The in vitro action of hydrocortisone on leucocyte migration

Gastrointestinal Graft-versus-Host Disease Is a Risk Factor for Postengraftment Bloodstream Infection in Allogeneic Hematopoietic Stem Cell Transplant Recipients

Bloodstream infection (BSI) is a well-known cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. Here, we conducted a retrospective study to assess the morbidity, etiology, risk factors, and outcomes of BSI in the postengraftment period (PE-BSI) after allo-HSCT. Forty-three of 316 patients (13.6%) developed 57 PE-BSI episodes, in which 62 pathogens were isolated: Gram-positive bacteria, gram-negative bacteria, and fungi, respectively, accounted for 54.8%, 35.5%, and 9.7% of the isolates. Multivariate analysis revealed methylprednisolone use for graft-versus-host disease (GVHD) prophylaxis (odds ratio [OR], 6.49; 95% confidence interval [CI], 1.49 to 28.2; P = .013) and acute gastrointestinal GVHD (GI-GVHD) (OR, 8.82; 95% CI, 3.99 to 19.5; P < .0001) as risk factors for developing PE-BSI. This finding suggested that GI-GVHD increases the risk of bacterial translocation and subsequent septicemia. Moreover, among patients with GI-GVHD, insufficient response to corticosteroids, presumably related to an intestinal dysbiosis, significantly correlated with this complication. Patients with PE-BSI presented worse outcome compared with those without (3-year overall survival, 47.0% versus 18.6%; P < .001). Close microbiologic monitoring for BSIs and minimizing intestinal dysbiosis may be crucial to break the vicious cycle between GI-GVHD and bacteremia and to improve transplant outcomes especially in patients who require additional immunosuppressants.

Association of Cumulative Steroid Dose with Risk of Infection after Treatment for Severe Acute Graft-versus-Host Disease

This study aimed to characterize the incidence and risk factors of invasive fungal disease, cytomegalovirus infection, other viral diseases, and gram-negative rod infection after glucocorticoid treatment for severe acute graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation and to elucidate the associations of cumulative steroid dose with the risks of individual infections. The study cohort included 91 consecutive patients who developed maximum grades III and IV acute GVHD at our center. The mean cumulative prednisolone-equivalent dose was 41 mg/kg during the first 4 weeks. The cumulative incidence rates of fungal disease, cytomegalovirus disease, other viral diseases, and gram-negative rod infection at 6 months after glucocorticoid treatment were remarkably high, at 14%, 21%, 28%, and 20%, respectively. GVHD within 26 days after transplantation and low lymphocyte count at GVHD treatment were associated with increased risks of several infections. Cumulative prednisolone-equivalent steroid doses ≥ 55 mg/kg during the first 4 weeks were associated with an increased risk of fungal disease (hazard ratio, 3.65; P = .03) and cumulative doses ≥ 23 mg/kg were associated with an increased risk of non-cytomegalovirus viral diseases (hazard ratio, 4.14; P = .02). Strategies to reduce the risk of infectious complications are needed, particularly for patients who have risk factors and those who receive high cumulative steroid doses.

THE REQUIREMENT FOR HYDROCORTISONE IN ANTIBODY-FORMING TISSUE CULTIVATED IN SERUM-FREE MEDIUM

It was previously reported from this laboratory that the secondary antibody response can regularly be elicited in vitro from fragments of rabbit lymph node node cultured in Eagle's medium supplemented with normal rabbit serum. Evidence is now presented that physiological levels of hydrocortisone (0.01 to 1.0 µM) can substitute for serum in the culture medium. However, with the omission of serum, serine (0.1 mM) must be included among Eagle's "essential" amino acids for consistent optimal antibody production. In some experiments the addition of insulin (0.5 unit/ml) and vitamin B₁₂ (0.5 µg/ml) has further enhanced the secondary response in this serum-free medium.

