Imaging lung inflammation in a murine model of Pseudomonas infection: a positron emission tomography study

Inflammatory Activity in Atelectatic and Normally Aerated Regions During Early Acute Lung Injury

RATIONALE AND OBJECTIVES

Pulmonary atelectasis presumably promotes and facilitates lung injury. However, data are limited on its direct and remote relation to inflammation. We aimed to assess regional 2-deoxy-2-[¹⁸F]-fluoro-D-glucose (¹⁸F-FDG) kinetics representative of inflammation in atelectatic and normally aerated regions in models of early lung injury.

MATERIALS AND METHODS

We studied supine sheep in four groups: Permissive Atelectasis (n = 6)-16 hours protective tidal volume (V_T) and zero positive end-expiratory pressure; Mild (n = 5) and Moderate Endotoxemia (n = 6)- 20-24 hours protective ventilation and intravenous lipopolysaccharide (Mild = 2.5 and Moderate = 10.0 ng/kg/min), and Surfactant Depletion (n = 6)-saline lung lavage and 4 hours high V_T. Measurements performed immediately after anesthesia induction served as controls (n = 8). Atelectasis was defined as regions of gas fraction <0.1 in transmission or computed tomography scans. ¹⁸F-FDG kinetics measured with positron emission tomography were analyzed with a three-compartment model.

RESULTS

¹⁸F-FDG net uptake rate in atelectatic tissue was larger during Moderate Endotoxemia (0.0092 ± 0.0019/min) than controls (0.0051 ± 0.0014/min, p = 0.01). ¹⁸F-FDG phosphorylation rate in atelectatic tissue was larger in both endotoxemia groups (0.0287 ± 0.0075/min) than controls (0.0198 ± 0.0039/min, p = 0.05) while the ¹⁸F-FDG volume of distribution was not significantly different among groups. Additionally, normally aerated regions showed larger ¹⁸F-FDG uptake during Permissive Atelectasis (0.0031 ± 0.0005/min, p < 0.01), Mild (0.0028 ± 0.0006/min, p = 0.04), and Moderate Endotoxemia (0.0039 ± 0.0005/min, p < 0.01) than controls (0.0020 ± 0.0003/min).

CONCLUSION

Atelectatic regions present increased metabolic activation during moderate endotoxemia mostly due to increased ¹⁸F-FDG phosphorylation, indicative of increased cellular metabolic activation. Increased ¹⁸F-FDG uptake in normally aerated regions during permissive atelectasis suggests an injurious remote effect of atelectasis even with protective tidal volumes.

Approaches to Evaluate Lung Inflammation in Translational Research

Inflammation is a common feature in several types of lung disease and is a frequent end point to validate lung disease models, evaluate genetic or environmental impact on disease severity, or test the efficacy of new therapies. Questions relevant to a study should be defined during experimental design and techniques selected to specifically address these scientific queries. In this review, the authors focus primarily on the breadth of techniques to evaluate lung inflammation that have both clinical and preclinical applications. Stratification of approaches to assess lung inflammation can diminish weaknesses inherent to each technique, provide data validation, and increase the reproducibility of a study. Specialized techniques (eg, imaging, pathology) often require experienced personnel to collect, evaluate, and interpret the data; these experts should be active contributors to the research team through reporting of the data. Scoring of tissue lesions is a useful method to transform observational pathologic data into semiquantitative or quantitative data for statistical analysis and enhanced rigor. Each technique to evaluate lung inflammation has advantages and limitations; understanding these parameters can help identify approaches that best complement one another to increase the rigor and translational significance of data.

18F-fluoro-2-deoxyglucose PET informs neutrophil accumulation and activation in lipopolysaccharide-induced acute lung injury

INTRODUCTION

Molecular imaging of the earliest events related to the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) could facilitate therapeutic development and patient management. We previously reported that 18F-fluoro-2-deoxyglucose (18F-FDG) PET identifies ALI/ARDS prior to radiographic abnormalities. The purpose of this study was to establish the time courses of 18F-FDG uptake, edema and neutrophil recruitment in an endotoxin-induced acute lung injury model and to examine molecular events required for 14C-2DG uptake in activated neutrophils.

METHODS

Lung uptake of 18F-FDG was measured by PET in control male Sprague Dawley rats and at 2, 6 and 24h following the intraperitoneal injection of 10mg/kg LPS. Lung edema (attenuation) was measured by microCT. Neutrophil influx into the lungs was measured by myeloperoxidase assay. Control and activated human donor neutrophils were compared for uptake of 14C-2DG, transcription and content of hexokinase and GLUT isoforms and for hexokinase (HK) activity.

