from Central Europe.

AIMS

To describe an outbreak of MWF-associated HP in workers from a compressor assembly manufacturing facility in Slovak Republic and to identify the potential antigens responsible for the outbreak.

METHODS

We investigated the history of worker's symptoms, physical examinations, lung function tests, radiographic scans and lung biopsies. The MWF samples were analysed for different strains of bacteria and fungi. Antigen extracts were produced from the microorganisms isolated from MWFs, and positive precipitin reactions were evaluated.

RESULTS

MWF-associated HP was diagnosed in 21 men and 6 women. All workers had work-related dyspnoea and cough with abnormal pulmonary diffusing capacity. Twenty-four cases had evidence of interstitial lung disease. Four cases were classified as having fibrotic HP. Nineteen microbial isolates (12 bacteria and 7 fungi) were cultured from the MWFs. Twenty-five cases had a positive response to at least one isolate. Eikenella corrodens and Bacillus subtilis were the most frequently reacting antigens (in 15 and 12 workers, respectively).

CONCLUSIONS

Despite decreasing reports of MWF-associated HP outbreaks over the past several decades, we describe one of the largest outbreaks in Europe. While the bacterium E. corrodens was found in the MWF samples, its relationship to the disease should be further investigated.

Assessment and Management of Occupational Hypersensitivity Pneumonitis

The diagnosis and treatment of occupational hypersensitivity pneumonitis (OHP) remain complex and challenging in the absence of diagnostic gold standards or clinical guidelines. This review provides an update of the recent literature regarding the different presentations of OHP and the diagnostic yield and value of the diagnostic tests currently available, which include occupational and medical history, laboratory tests (serum-specific immunoglobulins, environmental sampling), imaging, bronchoalveolar lavage, transbronchial biopsy, transbronchial cryobiopsy, surgical lung biopsy, and specific inhalation challenges. These tools provide a precise differential diagnosis within the framework of interstitial lung diseases. However, among the chronic fibrotic forms, distinguishing OHP from sarcoidosis, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis remains a diagnostic challenge. Avoidance of exposure is pivotal for OHP management, whereas corticosteroids are fundamental in the pharmacological approach to this disease. In addition, studies describing the long-term benefits of immunosuppressive and antifibrotic agents have increased the use of these treatments in OHP.

Exposure assessment in hypersensitivity pneumonitis: a comprehensive review and proposed screening questionnaire

Hypersensitivity pneumonitis is an immune-mediated inflammatory lung disease characterised by the inhalation of environmental antigens leading to acute and chronic lung injury. Along with suggestive clinical and radiological findings, history and timing of suspected antigen exposure are important elements for diagnostic confidence. Unfortunately, many diagnoses remain tentative and based on vague and imprecise environmental or material exposure histories. To date, there has not been a comprehensive report highlighting the frequency and type of environmental exposure that might lead to or support a more systematic approach to antigen identification. We performed a comprehensive literature review to identify and classify causative antigens and their associated environmental contexts or source materials, with emphasis on the extent of the supportive literature for each exposure type. Eligible publications were those that reported unique inciting antigens and their respective environments or contexts. A clinical questionnaire was then proposed based on this review to better support diagnosis of hypersensitivity pneumonitis when antigen testing or other clinical and radiological variables are inconclusive or incomplete.

Acellular filtrate of a microbial-based cleaning product potentiates house dust mite allergic lung inflammation

Microbial-based cleaning products (MBCPs) contain bacteria and chemical constituents. They are used in consumer applications such as odor reduction, unclogging drains, and surface cleaning. To determine the capacity of a model MBCP to contribute to acute allergic lung inflammation, a two-week repeated exposure regimen was used. Mice were exposed by endotracheal instillation to saline alone, MBCP alone, house dust mites (HDM) alone, or sequentially (i.e., MBCP followed by HDM, HDM followed by MBCP, or HDM + MBCP followed by HDM). Both whole MBCP and acellular MBCP filtrate were investigated, and showed minimal differences in the endpoints examined. HDM exposure caused pulmonary perivascular inflammation, bronchiolar mucous cell metaplasia, elevated bronchoalveolar lavage fluid (BALF) eosinophils, and HDM-specific IgG1. For MBCP, notable changes were associated with sequential exposures. MBCP/HDM caused elevated T_H2 cytokines in BALF, and elevated neutrophils, eosinophils and IL-5 in peripheral blood. Co-administration of MBCP and HDM followed by HDM resulted in elevated blood and BALF eosinophils and HDM-specific IgE and IgG1. These results demonstrated that acellular MBCP filtrate, and not bacteria within MBCPs, potentiated the acute allergic inflammation to HDM. This methodology could be extended to investigate chronic allergic inflammation and inflammatory potential of other MBCPs and biotechnology products with complex compositions.

