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Multifaceted analysis is recommended for the diagnosis of primary ciliary dyskinesia (PCD). A 31-year-old woman had situs inversus, bronchiectasis, family history of PCD, and compound heterozygous mutations in DNAH5. Her cilia were immotile. Defects in the outer dynein arms were revealed by transmission electron microscopy and loss of DNAH5 proteins in the entire length of axonemes using immunofluorescence (IF). A 17-year-old boy had bronchiectasis and heterozygous mutations in DNAH11. His cilia were motile with normal ultrastructure. The loss of DNAH11 proteins at the proximal region of cilia was revealed by IF. IF could be useful to support PCD diagnosis.

Hospital-acquired severe acute respiratory virus coronavirus 2 (SARS-CoV-2) infection is a healthcare challenge. We hypothesized that polymerase chain reaction testing of symptomatic triaged outpatients and all inpatients before hospitalization in Shinjuku, a coronavirus disease 2019 (COVID-19) epicenter in Tokyo, using the Tokyo Women's Medical University (TMWU) model would be feasible and efficient at preventing COVID-19. This retrospective study enrolled 2981 patients from March to May 2020. The prevalence of SARS-CoV-2 infection was 1.81% (95% credible interval [CI]: 0.95–3.47%) in triaged symptomatic outpatients, 0.04% (95% CI: 0.0002–0.2%) in scheduled asymptomatic inpatients, 3.78% (95% CI: 1.82–7.26%) in emergency inpatients, and 2.4% (95% CI: 1.49–3.82%) in symptomatic patients. There were no cases of hospital-acquired SARS-CoV-2 infection. This shows that the TWMU model could prevent hospital-acquired SARS-CoV-2 infection and is feasible and effective in reducing the impact of SARS-CoV-2 infection in the hospitals.

A 33-year-old woman presented with a productive cough from childhood. She had suffered from repeated bacterial pneumonia. Her clinical and imaging findings revealed chronic sinusitis, bronchiectasis and situs inversus. We suspected primary ciliary dyskinesia (PCD) and performed a bronchial mucosal biopsy. The ciliary beat pattern according to high-speed video microscopy was complete loss. Electron microscopic findings of cilia showed defect of outer dynein arm (ODA). A genetic examination detected compound heterozygous mutations of DNAH5 that encode ODA components. There are few reports of genetic mutation analyses in Japanese PCD patients. We herein report a PCD patient with DNAH5 mutations and review the related literature.

Introduction: Eosinophilic pneumonia (EP) is characterized by a marked accumulation of eosinophils in the lungs and blood. Eosinophils and mast cells play an important role in the pathogenesis of EP via release of biomarkers such as tryptase and interleukin (IL)-33. However, the potential role of these biomarkers is not fully understood. Objectives: We aimed to evaluate the differences among the levels of tryptase and IL-33 in bronchoalveolar lavage fluid (BALF) from several types of EP. We evaluated the differences between the levels of these biomarkers in the recurrent and nonrecurrent cases. Method: We prospectively collected the clinical data of patients with EP, diagnosed between 2006 and 2015 in our institution. Bronchoscopy was performed before steroid treatment; BALF was collected. The clinical characteristics of EP patients and the levels of tryptase and IL-33 in BALF were evaluated. Results: We enrolled 15 patients with chronic EP (CEP), 5 with acute EP (AEP), 10 with drug-induced EP, and 6 with angiitis-related EP. Tryptase levels in the CEP group were significantly higher than that in the drug-induced EP group (p = 0.048), while the AEP group had the highest IL-33 levels. Recurrence of EP was noted in 67% of patients with CEP. The levels of tryptase and IL-33 were notably higher in the recurrent cases than that in the nonrecurrent CEP group (p = 0.004, p = 0.04, respectively). Furthermore, there was a positive correlation between the levels of tryptase and IL-33 in the BALF of patients with CEP (ρ = 0.69, p = 0.004). Conclusions: Tryptase and IL-33 in BALF are useful biomarkers for the assessment of EP types. These biomarkers could be used to predict disease recurrence.

