Determinants of blood eosinophilia in moderate and severe asthmatic patients during childhood: Evidence from the severe asthma molecular phenotype (SAMP) cohort

BACKGROUND

Asthma is a heterogeneous disease in which the interaction between genetic and environmental factors plays a major role. The significance of blood eosinophil is unclear. The aim of the study was to determine the significance of blood eosinophil count in moderate-to-severe asthmatic children of preschool age and school age.

METHODS

This was a prospective cross-sectional study performed from 2011 to 2015 including children from the severe asthma molecular phenotype (SAMP) cohort at Trousseau Hospital (Paris, France). We included children with severe and moderate asthma, or severe and moderate recurrent wheeze, aged from 1 to 15 years at the time of exploration.

RESULTS

We analyzed data from 402 children: 248 of preschool age and 154 of school age. Blood eosinophil count third quartile thresholds were 322 and 600 cells/μL for the preschool- and school-age groups, respectively. In multivariate analysis, a blood eosinophil count over this threshold was associated with elevated total IgE (OR = 5.33, P < .01), multiple hospitalizations for asthma attacks (OR = 4.96, P = .03), and a maternal history of asthma (OR = 4.91, P = .01) in preschool children; and with staphylococcal toxin-specific IgE (OR = 2.75, P = .03) in children of school age. Random forest analysis reinforced these results.

CONCLUSION

High blood eosinophil count is linked to both atopic features and control of asthma with different parameters associated with these features depending on age.

Can the sensitisation to staphylococcal enterotoxin predict the severity of chronic rhinosinusitis?

BACKGROUND

Evidence is accumulating that Staphylococcus aureus plays an important role as a disease modifier in upper and lower airway disease. We aimed to assess the association of staphylococcal enterotoxins (SEs) with allergic multimorbidity as well as the severity of chronic rhinosinusitis.

METHODS

We retrospectively reviewed the medical records of 97 subjects aged 6 years or older between March 2018 and June 2019 and analysed symptom scores, computed tomography scores, serum IgE levels to SEs, serum total and specific IgE levels to inhalant allergens. To evaluate eosinophilic chronic rhinosinusitis (ECRS), we used refractory ECRS score from the Japanese epidemiological survey.

RESULTS

Of the 97 patients enrolled, 29 (29.9%) were non-sensitised, 33 (34.0%) were mono-sensitised, and 35 (36.1%) were poly-sensitised. Sensitisation to SEs was closely associated with poly-sensitisation to inhalant allergens. SE-sensitised participants had higher median values for total and specific IgE levels to inhalant allergens than did non-SE-sensitised participants. SE sensitisation was associated with allergic multimorbidity and severe allergic diseases, such as ECRS.

CONCLUSIONS

This preliminary study suggested that sensitisation to SEs may play a role in the initiation of type-2 inflammatory responses, such as allergic rhinitis, ECRS, and allergic multimorbidity. Furthermore, sensitisation to SEs correlated with the severity of ECRS.

Differential effects of postoperative oral corticosteroid on eosinophilic vs. non-eosinophilic CRSwNP subtypes

PURPOSE

The efficacy of postoperative oral corticosteroids on surgical outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) patients following endoscopic sinus surgery (ESS) remains controversial. This study evaluated the potential benefits of postoperative oral corticosteroids on surgical outcomes in CRSwNP patients and investigated the differential effects on eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (NECRSwNP).

MATERIALS AND METHODS

Patients with bilateral CRSwNP who underwent ESS were enrolled and randomized to receive either oral prednisolone (30 mg/day) or placebo for 2 weeks after surgery. Visual analog scale (VAS) and Sino-Nasal Outcome Test 22 (SNOT-22) scores were chosen as the subjective outcomes, evaluated at preoperative baseline and 1, 3, and 6 months postoperatively. Lund-Kennedy Endoscopic Scores (LKESs) were used as the objective outcome, evaluated at preoperative baseline and at 2 weeks and 2, 3, and 6 months postoperatively.

RESULTS

In total, 100 patients with bilateral CRSwNP were enrolled, of whom only 82 completed the 6-month follow-up. The subjective outcomes showed no significant difference at each follow-up points. Of the objective outcomes, the corticosteroid group reporting a trend of improvement in LKESs at 6 months postoperatively (p = 0.05). After stratification by tissue eosinophils, only patients with NECRSwNP (<10 eosinophils/HPF) demonstrated a significant improvement in LKESs at 3 months postoperatively (p = 0.03).