Hypersensitivity pneumonitis and antigen identification--An alternate approach

OBJECTIVES

Identification of the causal antigen for patients with hypersensitivity pneumonitis (HP) is challenging in a standard clinical setting. The purpose of this pilot study was to determine whether it was possible to evaluate the home/workplace of patients, and identify the causal antigen.

METHODS

Using a case-control study design we compared the presence of antibody to antigen collected in the environment of individuals with HP and controls consisting of family members/co-workers. Based on patient interviews, homes/workplaces were evaluated and suspected sources of antigen collected for use in immunoassays.

RESULTS

Nineteen individuals with HP participated with 15 classified as having fibrotic disease. Up to 54 bulk samples were collected from each patient's environment, with multiple isolates (antigens) cultured from each. Of the seven individuals who tested positive to one or more environmental samples, three had a positive response to more than 1 antigen from the environmental sample (range 1-9). Twelve individuals tested positive to antigen(s) on a standard panel, with only one overlapping with the antigen from the home/workplace sample. A significant association existed between results of interviews/site evaluations, and ability to collect antigen eliciting a positive response (p < 0.001).

CONCLUSION

Antigen identification was successful for patients with 'active' disease. Antigens for which patients test positive on standard panels may not be present in their environment. One benefit to patient-centered testing is the ability to develop recommendations specific to their environment. As most individuals tested positive for >1 antigen, further investigation is warranted to determine the actual antigen responsible for disease.

A study of the efficacy of bacterial biofilm cleanout for gastrointestinal endoscopes

AIM: To compare the influence and clearance effect of enzymatic and non-enzymatic detergents against Escherichia coli (E. coli) biofilm on the inner surface of gastroscopes.

METHODS: Teflon tubes were incubated in a mixture of different detergents and E. coli culture (10⁶ CFU/mL) for 72 h at 15°C, and biofilms on the inner surface of the teflon tubes were analyzed by bacterial count and scanning electron microscopy. To evaluate the clearance effect of detergents, after biofilms were formed on the inner surface of Teflon tubes by 72 h lavage with E. coli culture, tubes were lavaged by enzymatic and non-enzymatic detergents at a speed of 250 mL/min, then biofilms on the inner surface were analyzed by bacterial count and scanning electron microscopy.

RESULTS: Non-enzymatic detergent had a better inhibition function on biofilm formation than enzymatic detergent as it reduced bacterial burden by 2.4 log compared with the control samples (P = 0.00). Inhibition function of enzymatic detergent was not significantly different to that of control samples and reduced bacterial burden by 0.2 log on average (P > 0.05). After lavaging at 250 mL/min for 3 min, no living bacteria were left in the tubes. Scanning electron microscopy observation showed biofilms became very loose by the high shear force effect.

CONCLUSION: Non-enzymatic detergent has a better inhibition effect on biofilm formation at room temperature. High speed pre-lavage and detergents are very important in temporal formed biofilm elimination.

Longitudinal follow-up of oxidative stress and DNA damage parameters in detergent workers

BACKGROUND

The aim of this study was the follow-up of work place enzyme and detergent dust exposure effects and smoking habit on DNA damage parameters of workers and the evaluation of their antioxidant enzyme activities and lipid peroxidation with regard to bag-filter installation in the work place.

MATERIAL AND METHODS

All investigated parameters were studied in a group of 153 workers of enzyme-free detergent production plant (E-free) and a group of 138 workers of enzyme-plus detergent plant (E-plus) and compared with 45 controls 7.2 years before and 3.1 years after filter system installation. The following methods were used: antioxidant enzymes by an ultraviolet-visibles spectrophotometer, malondialdehyde (MDA), 8-hydroxy-2'deoxyguanosine (8OH-2'dG) by high-performance liquid chromatography, trace elements by atomic absorption spectroscopy, and comet assay by single cell gel electrophoresis.