Effect of carrageenan-induced acute inflammation on corticosterone levels in mice

Changes in corticosterone levels in plasma and inflammatory exudate were studied in the 6-day-old air pouch of mice. The pouch inflammation in the test group was induced by the injection of carrageenan prepared in physiological saline while the control received only the physiological saline. The results show that exudate and plasma of both groups showed a rapid rise in corticosterone as measured after 30 min and this early rise was probably due to the resulting effect of the ether used during the injection of irritant or vehicle. In contrast, corticosterone levels in the inflammatory exudate of the test group increased with time, reaching a peak at 24 hours after the carrageenan injection. The increased corticosterone levels in the inflammatory exudate appeared to be closely correlated with the increased exudate cell accumulation. This suggests that the increased accumulation of exudate corticosterone in the pouch might play an important role at the inflammatory site by modulating intensity of the inflammatory reactivity caused by the irritant.

Review: pharmacologic control of wound healing in glaucoma filtration surgery

An integrated understanding of the wound healing process, pharmacological agents, and surgical techniques are required for comprehensive treatment of wound healing in glaucoma filtration surgery. More well controlled basic and clinical studies are required to clarify the existing ambiguities in the selection of proper pharmacological agents, dosage, timing, and method of delivery. The most promising treatment modalities may be combination drug therapy and the use of bioerodible compounds for a sustained and localized delivery system.

Leucocyte function in patients with rheumatoid arthritis: quantitative in-vivo leucocyte mobilisation and in-vitro functions of blood and exudate leucocytes

Quantitative leucocyte mobilisation in vivo and the in-vitro random migration, chemotaxis, phagocytosis, and oxidative metabolic activity were studied in 15 patients with rheumatoid arthritis (RA). Patients mobilised leucocytes to chambers covering skin windows to the same degree as control subjects, and the mobilisation correlated with the blood leucocyte numbers and serum concentration of alpha-l-antitrypsin. Peripheral blood leucocytes showed slightly reduced migration in Boyden chambers but increased phagocytosis and increased unstimulated reduction of nitroblue tetrazolium. Exudate leucocytes from patients with RA showed migratory and phagocytic activity which did not differ from that of control subjects, but unstimulated exudate leucocytes reduced nitroblue tetrazolium more actively than leucocytes from control subjects. The observations indicate that leucocyte accumulation at an experimental inflammatory lesion and the function of these exudate leucocytes are not impaired in patients with rheumatoid arthritis.

Effect of hydrocortisone on the mobilisation of leucocytes in corneal wounds

We have studied in rabbits the effect of subconjunctivally injected hydrocortisone on the polymorphonuclear leucocyte invasion of corneal wounds at different times after an injury. One group of rabbits was treated with the steroid (hydrocortisone group) and the other not (control group). After making nonpenetrating trephine incisions on the cornea we obtained cellular samples by the impression technique at a given postoperative period (2, 4, or 6 hours), and then the animal was killed. The cornea was processed for histological study of the infiltrating cells. At any postoperative period the number of polymorphonuclear leucocytes in the corneal wounds of the hydrocortisone group was significantly less than the number in the identical wounds of the control group (p less than 0.01 to 0.001).

Inhibition of granulocyte function by prednisolone and non-steroid anti-inflammatory drugs. Quantitative evaluation with NBT test and its correlation with phagocytosis

The effect of prednisolone and non-steroid anti-inflammatory drugs on PMNL (polymorphonuclear leucocytes) oxidative metabolism was quantified with a newly standardized NBT test, and it was investigated whether these effects correlate with phagocytosing capacity of PMNL. Prednisolone inhibits NBT reduction in dose dependency already at concentrations, which do not interfere with phagocytosis. Thus prednisolone dissociates phagocytosis and phagocytosis-associated oxidative metabolism. High doses of prednisolone also inhibit phagocytosis. These effects of prednisolone are still demonstrable when PMNL are washed after pre-incubation with the drug. The non-steroid anti-inflammatory drugs (indomethacin, phenylbutazone and pyrazinobutazone) inhibit phagocytosis and NBT reduction at equivalent doses. When PMNL are washed after incubation with the drugs, they regain normal capacity to phagocyse and to reduce NBT. It is suggested that these drugs inhibit phagocytosis directly, and consequently the phagocytosis-associated oxidative metabolism is suppressed.