RESULTS

Significant uptake of 18F-FDG occurred by 2h following LPS, and progressively increased to 24h. Lung uptake of 18F-FDG preceded increased CT attenuation (lung edema). Myeloperoxidase activity in the lungs, supporting neutrophil influx, paralleled 18F-FDG uptake. Activation of isolated human neutrophils resulted in increased uptake of 14C-2DG, expression of GLUT 3 and GLUT 4 and expression and increased HK1 activity.

CONCLUSION

Systemic endotoxin-induced ALI results in very early and progressive uptake of 18F-FDG, parallels neutrophil accumulation and occurs earlier than lung injury edema. Activated neutrophils show increased uptake of 14C-2DG, expression of specific GLUT3, GLUT4 and HK1 protein and HK activity. ADVANCES IN KNOWLEDGE AND IMPLICATIONS FOR PATIENT CARE: 18F-FDG pulmonary uptake is an early biomarker of neutrophil recruitment in ALI and is associated with specific molecular events that mediate 14C-2DG uptake in activated neutrophils. 18F-FDG PET may provide a potential mechanism for early diagnosis and therapeutic assessment of ALI/ARDS.

Preclinical anatomical, molecular, and functional imaging of the lung with multiple modalities

In vivo imaging is an important tool for preclinical studies of lung function and disease. The widespread availability of multimodal animal imaging systems and the rapid rate of diagnostic contrast agent development have empowered researchers to noninvasively study lung function and pulmonary disorders. Investigators can identify, track, and quantify biological processes over time. In this review, we highlight the fundamental principles of bioluminescence, fluorescence, planar X-ray, X-ray computed tomography, magnetic resonance imaging, and nuclear imaging modalities (such as positron emission tomography and single photon emission computed tomography) that have been successfully employed for the study of lung function and pulmonary disorders in a preclinical setting. The major principles, benefits, and applications of each imaging modality and technology are reviewed. Limitations and the future prospective of multimodal imaging in pulmonary physiology are also discussed. In vivo imaging bridges molecular biological studies, drug design and discovery, and the imaging field with modern medical practice, and, as such, will continue to be a mainstay in biomedical research.

FDG-PET Quantification of Lung Inflammation with Image-Derived Blood Input Function in Mice

Dynamic FDG-PET imaging was used to study inflammation in lungs of mice following administration of a virulent strain of Klebsiella (K.) pneumoniae. Net whole-lung FDG influx constant (K_i) was determined in a compartment model using an image-derived blood input function. Methods. K. pneumoniae (~3 x 10⁵ CFU) was intratracheally administered to six mice with 6 other mice serving as controls. Dynamic FDG-PET and X-Ray CT scans were acquired 24 hr after K. pneumoniae administration. The experimental lung time activity curves were fitted to a 3-compartment FDG model to obtain K_i. Following imaging, lungs were excised and immunohistochemistry analysis was done to assess the relative presence of neutrophils and macrophages. Results. Mean K_i for control and K. pneumoniae infected mice were (5.1 ± 1.2) ×10⁻³ versus (11.4 ± 2.0) ×10⁻³ min⁻¹, respectively, revealing a 2.24 fold significant increase (P = 0.0003) in the rate of FDG uptake in the infected lung. Immunohistochemistry revealed that cellular lung infiltrate was almost exclusively neutrophils. Parametric K_i maps by Patlak analysis revealed heterogeneous inflammatory foci within infected lungs. Conclusion. The kinetics of FDG uptake in the lungs of mice can be noninvasively quantified by PET with a 3-compartment model approach based on an image-derived input function.

Molecular imaging of pulmonary disease in vivo

Characterization and noninvasive measurement of molecular pathways and biochemistry in living cells, animal models, and humans at the cellular and molecular level is now possible using remote imaging detectors. Positron and single photon emission tomography scanners, highly sensitive cameras for bioluminescence and fluorescence imaging, as well as high-magnetic-field magnetic resonance imaging scanners, can be used to study such diverse processes as signal transduction, receptor density and function, host response to pathogens, cell trafficking, and gene transfer. In many cases, images from more than one modality can be fused, allowing structure-function and multifunction relationships to be studied on a tissue-restricted or regional basis. "Molecular imaging" holds enormous potential for elucidating the molecular mechanisms of pulmonary disease and therapeutic response in intact animal models and humans.