RESULTS

Compared with controls, significant increases were observed in both detergent-exposed groups with respect to the levels of MDA, antioxidant enzyme activities, and DNA damage parameters, including 8OH-2'dG, endonuclease III-sensitive sites, and DNA strand breaks, with enhancement effect of smoking before filter system installation. After filter installation, besides significant decrease in the detergent and enzyme dust of airborne and oxidative stress indicators, there was improvement in all DNA damage investigated parameters at the end of this study. The levels of cumulative exposure index of detergent dusts decreased significantly after airborne improvement and showed positive correlation with internal biochemical parameters.

CONCLUSIONS

We concluded that high levels of enzyme and detergent contents of work place dusts had a cumulative effect and smoking had a synergistic effect on the imbalance of antioxidant status and lipid peroxidation, suggesting that oxidation stress is important in the occurrence and progression of DNA damage over this study. Detergent and enzyme contents in respirable and total dust had the main role and sufficient potential in their genotoxicity.

Bacterial species diversity in cigarettes linked to an investigation of severe pneumonitis in U.S. Military personnel deployed in operation iraqi freedom

This report presents results from a study on the bacterial diversity of cigarette brands collected from military personnel during the U.S. Army's investigation of a series of cases of acute eosinophilic pneumonitis in military personnel deployed in Operation Iraqi Freedom. Eight species of Bacillus, including five new species, and one new species of Kurthia were isolated from the cigarettes. Some of these species have been identified elsewhere as causes of hypersensitivity pneumonitis and other respiratory syndromes. All of the isolates were facultative anaerobes, and many displayed mucoid growth under anaerobic conditions. In addition, many isolates also displayed the ability to form surface biofilms under liquid culture. Although biofilm formation and mucoid growth were not correlated, the former was found to be much more pronounced under anaerobic conditions as opposed to aerobic ones. The implications of these findings are discussed.

Development and Reduction of Hypertension and Oxidative Stress among Detergent Industry Workers

Hypertension status and oxidative stress parameters were assessed in 291 workers (hypertensive workers were divided into three grades, non-equivalently) at two detergent production plants, one of which included enzymes in the detergent (n=138) and another which did not (n=153), and 45 control workers in another industry three times (at the time of employment, 7 yrs later at the time of installation of a filter system, and about 3 yrs later). Malondialdehyde (MDA) was measured by high-performance liquid chromatography, antioxidant enzymes and lipid status by ultraviolet-visible spectrophotometry, trace elements by atomic absorption spectroscopy, and blood pressure using an oscilometric device. Prior to filter system installation, enzyme-exposed workers had significantly higher MDA, antioxidant enzyme activities, and prevalence of hypertension, compared with controls. The filter system reduced airborne detergent and enzyme dusts, resulting in a decreased prevalence of hypertension and a significant improvement in workers' oxidative stress indicators. Alterations in antioxidant status may result from the cumulative effect of high levels of detergent and enzyme in airborne dust in the workplace.

Hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is a group of immunologically mediated lung diseases caused by the inhalation of environmental agents in susceptible individuals. Most HP patients are non-smokers and have been exposed to organic dusts from vegetable or animal products. Some HP cases are associated with exposures to relatively simple chemical compounds. HP may present as an acute, subacute, or chronic disease and may follow various clinical courses. The type of exposure is thought to be more important in the clinical outcome than the nature of the antigen. A diagnosis of HP is often considered on the basis of clinical history of exposure with resulting respiratory symptoms, but the definitive diagnosis requires a constellation of clinical, radiologic, laboratory, and pathologic findings. The characteristic histologic triad in HP includes bronchiolitis, interstitial lymphocytic infiltration, and granulomas; however, biopsy in HP cases may lack the diagnostic triad and manifest as nonspecific interstitial pneumonia (NSIP). Avoiding exposure to the offending antigen(s) is usually sufficient to resolve symptoms and physiological abnormalities. Pulmonary fibrosis and physiological abnormalities occurring in chronic HP may be irreversible. Steroid therapy is helpful for symptomatic relief, but probably does not affect the long-term prognosis. Type III and type IV hypersensitivity reactions are involved in the pathogenesis; alveolar macrophages and T cells (Th-1 type) play a central role in the immune responses after antigen exposure via their increased interaction and secretion of regulatory mediators.