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Choudhury S, Ramos M, Anjum H, Ali M, Surani S. Shrinking Lung Syndrome: A Rare Manifestation of Systemic Lupus Erythematosus. Cureus 2020; 12:e8216. [PMID: 32582477 PMCID: PMC7306665 DOI: 10.7759/cureus.8216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Shrinking lung syndrome (SLS) is a pulmonary complication of systemic lupus erythematosus (SLE) characterized by dyspnea, pleuritic chest pain, and progressive decrease in lung volumes with no evidence of pleural or interstitial disease on chest CT. We present a 51-year-old female with a 14-year history of SLE with symptoms of progressive shortness of breath, pleuritic chest pains, low grade fevers, and productive cough which was unresponsive to multiple courses of antibiotics. After careful review of her course of SLE and timeline of symptoms, she was diagnosed with SLS. Even though rare, clinicians should have a high suspicion of SLS in patients with a long-term history of SLE and worsening dyspnea. Early treatment can be initiated to help reduce long-term morbidity and mortality and maintain the quality of life.
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Affiliation(s)
- Saiara Choudhury
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Manuel Ramos
- Pulmonary Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Humayun Anjum
- Pulmonary/Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Mohammed Ali
- Pulmonary/Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA.,Internal Medicine, University of North Texas, Dallas, USA
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Effect of Thoracic Epidural Anesthesia in a Rat Model of Phrenic Motor Inhibition after Upper Abdominal Surgery. Anesthesiology 2019; 129:791-807. [PMID: 29952817 DOI: 10.1097/aln.0000000000002331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: One important example of impaired motor function after surgery is diaphragmatic dysfunction after upper abdominal surgery. In this study, the authors directly recorded efferent phrenic nerve activity and determined the effect of the upper abdominal incision. The authors hypothesized that phrenic motor output would be decreased after the upper abdominal incision; it was also hypothesized that blocking sensory input from the incision using thoracic epidural anesthesia would diminish this incision-induced change in phrenic motor activity. METHODS Efferent phrenic activity was recorded 1 h to 10 days after upper abdominal incision in urethane-anesthetized rats. Ventilatory parameters were measured in unanesthetized rats using whole-body plethysmography at multiple time points after incision. The authors then determined the effect of thoracic epidural anesthesia on phrenic nerve activity and ventilatory parameters after incision. RESULTS Phrenic motor output remained reduced by approximately 40% 1 h and 1 day after incision, but was not different from the sham group by postoperative day 10. One day after incision (n = 9), compared to sham-operated animals (n = 7), there was a significant decrease in spike frequency area-under-the-curve (median [interquartile range]: 54.0 [48.7 to 84.4] vs. 97.8 [88.7 to 130.3]; P = 0.0184), central respiratory rate (0.71 [0.63 to 0.79] vs. 0.86 [0.82 to 0.93]/s; P = 0.0460), and inspiratory-to-expiratory duration ratio (0.46 [0.44 to 0.55] vs. 0.78 [0.72 to 0.93]; P = 0.0023). Unlike humans, a decrease, not an increase, in breathing frequency has been observed after the abdominal incision in whole-body plethysmography. Thoracic epidural anesthesia attenuated the incision-induced changes in phrenic motor output and ventilatory parameters. CONCLUSIONS Upper abdominal incision decreased phrenic motor output and ventilatory parameters, and this incision-induced impairment was attenuated by thoracic epidural anesthesia. The authors' results provide direct evidence that afferent inputs from the upper abdominal incision induce reflex inhibition of phrenic motor activity.
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Wan YY, Zhai CC, Lin XS, Yao ZH, Liu QH, Zhu L, Li DZ, Li XL, Wang N, Lin DJ. Safety and complications of medical thoracoscopy in the management of pleural diseases. BMC Pulm Med 2019; 19:125. [PMID: 31291926 PMCID: PMC6617601 DOI: 10.1186/s12890-019-0888-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 07/01/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medical thoracoscopy is considered an overall safe procedure, whereas numbers of studies focus on complications of diagnostic thoracoscopy and talc poudrage pleurodesis. We conduct this study to evaluate the safety of medical thoracoscopy in the management of pleural diseases and to compare complications in different therapeutic thoracoscopic procedures. METHODS A retrospective study was performed in 1926 patients, 662 of whom underwent medical thoracoscopy for diagnosis and 1264 of whom for therapeutic interventions of pleural diseases. Data on complications were obtained from the patients, notes on computer system, laboratory and radiographic findings. Chi-square test was performed to compare categorical variables and Fisher's exact test was used for small samples. RESULTS The mean age was 51 ± 8.4 (range 21-86) years and 1117 (58%) were males. Diagnostic procedure was taken in 662 (34.4%) patients, whereas therapeutic procedure was taken in 1264 (65.6%) patients. Malignant histology was reported in 860 (44.6%) and 986 (51.2%) revealed benign pleural diseases. Eighty patients (4.2%) were not definitely diagnosed and they were considered as unidentified pleural effusion. One patient died during the creation of artificial pneumothorax, and the causes of death were supposed as air embolism or an inhibition of phrenic motoneurons and circulatory system. Complication of lung laceration was found in six patients (0.3%) and reexpansion pulmonary edema was observed in two patients (0.1%). Higher incidence of prolonged air leak was observed in bulla electrocoagulation group, in comparison with pleurodesis group. Moreover, pain and fever were the most frequently complications in pleurodesis group and cutaneous infection in entry site was the most frequently reported complication in pleural decortication of empyema group. CONCLUSIONS Medical thoracoscopy is generally a safe and effective method, not only in the diagnosis of undiagnosed pleural effusions, but also in the management of pleural diseases. Mastering medical thoracoscopy well, improving patient management after the procedure and attempts to reduce the occurrence of post-procedural complications are the targets that physicians are supposed to achieve in the future.