Real-time live imaging to study bacterial infections in vivo

In vitro studies have been essential to describe the molecular details of bacteria-host cell interactions in general and the functions of bacterial effector proteins in particular. Recent advancements in in vivo imaging techniques are facilitating the next logical step to visualize the dynamic infection process as it happens within the living host while analyzing the role of bacterial effector proteins in vivo. Data obtained from this emerging field of 'tissue microbiology', combined with the massive knowledge base generated from research in 'cellular microbiology' will eventually provide a complete picture of the complex infection process.

Animal models of human pneumonia

Pneumonia is a medical and public health priority, and advances against this disease will require improved knowledge of biological mechanisms. Human pneumonia is modeled with experimental infections of animals, most frequently mice. Mouse models are leading to important discoveries relevant to pneumonia, but their limitations must be carefully considered. Several approaches to establishing pneumonia in mice have been developed, and each has specific strengths and weaknesses. Similarly, procedures for characterizing microbial and host responses to infection have unique advantages and disadvantages. Mice are not small humans, and the applicability of results from murine models to human disease depends on understanding the similarities and differences between species. Additional considerations such as mouse strain, microbe strain, and prior mouse-microbe interactions also influence the design and interpretation of experiments. Results from studies of pneumonia in animals, combined with complementary basic and translational studies, are elucidating mechanisms responsible for susceptibility to and pathophysiology of lung infection.

Roundtrip explorations of bacterial infection: from single cells to the entire host and back

Host-pathogen interactions are highly regulated, dynamic processes that take place at the molecular, cellular and organ level. Innovative imaging technologies have emerged recently to investigate the underlying mechanisms of host-pathogen interactions. Innovations in fluorescence microscopy enable functional studies on the single-cell level. New light microscopes have been developed that improve the resolution to less than 100 nm. At the other extreme, intravital microscopy enables the correlation of cellular events on the organ level. This is also achieved by alternatives to microscopy such as bioluminescence, positron-emission tomography and magnetic resonance imaging. The methodologies described here will have a tremendous effect on our understanding of host-pathogen interactions.

FDG-PET imaging of pulmonary inflammation in healthy volunteers after airway instillation of endotoxin

Recent studies indicate that a focal, limited, inflammatory response can be safely elicited after direct bronchial instillation of small doses of endotoxin into a single lung segment. Because the radiotracer [18F]fluorodeoxyglucose ([18F]FDG) is taken up at accelerated rates within inflamed tissues, we hypothesized that we could detect and quantify this regional inflammatory response with positron emission tomography (PET). We imaged 18 normal volunteers in a dose-escalation study with 3 endotoxin dosing groups ( n = 6 in each group): 1 ng/kg, 2 ng/kg, and 4 ng/kg. Endotoxin was instilled by bronchoscopy into a segment of the right middle lobe, with imaging performed ∼24 h later, followed by bronchoalveolar lavage (BAL). A “subtraction imaging analysis” was performed in the highest dose cohort to identify the area of inflammation, using the preendotoxin scan as a baseline. BAL neutrophil counts were significantly higher in the highest dose group compared with the other two groups (1,413 ± 625 vs. 511 ± 396 and 395 ± 400 cells/mm3; P < 0.05). Autoradiography performed on cells harvested by BAL showed specific [3H]deoxyglucose ([3H]DG) uptake limited to neutrophils. In vitro [3H]DG uptake in BAL neutrophils in the 4 ng/kg dose group (but not in the 2 ng/kg group) was statistically greater than in peripheral blood neutrophils obtained before endotoxin instillation. The rate of [18F]FDG uptake was greatest in the 4 ng/kg group, with a consistent, statistically significant increase in the rate of uptake after endotoxin instillation compared with baseline. We conclude that the inflammatory response to low-dose endotoxin in a single lung segment can be visualized and quantified by imaging with FDG-PET.

Magnetic resonance imaging of Klebsiella pneumoniae-induced pneumonia in mice

In vivo imaging of small animals is a rapidly developing field. However, the potential of global imaging of infectious processes in animal models remains poorly explored. We used magnetic resonance imaging (MRI) to follow the development and regression of inflammatory lesions caused by infection by Klebsiella pneumoniae in mouse lungs. A virulent strain caused an intense inflammation within 2 days in the whole lungs, while an avirulent strain did not show significant changes. Mice infected with the virulent strain and subsequently treated with antibiotics presented a severe inflammation localized mainly in the left lung that disappeared after a week. The lesions observed by MRI correlated with the damage seen by histological analysis and a 3D representation of the tissue allowed better visualization of the development and healing of inflammatory lesions. MRI thus represents a powerful technique to study in vivo the interactions between a pathogen and its host in real time.

