[Chronic and acute hypersensitivity pneumonitis in a dairy farmer and his son]

We encountered a dairy farmer and his son with farmer's lung who had worked on the same farm for 25 years and 5 years, respectively. The son was admitted to our hospital because of cough, sputum, and shortness of breath. Chest computed tomography (CT) on admission revealed diffuse ground-glass opacities in both lung fields. Following admission, the clinical symptoms and radiological findings improved spontaneously without specific treatment. A provocation test (following return to work on the farm) elicited recurrence of the symptoms and radiological findings. He was diagnosed with acute hypersensitivity pneumonitis (HP) based on the clinical findings. After quitting his job, no reccurence was noted. The farther was admitted to our hospital complaining of repeated episodes of cough and high fever. He had been diagnosed with lung fibrosis 10 years previously. Chest CT on admission revealed progression of thin-walled cystic changes over ten years. Following admission, his symptoms improved without medication. However, because he has continued working on the farm, his radiological findings have gradually deteriorated. He was diagnosed with chronic HP based on his clinical features. These cases are suggestive of farmer's lung with familial occurrence, difference between acute HP and chronic HP, and long-term prognosis.

Intrapulmonary cellular schwannoma

A 75-year-old asymptomatic woman was admitted to our hospital after an abnormal shadow was found on a chest roentgenogram. Chest computed tomography showed a round mass in the right lower lobe. Magnetic resonance imaging showed the mass with high signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images. Fluorine-18-fluorodeoxyglucose-positron emission tomography showed high fluorine-18-fluorodeoxyglucose accumulation in the mass. A lobectomy was performed thoracoscopically. The pathologic diagnosis was cellular schwannoma. Immunohistochemical staining demonstrated the presence of S-100 protein, and the Ki67 labeling index was 12%. We present this case of intrapulmonary cellular schwannoma, which is extremely rare.

[Autopsy case of von Recklinghausen's disease associated with lung cancer, gastrointestinal stromal tumor of the stomach, and duodenal carcinoid tumor]

A 58-year-old man with von Recklinghausen's disease was admitted for further investigation of right chest pain. Chest X-ray revealed multiple emphysematous bullae in both lungs and a tumor shadow in the right upper lobe. Bronchofiberscopy was performed, but an adequate specimen was not obtained. The tumor was diagnosed as a non-small-cell lung cancer with direct invasion to the adjacent rib. Although chemotherapy and radiotherapy resulted in decrease in tumor size, the tumor subsequently increased in size and the patient died 14 months after the first admission. Autopsy revealed multiple emphysematous bullae, poorly differentiated adenosquamous cell carcinoma of the lung, gastrointestinal stromal tumor of the stomach, and duodenal carcinoid tumor. This case suggests the possibility that von Recklinghausen's disease associated with emphysematous bullae is a risk factor for lung cancer. It has also been suggested that the genetic abnormality responsible for von Recklinghausen's disease increases the risk for various types of malignancy. Although von Recklinghausen's disease is reportedly associated with various malignant tumors, it is quite rare for von Recklinghausen's disease to be associated with triple non-neurogenic tumors. Careful observation is mandatory for patients with von Recklinghausen's disease.

[A case of status asthmaticus complicated by takotsubo cardiomyopathy]

A 51-year old woman was admitted to our hospital because of status asthmaticus. Electrocardiography (ECG) revealed ST-segment elevation in leads II.III.aVF, and V2 through V6 accompanied by T-wave inversion in leads V3 through V6. The serum levels of creatine kinase, its MB isozyme, and troponin T were slightly elevated, whereas the markedly high levels of serum catecholamine were observed. Despite the ECG changes and elevated cardiac markers, coronary angiography demonstrated normal findings. Left ventriculography revealed apical akinesis and basal hyperkinesis. Takotsubo cardiomyopathy was diagnosed on the basis of these characteristic findings. Methylprednisolone and theophylline were administrated intravenously under mechanical ventilation. The abnormal findings in ECG had improved on day 4 followed by complete recovery from the motional abnormalities of left ventricular wall on day 7. The mechanical ventilation was discontinued on day 15 due to the improvement of respiratory symptoms. Takotsubo cardiomyopathy is a recently described cardiac syndrome that is possibly caused by direct action of excessively released catecholamines on cardiac adrenoceptors when emotional or physical stress is loaded, especially in postmenopausal women. This report has presented a typical case of stress-induced Takotsubo cardiomyopathy in a postmenopausal woman with bronchial asthma.