Objective Primary ciliary dyskinesia (PCD) is a rare hereditary disease. Most reports of PCD in Japan are case reports, and clinical analysis has not been performed. Differences in the causative genes might affect the clinical features in different ethnic groups. The purpose of this study was to clarify the clinical features of Japanese patients with PCD. Methods We performed a retrospective chart review of PCD patients seen at Mie University Hospital and patients whose blood samples were sent to us for genetic analysis from 2011 to 2020. Data on the following items were collected and analyzed: age at first visit to the hospital, age at diagnosis of PCD, process of referral to our facility, chief complaint, situs status, PrImary CiliARy DyskinesiA Rule (PICADAR) score, nasal nitric oxide concentration, otoscopic findings, rhinoscopic findings, and paranasal computed tomography scan findings. Results Sixty-seven patients (24 male, 43 female) were diagnosed with PCD during the study period. Age at diagnosis ranged from 2 months to 69 years (median, 17 years). Respiratory symptoms (77%) were the most common complaint, followed by nasal (15%) and aural (8%) symptoms. Situs inversus was present in 17 (25%) cases. Only 2 cases had congenital cardiac anomalies. The mean PICADAR score was 7.3 (range, 3-14) points. Approximately 50% of tympanic membranes showed retraction, suggesting otitis media with effusion. The mean Lund-Mackay score was 12.8 (range, 7-17) points, suggesting that the radiographic findings were not always severe. There was no significant difference in the total Lund-Mackay score between patients with and without situs inversus (12.7 vs. 12.6, respectively). Conclusion Situs inversus was present in 25% of Japanese PCD patients, which is much lower than observed in other countries. This is a result of differences in the major disease-causing genes. The general rule that "situs inversus is observed in approximately 50% of PCD patients" cannot be applied, at least, in Japanese PCD patients.

BACKGROUND Asthma control has been shown to improve after clinical use of molecular-targeted biologic drugs. Although most patients have shown favorable responses to biologic drugs, some individuals need to switch to another biologic drug. To date, limited data are available regarding patients who received multiple biologic drugs. OBJECTIVE We aimed to evaluate the characteristics and outcomes of patients treated with multiple biologic drugs. METHODS We reviewed severe asthma patients who received biologic drugs between May 2009 and September 2019. Clinical characteristics of patients and changes in annualized asthma exacerbation rates, asthma control test (ACT), and oral corticosteroid (OCS) dose, before and after the use of the final biologic drug, were evaluated. RESULTS Of the 105 patients who received biologic drugs, 20 patients received multiple biologic drugs. Twelve patients received two biologic drugs, six received three, and two received four. Patients who received multiple biologic drugs tended to have a significantly higher number of allergic or eosinophilic airway comorbidities (allergic rhinitis: p = 0.02, chronic rhinosinusitis with nasal polyps: p < 0.001). Approximately half of the patients changed to different treatments due to uncontrolled comorbidities. Annualized exacerbation rates, ACT, and OCS dose significantly improved after the latest biologic drug use (p = 0.035, p < 0.001, and p = 0.038, respectively). CONCLUSIONS The results of this study indicated that allergic and eosinophilic airway comorbidities should be considered during the selection of biologic drugs. Furthermore, most patients who received multiple biologic drugs achieved disease control after switching to the optimal biologic drug.

Background Obesity-associated asthma is a phenotype of severe asthma. Late-onset, non-eosinophilic and female-dominant phenotype is highly symptomatic and difficult to treat. Leptin, an adipokine, exerts an immunomodulatory effect. IL-33 associated with innate immunity induces type 2 inflammation and is present in adipose tissue. The purpose of this study was to elucidate the pathogenesis of obesity-associated asthma by focusing on the interaction between leptin and IL-33. Methods In leptin-deficient obese (ob/ob) and wild-type mice, IL-33 was instilled intranasally on three consecutive days. In part of the mice, leptin was injected intraperitoneally prior to IL-33 treatment. The mice were challenged with methacholine, and airway hyperresponsiveness (AHR) was assessed by resistance (Rrs) and elastance (Ers) of the respiratory system using the forced oscillation technique. Cell differentiation, IL-5, IL-13, eotaxin, keratinocyte-derived chemokine (KC) in bronchoalveolar lavage fluid (BALF) and histology of the lung were analyzed. For the in vitro study, NCI-H292 cells were stimulated with IL-33 in the presence or absence of leptin. Mucin-5AC (MUC5AC) levels were measured using an enzyme-linked immunosorbent assay. Results Ob/ob mice showed greater Rrs and Ers than wild-type mice. IL-33 with leptin, but not IL-33 alone, enhanced Ers rather than Rrs challenged with methacholine in ob/ob mice, whereas it enhanced Rrs alone in wild-type mice. IL-33-induced eosinophil numbers, cytokine levels in BALF, eosinophilic infiltration around the bronchi, and goblet cell metaplasia were less in ob/ob mice than in wild-type mice. However, leptin pretreatment attenuated these changes in ob/ob mice. MUC5AC levels were increased by co-stimulation with IL-33 and leptin in vitro. Conclusions Ob/ob mice show innate AHR. IL-33 with leptin, but not IL-33 alone, induces airway inflammation and goblet cell metaplasia and enhances AHR involving peripheral airway closure. This is presumably accelerated by mucus in ob/ob mice. These results may explain some aspects of the pathogenesis of obesity-associated asthma.