CONCLUSIONS

Postoperative oral corticosteroids did not provide additional improvements in VAS and SNOT-22 scores; nevertheless, a trend of LKES improvement was noted at 6 months postoperatively. After stratification by tissue eosinophils, this effect was significant only among NECRSwNP patients at 3 months follow-up.

Understanding the Role of Biofilms and Superantigens in Chronic Rhinosinusitis

PURPOSE OF REVIEW

This review explores recent discoveries in our understanding of how biofilms and superantigens contribute to the pathogenesis of chronic rhinosinusitis (CRS). It also examines clinical implications and novel treatment approaches for biofilm associated CRS.

RECENT FINDINGS

While the role of biofilms in CRS has been studied for 14 years, research interest has now turned toward elucidating new methods of biofilm detection, microbial diversity, and novel treatment approaches. Recent studies on biofilm superantigens aim to clarify the immunological mechanisms of upper airway inflammation, particularly the type-2 response seen in nasal polyposis.

SUMMARY

Biofilms are a topic of research interest for their role in the pathogenesis of chronic rhinosinusitis, particularly when they elute superantigens. New studies on this topic focus on the molecular and cellular mechanisms at play.

Altered Expression of Genes Associated with Innate Immunity and Inflammation in Recalcitrant Rhinosinusitis with Polyps

Background

The role of the innate immune system in the pathophysiology of chronic rhinosinusitis (CRS) is poorly understood. In this study, we compared sinonasal expression of toll-like receptors (TLRs), complement components, serum amyloid A, and inflammatory genes (chemokines and cytokines) in control subjects and patients undergoing sinus surgery for CRS.

Methods

Eleven control subjects and 30 subjects with CRS unresponsive to medical management were enrolled prospectively before undergoing endoscopic sinus surgery. Ethmoid mucosal specimens were obtained surgically and processed for RNA extraction. Real-time polymerase chain reaction was used to quantitate the level of expression of messenger RNA (mRNA) for TLR, acute phase proteins, and cytokine genes. Subjects were followed for a minimum of 6 months postoperatively with nasal endoscopy to assess for recurrence of polyps.

Results

mRNA for all target genes was detected in the ethmoid mucosa of both control and CRS subjects. The level of gene expression was normalized to the housekeeping genes 18s RNA and glyceraldehyde-3-phosphate dehydrogenase. As compared with controls, CRS was associated with significantly higher expression of TLR2 and the inflammatory genes macrophage-inflammatory protein a, RANTES, and granulocyte-macrophage colony-stimulating factor. Patients with early recurrence of polyps after surgery had significantly decreased expression of TLR2, 9, and serum amyloid A and increased expression of macrophage-inflammatory protein a compared with surgery-responsive patients.

Conclusion

This study shows the increased levels of expression of TLR2 and a variety of inflammatory genes in sinonasal mucosa of CRS patients compared with controls. Whether these differences play a role in pathogenesis or are merely manifestations of disease activity is worthy of investigation.

Staphylococcal Exotoxins and Nasal Polyposis: Analysis of Systemic and Local Responses

Background

Staphylococcal exotoxins have been implicated in the pathogenesis of several chronic inflammatory diseases including atopic dermatitis (AD), asthma, and, most recently, chronic rhinosinusitis with nasal polyposis (CRS/NP). In severe AD, these toxins act both as superantigens (SAg), triggering massive T-cell activation, and as conventional allergens, triggering toxin-specific immunoglobulin E (IgE) in the serum. In CRS/NP, evidence for both processes has been reported but it is unclear whether these processes are linked. The aim of this study was to correlate SAg activity as inferred by staphylococcal-specific T-cell receptor (TCR) V-β expansion in the polyp and blood of CRS/NP patients with staphylococcal-specific anti-IgE antibodies in the serum.

Methods

IgE antibodies to staphylococcal exotoxin A (SEA), staphylococcal exotoxin B (SEB), and toxic shock syndrome toxin (TSST) 1 were measured in the serum of 12 individuals with CRS/NP before functional endoscopic sinus surgery. Flow cytometry was used to analyze the SEA, SEB, and TSST-1–specific TCR V-β domains on the T cells from the polyp and blood of these patients.