[A case of pulmonary MALT lymphoma with 6-year natural history]

A 58-year-old asymptomatic man was referred for investigation of an abnormal shadow on chest X-ray films. Chest computed tomography (CT) revealed an infiltrative shadow containing an air-bronchogram. Video-assisted thoracic surgery was performed for a lung biopsy of an abnormal region in the right upper lobe of the lung. Based on immunohistochemical examinations and gene analysis, the abnormal shadow was diagnosed as primary pulmonary B-cell lymphoma of mucosa-associated lymphoid tissue, t(11; 18)/API2-MALT1. Rituximab-CHOP therapy yieled a complete response. He had abnormal shadows on chest X-ray films in both lung fields since 6 years previously. Retrospective examination of chest radiographs revealed slow growth during the 6 years.

Association between nonspecific airway hyperresponsiveness and Arg16Gly beta2-adrenergic receptor gene polymorphism in asymptomatic healthy Japanese subjects

BACKGROUND

Nonspecific airway hyperresponsiveness (AHR), a cardinal feature of asthma, is thought to result from several genetic and environmental factors. Asymptomatic AHR in nonasthmatic healthy subjects might be a risk factor for the development of asthma. Genetic variations in codons 16 and 27 of the human beta(2)-adrenergic receptor (beta(2)-AR) alter receptor function in vitro and are associated with various asthma-related phenotypes, including asthma severity and AHR. To date, however, few reports have examined the impact of beta(2)-AR gene polymorphism on AHR in asymptomatic healthy subjects.

OBJECTIVE

To determine whether polymorphism of the beta(2)-AR gene (Arg16Gly and Gln27Glu) might influence nonspecific AHR in asymptomatic healthy Japanese subjects.

DESIGN AND PARTICIPANTS

A cohort of 120 asymptomatic healthy subjects was analyzed using a stepwise linear regression model. Nonspecific airway responsiveness was measured using a continuous methacholine inhalation method (Astograph; Chest; Tokyo, Japan). We used values of the cumulative dose of inhaled methacholine measured at the inflection point at which respiratory conductance starts to decrease (Dmin) as an index of AHR. Genotyping to identify polymorphisms at codons 16 and 27 was conducted using an assay combining kinetic real-time quantitative polymerase chain reaction with allele-specific amplification.

RESULTS

The Gly16Gly genotype was associated with lower Dmin values. The log Dmin value of asymptomatic healthy subjects carrying the Arg16 allele (Arg16/Arg or Arg16/Gly, n = 90) was 1.09 +/- 0.56 (mean +/- SD), while those homozygous for the Gly16 allele (n = 30) yielded a log Dmin value of 0.85 +/- 0.56 (p < 0.05).

CONCLUSION

This study indicates that a specific beta(2)-AR polymorphism at codon 16 might be a genetic determinant of AHR, as judged by methacholine-induced bronchoconstriction in asymptomatic healthy subjects.

Polymorphisms in the muscarinic receptor 1 gene confer susceptibility to asthma in Japanese subjects

RATIONALE

The human cholinergic receptor muscarinic-1 (CHRM1) is widely distributed in the lungs. In patients with asthma, CHRM1 may be involved in airway constriction, airway epithelial cell proliferation, and airway inflammation. The CHRM1 gene is located on chromosome 11q13, which is one of the candidate loci for asthma and atopy.

OBJECTIVES

To determine the role of the CHRM1 gene polymorphisms in asthma.

METHODS

We studied nine single-nucleotide polymorphisms (-18379G > A, -9697C > T, -6965T > C, -4953A > G, +267A > C, +1353C > T, +3970C > G, +5418C > G, and +5455G > T) in a case-control study using 326 patients with asthma and 333 healthy control subjects. We also examined functional consequences of the -9697C > T and -4953A > G polymorphisms at the regulatory region using an mRNA reporter assay.

