Anti-Inflammatory Actions of Expectorants in a Rat Carrageenan-Induced Footpad Edema Model

S-Carboxymethyl-L-cysteine (SCMS) exhibits sputum-regulating and anti-inflammatory actions. Previous studies reported the anti-inflammatory effects of SCMS on chronic inflammatory diseases, but no study has examined these effects on acute inflammatory diseases. In this study, we investigated the anti-inflammatory effects of SCMS in a rat carrageenan-induced footpad edema model, which is routinely used as an acute inflammation model. Expectorants were administered to rats with footpad edema induced by subcutaneously administering 1%λ-carrageenan to the footpad of the left posterior limb, and the dose dependency of the anti-inflammatory effects was evaluated. As a result, even when the dose of SCMS was increased to 400 mg/kg, there were no inhibitory effects on edema. Furthermore, we examined the inhibitory effects of other expectorants (ambroxol hydrochloride, N-acetyl-L-cysteine, L-cysteine ethylester hydrochloride, and L-cysteine methylester hydrochloride), which were reported to exhibit anti-inflammatory effects on chronic inflammation, on edema. However, none of these expectorants inhibited edema.

Sensitization of GSH synthesis by curcumin curtails acrolein-induced alveolar epithelial apoptosis via Keap1 cysteine conjugation: A randomized controlled trial and experimental animal model of pneumonitis

INTRODUCTION

Epidemiological studies have reported an association between exposures to ambient air pollution and respiratory diseases, including chronic obstructive pulmonary disease (COPD). Pneumonitis is a critical driving factor of COPD and exposure to air pollutants (e.g., acrolein) is associated with increased incidence of pneumonitis.

OBJECTIVES

Currently available anti-inflammatory therapies provide little benefit against respiratory diseases. To this end, we investigated the preventive role of curcumin against air pollutant-associated pneumonitis and its underlying mechanism.

METHODS

A total of 40 subjects was recruited from Chengdu, China which is among the top three cities in terms of respiratory mortality related to air pollution. The participants were randomly provided either placebo or curcumin supplements for 2 weeks and blood samples were collected at the baseline and at the end of the intervention to monitor systemic markers. In our follow up mechanistic study, C57BL/6 mice (n = 40) were randomly allocated into 4 groups: Control group (saline + no acrolein), Curcumin only group (curcumin + no acrolein), Acrolein only group (saline + acrolein), and Acrolein + Curcumin group (curcumin + acrolein). Curcumin was orally administered at 100 mg/kg body weight once a day for 10 days, and then the mice were subjected to nasal instillation of acrolein (5 mg/kg body weight). Twelve hours after single acrolein exposure, all mice were euthanized.

RESULTS

Curcumin supplementation, with no noticeable adverse responses, reduced circulating pro-inflammatory cytokines in association with clinical pneumonitis as positive predictive while improving those of anti-inflammatory cytokines. In the pre-clinical study, curcumin reduced pneumonitis manifestations by suppression of intrinsic and extrinsic apoptotic signaling, which is attributed to enhanced redox sensing of Nrf2 and thus sensitized synthesis and restoration of GSH, at least in part, through curcumin-Keap1 conjugation.

CONCLUSIONS

Our study collectively suggests that curcumin could provide an effective preventive measure against air pollutant-enhanced pneumonitis and thus COPD.

Bucillamine-induced Pneumonitis in a Patient with Rheumatoid Arthritis-associated Interstitial Pneumonia: A Case Report and Review of the Literature

An 81-year-old woman with rheumatoid arthritis (RA) who had been treated with bucillamine presented with dyspnea. Computed tomography of the chest showed ground-glass opacities and consolidations in both lungs and honeycombing in both basal lung areas. An elevation of the serum Krebs von den Lungen-6 level and hypoxemia were seen. Lymphocytosis with a decreased CD4/CD8 ratio was seen in the bronchoalveolar lavage fluid. A transbronchial lung biopsy specimen showed organizing pneumonia. Based on a diagnosis of bucillamine-induced pneumonitis (BIP) with RA-associated pre-existing interstitial pneumonia, she was successfully treated with the cessation of bucillamine and systemic corticosteroid therapy. The risk factors and prognosis of BIP are discussed.

Effects of Cysteine-stabilized Peptide Fraction of Morinda lucida Leaf on Selected Kidney Function Indices in Mice

OBJECTIVE

This study evaluated the effect of cysteine-stabilized peptide fraction (CSPF) of Morinda lucida leaf on selected kidney function indices in mice.

METHODS

Sixty mice were assigned into six groups. Group A served as the control while groups B, C, D, E and F received 31.25, 61.5, 125, 250, and 500 mg/kg body weight of CSPF respectively for 7 or 28 days.

RESULTS

Administration of CSPF for 7 and 28 days caused no significant (p>0.05) alteration in kidney-body weight ratio, plasma concentrations of the selected electrolytes, urea and creatinine at all doses compared to controls. However, plasma uric acid concentration was significantly increased (p<0.05) after administration of CSPF for 7 days at doses of 125 and 500 mg/kg body weight while it was significantly reduced (p<0.05) after administration for 28 days at doses higher than 31.25 mg/Kg body weight compared to controls. The activities of Ca²⁺, Mg²⁺-ATPase and Na⁺, K⁺-ATPases in the kidney and the histology of the kidney remained unaltered (p>0.05) throughout the experimental period compared to controls.

CONCLUSION

CSPF may adversely affect uric acid metabolism after prolonged administration.

