C1q and C3 in bronchoalveolar lavage fluid from patients with summer-type hypersensitivity pneumonitis

Immune complexes have been thought to participate in the pathogenesis of hypersensitivity pneumonitis, but the role of complement components is not defined. In our study of nine patients with summer-type hypersensitivity pneumonitis (summer-type HP), C1q in bronchoalveolar lavage fluid (BALF) was strikingly increased (mean 3.7, range 0.4 to 10 micrograms/ml). The value of C1q/albumin was several to 20 times greater in BALF than in serum samples from individual patients. In contrast, BALF samples from control subjects (ten patients with sarcoidosis and nine normal subjects) contained an undetectable amount (less than 0.02 micrograms/ml) of C1q. C3 in BALF also increased in the summer-type HP patients. Furthermore, C1q (as well as specific IgG and IgA antibody activities to Trichosporon cutaneum antigen) in BALF correlated with clinical symptoms and diffusing capacity (DCO), while the BAL lymphocytosis or the change of OKT4/OKT8 ratio did not. These findings are indicative of local secretion or concentration mechanism of C1q and C3, supporting the involvement of immune complexes in the respiratory tract of the patients.     

A case of summer-type hypersensitivity pneumonitis with bronchoalveolar lavage performed 4 years before onset

A 51-year-old man with chief complaints of cough, fever, and dyspnea was admitted to our hospital. Based on a home provocation test, transbronchial lung biopsy specimens, and a serum antibody, we diagnosed summer-type hypersensitivity pneumonitis. In 1983 when the patient was 46 years old, thymectomy was performed for thymoma. Prior to surgery, bronchoalveolar lavage (BAL) was performed. Total cell count and neutrophils had already increased in BALF. Furthermore, the increase in BALF cell neutrophil count was also seen at the time of admission and after the home provocation test. Because an increase of neutrophils in BALF cells was seen not only at onset but before onset, further studies are required to clarify the role of neutrophils and the factors that increase them in hypersensitivity pneumonitis.     

Lung injuries and serial bronchoalveolar lavage findings in patients with summer-type hypersensitivity pneumonitis

To evaluate acute lung injuries and their persistence in patients with summer-type hypersensitivity pneumonitis, repeated bronchoalveolar lavage (BAL) and pulmonary function tests were performed. BAL was performed on 36 occasions in 17 patients with hypersensitivity pneumonitis. Nineteen BAL procedures in 16 cases were done during the active phase within the three hospital day and BAL was repeated in 8 cases during inactive phase. Anti-Trichosporon cutaneum antibodies were detected in all of 15 cases examined using the Ouchterlony method and indirect immunofluorescent methods. The number of total BAL cells, lymphocyte and neutrophils were increased in the active phase, and OKT4/OKT8 was quite low (0.39). As the disease became inactive, the number of total BAL cells, lymphocytes and neutrophils decreased. On the other hand OKT4/OKT8 increased quickly. Significantly negative correlations were recognized between the number of BAL lymphocytes and %VC, and lymphocytes and %DLCO4. More improvements in BAL findings, %VC and %DLCO one year after acute episodes were seen in cases that moved house than cases that did not move, and these often relapsed. We concluded that complete clearing of the patient's house or moving out, if necessary, were needed to avoid relapse and persistent lung injuries.     

A familial case of summer-type hypersensitivity pneumonitis possibly associated with bird breeder's lung diagnosed by bronchoalveolar lavage fluid]

Case 1: A 32-year-old woman had cough and exertional dyspnea in August 2002, and chest computed tomographic scan revealed diffuse centrilobular nodules. Bronchoalveolar lavage fluid (BALF) showed a high proportion of lymphocytes with a decreased CD 4/CD 8 ratio. Transbronchial lung biopsy (TBLB) specimens showed alveolitis. Summer-type hypersensitivity pneumonitis was diagnosed on the basis of positive findings of anti-Trichosporon antibodies in the serum. Case 2: A 64-year-old man, the father of Case 1, also had cough and exertional dyspnea in August 2003. He had been in close contact with pigeons. Chest computed tomographic scan revealed bilateral map-like ground-glass opacities predominantly in the upper lobes. BALF showed a high proportion of lymphocytes with a decreased CD 4/CD 8 ratio. TBLB specimens showed alveolitis, granuloma and Masson body in the air spaces. Specific IgG and IgA antibodies against Trichosporon asahii, IgA antibodies against Trichosporon mucoides, and IgA antibodies against pigeon dropping extracts were found only in the BALF but not in the serum. Although a positive finding of returning-home provocation test was definitive in diagnosing summer-type hypersensitivity pneumonitis, he was also suspected of having bird fancier's lung.     