Experimental Acanthamoeba infections in mice pretreated with methylprednisolone or tetracycline

Human infections due to free-living amebas of the genus Acathamoeba have been reported sporadically, occasionally in individuals with underlying diseases. To determine if such infections may be considered opportunistic, groups of laboratory mice were pretreated with either methylprednisolone or tetracycline and inoculated intranasally with 1.075 times 10(4) Acanthamoeba castellanii isolated from a natural fresh water well. Results were compared with controls receiving either drug or amebas alone and with controls receiving saline injections with and without amebas. The mortality rate for those animals receiving methylprednisolone and amebas (50%) was found to be greater than the mortality in ameba controls (10%) (P equal 0.074). Similarly, the mortality rate for animals receiving tetracycline and amebas (60%) was higher than the mortality in the ameba controls (10%) (P equal 0.0286). Precise mechanisms for the increased mortality were unknown but were suspected to be due to the capacity of either corticosteroids or tetracycline to suppress host defenses, particularly those depending on neutrophils. The findings suggest a potentially pathogenic role for naturally occurring Acanthamoeba sp in humans with depressed host immunity.

Steroids, aspirin, and inflammation

The ability of adrenal corticosteroids to both both suppress inflammation and compromise host defenses has been well documented. Recently, a series of in vitro and in vivo experiments, based on our new knowledge of the cell biology of inflammation and the biochemistry of the phagocytic cell itself, has provided new insights into the mechanism of steroid action in the inflammatory process. Evidence is presented that pharmacologic doses of steroids are capable of inhibiting each of the steps in phagocytic-micro-organism interaction: chemotaxis, recognition and opsonization, phagocytosis, membrane fusion, and degranulation. In addition, steroid alteration of the postphagocytic superoxide production, hydrogen peroxide generation, and prostaglandin and thromboxane synthesis is described. The antiinflammatory effects of aspirin and indomethacin can be explained almost entirely by virtue of their ability to inhibit cyclooxygenase, this preventing the transformation of arachidonic acid to both prostaglandins and thromboxanes. The cortisol-induced inhibition of endoperoxides, prostaglandins, and thromboxanes (at a site proximal to the release of arachidonic acid) may well explain those antiinflammatory actions that cortisone shares with aspirin. However, patients treated with nonsteroidal antiinflammatory agents effectively combat infections. In contrast, corticosteroids have more profound effects, as can be seen by the inhibition of superoxide production, with the subsequent decrease in hydrogen peroxide generation and the diminution in release of the antibacterial lysosomal hydrolases within the phagocytic vacuole. Thus, corticosteroids interfere with the killing of microorganisms. This new understanding of the pharmacologic action of cortisol on phagocytic cells explains, we believe, how glucocorticoids alleviate inflammation while, at the same time, they permit multiplication of the offending microorganism within the phagocyte.

Functional capabilities of steroid-recruited neutrophils harvested for clinical transfusion

To determine whether steroids exert a direct inhibitory effect on neutrophil function, thus contraindicating their use to increase granulocyte yields for white-cell transfusions to infected neutropenic patients, we gave normal donors a single intravenous dose of dexamethasone (4 mg per square meter of body-surface area). Approximately two hours later the absolute neutrophil count increased from an initial value (mean +/- 1S.D.) of 3800 +/- 1400 to 5700 +/- 2400 per microliter. Granulocytes were then collected by discontinuous-flow centrifugation and tested. Viability (98.4 per cent), the percentage of neutrophils capable of phagocytosis (97.6), particle accumulation (12.3 candida per phagocyte), fungicidal activity (1.08 "ghost" yeast cells per phagocyte), the percentage of bacteria killed (97.7) and chemotaxis (119 per cent) did not significantly differ from observations in nontreated paired controls. The functional competence of neutrophils used for granulocyte transfusions was not altered after short-term exposure of these healthy donors to steroid medication.