Hyperplasia of Lymphoid Follicles and Lymphangiectasia in the Parietal Pleura in Bucillamine-induced Yellow Nail Syndrome

Yellow nail syndrome (YNS) pleurisy is often difficult to control, and pathological examinations have rarely been reported. We herein report a case of bucillamine-induced YNS in which histopathology of the parietal pleura revealed hyperplasia of the lymphoid follicles and lymphangiectasia. Even after the discontinuation of bucillamine, the pleurisy and lymphedema showed no change. Based on the histopathological findings showing similarity to rheumatoid pleurisy, we administered corticosteroid treatments, and both the pleurisy and lymphedema improved. The findings in the present case suggest that, in bucillamine-induced YNS, pleurisy may be related to inflammation caused by rheumatoid arthritis in addition to abnormalities in lymphatic vessels.

[DMARDs (Focusing on iguratimod)]

Conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) other than methotrexate (MTX: anchor csDMARDs) are effective for single use, reinforcement of MTX, biologics and induction and maintenance of biologics-free condition. Newly developed iguratimod (IGU) does not suppress immunological reaction, therefore, it is useful for single use or combination with other csDMARDs in patients with complications. IGU can be used as a first csDMARDs before MTX use during the screening for MTX. IGU might be effective for reinforcement of MTX, biologics and induction and maintenance of biologics-free condition just like other csDMARDs. IGU can be used in wide variety of situation of the treatment of rheumatoid arthritis and it is desired that after the all-case surveillance condition for approval, IGU become a standard csDMARDs all over the world which was made in Japan.

Bucillamine-Induced Toxic Epidermal Necrolysis and Fixed Drug Eruption

We report two cases of bucillamine-induced bullous reactions with keratinocyte necrosis. The first patient, a 27-year-old woman, developed toxic epidermal necrolysis (TEN) over her whole body after taking bucillamine 300 mg/day for seven days. The second patient, a 63-year-old woman, developed several bullous erythemas on the mucous membranes and legs after taking bucillamine for more than two years. The fixed drug eruptions were diagnosed based on a provocation test in addition to clinical and histopathologic findings. These cases highlight the importance of considering fixed drug eruption as well as TEN in the differential diagnosis of bucillamine-induced bullous drug eruption.

[DMARDs (disease-modifying antirheumatic drugs)]

Disease-modifying antirheumatic drugs (DMARDs) have largely contributed to recent paradigm shift of rheumatoid arthritis (RA) treatment strategy. DMARDs can be indicated for all RA patients and early use of DMARDs after diagnosis of RA is recommended. Individual DMARDs have common characteristics. Understanding these characteristics is very important in treating RA. As for safety, the pattern of adverse reactions (ADRs) associated with DMARDs has been generally understood. It is necessary to select DMARDs and follow up patients with recognition of the pattern of ADRs. Regular monitoring is also essential to ensure the safety of DMARDs. This chapter deals with some major DMARDs in Japan, including methotrexate, which is indispensable in current RA treatment; salazosulfapyridine and bucillamine; tacrolimus, which is recently increasing in use; and iguratimod, which became available in 2012.

Healthy and adverse effects of plant-derived functional metabolites: the need of revealing their content and bioactivity in a complex food matrix

In recent years, both food quality and its effect on human health have become a fundamental issue all over the world. As a consequence of this new and increased awareness, American, European, and Asian policymakers have strongly encouraged the research programs on food quality and safety thematic. Attempts to improve human health and to satisfy people's desire for healthcare without intake of pharmaceuticals, has led the food industry to focus attention on functional or nutraceutical food. For a long time, compounds with nutraceutical activity have been produced chemically, but the new demands for a sustainable life have gradually led the food industry to move towards natural compounds, mainly those derived from plants. Many phytochemicals are known to promote good health, but, sometimes, undesirable effects are also reported. Furthermore, several products present on the market show few benefits and sometimes even the reverse - unhealthy effects; the evidence of efficacy is often unconvincing and epidemiological studies are necessary to prove the truth of their claims. Therefore, there is a need for reliable analytical control systems to measure the bioactivity, content, and quality of these additives in the complex food matrix. This review describes the most widespread nutraceutics and an analytical control of the same using recently developed biosensors which are promising candidates for routine control of functional foods.

Single-center, retrospective analysis of efficacy and safety of tacrolimus as a second-line DMARD in combination therapy and the risk factors contributing to adverse events in 115 patients with rheumatoid arthritis

To retrospectively evaluate the efficacy and safety of combination therapy with tacrolimus (TAC) and other disease-modifying antirheumatic drugs (DMARDs). One hundred fifteen rheumatoid arthritis (RA) patients treated with tacrolimus were enrolled in this retrospective analysis. We collected clinical information, including patient background, treatment efficacy (evaluated using the DAS score), and adverse events observed. Multiple logistic regression analysis was conducted to analyze factors contributing to clinical response and adverse effects. The disease activity score of 28 joints (DAS28) improved significantly at 24 weeks, and continuation rate at 1 year was 57.9%. There was no difference in continuation rate between different DMARD combinations, and not only methotrexate (MTX) but also bucillamine (BUC) and salazosulfapyridine (SSZ) were effective combination partners with TAC. No serious adverse events were observed, and no different inefficacy or safety was observed between non-elderly (<65 years old) and elderly (≥65 years old) RA patients. By conducting multiple logistic regression analysis, combination therapy with MTX and TAC, the number of baseline DMARDs (specifically, ≥3), and old age were identified as risk factors for adverse events. Our findings indicate that TAC is a valuable DMARD for second-line combination therapy in RA.