Results

Serum SEA-, SEB-, and TSST-1-specific IgE antibodies were detected in 0/12 (0%), 6/12 (50.0%), and 9/12 (75%) of CRS/NP patients, respectively. Evidence of SAg effect in the polyp lymphocytes (TCR V-β expansion in both CD4+ and CD8+ subsets) was noted in 7/12 (58.3%) patients. Five of 6 CRS/NP patients had overlapping evidence of a systemic IgE response and TCR V-β expansion, suggestive of exposure to the same exotoxin. No patients had evidence a SAg effect in blood lymphocytes. Nine of 12 subjects also had coexistent asthma.

Conclusion

These results provide evidence for a local SAg effect in 7/12 (58.3%) polyp patients and establish a positive correlation of V-β expansion with the presence of corresponding toxin-specific IgE in the serum.

Serum levels of specific IgE to Staphylococcus aureus enterotoxins in patients with chronic rhinosinusitis

The aim of this study was to determine the prevalence of Staphylococcus aureus enterotoxins (SEs) in the serum from patients with chronic rhinosinusitis (CRS) and its involvement in the condition. Thirty CRS patients without nasal polyps (CRSsNP), 40 CRS patients with nasal polyps (CRSwNP), and 30 healthy controls were enrolled in this study. Peripheral blood was obtained and analyzed to measure the serum levels of total IgE, specific IgE to SEA, SEB and SEC, and eosinophil cationic protein (ECP) using ImmunoCAP assays. The positive rate and level of serum specific IgE to SEB, but not to SEA or SEC, were significantly higher in CRSwNP patients compared with the controls (P=0.027 and P=0.021, respectively). No significant differences were found between CRSsNP patients and controls, or between CRSsNP and CRSwNP patients. Serum total IgE was significantly elevated and positively correlated with SEB-specific IgE in the CRSsNP (P<0.001; r=0.393, P=0.032) and CRSwNP (P<0.001; r=0.581, P<0.001) groups. ECP was also significantly increased in the CRSsNP (P=0.002) and CRSwNP (P<0.001) groups, but not correlated with specific IgE to SEs in either CRS group. The results suggest that SEB may play a role in the pathogenesis of CRSwNP.

Chronic rhinosinusitis and antibiotics: the good, the bad, and the ugly

BACKGROUND

Despite the recognition that bacteria are universally present in the sinuses of patients with chronic rhinosinusitis (CRS) no compelling role for a primary infectious etiology of CRS has been elucidated. CRS is a constellation of inflammatory diseases that typically involve either noneosinophilic or eosinophilic processes, distinct conditions that must be treated individually.

METHODS

The bacteria that are present in the sinuses may be innocuous bystanders but alternatively may contribute to the presence and severity of the disease through their ability to influence immune responses, function as immune adjuvants, provide antigens or superantigens that contribute to adaptive immune activation, or in forming the basis for the frequent acute superinfections. However, those bacteria that do contribute to the persistence and severity of CRS primarily reside in biofilms, and, as such, are not capable of being eradicated with antibiotics at the doses at which they can be used, even when local irrigation is considered.

RESULTS

Biofilms create an inhospitable environment for antibiotic potency by down-regulating the metabolic activity of their "core" bacteria, decreasing the oxygen concentration, and altering the pH at the core of the biofilm.

CONCLUSION

Ultimately, if topical antibiotics are considered, they should be primarily focused on treating acute exacerbations and choices of antibiotics should optimally be based on endoscopic culture. This should be done with the recognition that while under certain circumstances antibiotics can ameliorate the severity of CRS, even if bacterial eradication were possible, this would not eliminate the underlying primary pathogenic mechanism or the natural history of these conditions.

The presence of fungal-specific IgE in serum and sinonasal tissue among patients with sinonasal polyposis

Nasal polyposis (NP) is a common inflammatory disorder with different proposed etiologies. There is some evidence that the local production of specific IgE against fungal allergens may contribute to the pathogenesis of this condition. The aim of this study was to compare local and systemic production of fungal-specific IgE among patients with NP. In a prospective cross-sectional study, 141 patients with sinonasal polyposis who were surgical candidates were enrolled. Total IgE and fungal-specific IgE antibodies in serum and tissue homogenates were measured by the ELISA and ImmunoCAP method, respectively. Twelve cases (9.45 %) met the allergic fungal rhinosinusitis (AFRS) criteria while the remaining 129 patients showed histopathological features of chronic hyperplastic rhinosinusitis. Considering a cutoff point of 0.4 KUI/L for specific IgE as a positive reaction against fungal elements, seven and 62 cases showed positive results in serum and homogenate tissue, respectively. All serum positive reactions were seen among patients with AFRS. In conclusion, IgE antibody could be locally produced in the nasal polyp tissue while not detectable in the serum.