Leukocyte chemotaxis: a new in vivo testing technique

A new and sensitive technique is introduced for evaluating in vivo leukocyte chemotaxis. A small, disposable plastic chamber is used for holding the test solution, and an electric ink eraser for controlled abrasion of the skin test site. Another innovation is the use of capturing micropore membranes that, when placed between the test solution and the skin, collect cells for a permanent record. The small size of the chamber, the ease of application and immobilization, and the short time needed for cell collection permit experimentation with laboratory animals as well as with human volunteers. The accumulation of leukocytes in the chambers containing previously frozen or complement-activated autologous serum was 20 to 40-fold greater than in buffer controls after 3 h. Cell counts of approximately (1--2) x 10(3) leukocytes per mm3 were obtained in 3 h when serum diluted 1:1 with Hank's solution was applied to human or rabbit skin. Although predominantly polymorphonuclear leukocytes were detected in the chambers after just 3 h, prolonged incubations of 6--12 h found mononuclear cells also invading the chambers. These results clearly simulate the sequences of cellular emigration commonly observed in local inflammation.

An evaluation of the role of leukocytes in the pathogenesis of experimentally induced corneal vascularization. II. Studies on the effect of leukocytic elimination on corneal vascularization

Investigations on several experimental models in the past have supported the hypotheses that corneal vascularization is a manifestation of the inflammatory response and that leukocytes perform an essential role in stimulating corneal vascular ingrowth. To evaluate the possible role of leukocytes further in this phenomenon, the effect of leukocyte elimination on corneal vascularization induced by silver nitrate cauterization was investigated. Weanling Fischer albino rats received doses of total body x-irradiation ranging from 1100 to 2100 rads to deplete circulating leukocytes, and corneal silver nitrate cauterization was performed 4 days later. In this model, animals that received 1500 rads or more total body x-irradiation became severely leukopenic within 4 days. As a rule, neither leukocytes nor blood vessels invaded the cauterized corneas, whereas both a leukocytic and vascular invasion occurred at lower doses of irradiation that did not totally eliminate circulating leukocytes. Corneal vascularization ensued if the corneal cauterization was performed immediately after total body x-irradiation with 1500 rads before the leukopenic effect of x-irradiation occurred. Control studies in which the cornea was cauterized 4 days after only the head received 1500 rads x-irradiation ruled out the possibility of irradiation-induced limbal endothelial damage as the explanation for the vascular suppression observed by x-ray treatment. In nonirradiated rats, silver nitrate cauterization of the cornea consistently induced corneal vascularization by 2 to 3 days. In further experiments, methylprednisolone acetate was administered subconjunctivally after corneal cauterization. This corticosteroid inhibited the infiltration of leukocytes and the subsequent vascular invasion into the corneal stroma, if administered immediately after silver nitrate cauterization. However, when the same glucocorticoid was administered 1 day after cauterization, both a leukocytic infiltration and vascular ingrowth occurred but to a less severe degree than in non-glucocorticoid-treated cauterized corneas. These investigations together demonstrated that a vascular ingrowth of the cornea did not follow corneal cauterization with silver nitrate in the absence of leukocytes, and gives further support to the hypothesis that leukocytes serve a crucial function in corneal vascularization.

The mechanism of action of a single dose of methylprednisolone on acute inflammation in vivo

A model system for the study of inflammation in vivo has been developed using the 16-h polyvinyl sponge implant in the rat. This system allows for simultaneous measurement of in vivo chemotaxis, volume of fluid influx, and fluid concentrations of lysosomal and lactic dehydrogenase (LDH) enzymes. In addition, the enzyme content of inflammatory fluid neutrophils may also be determined. A parallel time course of neutrophil and lysosomal enzyme influx into sponge implants was observed. This was characterized by an initial lag phase and a rapid increase between 5 and 16 h. The origin of supernatant LDH and lysosomal enzymes was studied with anti-neutrophil serum to produce agranulocytic rats. Inflammatory fluid in these rats was almost acellular and contained decreased concentrations of beta glucuronidase (-96%) and LDH (-74%). In control rats all of the supernatant beta glucuronidase could be accounted for by cell death and lysis, as estimated from measurements of soluble DNA. Only 15-20% of the LDH activity could be accounted for on the basis of cell lysis. The remainder was derived from neutrophil-mediated injury to connective tissue cells. Large intravascular doses of methylprednisolone markedly inhibited neutrophil influx into sponges and adjacent connective tissue. Secondary to decreased neutrophil influx, fewer neutrophils were available for lysis, and lysosomal enzyme levels in inflammatory fluid decreased. No evidence for intracellular or extracellular stabilization of neutrophil lysosomal granules by methylprenisolone was found.