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Affiliation(s)
- Yun-Yan Wan
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Cong-Cong Zhai
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Xin-Shan Lin
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Zhou-Hong Yao
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Qing-Hua Liu
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - De-Zhi Li
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Xi-Li Li
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Ning Wang
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
| | - Dian-Jie Lin
- Department of Respiratory Medicine, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, No. 324 Jingwuweiqi Road, Jinan, Shandong Province 250021 People’s Republic of China
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Borrell H, Narváez J, Alegre JJ, Castellví I, Mitjavila F, Aparicio M, Armengol E, Molina-Molina M, Nolla JM. Shrinking lung syndrome in systemic lupus erythematosus: A case series and review of the literature. Medicine (Baltimore) 2016; 95:e4626. [PMID: 27537601 PMCID: PMC5370827 DOI: 10.1097/md.0000000000004626] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Shrinking lung syndrome (SLS) is a rare and less known complication mainly associated with systemic lupus erythematosus (SLE). In this study, we analyze the clinical features, investigation findings, approaches to management, and outcome in a case series of 9 adult patients with SLE and SLS diagnosed during a 35-year period in 3 referral tertiary care hospitals in Spain. Additionally, we reviewed 80 additional cases previously reported (PubMed 1965-2015). These 80 cases, together with our 9 patients, form the basis of the present analysis.The overall SLS prevalence in our SLE population was 1.1% (9/829). SLS may complicate SLE at any time over its course, and it usually occurs in patients without previous or concomitant major organ involvement. More than half of the patients had inactive lupus according to SELENA-systemic lupus erythematosus disease activity index (SLEDAI) scores. Typically, it presents with progressive exertional dyspnea of variable severity, accompanied by pleuritic chest pain in 76% of the cases.An important diagnostic delay is common. The diagnostic tools that showed better yield for SLS detection are the imaging techniques (chest x-ray and high-resolution computed tomography) along with pulmonary and diaphragmatic function tests. Evaluation of diaphragm dome motion by M-mode ultrasonography and phrenic nerve conduction studies are less useful.There are no standardized guidelines for the treatment of SLS in SLE. The majority of patients were treated with medium or high doses of glucocorticoids. Several immunosuppressive agents have been used in conjunction with steroids either if the patient fails to improve or since the beginning of the treatment. Theophylline and beta-agonists, alone or in combination with glucocorticoids, have been suggested with the intent to increase diaphragmatic strength.The overall long-term prognosis was good. The great majority of patients had significant clinical improvement and stabilization, or mild to moderate improvement on pulmonary function tests. The mortality rate was very low.
