Quantitation in inflammatory pleural disease to distinguish tuberculous and paramalignant from chronic non-specific pleuritis

Combined evaluation of adenosine deaminase level and histopathological findings from pleural biopsy with Cope's needle for the diagnosis of tuberculous pleurisy

INTRODUCTION

Closed needle pleural biopsy (CNPB) has historically been the gold standard procedure for the diagnosis of pleural tuberculosis. Adenosine deaminase (ADA) is an efficient biomarker for tuberculosis that is measurable in pleural fluids.

OBJECTIVE

We compared the diagnostic accuracy of the pleural ADA (P-ADA) level and histopathological findings of CNPB specimens in patients with pleural tuberculosis.

METHODS

This prospective study consisted of two groups of examinations with a proven diagnosis of pleural effusion. The P-ADA level was measured in 218 patients with pleural effusion due to a number of causes, and 157 CNPB specimens underwent histopathological analysis.

RESULTS

CNPBs were performed in patients with tuberculosis (n=122) and other diseases: adenocarcinoma (n=23), lymphoma (n=5), systemic lupus erythematosus (n=4), squamous cell carcinoma (n=2), and small cell lung cancer (n=1). According to the ROC curve, the optimal cut-off value of the P-ADA level (Giusti and Galanti colorimetric method) was equal to or greater than 40.0 U/L. The diagnostic accuracy of the P-ADA test was 83.0%, and that of histopathological examination of the CNPB tissue, was 78.8% (AUC=0.293, P=0.7695). The association between the P-ADA assay and pleural histopathology was 24.41 (P<0.0001). The tetrachoric correlation coefficient was 0.563 (high correlation).

CONCLUSION

In Brazil and other countries with a high incidence of tuberculosis, P-ADA activity is an accurate test for the diagnosis of tuberculous pleural effusions, and its use should be encouraged. The high diagnostic performance of the P-ADA test could to aid the diagnosis of pleural tuberculosis and render CNPB unnecessary.

Immune response to Mycobacterium tuberculosis infection in the parietal pleura of patients with tuberculous pleurisy

The T lymphocyte-mediated immune response to Mycobacterium tuberculosis infection in the parietal pleura of patients with tuberculous pleurisy is unknown. The aim of this study was to investigate the immune response in the parietal pleura of tuberculous pleurisy compared with nonspecific pleuritis. We have measured the numbers of inflammatory cells particularly T-cell subsets (Th1/Th2/Th17/Treg cells) in biopsies of parietal pleura obtained from 14 subjects with proven tuberculous pleurisy compared with a control group of 12 subjects with nonspecific pleuritis. The number of CD3+, CD4+ and CCR4+ cells and the expression of RORC2 mRNA were significantly increased in the tuberculous pleurisy patients compared with the nonspecific pleuritis subjects. The number of toluidine blue+ cells, tryptase+ cells and GATA-3+ cells was significantly decreased in the parietal pleura of patients with tuberculous pleurisy compared with the control group of nonspecific pleuritis subjects. Logistic regression with receiver operator characteristic (ROC) analysis for the three single markers was performed and showed a better performance for GATA-3 with a sensitivity of 75%, a specificity of 100% and an AUC of 0.88. There was no significant difference between the two groups of subjects in the number of CD8, CD68, neutrophil elastase, interferon (IFN)-γ, STAT4, T-bet, CCR5, CXCR3, CRTH2, STAT6 and FOXP3 positive cells. Elevated CD3, CD4, CCR4 and Th17 cells and decreased mast cells and GATA-3+ cells in the parietal pleura distinguish patients with untreated tuberculous pleurisy from those with nonspecific pleuritis.

Evaluation of the effects of ozone therapy in the treatment of intra-abdominal infection in rats

INTRODUCTION

The antibacterial effect of ozone (O(3)) has been described in the extant literature, but the role of O(3) therapy in the treatment of certain types of infection remains controversial.