The cellular basis of the mechanism of action of cortisone acetate on contact sensitivity to oxazolone in the mouse

The cellular aspects of the action of cortisone acetate on the induction and recall phases of contact sensitivity to oxazolone in the mouse have been investigated. The present findings indicate that cortisone has a much less damaging effect on the thymus-derived than on the non-thymus-derived lymphoid population in the peripheral lymphoid organs. It is also shown that the permanent immunosuppressive effect of cortisone given before sensitization is associated with the virtual absence of polymorph infiltration of the dermis, absence of epidermal vesication at the site of application of oxazolone and a considerable reduction in the amount of lymphocyte transformation amongst the thymus-derived cells in the draining lymph node. The temporary immunosuppression observed when cortisone is given just before recall is also associated with absence of polymorph infiltration of the dermis and of epidermal vesication at the test site. It is suggested that in the present model of cell-mediated immunity cortisone is immunosuppressive mainly by preventing the antigenic stimulus from being received. Some of the mechanisms by which cortisone could achieve this form of immunosuppression are discussed.

Chemotaxis of polymorphonuclear leukocytes from patients with rheumatoid arthritis

Using a new in vitro method of measuring the chemotaxis of polymorphonuclear leukocytes from peripheral blood, a chemotactic index has been calculated. The mean chemotactic index of 320 in 24 patients with definite rheumatoid arthritis, was significantly less (P < 0.0005) than the mean of 555 in 24 normal controls matched for age and sex. The mean chemotactic index of 435 in eight patients with juvenile rheumatoid arthritis was also significantly less (P < 0.01) than that of 553 in similarly matched controls. The chemotactic index could not be correlated with age, sex, disease activity, drugs used in treatment, latex titer, immunoglobulin levels, or protein coating on the cells. However, there was a correlation between the chemotactic index and the serum complement B(1e)/B(1a) value (P < 0.01) in 17 patients with adult onset rheumatoid arthritis. Although the serum complement B(1e)/B(1a) values were within the normal range, the lowest chemotactic indices were associated with the lowest complement values. The chemotactic indices in three patients with severe connective tissue disease (seropositive rheumatoid arthritis, systemic lupus erythematosus, and polymyositis) returned to normal after 5 days' treatment with 60 mg of prednisolone per day. Incubation of the cells from patients with rheumatoid arthritis with hydrocortisone in vitro failed to alter the chemotactic indices. Prior incubation of normal cells with purified rheumatoid factor complexes, rheumatoid serum, or macromolecules of iron dextran impaired their chemotaxis. It is suggested that phagocytosis of complexes in vivo is a possible mechanism by which the chemotaxis of the polymorphonuclear leukocytes of patients with rheumatoid arthritis is impaired. This impairment in chemotaxis may explain the increased incidence of bacterial infection, both during life and as a cause of death in these patients.

The effect of an NADH oxidase inhibitor (hydrocortisone) on polymorphonuclear leukocyte bactericidal activity

Polymorphonuclear neutrophils (PMN) from patients with chronic granulomatous disease of childhood have impaired bactericidal activity and are deficient in diphosphopyridine nucleotide, reduced form of, (NADH) oxidase. Since hydrocortisone had been shown to inhibit NADH oxidation, experiments were undertaken to determine the effect of hydrocortisone on several parameters of human PMN function. The phagocytic and bactericidal capacity of PMN with or without hydrocortisone (2.1 mM) was determined by quantitation of cell-free, cell-associated, and total bacteria. Phagocytosis of Staphylococcus aureus and several gram-negative rods was unimpaired by the presence of hydrocortisone in the media. In contrast, killing of bacteria was markedly impaired by hydrocortisone. After 30 min of incubation, there were 20-400 times as many bacteria surviving in hydrocortisone-treated PMN as in simultaneously run controls without hydrocortisone. The defect of intracellular killing noted in the presence of hydrocortisone was not related to impaired degranulation. Quantitative kinetic studies of degranulation revealed no difference in the release of granule associated acid phosphatase in hydrocortisone-treated and control PMN after phagocytosis. Electron microscopy of PMN also indicated that the presence of hydrocortisone had no effect on the extent of degranulation after phagocytosis. These observations were confirmed by studies using histochemical techniques to detect lysosomal enzymes. After phagocytosis, hydrocortisone-treated PMN demonstrated less NADH oxidase activity, oxygen consumption, and hydrogen peroxide production than postphagocytic control PMN. In addition, Nitro blue tetrazolium dye reduction was diminished in hydrocortisone-treated PMN.Thus, impairment of NADH oxidase activity in normal human PMN by hydrocortisone results in reduced intracellular killing of bacteria, diminished postphagocytic oxygen consumption, decreased ability to reduce Nitro blue tetrazolium, and decreased hydrogen peroxide production. These abnormalities are similar to those seen in the PMN of patients with chronic granulomatous disease of childhood.