MEASUREMENTS AND MAIN RESULTS

Two common single-nucleotide polymorphisms (-9697C > T and -4953A > G) were associated with asthma. The odds ratio for the TT homozygotes at the -9697C > T polymorphism was 0.29 compared with the CC homozygotes (95% confidence interval, 0.12-0.73; p = 0.008), and the odds ratio for the GG homozygotes at the -4953A > G polymorphism was 1.86 compared with the AA homozygotes (95% confidence interval, 1.04-3.34; p = 0.038). Haplotype analysis showed that the -9697T/-6965T/-4953A haplotype was associated with a lower risk of asthma (p = 0.00055) and the -9697C/-6965T/-4953G haplotype was associated with an increased risk of asthma (p = 0.020). The -9697T/-4953A haplotype was also associated with lower luciferase activity in vitro compared with the -9697C/-4953G haplotype.

CONCLUSIONS

This study, together with an in vitro functional study, suggests that the CHRM1 gene is an important susceptibility locus for asthma on chromosome11q13.

[Case of drug-induced pneumonia followed by sequential bronchoalveolar lavage]

A 30-year-old woman who had been receiving minocycline for 11 days to treat a skin burn presented with high fever and progressive dyspnea. Chest radiography demonstrated bilateral pulmonary infiltrates with ground glass opacities. She was admitted to our hospital under a tentative diagnosis of minocycline-induced pneumonia. Minocycline therapy was discontinued at hospital admission, which led to dramatic clinical and radiographic improvement. Bronchoalveolar lavage fluid (BALF) analysis three days after the onset of the pneumonia showed increased numbers of total cells (7.68 x 10(5)/ml), neutrophils (33%) and eosinophils (14%). An increased number of peripheral blood neutrophils was also noted at the time of hospital admission. Follow-up evaluations of BALF 10 days and 34 days after the onset showed rapidly declining numbers of neutrophils and eosinophils. We also measured the levels of several cytokines in BALF, suggesting that TNF-alpha and IL-8 contributed to the accumulation of neutrophils, whereas IL-5 contributed to the accumulation of eosinophils. In summary, we report here the temporal change in the inflammatory cell and cytokine profile in BALF, serum, or both, in a case of drug-induced pneumonia.

[Studies on airway hyperresponsiveness by the Astograph(r) method in asthmatics and young adult non-asthmatic asymptomatics]

We investigated airway hyperresponsiveness (AHR) by the continuous inhalation method using an Astograph(R) in 105 asthmatics and 141 non-asthmatic asymptomatics. The range of Dmin (1 U=one minute inhalation of 1 mg/ml of methacholine) of asthmatics was 0.001 to 28.70 U, and that of adjusted Dmin of non-asthmatic asymptomatics was 0.28 to 190 U; thus, an apparent overlap was recognized in the distributions of Dmin. Ninety-five percent of asthmatics had a Dmin lower than 7 U, and 95% of non-asthmatic asymptomatics had a Dmin higher than 0.9 U. Presuming that almost all asthmatics had AHR, it was inferred that nearly half of non-asthmatic asymptomatics had AHR, too. Comparison with previous reports suggests that AHR in healthy people may be increasing generally. When Dmin is determined to be>7 U by the Astograph(R) method, it is likely that the patient does not have asthma. When a patient has a Dmin<0.9 U, it is highly probable that the patient has asthma.

A functional polymorphism in the RANTES gene promoter is associated with the development of late-onset asthma

The CC chemokine regulated upon activation, normal T-cell expressed and secreted (RANTES) attracts eosinophils, basophils, and T cells during inflammation and immune response, indicating a possible role for this chemokine in asthma. Both the -403A and -28G alleles of the RANTES promoter region exhibit significantly enhanced promoter activity in reporter constructs in vitro. We therefore investigated the genetic influence of these alleles on the development of asthma using case-control analysis in a Japanese population (298 patients with asthma and 311 control subjects). Given the evidence for heterogeneity of asthma according to age at onset, we divided patients with asthma into three subgroups: 117 late-onset patients with asthma (onset at more than 40 years of age), 83 middle-onset patients with asthma (onset at 20 to 40 years of age), and 98 early-onset patients with asthma (onset at less than 20 years of age). The -28G allele was significantly associated with late-onset asthma (odds ratio = 2.033; 95% confidence interval, 1.379-2.998; corrected p < 0.0025) but was not associated with the other two asthma subgroups. The -403A allele was not associated with any of the asthma subgroups. Further evidence of the importance of the -28G allele was a significant increase in the production of RANTES in vitro in individuals who carried this allele. Our findings suggest that, among Japanese, the -28G allele of the RANTES promoter region confers susceptibility to late-onset asthma.