Proteome analysis of bronchoalveolar lavage fluid in chronic hypersensitivity pneumonitis

BackgroundHypersensitivity pneumonitis (HP) is an immune-mediated lung disease induced by inhalation of numerous antigens. Pathologically, chronic HP tends to show usual interstitial pneumonia (UIP) and fibrotic nonspecific interstitial pneumonia (fNSIP) patterns. Patients with UIP pattern present insidious onset and a risk for acute exacerbations.MethodsTo evaluate the proteomic differences of bronchoalveolar lavage fluid (BALF) between UIP and fNSIP patterns, BALF from seven patients with UIP pattern and four patients with fNSIP pattern was examined using two-dimensional gel electrophoresis and mass spectrometry.ResultsBy individually comparing each BALF sample, we found that the protein levels of surfactant protein A (SP-A), immunoglobulin heavy chain α, α-2 heat shock glycoprotein, haptoglobin β, and immunoglobulin J chain were significantly higher in the patients with UIP pattern than those in the patients with fNSIP pattern. In contrast, the protein levels of glutathione s-transferase, vitamin D-binding protein, and β-actin were significantly higher in the patients with fNSIP pattern than those in the patients with UIP pattern. To confirm the results of SP-A in the BALF proteome, we performed enzyme-linked immunosorbent assay in a larger group. The concentrations of SP-A in BALF from the patients with UIP pattern were significantly higher than those from the patients with fNSIP pattern (2.331 ± 1.656 μg/ml vs. 1.319 ± 1.916 μg/ml, p = 0.034).ConclusionsWe identified several proteins that may play roles in the development of pathological differences between UIP and fNSIP patterns of chronic HP.     

Specific bronchoalveolar lavage IgA antibody in patients with summer-type hypersensitivity pneumonitis induced by Trichosporon cutaneum

Patients with summer-type hypersensitivity pneumonitis induced by Trichosporon cutaneum were studied with respect to specific IgG, IgA, and secretory IgA (S-IgA) antibody activities to T. cutaneum in serum and bronchoalveolar lavage fluid (BALF). A strain of T. cutaneum was isolated from 1 patient's pillow. All serum samples from the family members (2 patients and 2 asymptomatic) contained IgG antibody activity to T. cutaneum, and the titers showed no difference between the patients and asymptomatic family members. On the other hand, IgA and S-IgA antibody activities in serum and BALF were markedly increased only in the patients, and the titers were well correlated with the clinical course. The BALF/serum ratio of specific antibody activity was markedly elevated in IgA and S-IgA antibody activities in striking contrast to that in IgG, suggesting an immune reaction of the respiratory tract. The bronchial challenge test with T. cutaneum antigen was positive in the patients, but not in an asymptomatic family member. These results indicate that measurement of IgA and S-IgA antibody activities in serum and BALF is useful for diagnosis and evaluation of disease activity in summer-type hypersensitivity pneumonitis.     

Apoptosis of bronchoalveolar lavage lymphocytes in hypersensitivity pneumonitis.

The aim of this study was to look at the apoptosis of alveolar lymphocytes in hypersensitivity pneumonitis (HP). HP patients and normal unexposed controls were studied. The percentage of apoptotic lymphocytes was significantly lower in HP patients than in normal patients (37.4 +/- 3.4 versus 56.5 +/- 5.5% for Annexin V and propidium iodine detection methods and 0.4 +/- 0.1 versus 1.0 +/- 0.2% for dUTP nick end-labelling technique (TUNEL)). The proportion of bronchoalveolar lavage (BAL) lymphocytes positive for Fas antigen was significantly higher in HP patients than in normal subjects (71.7 +/- 5.4 versus 50.4 +/- 9.0%). However, no significant difference was found in the proportion of BAL lymphocytes positive for Fas ligand (FasL) between the two groups. Soluble Fas (sFas) levels in the BAL fluid of the patients and normals were 80.5 +/- 8.5 pg x mL(-1) and 23.2 +/- 3.1 pg x mL(-1), respectively. A positive correlation was found between the percentage of BAL lymphocytes and the levels of sFas for the total subjects but not within the separate study groups. The intracellular quantity of the inducible anti-apoptotic gene Bcl-xL product was significantly higher in the pulmonary lymphocytes of HP patients than in lymphocytes of the control, while no difference was found for constitutive anti-apoptotic protein (Bcl-2). In conclusion, the apoptosis of pulmonary lymphocytes is lower in hypersensitivity pneumonitis than in normal subjects. This could be explained, at least in part, by an increase of soluble Fas, the anti-apoptic gene, and Bcl-xL.     

Rheumatoid factor activity in serum and bronchoalveolar lavage fluid from patients with acute hypersensitivity pneumonitis.