Chronic sinusitis pathophysiology: the role of allergy

BACKGROUND

Chronic hyperplastic eosinophilic sinusitis (CHES) is an inflammatory disease characterized by eosinophil infiltration of sinus tissue that can present with and without nasal polyps (NPs). Aeroallergen sensitization in CHES occurs regularly, but the causality between allergen sensitivity, exposure, and disease is unclear.

METHODS

Allergen is unlikely to directly enter healthy sinuses either by diffusion or ciliary flow, and, even this is more problematic given the loss of patency of the ostia of diseased sinuses. Inflammation and tissue eosinophilia can develop secondary to allergen exposure in the nares, with systemic humoral recirculation of allergic cells including eosinophils, Th2 lymphocytes, and eosinophil precursors that are nonspecifically recruited back to the diseased sinuses.

RESULTS

The possibility of an allergic reaction to peptides derived from bacteria (i.e., Staphylococcus or superantigens) or fungi that colonize the diseased sinus also provides a plausible allergic mechanism.

CONCLUSION

Treatments of this disease include agents directed at allergic mediators such as leukotriene modifiers and corticosteroids, although this does not necessarily signify that an IgE-dependent mechanism can be ascribed. However, more recently, omalizumab has shown promise, including in patients without obvious aeroallergen sensitization. Although many aspects of the role of allergy in CHES remain a mystery, the mechanisms that are being elucidated allow for improved understanding of this disease, which ultimately will lead to better treatments for our patients who live daily with this disease.

Detection of Staphylococcal Exotoxins in Antrochoanal Polyps and Chronic Rhinosinusitis with Nasal Polyps

Objective

Staphylococcal exotoxins have been reported in the pathogenesis of many chronic inflammatory diseases. Recent reports have hypothesized that staphylococcal exotoxins might be related to inflammatory mucosal changes seen in chronic sinusitis with nasal polyps (CRS-NPs). Staphylococcal exotoxins have the capacity to act as superantigens (SAgs), bypassing normal antigen processing and directly stimulating a massive inflammatory response. The objective of this study was to analyze polyp tissue samples from patients with antrochoanal polyps (ACPs) and CRS-NPs for the presence of staphylococcal exotoxins.

Study Design

Prospective cohort study.

Setting

Tertiary medical center.

Subjects and Methods

Tissue samples were obtained from 29 patients and 16 controls. Thirteen of 29 patients had ACPs, and 16 had CRS-NPs. Specimens were analyzed for the presence of 5 staphylococcal exotoxins (SEA, SEB, SEC, SED, and toxic shock syndrome toxin–1) using enzyme-linked immunosorbent assay (ELISA).

Results

At least 1 toxin was detected in 7 of 13 patients with ACPs and in 13 of 16 patients with CRS-NPs, whereas it was detected in only 4 controls. There were no statistically significant differences between ACP and control groups ( P = .063). Our results showed a statistically significant association between toxin detection and patients with CRS-NPs ( P = .003).

Conclusion

Inflammatory triggers in ACP remain a subject of debate, and this study does not support the hypothesis that staphylococcal exotoxins may play a role in ACP ethiopathogenesis. Our research is consistent with the possibility of SAgs as etiological agents in the development of bilateral nasal polyposis.

Chronic rhinosinusitis with nasal polyps: elevated serum immunoglobulin E is associated with Staphylococcus aureus on culture

BACKGROUND

Recent data has implicated Staphylococcus aureus (SA) superantigen as a potential disease modifier in patients with chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP). The objective of this work was to compare total serum immunoglobulin E (IgE) and serum eosinophils in patients with CRSwNP and CRS without nasal polyps (CRSsNP) based on culture results of the 3 most commonly isolated bacteria.

METHODS

Retrospective review at a tertiary rhinology referral center of patients with CRS over a 4-year period.