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Affiliation(s)
- Helena Borrell
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
- Correspondence: Dr Francisco Javier Narváez García, Department of Rheumatology (Planta 10–2), Hospital Universitario de Bellvitge, Feixa Llarga, s/n, Hospitalet de Llobregat, Barcelona 08907, Spain (e-mail: )
| | - Juan José Alegre
- Department of Rheumatology, Hospital Universitario Dr. Peset, Valencia
| | | | | | - María Aparicio
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Eulàlia Armengol
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - María Molina-Molina
- Department of Pneumology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Joan M. Nolla
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
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Rocca G, Pizzorno E, Tajana L, Osculati A, Ventura F. Sudden death during medical thoracoscopy. J Forensic Leg Med 2014; 21:38-41. [DOI: 10.1016/j.jflm.2013.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 10/15/2013] [Accepted: 10/19/2013] [Indexed: 10/26/2022]
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Henderson LA, Loring SH, Gill RR, Liao KP, Ishizawar R, Kim S, Perlmutter-Goldenson R, Rothman D, Son MBF, Stoll ML, Zemel LS, Sandborg C, Dellaripa PF, Nigrovic PA. Shrinking lung syndrome as a manifestation of pleuritis: a new model based on pulmonary physiological studies. J Rheumatol 2013; 40:273-81. [PMID: 23378468 PMCID: PMC4112073 DOI: 10.3899/jrheum.121048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The pathophysiology of shrinking lung syndrome (SLS) is poorly understood. We sought to define the structural basis for this condition through the study of pulmonary mechanics in affected patients. METHODS Since 2007, most patients evaluated for SLS at our institutions have undergone standardized respiratory testing including esophageal manometry. We analyzed these studies to define the physiological abnormalities driving respiratory restriction. Chest computed tomography data were post-processed to quantify lung volume and parenchymal density. RESULTS Six cases met criteria for SLS. All presented with dyspnea as well as pleurisy and/or transient pleural effusions. Chest imaging results were free of parenchymal disease and corrected diffusing capacities were normal. Total lung capacities were 39%-50% of predicted. Maximal inspiratory pressures were impaired at high lung volumes, but not low lung volumes, in 5 patients. Lung compliance was strikingly reduced in all patients, accompanied by increased parenchymal density. CONCLUSION Patients with SLS exhibited symptomatic and/or radiographic pleuritis associated with 2 characteristic physiological abnormalities: (1) impaired respiratory force at high but not low lung volumes; and (2) markedly decreased pulmonary compliance in the absence of identifiable interstitial lung disease. These findings suggest a model in which pleural inflammation chronically impairs deep inspiration, for example through neural reflexes, leading to parenchymal reorganization that impairs lung compliance, a known complication of persistently low lung volumes. Together these processes could account for the association of SLS with pleuritis as well as the gradual symptomatic and functional progression that is a hallmark of this syndrome.
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Affiliation(s)
- Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, MA 02115, USA
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Allen D, Fischer A, Bshouty Z, Robinson DB, Peschken CA, Hitchon C, El-Gabalawy H, Meyers M, Mittoo S. Evaluating systemic lupus erythematosus patients for lung involvement. Lupus 2012; 21:1316-25. [DOI: 10.1177/0961203312454343] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: We set out to determine the frequency of respiratory symptoms, abnormal lung function, and shrinking lung syndrome (SLS) among patients with systemic lupus erythematosus (SLE) and to determine correlates of SLS. Methods: Consecutive adult patients who fulfilled the American College of Rheumatology classification criteria for SLE were enrolled. Demographics, clinical, and serologic characteristics were recorded; all patients underwent pulmonary function tests (PFT) and had either a chest X-ray or computed tomography scan. SLS was defined as dyspnea with restrictive lung physiology (defined as a forced vital capacity (FVC) <80% predicted in the absence of obstruction) who did not have any evidence of interstitial lung disease on chest imaging; controls were symptomatic patients with no restrictive physiology and the absence of interstitial changes on chest imaging. Results: Sixty-nine out of 110 (63%) patients had respiratory symptoms, 73 (66%) patients had abnormal lung function, and 11 (10%) patients met the definition for SLS. In a multivariate model controlling for disease duration, a history of pleuritis, modified American College of Rheumatology total score, seropositivity for dsDNA and RNP antibodies, increased disease duration (odds ratio (OR) = 1.2; 95% confidence interval (CI) of 1.0–1.3, p = 0.04), seropositivity for anti-RNP (OR = 24.4; 95% CI of 1.6–384.0, p = 0.02), and a history of serositis were significantly associated with SLS when compared with symptomatic controls. Conclusion: Respiratory symptoms, abnormal lung function, and SLS are common in SLE. Clinicians should consider evaluation for SLS among symptomatic patients with long-standing disease and a history of pleuritis.