The presence of rheumatoid factor was detected in both serum and bronchoalveolar lavage fluid (BALF) from patients with acute pigeon breeder's disease. IgM rheumatoid factor was positive in 14 of 20 serum samples and 6 of 20 BALF samples by ELISA. In contrast, negative results were found in 20 healthy subjects with a history of avian antigen exposure, as well as in the serum and BALF from 10 normal subjects. The simultaneous presence of rheumatoid factor in serum and BALF occurred in five patients, and four of them revealed high levels of rheumatoid factor in BALF in comparison with serum determinations. These abnormalities may play an important role during the acute inflammatory reaction in hypersensitivity pneumonitis.     

Increased soluble CD14 in bronchoalveolar lavage fluid of stable lung transplant recipients.

Macrophages, neutrophils and infection have been implicated in the genesis of the bronchiolitis obliterans syndrome (BOS) post lung transplantation. sCD14 is a soluble form of a shed-cell surface protein. It is capable of promoting cytokine-induced inflammation and it's presence in clinically stable lung transplant recipients (LTR) might be important as an early marker of BOS. Bronchalveolar lavage (BAL) and blood samples were taken from 26 stable LTR, at or near their best forced expiratory volume in one second who were free from infection. sCD14 levels were measured via enzyme-linked immunosorbent assay. Cell counts were performed on unfiltered BAL. LTR neutrophil count, BAL sCD14 and serum sCD14 levels were higher than controls (median 3.8% versus 1.3%, p<0.05; 11.5 ng x mL(-1) versus 6 ng x mL(-1), p<0.001; 6.2 microg x mL(-1) versus 2.4 microg x mL(-1), p<0.05, respectively). BAL albumin and sCD14 correlated (regression coefficient: 0.77, p<0.001). In this hypothesis-generating, cross-sectional study, the authors have described for the first time soluble CD14 levels in the bronchoalveolar lavage and serum of stable lung transplant recipients, and show that these are elevated compared to controls. This is a practicable candidate marker system, which can be tested for a predictive role in bronchiolitis obliterans syndrome following lung transplantation. The origin of this cellular protein and its temporal relationship to the development of the bronchiolitis obliterans syndrome remains to be elucidated in more definitive longitudinal studies, which should include other measurements potentially relevant to the innate immune system, such as bronchoalveolar lavage endotoxin levels.     

Bronchoalveolar lavage fluid findings in children with hypersensitivity pneumonitis.

Bronchoalveolar lavage (BAL) has been shown to be useful in the diagnosis of hypersensitivity pneumonitis (HP) in adults, the typical constellation being lymphocytosis with a decrease in the CD4/CD8 ratio. Only limited data exist for the diagnostic value of BAL cytology in paediatric patients with this disorder. Children aged 6-15 yrs (n=9) with acute HP were studied. BAL was performed before initiation of anti-inflammatory treatment via a flexible bronchoscope in the middle lobe with 3 mL x kg body weight(-1) normal saline warmed to body temperature; BAL cytology and lymphocyte surface markers were compared with age-matched controls. The percentage of lymphocytes was significantly increased in all patients with HP. No significant differences were observed in the CD4/CD8 ratio between children without lung disease and those with HP. Increased expression of human leukocyte antigen-DR was found in seven of eight children with HP, whereas natural killer cells were elevated in five of eight children. Every patient had at least one of these two alterations in BAL fluid in addition to lymphocytosis. It was concluded that while lymphocytosis is generally present in children with hypersensitivity pneumonitis, the CD4/CD8 ratio is not increased in these patients. Assessing natural killer cells and human leukocyte antigen-DR expression appears to be a helpful adjunct in the diagnosis of paediatric patients with this disorder.     

Induced sputum and bronchoalveolar lavage from patients with hypersensitivity pneumonitis

BACKGROUND AND AIM: Hypersensitivity pneumonitis (HP) is an immunologically induced inflammation of the lung parenchyma, though bronchial airways may be also involved. The aim of this study was to compare the cellular profiles of induced sputum (IS) in patients with newly diagnosed HP to that of healthy subjects, and to examine the relationship between inflammatory cells from IS and BAL. METHODS: Nine HP patients and 9 healthy volunteers were studied. IS was obtained by inhalation of hypertonic saline solution in all subjects. Bronchoscopy was performed on a different occasion in all patients and in five controls. RESULTS: IS was well tolerated and preferred to BAL by all subjects. Both IS and BAL from HP patients showed a significant increase in total cells (P < 0.02 and P < 0.001) and in lymphocytes (P < 0.02 and P < 0.001) and a significant decrease in macrophages (P < 0.05 and P < 0.001), when compared with normal subjects. In HP patients, total cells number in IS was higher than that in BAL (P < 0.02). Moreover, the percentage of lymphocytes was significantly lower in IS than in BAL (P < 0.001). No significant relationship was found between total cells or inflammatory cells from IS and the corresponding ones from BAL and wide limits of agreement were found between lymphocytes from IS and BAL. CONCLUSIONS: This study demonstrated that both BAL and IS from newly diagnosed HP patients contained significantly more total cells and lymphocytes, when compared to healthy subjects. Moreover, differential cell counts in HP patients showed that IS and BAL reflected different compartments of inflammation. Thus, IS could represent a complementary, but not alternative tool to bronchoscopy both in research and in the clinical monitoring of HP patients.     