RESULTS

Bacterial cultures and immunologic data were obtained from 62 patients with CRSwNP and 34 patients with CRSsNP. SA was the most prevalent bacteria in the CRSwNP group, isolated in 19 patients (31%). Patients with elevated total serum IgE (>114 IU/mL) were more likely to have SA on culture (p = 0.04) in this population. The percent serum eosinophil levels in the SA+ group compared with the SA- group was not significant (6.0 vs 5.1, p = 0.17). Lund-Mackay computed tomography (CT) scores, but not Sino-Nasal Outcome Test 20 (SNOT-20) scores were significantly higher in the SA+ vs SA- group (p = 0.03) in patients with CRSwNP. The CRSsNP group demonstrated no difference in IgE or serum eosinophils between different bacterial groups.

CONCLUSION

Our findings suggest that there is an association between SA sinonasal presence and elevated total serum IgE in patients with CRSwNP. In addition, SA+ patients had higher Lund-Mackay CT scores, indicating a higher objective burden of disease in this group of patients.

Association of T Cells and Eosinophils with Staphylococcus aureus Exotoxin a and Toxic Shock Syndrome Toxin 1 in Nasal Polyps

Background

Staphylococcus aureus exotoxins (SEs) have been implicated in the pathogenesis of nasal polyps (NPs) in patients with chronic rhinosinusitis (CRS). The aim of this study was to identify the correlation between SEs and T cells in NPs.

Methods

After a nasal smear culture, the nasal lavage fluid and NP tissue were obtained from 30 CRS with NP (CRSwNP) patients. The control samples were taken from 10 normal individuals. The presence of S. aureus exotoxin A (SEA) and toxic shock syndrome toxin 1 (TSST-1) was verified through a polymerase chain reaction (PCR) analysis and immunohistochemical staining. Immunohistochemical staining for CD4+ and CD8+ T cells was performed, followed by hematoxylin and eosin (H&E) staining for eosinophils.

Results

The PCR analysis and immunohistochemical staining for SEA and TSST-1 showed a significantly higher expression in the NP group when compared with that in the control group. Furthermore, the number of T cells and eosinophils were notably increased in the NP group when compared with that in the control group. Significant correlation was observed between the results of the culture, PCR, and immunohistochemical staining in the NP group. Moreover, the number of T cells and eosinophils was significantly increased in the positive experimental groups, when compared with that in the control group.

Conclusion

Our results indicate that there was, indeed, some correlation between the expression of SE in the nasal cavity and the increased number of T cells and eosinophils in NPs.

Staphylococcus Aureus Increases Cytokine and Matrix Metalloproteinase Expression in Nasal Mucosae of Patients with Chronic Rhinosinusitis and Nasal Polyps

Background

Staphylococcus aureus is a common bacterial pathogen associated with chronic rhinosinusitis with/without nasal polyps (CRSw/sNP). We investigated the effect of S. aureus on the secretion of eotaxin, interleukin (IL)-5, IL-8, IL-13, matrix metalloproteinase (MMP) 2, MMP-9, and tissue inhibitor of MMP (TIMP) 1 in nasal mucosae from CRSwNP patients to assess the roles of these materials in NP pathogenesis.

Methods

We infected organ cultures of NP and inferior turbinate (IT) mucosae taken from patients with CRSwNP with S. aureus ATCC 25923 for 24 hours and incubated the cultures for an additional 48 hours at 37°C. S. aureus infection and staphylococcal enterotoxins were confirmed by real-time polymerase chain reaction. Eotaxin, IL-5, IL-8, IL-13, MMP-2, MMP-9, and TIMP-1 protein levels were measured by ELISA.

Results

S. aureus infection significantly increased the concentrations of eotaxin, IL-5, IL-8, and IL-13 in the IT and NP groups (p < 0.01 for all comparisons). S. aureus infection also significantly increased the concentrations of MMP-2, MMP-9, and TIMP-1 in both groups (p < 0.001 for all comparisons). After S. aureus infection, the relative increases in eotaxin (6.42 versus 3.56), IL-5 (15.29 versus 8.89), MMP-2 (1.95 versus 1.58), MMP-9 (2.34 versus 1.95), and TIMP-1 (1.45 versus 1.31) were greater in the NP group than in the IT group.

Conclusion

S. aureus infection enhances the secretion of cytokines, MMP-2, MMP-9, and TIMP-1 by both NPs and IT mucosae from patients with CRSwNP. S. aureus may play an important role in the pathogenesis of NP via tissue remodeling as well as eosinophilic inflammation.