Efficacy and safety of intravenous stronger neo-minophagen C and S-adenosyl-L-methionine in treatment of pregnant woman with chronic hepatitis B: a pilot study

BACKGROUND

There have been no studies evaluating the efficacy and potential risks of stronger neo-minophagen C (SNMC) in pregnant women with chronic hepatitis B CHB.

MATERIAL/METHODS

A total of 36 pregnant women with CHB, but without severe complications, were randomized to intravenously receive SNMC or S-adenosyl-L-methionine (SAM) daily for 4 weeks or until birth. Normalization of serum alanine transaminase (ALT) and aspartate transaminase (AST) levels and changes in ALT and AST levels from baseline were determined. All neonates were regularly examined for up to 1 year.

RESULTS

Treatment with SNMC and SAM resulted in normalization of ALT levels at 4 weeks in 64.3% and 21.4% of patients, respectively (OR=6.60, 95% CI: 1.23-35.44, P=0.0540). SNMC and SAM significantly decreased ALT (from 558.28+/-390.24 to 47.07+/-24.94 IU/L, P<0.0001 and from 525.61+/-483.87 to 117.43+/-85.44 IU/L, P=0.0041, respectively) and AST (from 419.72+/-409.49 to 38.14+/-18.87 IU/L, P=0.0016, and from 510.78+/-621.58 to 79.93+/-63.25 IU/L, P=0.0152, respectively) at 4 weeks relative to baseline values. Hypokalemia was observed in 4 SNMC-treated patients and in 2 SAM-treated patients and hypernatremia in 3 SNMC-treated and in 3 SAM-treated patients. Hypertension was observed in 1 SNMC-treated patient. There was no significant difference in the volume of amniotic fluid or meconium between SNMC-treated and SAM-treated groups. All the neonates were physically normal at birth and at the 1-year follow-up examination.

CONCLUSIONS

Both SNMC and SAM improve liver function, with SNMC appearing more effective, in pregnant women with chronic hepatitis B without impact on fetal development.

Proteomics of S-(1, 2-dichlorovinyl)-L-cysteine-induced acute renal failure and autoprotection in mice

Previous studies (Vaidya VS, Shankar K, Lock EA, Bucci TJ, Mehendale HM. Toxicol Sci 74: 215-227, 2003; Korrapati MC, Lock EA, Mehendale HM. Am J Physiol Renal Physiol 289: F175-F185, 2005; Korrapati MC, Chilakapati J, Lock EA, Latendresse JR, Warbritton A, Mehendale HM. Am J Physiol Renal Physiol 291: F439-F455, 2006) demonstrated that renal repair stimulated by a low dose of S-(1,2-dichlorovinyl)l-cysteine (DCVC; 15 mg/kg i.p.) 72 h before administration of a normally lethal dose (75 mg/kg i.p.) protects mice from acute renal failure (ARF) and death (autoprotection). The present study identified the proteins indicative of DCVC-induced ARF and autoprotection in male Swiss Webster mice. Renal dysfunction and injury were assessed by plasma creatinine and histopathology, respectively. Whole-kidney homogenates were run on two-dimensional gel electrophoresis gels, and the expression of 18 common proteins was maximally changed (> or =10-fold) in all the treatment groups and they were conclusively identified by liquid chromatography tandem mass spectrometry. These proteins were mildly downregulated after low dose alone and in autoprotected mice in contrast to severe downregulation with high dose alone. Glucose-regulated protein 75 and proteasome alpha-subunit type 1 were further investigated by immunohistochemistry for their localization in the kidneys of all the groups. These proteins were substantially higher in the proximal convoluted tubular epithelial cells in the low-dose and autoprotected groups compared with high-dose alone group. Proteins involved in energetics were downregulated in all the three groups of mice, leading to a compromise in cellular energy. However, energy is recovered completely in low-dose and autoprotected mice. This study provides the first report on proteomics of DCVC-induced ARF and autoprotection in mice and reflects the application of proteomics in mechanistic studies as well as biomarker development in a variety of toxicological paradigms.

Endogenous thiols enhance thallium toxicity

Either L-methionine (L-met) or L-cysteine (L-cys), given alone and in combination with Prussian blue (PB) was characterized as treatment against acute thallium (Tl) toxicity in rats. Animals were intoxicated with 32 mg/kg Tl acetate corresponding to rat LD(50). Antidotal treatments were administered during 4 days, as follows: (1) vehicle, (2) L-met 100 mg/kg i.p. twice a day, (3) L-cys 100 mg/kg i.p. twice a day, (4) PB 50 mg/kg oral, twice a day, (5) L-met + PB and (6) L-cys + PB. Mortality was as follows: control 50%; L-met 80%; L-cys 80%; PB 20%; L-met + PB 90% and L-cys + PB 100%. In a different experiment, using 16 mg/kg of Tl, tissue levels of this metal were analyzed. PB treatment statistically diminished Tl content in body organs and brain regions (P<0.01). Whereas, separate treatments of L-met and L-cys failed to decrease Tl content in organs and brain regions; while its administration in combination with PB (L-met + PB and L-cys + PB groups) lowered Tl levels in body organs in the same extent as PB group. Results indicate that L-met and L-cys administered alone or in combination with PB should not be considered suitable treatments against acute Tl toxic effects because this strategy failed to prevent mortality and Tl accumulation in brain.