Increase in soluble CD138 in bronchoalveolar lavage fluid of multicentric Castleman's disease

Multicentric Castleman's disease (MCD) is a rare and often incurable lymphoproliferative disorder. It is typically a systemic illness, but occasionally manifests primarily as a pulmonary parenchymal disease with massive infiltration of CD138 (syndecan-1)-positive plasma cells. This is the first report to demonstrate a marked elevation of soluble CD138, despite the absence of plasma cells, in BAL fluid in an MCD patient with pulmonary involvement. This finding suggests that the quantitative measurement of soluble CD138 in BAL fluid may reflect plasma cell infiltration and disease activity in the lungs of patients with MCD.     

Specific bronchoalveolar lavage IgG antibody in hypersensitivity pneumonitis from diphenylmethane diisocyanate

We evaluated a patient for dyspnea, fever, malaise, and hypoxemia that developed after exposure to diphenylmethane diisocyanate (MDI). Specific inhalation challenge with MDI caused fever, leukocytosis, a restrictive decline in forced vital capacity, and a decrease in Pao2 several hours after challenge. Bronchoalveolar lavage 24 h after challenge showed lymphocytic alveolitis. Specific IgG antibodies to MDI human serum albumin (MDI-HSA) conjugate were demonstrated in serum and bronchial lavage fluid using the enzyme-linked immunoabsorbent (ELISA) technique. These findings suggest participation of both humoral and cellular immunity in the pathogenesis of hypersensitivity pneumonitis from isocyanate exposure.     

A case of radiation pneumonitis with eosinophilia in bronchoalveolar lavage fluid]

A 78-year-old man was admitted to our hospital for irradiation therapy of non-resectable primary lung squamous cell carcinoma of the right middle lobe (T3N2M0). The Linac irradiation through opposing 2 gates (2Gy per day and 60Gy in total) was performed to the affected area including the metastatic right hilar and mediastinal lymphadenopathy. One week after completing the irradiation therapy, fever developed with infiltrates in the area from the right middle lobe to the right lower lobe, which did not necessarily coincide with the irradiated area. Antibiotic therapies were not effective. Both the serum LDH level and eosinophil count in the peripheral blood increased. Bronchoalveolar lavage was performed at the right B8, and differential cell counts of the lavage fluid were: macrophages, 17%; lymphocytes, 60%; neutrophils, 5%; and eosinophils, 18%. No significant organisms were obtained by culture of the lavage fluid. The %VC and DLCO/VA became lower than before the irradiation therapy. Thus, the patient was given a diagnosis of radiation pneumonitis. Treatment with 40mg/day oral prednisolone was commenced with a stepwise dose-reduction (5mg every two weeks) until reaching the maintenance dose of 15mg/day. The serum LDH level and blood eosinophil count recovered promptly to the normal range. The pulmonary infiltrates and the lung functions substantially improved. There have been few reports of radiation pneumonitis in which eosinophil counts increased in peripheral blood and bronchoalveolar lavage fluid after irradiation therapy. In the present case report, the possible mechanisms for the irradiation-induced eosinophilia were also reviewed.     

Provocation test coupled with bronchoalveolar lavage in diagnosis of propranolol-induced hypersensitivity pneumonitis

A 59-yr-old man was given over a 30-month period a cumulative dose of 36 g of propranolol for treatment of angina pectoris. He then presented with respiratory disease, having all the clinical, radiologic, and functional characteristics of interstitial pneumonitis. No other cause of pneumonitis was found. Bronchoalveolar lavage (BAL) showed a lymphocytic alveolitis with lymphocyte subset inverted ratio. After a 9-wk period of drug withdrawal, clinical and radiologic improvement was observed along with resolution of BAL abnormalities. Propranolol therapy was resumed for 6 wk and induced the recurrence of BAL abnormalities. Propranolol treatment was finally stopped, and 15 wk later, clinical symptoms abated, chest roentgenogram and pulmonary function tests were improved, and BAL data returned to normal. This observation seems to exemplify the possible diagnostic value of coupling provocation test with BAL cell data in some hypersensitivity pneumonitis induced by drugs. In addition, these data support the role of a cell-mediated immunologic mechanism in the pathogenesis of propranolol-induced pneumonitis.