(CCTTT)n repeat polymorphism in the NOS2 gene promoter is associated with atopy

BACKGROUND

Several studies have shown that nitric oxide (NO) plays a role in the regulation of the T(H)1/T(H)2 balance, indicating the potential for NO to contribute to the development of atopy and several other allergic diseases, including bronchial asthma. NO synthase 2 (NOS2) is critically involved in the synthesis of NO during several inflammatory states, and the gene encoding NOS2 is located at chromosome 17q11.2-q12, where 2 genome scans have identified a candidate locus for atopy and asthma.

OBJECTIVE

The 14-repeat allele of the (CCTTT)(n) repeat polymorphism in the NOS2 promoter region is a powerful enhancer of promoter activity in reporter constructs in vitro. We tested whether this potentially functional allele in the NOS2 gene influences the development of atopy and asthma.

METHODS

We studied a total of 497 unrelated Japanese subjects (141 nonatopic healthy controls, 102 atopic healthy controls, 56 nonatopic asthmatic subjects, and 198 atopic asthmatic subjects). The odds ratio (OR) was calculated for atopy and asthma in carriers of the 14-repeat allele through use of logistic regression models. Atopy was defined as a positive specific IgE level to at least 1 of 10 common inhaled allergens.

RESULTS

The 14-repeat allele was inversely associated with atopy (OR = 0.42, P < .01). The association remained significant when the model was controlled for asthmatic status (OR = 0.36, P < .01). This allele, however, was associated neither with the development of asthma nor with total serum IgE levels.

CONCLUSION

Our findings suggest that the (CCTTT)(n) repeat polymorphism in the promoter of the NOS2 gene that affects promoter activity is a risk factor for the development of atopy, and this genetic effect seems independent of asthma.

Increased total serum IgE levels in patients with asthma and promoter polymorphisms at CTLA4 and FCER1B

BACKGROUND

Increasing evidence indicates that total serum IgE levels are largely determined by genetic factors, and we recently established that the -109C/T promoter polymorphism at FCER1B is a genetic factor that affects total serum IgE levels. The gene encoding cytotoxic T lymphocyte antigen 4 (CTLA4) is another candidate factor in high IgE responsiveness, because B7-CD28/CTLA4 interaction can promote the differentiation and development of the T(H)2 lymphocyte subset.

OBJECTIVE

We intended to determine whether CTLA4 is associated with increased levels of total serum IgE or with the development of asthma or atopy.

METHODS

We performed a case-control study involving 339 patients with asthma and 305 healthy control subjects, of whom 226 of the patients with asthma and 219 of the healthy control subjects had previously been genotyped for the -109C/T promoter polymorphism at FCER1B. In the current study, we genotyped 2 polymorphisms in the CTLA4 gene, one involving the promoter (-318C/T) and the other involving exon 1 (+49A/G), in addition to the FCER1B promoter polymorphism.

RESULTS

Patients with asthma who were homozygous for the -318C allele at the CTLA4 promoter region had higher levels of total serum IgE than patients with asthma carrying the -318T allele (P =.00470). The analysis of -318C/T (at CTLA4) and -109C/T (at FCER1B) promoter polymorphisms showed a significant correlation between the combined genotypes and increased levels of total IgE in patients with asthma (P =.000014). In contrast, no correlation between total serum IgE levels and -318C/T or +49A/G genotypes was detected in 305 healthy control subjects. There was no evidence indicating an association between a putative allele for asthma or atopy and alleles at any of the CTLA4 polymorphic loci.

CONCLUSION

Our findings suggest that promoter polymorphisms of both CTLA4 and FCER1B are genetic factors that influence total serum IgE levels in patients with asthma. This supports the theory that variance in total serum IgE levels in patients with asthma is determined by mutations in multiple genes, each of which has a relatively small effect on the phenotype.