OBJECTIVES

To evaluate the effect of intraperitoneal (i.p.) O(3) application in a cecal ligation/puncture rat model on interleukins (IL-6, IL-10) and cytokine-induced neutrophil chemoattractant (CINC)-1 serum levels, acute lung injury and survival rates.

METHODS

FOUR ANIMAL GROUPS WERE USED FOR THE STUDY: a) the SHAM group underwent laparotomy; b) the cecal ligation/puncture group underwent cecal ligation/puncture procedures; and c) the CLP+O(2) and CLP+O(3) groups underwent CLP+ corresponding gas mixture infusions (i.p.) throughout the observation period. IL-6, CINC-1 and IL-10 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Acute lung injury was evaluated with the Evans blue dye lung leakage method and by lung histology. P<0.05 was considered significant.

RESULTS

CINC-1 was at the lowest level in the SHAM group and was lower for the CLP+O(3) group vs. the CLP+O(2) group and the cecal ligation/puncture group. IL-10 was lower for the SHAM group vs. the other three groups, which were similar compared to each other. IL-6 was lower for the SHAM group vs. all other groups, was lower for the CLP+O(3) or CLP+O(2) group vs. the cecal ligation/puncture group, and was similar for the CLP+O(3) group vs. the CLP+O(2) group. The lung histology score was lower for the SHAM group vs. the other groups. The Evans blue dye result was lower for the CLP+O(3) group vs. the CLP+O(2) group and the cecal ligation/puncture group but similar to that of the SHAM group. The survival rate for the CLP+O(3) group was lower than for the SHAM group and similar to that for the other 2 groups (CLP and CLP+O(2)).

CONCLUSION

Ozone therapy modulated the inflammatory response and acute lung injury in the cecal ligation/puncture infection model in rats, although there was no improvement on survival rates.

Ultrastructural acute features of active remodeling after chemical pleurodesis induced by silver nitrate or talc

This study evaluated submicroscopic features of active pleural remodeling associated with chemical pleurodesis. Twenty seven rabbits received intrapleural injection of 0.5% silver nitrate (SN; N = 9) or 400 mg/kg talc slurry (N = 9) in 2 ml of saline solution; control rabbits (N = 9) received 2 ml of saline alone. The rabbits were sacrificed 15 minutes, 24 hours, or 7 days postinjection, and specimens of visceral pleura were obtained, fixed, and photographed for submicroscopic analysis. After 15 minutes of talc or SN exposure, prominent injury to the mesothelial cells and mesothelial cell-mesothelial basement membrane (MC-MBM) union was visible. There was focal remesothelialization of the denuded area through mesothelial cell migration, proliferation, and differentiation. After 24 hours, early wound healing, characterized by a superficial exudate, was evident where myofibroblasts had proliferated through a gap in the MC-MBM. After 7 days, proliferation of highly active myofibroblasts was observed; these cells produced abundant extracellular matrix components in a more organized distribution paralleling the surface. This third stage of remodeling was more evident with SN than talc-induced chemical pleurodesis. Our results suggest that ideal chemical pleurodesis results from injury to the MC-MBM union and abnormal wound healing, involving three essential steps: remesothelialization, fibroblastic proliferation, and extracellular matrix accumulation and remodeling.

Quantitation of conventional histologic parameters and biologic factors in prostatic needle biopsy are useful to distinguish paramalignant from malignant disease