Hemophagocytic syndrome associated with rheumatoid arthritis

We report a patient with rheumatoid arthritis (RA) who showed bicytopenia with hyperferritinemia and hepatic dysfunction ascribable to hemophagocytic syndrome (HPS) 2 weeks after commencement of bucillamine. Pathology of the bone marrow showing infiltration of macrophages confirmed the diagnosis of HPS. On the basis of renal dysfunction with an increase in fibrin degradation products, disseminated intravascular coagulation was considered to be concurrent with HPS. Oral prednisolone and cyclosporine A were started right after cessation of bucillamine, and yielded complete normalization of hepatic and renal function and hematology. As there was neither disease activity of RA nor associated infection throughout the clinical course, bucillamine was suspected of being the cause of HPS in our patient. HPS is a very rare complication in RA, but should be actively considered when abnormalities in laboratory data, especially pancytopenia and hepatic dysfunction, quickly worsen.

A case of bucillamine-induced interstitial pneumonia with positive lymphocyte stimulation test for bucillamine using bronchoalveolar lavage lymphocytes

A 64-year-old woman with rheumatoid arthritis and treated with bucillamine presented with a productive cough. No obvious infiltration was detected in chest radiography, but CT revealed patchy ground glass opacities in bilateral lung fields. Her serum KL-6 level was elevated and transbronchial lung biopsy showed interstitial pneumonia. Drug lymphocyte stimulation test (DLST) for bucillamine was negative for blood lymphocytes, but positive for bronchoalveolar lavage (BAL) lymphocytes. The pneumonitis improved after the cessation of bucillamine. We therefore made a diagnosis of bucillamine-induced interstitial pneumonia. DLST with BAL lymphocytes is thus suggested to be useful for such diagnoses.

Radiographic Appearance of Bronchiolitis Obliterans Organizing Pneumonia (BOOP) Developing During Bucillamine Treatment for Rheumatoid Arthritis

Bucillamine, a disease-modifying antirheumatic drug, can have adverse effects, including lung injury. Development of interstitial pneumonia during treatment for patients with rheumatoid arthritis (RA) can pose a difficult differential diagnosis between a direct manifestation of RA and a drug effect. Our review of previous reports suggested bucillamine-induced interstitial pneumonia in the patient described here, visualized by chest radiography and computed tomography based on patchy ground-glass opacities in a peribronchial or peripheral distribution, suggesting the appearance of bronchiolitis obliterans organizing pneumonia (BOOP). As is typical for BOOP, steroid responsiveness may have contributed to recovery.

Bucillamine-induced pemphigus vulgaris in a patient with rheumatoid arthritis and polymyositis overlap syndrome

Bucillamine is a disease modifying anti-rheumatic drug, structurally similar to D-penicillamine. Although D-penicillamine-induced pemphigus has been not infrequently demonstrated, pemphigus associated with bucillamine was rarely reported. We describe a patient complicating pemphigus vulgaris after bucillamine treatment in rheumatoid arthritis (RA) and polymyositis (PM) overlap syndrome. PM and RA overlap syndrome was diagnosed three years ago and bucillamine was administrated for 20 months. Skin lesions including erythematous flaccid blisters on her chest, axillae, and back were occurred and were compatible with pemphigus vulgaris by typical pathology. Withdrawal from bucillamine and prednisolone treatment made rapid improvement of pemphigus lesions.

Outcome and treatment of bucillamine-induced nephropathy

BACKGROUND

Bucillamine (BCL), a treatment for rheumatoid arthritis, occasionally causes proteinuria. Renal specimens are reported to show segmental granular deposition of immunoglobulin G, associated with membranous nephropathy. Long-term course and optimal treatment have remained unknown, and were investigated here.

METHODS

We examined clinical records of 400 patients treated with BCL for rheumatoid arthritis, at our hospital from 1998 to 2003, finding 17 with proteinuria and biopsy-proven BCL-induced nephropathy.

RESULTS

In all 17 patients, proteinuria resolved without loss of renal function between 3 and 85 months after discontinuing BCL (14.1 +/- 3.4). The only factor influencing time to remission was pathologic stage of membranous nephropathy (stage I vs. stage II or III: 11.5 +/- 4.8 vs. 21.6 +/- 3.3 months; p = 0.02). Maximal proteinuria, total amount of BCL, BCL exposure time, and use of prednisolone or other immunosuppressant agents did not significantly influence time until remission.

CONCLUSION

The most important therapeutic step in treating BCL-induced nephropathy is to discontinue BCL. Prednisolone or other immunosuppressant agents might not be effective.

A case of interstitial pneumonia caused by bucillamine: a study using serological markers

The patient was a 61-year-old man diagnosed with rheumatoid arthritis (RA) in 2001. He initially received treatment at a nearby clinic, but his condition could not be satisfactorily controlled. He subsequently consulted our hospital during the same year. Although his symptoms improved in response to treatment at our hospital, slight fever, cough, and then high fever and dyspnea subsequently developed. A diagnosis of interstitial pneumonia was made on the basis of findings of diagnostic imaging. The time course of changes in serological markers, including surfactant protein A (SP-A), surfactant protein D (SP-D), and KL-6, as well as markers of inflammatory reaction and lactate dehydrogenase was examined to determine the clinical significance of serological markers in the management of interstitial pneumonia.