Short-term antibiotics treatment in patients with nasal polyps and enterotoxins producing Staphylococcus aureus strains

Enterotoxins produced by Staphylococcus aureus (SA) can act as super-antigens and thus influence the course of chronic rhinosinusitis with nasal polyps (NP). The aim of this study was to determine if antibiotic treatment administered after endoscopic sinus surgery (ESS) for NP can positively influence the course of the disease compared to placebo. After ESS, 23 patients who tested positive, in a perioperative culture, for SA strains producing enterotoxins A-E and TSST-1, were randomized into two groups. Group A which in addition to standard treatment received oral anti-staphylococcal antibiotics for 3 weeks. Group B received a placebo. Both groups were compared preoperatively, and at 3 and 6 months after surgery using a symptom-specific score, an endoscopic score and the SNOT-22 quality of life questionnaire. Slightly better results were achieved in patients who received antibiotic therapy. However, the differences were not statistically significant. Regardless of post-operative treatment, approximately 30% of patients had a SA-negative culture 6 months after surgery.

Bacterial colonization and granulocyte activation in chronic maxillary sinusitis in asthmatics and non-asthmatics

The impact of bacterial colonization on the severity and pattern of chronic inflammation in rhinosinusitis is not clear. In this study, it was hypothesized that bacterial colonization of the sinus mucosa would have a greater impact on inflammatory response modulation in asthmatic patients than in non-asthmatic patients with chronic rhinosinusitis. In order to test this hypothesis, granulocyte activation was measured and related to bacteria identified in the sinus lavage. Lavages from the maxillary sinuses of 21 asthmatic and 19 non-asthmatic patients with chronic rhinosinusitis (CRS) were microbiologically examined for aerobic and anaerobic growth. Eosinophil cationic protein (ECP), an eosinophil activation marker, and myeloperoxidase (MPO), a neutrophil activation marker, were measured in the sinus lavages. Bacteria were recovered in 20/32 samples from the asthmatics and in 21/33 samples from the non-asthmatics. Gram-positive aerobes and anaerobes were slightly more common than Gram-negative bacteria. A different bacterial profile was found when comparing Gram-negatives between the groups. Concentrations of MPO were significantly higher in samples with bacterial recovery from asthmatic patients, compared to sterile samples of both groups. Concentrations of ECP in the samples from asthmatic patients were significantly higher than in the controls, with no significant difference related to bacterial colonization. Bacterial colonization in chronically inflamed sinuses may have an impact on neutrophil granulocyte activation in patients with bronchial asthma, which was not confirmed for patients with CRS without asthma.

Human mast cell activation by Staphylococcus aureus: interleukin-8 and tumor necrosis factor alpha release and the role of Toll-like receptor 2 and CD48 molecules

The ability of Staphylococcus aureus to invade and survive within host cells is believed to contribute to its propensity to cause persistent and metastatic infections. In addition, S. aureus infections often are associated with atopic diseases such as dermatitis, rhinitis, and asthma. Mast cells, the key cells of allergic diseases, have a pivotal role in innate immunity and have the capacity of phagocytosis, and they can destroy some pathogenic bacteria. However, little is known about the ability of some other bacteria to survive and overcome mast cell phagocytosis. Therefore, we were interested in evaluating the interplay between mast cells and S. aureus. In this study, we show that human cord blood-derived mast cells (CBMC) can be infected by pathogenic S. aureus. S. aureus displayed a high adherence to mast cells as well as invasive and survival abilities within them. However, when infections were performed in the presence of cytochalasin D or when CBMC were preincubated with anti-Toll-like receptor 2 (TLR2) or anti-CD48 antibodies, the invasiveness and the inflammatory response were abrogated, respectively. Furthermore, we observed an increase of TLR2 and CD48 molecules on CBMC after S. aureus infection. The infection of CBMC with S. aureus also caused the release of tumor necrosis factor alpha (TNF-alpha) and interleukin-8 (IL-8). Both live and killed S. aureus organisms were found to trigger TNF-alpha and IL-8 release by CBMC in a time-dependent manner. Cumulatively, these findings suggest that S. aureus internalizes and survives in mast cells. This may play an important role in infections and in atopic diseases associated with S. aureus.