Five cases of the lymphangioma of the mediastinum in adult

Mediastinal lymphangioma is rare disease. Above all cavernous type of mediastinal lymphangioma is very rare. We report 5 cases of mediastinal lymphangioma including cavernous type. CT was performed in all and revealed that they were smoothly marginated and cystic. All were surgically resected and specimens were classified pathologically into cystic type (3 cases), cavernous type (1 case) and mixed type of the two (1 case). MRI was performed in the cavernous type and suggested that the mass was lymphangioma because of pathognomonic lesion. Despite preoperative diagnosis of mediastinal lymphangioma is difficult, MRI is able to useful examination. In the follow-ups there has been no recurrence in our series.

A common FCER1B gene promoter polymorphism influences total serum IgE levels in a Japanese population

Genetic factors are important in defining total serum IgE levels. Linkage analyses have localized a gene or genes that influence atopic phenotype at chromosome 11q13. Variants of the FCER1B gene have been identified, which are associated with an increased risk of developing atopy and bronchial asthma. Given uncertain functional consequences and low frequencies of these coding variants of FCER1B, we screened for new mutations using 24 subjects with atopic asthma. A common -109C/T polymorphism at the promoter region of FCER1B was identified, although no variant was found in the entire coding region. We genotyped this promoter polymorphism in 226 healthy control subjects and 226 asthmatic subjects using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. Allele frequencies were 0.697 for -109T and 0.303 for -109C in 226 healthy control subjects. No significant difference in the distribution of -109C/T polymorphism was found between asthmatic subjects and healthy control subjects. A homozygosity for the -109T allele, however, was associated with increased total serum IgE levels in 226 subjects with asthma (p = 0.0015). The strongest evidence for an association between total serum IgE levels and -109C/T polymorphism (p = 0.0004) was obtained when age at onset of asthma was incorporated into the analysis. Our findings may represent genetic heterogeneity and complex interactions between genetic and environmental components involved in the regulation of total IgE levels, providing evidence that the -109C/T polymorphism of the FCER1B promoter region is one of the genetic factors identified thus far, which affects total serum IgE levels in a Japanese population.

The role of the C-C chemokine receptor 2 gene polymorphism V64I (CCR2-64I) in sarcoidosis in a Japanese population

A number of chemokines are produced by alveolar cells in the course of inflammatory reactions of sarcoidosis. C-C chemokine receptor 2 (CCR2) is a prominent receptor for the monocyte chemoattractant protein (MCP) group of C-C chemokines. A transition causing a valine to isoleucine substitution in transmembrane domain I of the CCR2 gene (CCR2-64I) that has a protective effect against the progression of human immunodeficiency virus-1 (HIV-1) disease has been described. To elucidate the role of this CCR2 polymorphism in sarcoidosis, we investigated the distribution of the CCR2-64I in 100 subjects with sarcoidosis (40.2 +/- 18.6 yr [mean +/- SD], 37:63 [male:female]) and 122 healthy control subjects (44.4 +/- 14.1 yr, 75:47). The distribution of the CCR2-64I allele was significantly different between subjects with sarcoidosis and healthy control subjects (p < 0.001). The presence of the CCR2-64I allele conferred a lower risk for the development of sarcoidosis (adjusted odds ratio = 0.369, 95% CI = 0.203 to 0.673). Our study suggests that this polymorphism may play a role in the pathogenesis of sarcoidosis, and further studies are needed to define the role of CCR2-64I.

[Three adults with mild varicella and bronchial mucosal lesions]

We encountered three adults with varicella and bronchial mucosal lesions. Respiratory symptoms were minimal in all three. Chest X-ray films showed bilateral, diffuse, small, nodular shadows. Small, elevated lesions with white plaque's were seen on the bronchial mucosa bronchoscopically. Transbronchial lung biopsy, bronchial mucosal biopsy, and bronchoalveolar lavage were also done. The lung-biopsy specimen showed infiltration of lymphocytes into the interstitial space: VZV antigen was found by immunohistochemical staining of the lesion in one case. Analysis of bronchoalveolar lavage fluid revealed abnormally low CD 4/8 ratios in three cases. These findings suggest a high incidence of respiratory complications, especially bronchial lesions, despite the lack of respiratory symptoms, in adults with varicella.