The Examination of the Escape Phenomenon of the Disease Modifying Antirheumatic Drugs

Although disease-modifying antirheumatic drugs (DMARDs) are used in the treatment of rheumatoid arthritis (RA), the selection of agents in the case of relapse (escape phenomenon) lacks clear-cut standards. Therefore we investigated the rate and conditions of escape as well as the agents used after escapes had occurred. Outpatients of the Matsubara Mayflower Hospital with a history of DMARD administration during the 4 years prior to May 2003 were studied. Those receiving salazosulfapyridine (SASP) had a high escape rate and those receiving methotrexate (MTX) and bucillamine (BC) had a low rate. The continuous duration of administration was long for MTX and BC, but short for sodium aurothiomalate (GST). BC and Actarit (AR) gradually elevated C-reactive protein (CRP) levels and the erythrocyte sedimentation rate (ESR). In patients receiving SASP and MTX, a high level of CRP and high ESR was seen 2 months prior to the occurrence of escape and remained unchanged after escape. With respect to the agents used after escape, SASP and BC were substituted with other DMARDs. A combination with other DMARDs was usually administered to patients who had been receiving MTX. Taken together, the present results clarified the characteristics of DMARD escape and will contribute to the appropriate pharmacotherapy for RA.

The ability of disease modifying antirheumatic drugs to induce and maintain improvement in patients with rheumatoid arthritis. epidemiology of DMARDs treatment in Japan

OBJECTIVE

The effectiveness of the disease-modifying antirheumatic drugs (DMARDs) methotrexate (MTX), bucillamine (BUC), salazosulphapyridine (SASP) and gold sodium thiomalate (GST) over two courses of treatment with a follow-up period of at least 12 months was evaluated in 425 patients with rheumatoid arthritis.

METHODS

Clinical efficacy was evaluated on the basis of the numbers of painful and swollen joints, morning stiffness, grip strength, erythrocyte sedimentation rate, C-reactive protein and rheumatoid factor levels before and after treatment. Results were evaluated on the basis of the survival rate (Kaplan-Meier method) and the incidence and types of adverse drug reactions (ADR) following single and combined therapies.

RESULTS

In the first course of treatment, the survival rates for MTX, GST, BUC and SASP were 52.3%, 40.4%, 33.0% and 24.8%, respectively. The rates of development of ADR were 22.9%, 23.5%, 26.3% and 30.0% for BUC, SASP, GST and MTX, respectively. In the second course, the survival rates for MTX, BUC and SASP were 36.6%, 14.1% and 10%, respectively.

CONCLUSION

DMARDs used in the first course of treatment improved the clinical parameters until the 6th month after initiation of treatment. Combination treatments showed some effectiveness, but because of the high incidence of ADR the survival rate was low. DMARDs used in the second course of treatment were not efficacious and there was no improvement in the survival rate compared to the first course of treatment.

[Bucillamine-induced dermatomyositis-like clinical features in a patient with rheumatoid arthritis]

A 78 year-old woman was admitted to our hospital because of subacutely progressive dysarthria, dysphagia, proximally dominant muscle weakness and erythema in the neck and back. She was diagnosed as having rheumatoid arthritis (RA) at the age of 60 and treated with bucillamine (BUC) for 8 years. Laboratory tests included a rheumatoid factor of 1,472U/ml. Serum creatine kinase level was slightly elevated. The activated T cells in the peripheral blood were markedly increased. Needle EMG demonstrated myogenic changes. The magnetic resonance image of the left upper arm showed diffuse muscle atrophy and inflammatory changes in the triceps muscle. The muscle biopsy revealed perivascular inflammatory cell infiltraton and type II fiber atrophy. A biopsy from the skin showed mild perivascular inflammatory cell infiltraton. According to the results of these findings, she was thought to have dermatomyositis due to BUC. After withdrawal of BUC followed by the administration of prednisolone 1mg/kg, her symptoms improved and activated T cells in the peripheral blood were decreased. In Japan, BUC is widely accepted as an effective drug in the treatment of RA, even though it is known to induce some autoimmune diseases. However, the mechanism of the development of autoimmune disease is unclear. We considered that the long-term use of bucillamine could trigger an autoimmune response such as an increase in activated T cells and the development of dermatomyositis-like clinical features in our patient. In conclusion, when RA patients treated with BUC show a clinical picture compatible with dermatomyositis, its causative relationship has to be considered.

[Drug induced nephrotic syndrome]

This review summarizes drug induced nephrotic syndrome. Major drugs which induce drug related nephrotoxicity are antibiotics, NSAID, radiocontrast media, anticancer drug and antirheumatic drug. Drug induced nephropathy can show various forms of renal diseases. The nephropathy consists of acute tubular necrosis, acute tubulointerstitial nephritis, pre-renal type renal failure, obstructive renal failure, chronic tubulointerstitial nephritis and glomerular damage. Major drugs which induce nephrotic syndrome and glomerular damage are gold, penicillamine, bucillamine and NSAID. In the nephrotic syndrome due to these drugs, the major type of renal disease is the membranous glomerulonephritis and the nephropathy resolves completely when the drug is withdrawn; renal function does not deteriorate, and corticosteroids are unnecessary.

Clinical course of bucillamine-induced nephropathy in patients with rheumatoid arthritis

BACKGROUND

Bucillamine, a disease-modifying antirheumatic drug widely prescribed in Japan, is reported to be a cause of proteinuria. However, to date, the clinical course of the nephropathy associated with the use of bucillamine has not been described in detail.

METHODS

We analyzed renal biopsy findings from 10 patients with rheumatoid arthritis and concomitant bucillamine-induced nephropathy. Each patient was followed up until proteinuria had resolved.

RESULTS

Proteinuria appeared 2-11 months after the initiation of the treatment with bucillamine. Nine patients, who stopped bucillamine treatment immediately (within 3 months) after the onset of proteinuria, were diagnosed as having stage I membranous nephropathy. Only one patient, who used bucillamine for 9.5 months after the onset of proteinuria, was diagnosed as having stage II membranous nephropathy. In all patients with stage I membranous nephropathy, the proteinuria disappeared within 7 months after they stopped bucillamine treatment. On the other hand, in the patient with stage II membranous nephropathy, the proteinuria persisted for 14 months after the use of bucillamine was stopped. In all the patients, the proteinuria resolved completely without deterioration of renal function. None of the patients has experienced recurrence of proteinuria.