Local IgE and inflammation in chronic rhinosinusitis of asthmatics and non-asthmatics

The aim of the study was to show the difference in the pattern of inflammation, and Th1/Th2 polarization between asthmatic and non-asthmatic patients with CRS, specifically eosinophil activation, local IgE levels in the sinus fluid and tissue, and the severity of inflammation were measured. The maxillary sinus lavages, mucosal biopsies and bacteriological swabs were taken in 17 asthmatic and 36 non-asthmatic adult patients with CRS. The concentrations of IgE, eosinophil cationic protein (ECP), myeloperoxidase (MPO), and tryptase were analyzed and IgE+ cells, eosinophils, lymphocytes and plasma cells were counted. The granulocyte activation markers and IgE in sinus lavages, and the inflammatory and IgE+ cells counts were significantly higher in the asthmatics with the greatest difference in ECP and IgE concentrations. The tryptase concentrations did not differ, but only in the asthmatics they correlated significantly with the IgE concentrations and IgE+ cells count. Asthmatic patients present a distinct subgroup among the patients with chronic rhinosinusitis (CRS). The levels of the cellular markers and IgE in the sinus fluid differ from those of non-asthmatic patients with CRS. The activation of granulocytes (especially eosinophils), local IgE concentrations and the inflammatory cells infiltration are significantly higher in the asthmatics.

Innate responses to Aspergillus: role of C1q and pentraxin 3 in nasal polyposis

BACKGROUND

Pentraxin 3 (PTX3) and complement component C1q are humoral factors of innate immunity, produced at sites of inflammation, and are essential in immune defense against several microbes such as Aspergillus, which is commonly implicated in nasal polyposis.

METHODS

PTX3 and C1q were measured in nasal polyp tissue, normal nasal mucosa, and serum of patients and healthy subjects. Immunohistochemistry for the two proteins was done on normal nasal mucosa and nasal polyps. In addition, PTX3 and C1q production from mononuclear cells from patients and healthy subjects was assessed.

RESULTS

Normal nasal mucosa was found to have 100-fold higher levels of PTX3 compared with serum. No measurable local increase of PTX3 was observed in polyps compared with normal mucosa. Immunohistochemistry revealed PTX3 expression in the lining of blood vessels both within normal mucosa and nasal polyps. PTX3 also was present in mononuclear cells infiltrating nasal polyps. C1q levels were higher in polyps than in normal nasal mucosa.

CONCLUSION

High levels of PTX3 are present in normal nasal mucosa, suggesting a role in the maintenance of tissue homeostasis. Elevated C1q levels in nasal polyps might be indicative of an ongoing inflammatory response in the nasal mucosa in these patients.

Superantigens and chronic rhinosinusitis II: analysis of T-cell receptor V beta domains in nasal polyps

BACKGROUND

The superantigen (SAg) hypothesis of chronic rhinosinusitis (CRS) suggests that toxins within the nose stimulate massive oligoclonal expansion of T-cell populations with subsequent eosinophil recruitment and tissue inflammation. SAgs are capable of activating 1 x 10(4) more lymphocytes than conventional antigens by binding specific Vbeta-domains of the T-cell receptor (TCR). The net effect is skewing from the normal Vbeta-profile by oligoclonal expansion of specific domains. This study will assess polyp tissue for evidence of an SAg response in CRS with nasal polyps (CRSwNP).

METHODS

This study consists of a prospective analysis of 18 CRSwNP subjects undergoing sinus surgery. Flow cytometry was used to analyze the distribution of 24 specific TCR V beta-domains in lymphocytes from polyp tissue and blood. Evidence of oligoclonal expansion was tabulated for each specimen and defined as mean normative percentage + 2 SD.

RESULTS

Eighteen of 18 CRSwNP subjects showed expansion of polyp lymphocytes expressing TCRs with specific V beta-domains. The average number of V beta-clones per CRSwNP subject was seven in polyp lymphocytes but only two in blood lymphocytes.

CONCLUSION

The current results indicate that polyp lymphocytes exhibit significant oligoclonal expansion of specific V beta-domains. These data are considered diagnostic of a SAg effect. The corresponding blood profile is much less, suggesting that the nose is the primary source of stimulus. Although the trigger(s) for this expansion are unknown, these data are consistent with the hypothesis that staphylococcal toxins are central to the development of CRSwNP.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Chronic rhinosinusitis and superantigens

This article discusses the potential role of bacterial superantigens (SAgs) in chronic rhinosinusitis with nasal polyposis (CRS/NP). First, it briefly describes SAgs, focusing on how they interact with the immune system by binding to T-cell receptors (TCR) and major histocompatibility complex (MHC) class II molecules. Second, it discusses the role of SAgs in other chronic inflammatory diseases.Finally, it presents evidence for the role of SAgs in the pathogenesis and maintenance of CRS/NP focusing on current research and future considerations.