The chemosuppression of chemotaxis

The effects of various drugs on chemotaxis of polymorphonuclear leukocytes (PMN's) in vitro and in vivo have been studied. Response of rabbit PMN's in vitro to the chemotactic factor of rabbit serum, consisting of an activated protein-protein complex of the fifth and sixth (and probably seventh) components of complement (C'), is suppressed by hydrocortisone, methyl prednisolone, and chloroquine. Drug concentrations causing 50% inhibition of chemotaxis in vitro were found to be: hydrocortisone, 2.9 x 10(-4)M; methly prednisolone, 1.2 x 10(-4)M; and chloroquine 8.5 x 10(-6)M. The hydrocortisone effect on PMN's appeared to be irreversible, since washing of the cells did not restore their chemotactic response. 2, 4-Dinitrophenol (DNP), vitamin A, and endotoxin did not inhibit chemotaxis. Hydrocortisone and chloroquine did block serum C' activity in vitro, but only at substantially higher concentrations. Using the reversed passive Arthus reaction in guinea pigs as a model for chemotaxis in vivo, systemic treatment of animals with hydrocortisone or chloroquine inhibited development of the vasculitis. Circulating antigen and C' were fixed in vascular structures, and serum C' was not perceptibly altered. Nevertheless, PMN infiltrates failed to occur. Local administration of hydrocortisone also prevented influx of PMN's in the Arthus reaction, in spite of the fact that immune reactants were found fixed in the vascular walls. Systemic treatment of guinea pigs with DNP did not diminish the intensity of the Arthus reactions. Phagocytosis of zymosan particles by rabbit PMN's was inhibited by hydrocortisone, methyl prednisolone, and chloroquine, but not by DNP or endotoxin. The concentrations of drugs inhibitory in phagocytosis were substantially higher than those required for inhibition of chemotaxis in vitro. These findings suggest that hydrocortisone and chloroquine inhibit the inflammatory process by preventing the response of leukocytes to chemotactic stimuli.

The effects of anticoagulants and other drugs on cellular and cutaneous reactions to antigen in guinea-pigs with delayed-type hypersensitivity

Delayed-type hypersensitivity to tuberculin was induced in guinea-pigs by vaccination with BCG. The effects of several drugs on the responses of peritoneal exudate cells to tuberculin (PPD) and on delayed skin reactions to PPD were investigated. In untreated animals intraperitoneal injections of PPD were followed by the virtually complete loss of macrophages from the exudates (the macrophage disappearance reaction), the partial loss of lymphocytes and a marked increase in the number of polymorphs in the exudates. The macrophage disappearance reaction was markedly or completely inhibited in animals treated with the anticoagulant drugs heparin or sodium warfarin, very slightly inhibited in animals treated with cortisone acetate or promethazine and not inhibited in animals treated with reserpine. The other peritoneal cellular responses were variably but only slightly affected by these drugs. Delayed skin reactions to PPD were partly inhibited in animals treated with heparin, sodium warfarin or cortisone acetate and more strongly inhibited in animals treated with a combination of sodium warfarin and cortisone acetate. Histological examination of the skin test sites of untreated animals and of animals treated with sodium warfarin and/or cortisone acetate showed that the accumulation of macrophages was more markedly inhibited in animals treated with sodium warfarin than in animals treated with cortisone alone. No correlation could be established between the effect of treatment with sodium warfarin on the macrophage disappearance reaction, on blood coagulation and on serum complement levels.