CONCLUSIONS

In patients with proteinuria induced by treatment with bucillamine, membranous nephropathy is the most common disorder. Immediate withdrawal of bucillamine results in prompt and complete resolution of proteinuria without deterioration of renal function.Bucillamine, a disease-modifying antirheumatic drug widely prescribed in Japan, is reported to be a cause of proteinuria. However, to date, the clinical course of the nephropathy associated with the use of bucillamine has not been described in detail.

Serofendic acid prevents acute glutamate neurotoxicity in cultured cortical neurons

We have previously reported that a novel neuroprotective substance named serofendic acid was purified and isolated from ether extract of fetal calf serum. In the present study, we investigated the effect of serofendic acid on acute neurotoxicity induced by L-glutamate (Glu) using primary cultures of rat cortical neurons. Exposure of cortical cultures to Glu for 1 h caused a marked decrease in cell viability, as determined by trypan blue exclusion. This acute Glu neurotoxicity was prevented by N-methyl-D-aspartate (NMDA) receptor antagonists, extracellular Ca(2+) removal, nitric oxide (NO) synthase inhibitor and NO scavenger. Serofendic acid prevented acute Glu neurotoxicity in a concentration-dependent manner. Acute neurotoxicity was induced by ionomycin, a Ca(2+) ionophore, and S-nitroso-L-cysteine, an NO donor. Serofendic acid also prevented both ionomycin- and S-nitroso-L-cysteine-induced neurotoxicity. Moreover, the protective effect of serofendic acid on acute Glu neurotoxicity was not affected by cycloheximide, a protein synthesis inhibitor, and actinomycin D, an RNA synthesis inhibitor. These results indicate that serofendic acid protects cultured cortical neurons from acute Glu neurotoxicity by reducing the cytotoxic action of NO and de novo protein synthesis is not required for this neuroprotection.

Gigantomastia induced by bucillamine

Drug-induced mammary hyperplasias have been reported as rare complications of D-penicillamine and Neothetazone. The authors report the first case of bucillamine-induced giant mammary hyperplasia. Bucillamine is used as an antirheumatic drug that is structurally analogous to D-penicillamine. A 25-year-old woman with rheumatoid arthritis for the past 5 years started to develop gradual enlargement of her breasts 15 months before presentation. She had been on a combined treatment of steroid and lobenzarit disodium for the first 3 years, and then continued with a combined treatment of steroid and bucillamine for the following years until she was found to have pulmonary tuberculosis, at which time the steroid was suspended 10 months before she visited the authors' clinic. An almost total breast reduction was performed; 5 kg of right breast tissue and 7 kg of left breast tissue were excised. Retrospectively, bucillamine was believed to be the cause of the giant hypertrophy because of its structural similarity to D-penicillamine, which was the subject of an abundance of reports of mammary hyperplasia.

Role of isoprenylcysteine carboxyl methyltransferase in tumor necrosis factor-alpha stimulation of expression of vascular cell adhesion molecule-1 in endothelial cells

We have previously shown that cytokine stimulation of the expression of vascular cell adhesion molecule-1 (VCAM-1), but not that of intercellular adhesion molecule-1 (ICAM-1), is redox sensitive in endothelial cells. Here, we investigated the role of isoprenylcysteine carboxyl methyltransferase (ICMTase), which methylates isoprenylated CAAX (where C indicates cysteine; A, aliphatic amino acids; and X, almost any other amino acid) proteins, including Rac1, a component of superoxide-generating NAD(P)H oxidase, in the expression of VCAM-1. Pretreatment of endothelial cells with N-acetyl-S-farnesyl-L-cysteine (AFC) or N-acetyl-S-geranylgeranyl-L-cysteine (AGGC), specific inhibitors of ICMTase, inhibited the tumor necrosis factor-alpha (TNF-alpha) stimulation of mRNA expression of VCAM-1 but not that of ICAM-1. Endothelial cells expressed constitutively active ICMTase, as suggested by the presence of methylated Rac1 and the methylation of AFC by the cells. TNF-alpha stimulation of the cells significantly increased the methylation of AFC and Rac1 in endothelial cells. That ICMTase was a component of the redox-sensitive signaling pathway was also suggested by the AFC inhibition of the generation of reactive oxygen species by TNF-alpha. Interestingly, the dominant-negative isoform of Rac1 was not selective but inhibited the TNF-alpha stimulation of the mRNA expression of VCAM-1 and ICAM-1. Thus, ICMTase is a critical component of the redox-sensitive VCAM-1-selective signaling pathway, and it appears to activate a discrete inflammatory signaling pathway, at least in part, through the methylation of Rac1.

[A case of pulmonary infiltration with eosinophilia (PIE) syndrome induced by bucillamine treatment of rheumatoid arthritis]

Bucillamine is used mainly in treating rheumatoid arthritis (RA). We report a case of bucillamine-induced pulmonary infiltration with eosinophilia (PIE) syndrome in a 51-year-old woman. When RA was diagnosed, she was treated with bucillamine from December 2000. In April 2001, she was admitted to our hospital because of fever and skin eruptions. Chest radiography and CT revealed both diffuse ground-glass opacity and fine nodular shadows. Laboratory data showed a normal white cell count with eosinophilia. Bronchoalveolar lavage (BAL) studies showed that total cell counts and the proportion of eosinophils were increased, and that the CD4/CD8 ratio of the T-cell subsets was decreased to 0.93. The patch test to bucillamine was positive. After bucillamine was withdrawn, the fever and the abnormal chest shadows improved. We concluded from the patient's clinical course, laboratory data and BAL findings that this was a case of bucillamine-induced PIE syndrome. Since most cases of bucillamine-induced interstitial pneumonitis are lymphocytic alveolitis, we consider that PIE syndrome in such a case is a very rare condition. We concluded that bucillamine should be added to the list of drugs capable of producing PIE syndrome.