The scope of this work was to determine the potential use of prostatic conventional histologic parameters and biologic factors in distinguishing between paramalignant and malignant prostatic disease, taking into account benign fragments of biopsies obtained from patients with prostatic cancer or from patients suspected to have cancer. Each prostate sample was semi-quantified for macronucleoli, mucin, crystalloid, collagen micronodules, and quantified for glands, stroma, AgNOR, and p53. The database covered 185 biopsy specimens from 136 patients: 56 samples from the same number of patients in whom all the biopsies were benign; 49 samples from patients whose biopsies showed malignant features, and 80 malignant samples. Discriminant analysis of the results showed statistical differences for four parameters: macronucleoli, mucin, gland volume, and AgNOR, allowing us to identify three patterns of prostate involvement: normal, paramalignant, and malignant. The discriminant function permitted an adequate classification of the three patterns in 84% of the cases. Normal areas showed glands with a mean volume of 38.93 microm3, inconspicuous nucleoli, low mucin production, and a mean AgNOR area of 1.26 microm2. Prostatic biopsies with prominent nucleoli and the presence of mucin (60%), gland volume of 22.31 microm3, and AgNOR area of 2.14 microm2 characterized the paramalignant condition. Malignant areas were characterized by mean glands with a volume of 8.11 microm3, prominent nucleoli, high mucin secretion (100%), and AgNOR area of 4.47 microm2. We concluded that modifications in prostate histoarquitecture and function, such as the presence of macronucleoli, volume of glands, abnormal secretion of acid mucin and AgNOR expression, represent important parameters that must be incorporated in the pathologist's evaluation of prostate biopsies to the purpose of indicating a subsequent biopsy, particulary in those patients with clinical suspicion of malignancy, and whose prostate biopsy specimen showed paramalignant areas.

Lung tissue mechanics and extracellular matrix composition in a murine model of silicosis

The dynamic mechanical properties of lung tissue and its contents of collagen and elastic fibers were studied in strips prepared from mice instilled intratracheally with saline (C) or silica [15 (S15) and 30 days (S30) after instillation]. Resistance, elastance, and hysteresivity were studied during oscillations at different frequencies on S15 and S30. Elastance increased from C to silica groups but was similar between S15 and S30. Resistance was augmented from C to S15 and S30 and was greater in S30 than in S15 at higher frequencies. Hysteresivity was higher in S30 than in C and S15. Silica groups presented a greater amount of collagen than did C. Elastic fiber content increased progressively along time. This increment was related to the higher amount of oxytalan fibers at 15 and 30 days, whereas elaunin and fully developed elastic fibers were augmented only at 30 days. Silicosis led not only to pulmonary fibrosis but also to fibroelastosis, thus assigning a major role to the elastic system in the silicotic lung.

ARYONALMEIDA. Impacto de múltiplas biópsias em dois pontos distintos da superfície pleural no diagnóstico de tuberculose

Com o objetivo de avaliar se a retirada de maior número de fragmentos pleurais em um único sítio (A), bem como se a biópsia em um segundo sítio (B) da sua superfície, através do mesmo orifício cutâneo, acrescenta em rendimento diagnóstico aos três fragmentos habitualmente retirados, conduzimos um estudo prospectivo no Hospital Octávio Mangabeira, envolvendo 115 pacientes com indicação de biópsia pleural. Os fragmentos pleurais foram colocados em três frascos distintos: FRA1-3 = 3 primeiros fragmentos, FRA4-8 = 5 fragmentos subseqüentes e FRB1-5 = 5 fragmentos em segundo sítio da superfície pleural. Era retirada a agulha até o subcutâneo, feitas inclinação lateral e reintrodução no espaço pleural. A análise dos fragmentos provindos do FRA1-3 evidenciou granuloma em 72/92 casos de tuberculose (78,3%) e no FRA4-8 e FRB1-5, em 74/92 casos (80,5%). Em 6/92 pacientes foram encontrados pleurite inespecífica no FRA1-3 e granuloma no FRA4-8, resultando em acréscimo diagnóstico de 8,3% (6 aos 72 pacientes). Em 7/92 pacientes (7,6%) a HP foi inespecífica no sítio A e mostrou granuloma no sítio B, resultando em acréscimo diagnóstico de 9,0% (7 aos 78 pacientes). A concordância histológica intra-observador teve um índice kappa de 0,62 (0,54 a 0,70) e interobservador de 0,64 (0,56 a 0,72). Concluímos que a realização de múltiplas biópsias em dois sítios diferentes da superfície pleural diagnosticou 13 pacientes que não obteriam diagnóstico definitivo se fossem retirados apenas três fragmentos pleurais, resultando em incremento diagnóstico de 18,0% (13 aos 72 diagnosticados no FRA1-3), sendo considerado significativo do ponto de vista médico e social.