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Affiliation(s)
- D Allen
- Department of Medicine, University of Manitoba, Canada
| | - A Fischer
- Autoimmune Lung Center, University of Colorado, USA
| | - Z Bshouty
- Department of Medicine, University of Manitoba, Canada
| | - DB Robinson
- Department of Rheumatology, University of Manitoba, Canada
| | - CA Peschken
- Department of Rheumatology, University of Manitoba, Canada
| | - C Hitchon
- Department of Rheumatology, University of Manitoba, Canada
| | - H El-Gabalawy
- Department of Rheumatology, University of Manitoba, Canada
| | - M Meyers
- Department of Radiology University of Manitoba, Canada
| | - S Mittoo
- Department of Rheumatology, University of Toronto, Canada
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Kouritas VK, Tsantsaridou A, Tepetes K, Tsilimingas N, Gourgoulianis KI, Molyvdas PA, Hatzoglou C. Effect of histamine on the electrophysiology of the human parietal pleura. Mol Cell Endocrinol 2011; 332:271-6. [PMID: 21078365 DOI: 10.1016/j.mce.2010.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 10/07/2010] [Accepted: 11/07/2010] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Histamine is involved in the pathogenesis of numerous diseases and regulates the permeability of different tissues. The aim of this study is to investigate the effects of histamine on the electrophysiology of human parietal pleura and the underlying mechanisms involved. MATERIALS AND METHODS Pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Histamine solutions (1μM to 1mM) were applied in native and pretreated specimens with dimetindene maleate, cetirizine, ranitidine, amiloride and ouabain. Trans-mesothelial resistance was determined (R(TM)). RESULTS Histamine induced a rapid R(TM) increase on the mesothelial (p = 0.008) and a decrease on the interstitial surface (p = 0.029). This effect was dose-dependent and was totally abolished by dimetindene maleate, cetirizine and amiloride and partially by ranitidine and ouabain. CONCLUSIONS Histamine induces acute electrochemical changes in human pleura mainly via interaction with the H(1) and partially with the H(2) histamine receptors. It also interferes with trans-cellular permeability and therefore may participate in pleural fluid recycling.
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Affiliation(s)
- V K Kouritas
- Deparment of Physiology, Larissa Medical School, University of Thessaly, Greece.
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Widdicombe J. Lung afferent activity: Implications for respiratory sensation. Respir Physiol Neurobiol 2009; 167:2-8. [DOI: 10.1016/j.resp.2008.09.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 09/22/2008] [Accepted: 09/23/2008] [Indexed: 02/07/2023]
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Association of the shrinking lung syndrome in systemic lupus erythematosus with pleurisy: a systematic review. Semin Arthritis Rheum 2008; 39:30-7. [PMID: 18585760 DOI: 10.1016/j.semarthrit.2008.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 04/01/2008] [Accepted: 04/28/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To report 2 patients with systemic lupus erythematosus and typical shrinking lung syndrome (SLS) in which pleuritic chest pain was the predominant symptom. In addition, to record the prevalence of pleuritic chest pain in all reported cases of patients with SLS and diaphragmatic dysfunction. METHODS We conducted a comprehensive search of the English literature to record the association of pleurisy and SLS in all reported cases using the MEDLINE database from 1965 to present. RESULTS Of the 77 patients with SLS reported in the literature, 50 (65%) patients had pleuritic chest pain at the time of evaluation. Treatment with anti-inflammatory agents improved symptoms in the majority of cases. CONCLUSIONS Pleuritic inflammation and pain may have an important role in the pathogenesis of SLS. A possible mechanism linking pleural inflammation and diaphragm dysfunction may be via a reflex inhibition of diaphragmatic activation.
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Pintelon I, Brouns I, De Proost I, Van Meir F, Timmermans JP, Adriaensen D. Sensory Receptors in the Visceral Pleura. Am J Respir Cell Mol Biol 2007; 36:541-51. [PMID: 17170382 DOI: 10.1165/rcmb.2006-0256oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Today, diagnosis and treatment of chest pain related to pathologic changes in the visceral pleura are often difficult. Data in the literature on the sensory innervation of the visceral pleura are sparse. The present study aimed at identifying sensory end-organs in the visceral pleura, and at obtaining more information about neurochemical coding. The immunocytochemcial data are mainly based on whole mounts of the visceral pleura of control and vagally denervated rats. It was shown that innervation of the rat visceral pleura is characterized by nerve bundles that enter in the hilus region and gradually split into slender bundles with a few nerve fibers. Separate nerve fibers regularly give rise to characteristic laminar terminals. Because of their unique association with the elastic fibers of the visceral pleura, we decided to refer to them as "visceral pleura receptors" (VPRs). Cryostat sections of rat lungs confirmed a predominant location on mediastinal and interlobar lung surfaces. VPRs can specifically be visualized by protein gene product 9.5 immunostaining, and were shown to express vesicular glutamate transporters, calbindin D28K, Na+/K+-ATPase, and P2X3 ATP-receptors. The sensory nerve fibers giving rise to VPRs appeared to be myelinated and to have a spinal origin. Because several of the investigated proteins have been reported as markers for sensory terminals in other organs, the present study revealed that VPRs display the neurochemical characteristics of mechanosensory and/or nociceptive terminals. The development of a live staining method, using AM1-43, showed that VPRs can be visualized in living tissue, offering an interesting model for future physiologic studies.
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Affiliation(s)
- Isabel Pintelon
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Groenenborgerlaan 171, BE-2020 Antwerp, Belgium
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