Bucillamine induces membranous glomerulonephritis

A variety of renal histopathologic lesions, such as amyloidosis, mesangial proliferative glomerulonephritis, and membranous glomerulonephritis (MGN), are associated with rheumatoid arthritis (RA). Bucillamine (BCL), a disease-modifying antirheumatic drug, has a chemical structure and side-effect profile similar to that of d-penicillamine, which can induce MGN in RA. There are a few reports of MGN occurring in association with BCL treatment. However, lacking detailed analyses of immunoglobulin deposition in glomerular lesions, these studies did not elucidate the pathogenesis of BCL-induced MGN. We evaluated seven biopsy specimens from six patients with RA who had undergone BCL treatment with a mean BCL dose of 72.5 g before the appearance of proteinuria. Light microscopic evaluation showed mild to moderate mesangial proliferation. Two biopsy specimens showed spikes along glomerular capillary walls. Granular deposition of immunoglobulin G (IgG) along glomerular capillary walls was seen in all cases, and five specimens showed deposition of IgG2 and/or IgG3 components, in addition to IgG4. Furthermore, subepithelial dense deposits were distributed segmentally in four biopsy specimens on electron microscopy. IgG4, reported to be the predominant IgG subclass deposited, is distributed diffusely in idiopathic MGN. Thus, there were obvious differences between BCL-induced and idiopathic MGN in regard to both IgG subclasses deposited and deposition pattern within the glomerulus. Because IgG3 has the strongest affinity for C1q, these findings suggest that BCL-induced MGN activates the classical pathway more efficiently than idiopathic MGN and that the pathogenesis is different between these two diseases.

[A case of rheumatoid arthritis complicated with a pneumonitis during concomitant treatment with methotrexate and bucillamine]

A 70-year-old female was diagnosed as having rheumatoid arthritis (RA) in 1971, which was then treated with steroid and nonsteroidal anti-inflammatory drugs. In 1999, after total replacement of her knee joint, 4 mg of methotrexate (MTX) per week was administered. Two months after the MTX administration, 200 mg of bucillamine per day was administered. On May 10, 2001, the patient was rushed to the hospital due to fever and difficulty in breathing. Chest X-ray and computed tomography (CT) revealed shadows of ground-glass-like opacity occurring sporadically in many places in the upper lung field bilaterally and interstitial shadows mainly on the lateral side of the lower lung field bilaterally. Instead of MTX and bucillamine, which were withheld, an MTX antagonist was administered and oxygen-supported therapy was performed; consequently, the patient recovered without the need to increase the amount of steroid. The percentage of lymphocytes in the broncholaveolar lavage fluid increased to 72%, and the CD4/CD8 ratio to 3.13. The level of serum KL-6 increased while that of serum SP-D returned to the normal level at different time. Following MTX and bucillamine administration, shadows of ground-glass-like opacity occurred sporadically in many places in the upper lung field bilaterally, which is not usually observed. It is suggested that such an unusual pulmonary disorder occurred due to concomitant use of drugs or other factors.

Cutaneous drug reaction case reports: from the world literature

Skin disorders are the most common adverse reactions attributed to drugs. Any skin disorder can be imitated, induced or aggravated by drugs. To help you keep up-to-date with the very latest skin reactions occurring with both new and established drugs, this section of the journal brings you information selected from the adverse drug reaction alerting service Reactions Weekly. The following case reports are selected from the very latest to be published in the world dermatology literature. Any claim of a first report has been verified by a search of AdisBase (a proprietary database of Adis International, Auckland, New Zealand) and Medline. Each case report is assessed for seriousness using the FDA MedWatch definition of serious (patient outcome is: death; life-threatening; hospitalization; disability; congenital anomaly; or requires intervention to prevent permanent impairment or damage).

A case of BOOP developed during bucillamine treatment for rheumatoid

We describe a patient with rheumatoid arthritis(RA) who developed bronchiolitis obliterans organizing pneumonia(BOOP) during the treatment of bucillamine. A 51 year-old man was admitted to the hospital for an abnormal shadow on his chest radiograph. He had been diagnosed as having RA 3 years previously and had been receiving 200 mg of bucillamine for 21 months. Two months prior to admission, he presented with a cough and his chest X-ray showed opacities in both lower lungs. He was treated with antibiotics for 2 months after the development of cough and lesions on the chest X-ray, but the symptoms and lung lesions became more aggravated. On admission, an HRCT revealed airspace consolidations in the subpleural space of both basal lungs and a CT-guided fine needle aspiration biopsy showed Masson's body filling air space, interstitial infiltration of acute and chronic inflammatory cells and type II cell hyperplasia, consistent with BOOP. Bucillamine was stopped and 50 mg of prednisolone was administered. His symptoms and infiltrations on the chest X-ray resolved. We suggest that bucillamine should be considered as a drug possibly associated with BOOP.