Superantigens and chronic rhinosinusitis: detection of staphylococcal exotoxins in nasal polyps

OBJECTIVE/HYPOTHESIS

The role of infectious agents in the etiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) remains unclear. Recent studies have provided indirect evidence of exposure to staphylococcal exotoxins in the blood and polyp tissue of patients with CRSwNP. These exotoxins have the capacity to act as superantigens, bypassing normal antigen processing and directly stimulating a massive inflammatory response. The objective of the study was to analyze mucus and polyp tissue samples from patients with CRSwNP for the presence of staphylococcal exotoxins.

STUDY DESIGN

Prospective study.

METHODS

Tissue and mucus samples were obtained from 42 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis and 11 normal control patients. Twenty-nine of 42 patients had chronic rhinosinusitis with bilateral nasal polyposis, 2 had antrochoanal polyps, and 11 had chronic rhinosinusitis without nasal polyps. Eleven patients without chronic rhinosinusitis or polyps served as normal control patients. Specimens were analyzed for the presence of five staphylococcal exotoxins (SEA, SEB, SEC, SED, and toxic shock syndrome toxin type 1 [TSST-1]) using enzyme-linked immunosorbent assay (ELISA). Histological analysis of specimens and mean eosinophil counts were correlated with the presence of toxin.

RESULTS

At least one toxin was detected in 14 of 29 patients with bilateral nasal polyposis. Nine of the 14 patients also had positive findings for additional toxins. The dominant histological pattern in the CRSwNP patient group was polypoid mucosa with edema, which was found in both ELISA-positive and ELISA-negative patients. Mean eosinophil counts tended to be higher in ELISA-positive patients with polyps compared with patients without toxin detection. No toxin was detected in the 11 specimens taken from normal control patients. Only 1 of the 13 patients with CRS without polyps had positive ELISA results for toxin.

CONCLUSION

The current study demonstrates the presence of superantigen toxins in 14 of 29 patients with CRSwNP, with SEB and TSST-1 being the most common. Further studies are necessary to correlate the presence of toxin with the pathological changes present in polyp tissue.

Rhinosinusitis derived Staphylococcal enterotoxin B possibly associates with pathogenesis of ulcerative colitis

Background

During clinical practice, we noticed that some patients with both ulcerative colitis (UC) and chronic rhinosinusitis (CRS) showed amelioration of UC after treatment of CRS. This study was designed to identify a possible association between CRS and UC.

Methods

Thirty-two patients with both CRS and UC received treatment with functional endoscopic sinus surgery (FESS) for CRS. Clinical symptom scores for CRS and UC, as well as serum levels of anti-Staphylococcal enterotoxin B (SEB) were evaluated at week 0 and week 12. Sinus wash fluid SEB content was measured with enzyme-linked immunosorbent assay (ELISA). The surgically removed tissues were cultured to identify growth of Staphylococcus. aureus (S. aureus). Immunohistochemistry was employed to identify anti-SEB positive cells in the colonic mucosa. Colonic biopsies were obtained and incubated with SEB. Mast cell activation in the colonic mucosa in response to incubation with SEB was observed with electron microscopy and immunoassay.

Results

The clinical symptom scores of CRS and UC severe scores (UCSS) were significantly reduced in the UC-CRS patients after FESS. The number of cultured S. aureus colonies from the surgically removed sinus mucosa significantly correlated with the decrease in UCSS. High levels of SEB were detected in the sinus wash fluids of the patients with UC-CRS. Histamine and tryptase release was significantly higher in the culture supernate in the patients with UC-CRS than the patients with UC-only and normal controls. Anti-SEB positive cells were located in the colonic mucosa.

Conclusion

The pathogenesis of UC in some patients may be associated with their pre-existing CRS by a mechanism of swallowing sinusitis-derived SEB. We speculate that SEB initiates inappropriate immune reactions and inflammation in the colonic mucosa that further progresses to UC.