Molecular imaging of the lungs

An emerging suite of new imaging techniques offer the ability to monitor and quantify molecular and cellular processes in the lungs noninvasively. These techniques take advantage of dramatic advances in both imaging technology as well as molecular and cell biology. Molecular imaging is being used with increasing regularity in research protocols, and forms of molecular imaging have found their way into the patient care setting (eg, positron emission tomography imaging in cancer). Such techniques will afford the basic scientist as well as the clinician an unprecedented opportunity for in vivo study of the lung biology that drives normal pulmonary physiology as well as pathophysiology.

Noninvasive mapping of regional response to segmental allergen challenge using magnetic resonance imaging and [F-18]fluorodeoxyglucose positron emission tomography

Magnetic resonance (MR) and positron emission tomography (PET) imaging techniques were coregistered to demonstrate regional ventilation and inflammation in the lung for in vivo, noninvasive evaluation of regional lung function associated with allergic inflammation. Four Brown Norway rats were imaged pre- and post segmental allergen challenge using respiratory-gated He-3 magnetic resonance imaging (MRI) to visualize ventilation, T(1)-weighted proton MRI to depict inflammatory infiltrate, and [F-18]fluorodeoxyglucose-PET to detect regional glucose metabolism by inflammatory cells. Segmental allergen challenges were delivered and the pre- and postchallenge lung as well as the contralateral lung were compared. Coregistration of the imaging results demonstrated that regions of ventilation defects, inflammatory infiltrate, and increased glucose metabolism correlated well with the site of allergen challenge delivery and inflammatory cell recruitment, as confirmed by histology. This method demonstrates that fusion of functional and anatomic PET and MRI image data may be useful to elucidate the functional correlates of inflammatory processes in the lungs.

PET: a revolution in medical imaging

FDG-PET has had remarkable influence on the assessment of physiologic and pathologic states. The authors predict that FDG-PET imaging could soon become the most common procedure used by nuclear medicine laboratories and could remain so for an extended period of time. The power of molecular imaging lies in the vast potential for using biochemical and pharmacologic probes to extend applications arising from an understanding of cell biology to a large number of well-characterized pathologic states. Molecular imaging based upon tracer kinetics with positron-emitting radiopharmaceuticals could become the main source of information for the management of cancer patients. In that case, nuclear medicine procedures might become the most common imaging studies performed in the practice of medicine. This speculation is not farfetched when one realizes the enormous change that a single biologically important compound, FDG, has brought to the medical arena. The major challenge today is to attract the highly qualified individuals and to secure the resources needed to harness the opportunities in the specialty of molecular imaging.

Recent advances in imaging the lungs of intact small animals

A new generation of imaging devices now make it possible to generate both structural and functional images for the study of lung biology in small animals, including common laboratory mouse and rat models. "Micro" X-ray computed tomography and positron emission tomography scanners, highly sensitive cooled charge coupled device cameras for bioluminescence and fluorescence imaging, high magnetic field magnetic resonance imaging scanners, and recent advances in ultrasound system technology can be used to study such diverse processes as ventilation, perfusion, pulmonary hypertension, lung inflammation, and gene transfer, among others. Images from more than one modality can also be fused, allowing structure-function and function-function relationships to be studied on a regional basis. These new instruments, part of an emerging suite of techniques collectively known as "molecular imaging," provide an enormous potential for elucidating lung biology in intact animal models and systems.

Molecular imaging for pediatric lung diseases

Molecular imaging is a rapidly developing multidisciplinary field that combines advances in contrast agent development, instrumentation, and molecular/cell biology to follow cellular and sub-cellular events in intact organisms. Platforms for molecular imaging include radionuclide-based methods, optical methods, and magnetic resonance. To date, molecular imaging studies of the lungs have been used to monitor the effectiveness of gene transfer, neutrophilic inflammation, and cell trafficking. Eventually, the goal will be to translate these new techniques to clinical settings such as cystic fibrosis.

Molecular imaging of host-pathogen interactions in intact small animals

Characterization and non-invasive measurement of host-pathogen interactions in living cells, animal models and humans at the cellular and molecular levels is now possible using remote imaging detectors. Positron emission tomography scanners, highly sensitive cooled charge-coupled device cameras for bioluminescence and fluorescence imaging as well as high-magnetic-field magnetic resonance imaging scanners can be used to study such diverse processes as pathogen tropism, pathogen life cycle, signal transduction, host response, cell trafficking and gene transfer. In many cases, images from more than one modality can be fused, allowing structure-function and multifunction relationships to be studied on a tissue-restricted or regional basis. These new instruments, when used in conjunction with targeted contrast agents, reporter substrates and radiopharmaceuticals, enable "molecular imaging" with enormous potential for elucidating host-pathogen interactions in intact animal models.