Subcorneal pustular dermatosis-type IgA pemphigus induced by thiol drugs

We report a case of subcorneal pustular dermatosis (SPD)-type IgA pemphigus arising in a 49 year-old woman with rheumatoid arthritis who had been treated with chrysotherapy. Scaly erythemic plaques containing vesicles and pustules occurred on her chest and abdomen during the course of anti-rheumatic treatments using prednisolone at 11 mg/day and thiol compounds (bucillamine and gold sodium thiomalate). Histological investigations revealed subcorneal pustules containing many neutrophils and a few acantholytic cells, and intercellular IgA deposits at the upper epidermis of the eruptions without any other immunoglobulins and complement component C3. Circulating IgA antibodies directed against intercellular spaces of the epidermis were found by prolonged incubation of normal skin specimens in medium containing 20% patient's serum in an explant culture, although standard indirect immunofluorescence for IgA antibodies was negative. The eruptions were treated successfully with prednisolone, 30 mg/day, dapsone, 50 mg/day, and discontinuance of the thiol compound. In addition to the coexistent rheumatoid arthritis, both thiol compounds might have been responsible for the development of the eruptions.

[A case of drug-induced interstitial pneumonitis in rheumatoid arthritis treated with bucillamine]

We report a case of bucillamine-induced interstitial pneumonitis in a 57-year-old woman. Rheumatoid arthritis was diagnosed in May 1999, and she was treated with bucillamine from June 1999, with a favorable outcome. After complaining of cough, fever, and dyspnea in October, she was admitted to this hospital. Blood gas analysis showed severe hypoxemia. The chest CT revealed both bilateral diffuse ground-glass opacity along the bronchovascular bundles, and thickening of the interlobular septa. We suspected bucillamine-induced interstitial pneumonitis from the findings of the CT scan, BALF and TBLB, and also from the improvement of PaO2 after the withdrawal of bucillamine. We treated the patient with prednisolone, and a favorable response was noted. A lymphocyte stimulation test using bucillamine was positive. A video-assisted thoracic surgery lung biopsy showed findings compatible with acute interstitial pneumonia without the association of hyaline membrane formation. A focal fibrosis was also observed. We believe that this is the only reported case of pathologically proven bucillamine-induced interstitial pneumonitis, in which a surgical lung biopsy was performed.

Effects of various arterial infusion solutions on red blood cells in the newborn

AIM

To examine in vitro the effects of brief contact with various infusion solutions on red blood cells from newborn infants, as occurs in the "waste" syringe during routine blood sampling from umbilical artery catheters. The mixture of blood and solution in the "waste" syringe is usually reinfused into the baby. Reinfused red blood cells may be damaged by the infusion solution. It is hypothesised that an isotonic amino acid solution would cause no red blood cell agglutination and no more haemolysis than many commonly used solutions.

METHODS

Blood was obtained from the placentas of 15 normal term babies. Haemolysis was estimated by measuring plasma (free) haemoglobin after mock blood sampling. Agglutination was measured semiquantitatively by direct observation.

RESULTS

A 0.25% normal saline solution caused 5.4% haemolysis, significantly more than all the other fluids tested. There was less haemolysis with 0. 25% normal saline when there was complete mixing of blood and solution within the "waste" syringe. Normal saline and isotonic sodium acetate solutions caused < 0.1% haemolysis, significantly less than all the other fluids tested. The isotonic amino acid solution caused 0.8% haemolysis, which is similar to that caused by the remaining solutions tested. Agglutination was seen with isotonic dextrose and with the two isotonic amino acid solutions containing cysteine.

CONCLUSIONS

Isotonic amino acid solution (without added cysteine) caused no agglutination and the same or less haemolysis than many commonly used solutions and may offer advantages in nutrition and fluid balance.

[A case of rheumatoid arthritis with bucillamine-induced myasthenia gravis treated by immunoadsorption therapy]

We report a case of 48-year old female with rheumatoid arthritis (RA) complicated with myasthenia gravis. In 1988, she was diagnosed of having RA, and several therapeutic drugs were administered, but her disease activity was in poor control. In July 1993, bucillamine (BU) was started at a dose of 100 mg/day, and her arthritis subsided. However, in October 1996, she was admitted with a rapidly progressive ptosis and double vision in the left eye, which became prominent in the evening. Because serum concentration of the antibody to acetylcholine receptors (AchR Ab) was elevated at 12.6 nmol/l, and the ptosis was reversed immediately after a tensilon test, ocular type myasthenia gravis (MG) was diagnosed and it was thought to have been induced by BU. Immunoadsorption therapy was started after discontinuation of this drug, and was continued for 6 months, resulting in improvement of neurological symptoms and decrease in AchR Ab level. MG has not recurred since. Although several cases of D-penicillamine (DP) induced MG are reported, only two cases are reported which were induced by BU, sulfhydryl compound which has a structure similar to DP. Since BU has been widely used as one of the disease modifying anti-rheumatic drugs in Japan, MG induced by this drug should be paid attention as one of the adverse effects.

[Bronchial asthma due to Stronger Neo-Minophagen C]

A 24-year-old woman who visited our hospital because of urticaria had a bronchial asthma attack about 5 min. after receiving Stronger Neo-Minophagen C (SNMC) intravenously. A skin test for SNMC and its components (glycyrrhizin, L-cystein, aminoacetic acid, and sodium sulfite) was positive for SNMC and borderline for sodium sulfite after 15 min. A skin test for mixtures of L-cystein and sodium sulfite was also positive. Inhalation provocation tests for SNMC and mixtures of L-cystein and sodium sulfite were positive after 5 min. An inhalation provocation test for sulpyrin was also positive. The patient's bronchial asthma attack was ascribed to SNMC. Type I allergy to mixtures of L-cystein and sodium sulfite was the suspected cause.