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.     

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.     

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.     

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 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.     

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 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.     

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.     

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.     

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.     

Disopyramide-induced pneumonitis, diagnosed by lymphocyte stimulation test using bronchoalveolar lavage fluid

A 72-year-old man was admitted to our hospital with fever and cough. He had been on disopyramide treatment for nine days to control cardiac arrhythmia. On admission, chest X-ray examination revealed reticulonodular opacities in both lungs, and impending respiratory failure was evident. A differential cell count of the bronchoalveolar lavage fluid (BALF) showed a marked increase of lymphocytes. A lymphocyte stimulation test (LST) for disopyramide using BALF was positive, although the test using peripheral blood was negative. This case suggests that LST using BALF is useful for the diagnosis of drug-induced pneumonitis.     

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.     

A raised level of soluble CD8 in bronchoalveolar lavage fluid in summer-type hypersensitivity pneumonitis in Japan.

We used ELISA to measure soluble CD8 (sCD8) in the bronchoalveolar lavage fluid (BALF) and serum of patients with summer-type hypersensitivity pneumonitis (HP). The sCD8 levels in BALF were significantly higher in the patients with summer-type HP, surpassing those found in sarcoidosis and the other pulmonary diseases studied; however, the sCD8 levels in the serum of patients with summer-type HP did not differ from the levels of the healthy controls. The numbers of CD8+ T cells were increased in the BALF of the patients with summer-type HP, and there was a correlation between the sCD8 levels and the concentrations of CD8+ T cells. Gel filtration and polyacrylamide gel electrophoresis of the fluid revealed that the anti-CD8 monoclonal antibody-reactive components in the BALF of patients with pneumonitis corresponded to a protein with a molecular weight of between 52 and 54 kDa. Soluble CD8-rich fraction purified from the BALF of patients with summer-type HP augmented in vitro lymphocytes' proliferative responses stimulated with Cryptococcus neoformans, one of the causative agents for summer-type HP. Our result suggests that soluble CD8 in the BALF may play an important role in the pathogenesis of summer-type HP.     

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.