Introduction: Omalizumab has been widely used in Japan. Although some cases cannot achieve good control, the reason for treatment failure with omalizumab has not been fully elucidated. Therefore, in this study, we aimed to evaluate the characteristics of patients who had failed to achieve disease control by omalizumab treatment in a real world setting. Method: We retrospectively reviewed medical record between March 2009 and May 2016 (only omalizumab available in this period in Japan). We evaluated the patient characteristics including age, sex, treatment duration, complication, smoking status, eosinophil counts, total IgE, BMI, FeNO, and OCS use. Treatment failure was judged by physician’s decision based on the exacerbation rate, ER visit, and symptoms. We also evaluated alternative treatment after discontinuation of omalizumab. Results: Total 65 patients were included in this study. Compared to the omalizumab-effective group, the omalizumab-ineffective group contained significantly higher number of patients who had eosinophilic complication (otitis media and sinusitis) and OCS use. Multivariate analysis showed that eosinophilic otitis media was associated with treatment failure with omalizumab (odds ratio 17.35, 95%CI (1.535-196.3), p=0.021). Most of the omalizumab-ineffective group with eosinophilic complication received mepolizumab or benralizumab as an alternative therapy. Conclusion: Eosinophilic complication may affect treatment failure with omalizumab. Anti-IL-5 or anti-IL-5Rα antibodies rather than anti-IgE antibody, omalizumab, should be considered as an additional therapy for severe asthma patients who have eosinophilic complication.

The efficacy of transbronchial needle aspiration (TBNA) with endobronchial ultrasonography using a guide sheath (EBUS-GS) for cases of peripheral pulmonary lesions (PPLs) has not been well established. The purpose of this study was to evaluate the efficacy of TBNA with EBUS-GS for PPLs.We evaluated 130 patients suspected to have lung cancer who underwent transbronchial brushing (brushing), transbronchial biopsy (TBB), and TBNA with EBUS-GS. The pathological diagnostic yields of TBNA were compared to that of TBB and brushing. The histological diagnosis of TBNA was compared to that of surgical specimens. The results of epidermal growth factor receptor (EGFR) gene mutation in TBNA samples were compared to that in TBB or surgical specimens.The diagnostic yields of this study were 62.9% for brushing, 80.0% for TBB, and 77.1% for TBNA. Histological diagnosis was 84.8% for TBB and/or TBNA and pathological diagnosis was 86.7% for all the procedures. TBB and TBNA had significance higher than brushing (p0.05). TBB and TBNA had a tendency of higher diagnostic yields than brushing if EBUS probe was adjacent to PPLs (p = 0.058). Histological evaluations were obtained from TBNA specimens from 50 of 105 patients (47.6%) and these were identical to those of surgical specimens from 29 of 32 patients (90.6%). The results of EGFR gene mutation in TBNA specimens were identical to the same tissue obtained by surgery or TBB.TBNA with EBUS-GS for PPLs was a useful tool for accurate diagnosis and EGFR gene mutation analysis. This method may improve diagnostic accuracy and be useful for molecular testing. This study was approved by the institutional review board (Date of approval: May 27, 2013, approval number: 2816) of Tokyo Women's Medical University Hospital.

Background: To improve postoperative outcomes associated with interstitial pneumonia (IP) in patients with lung c ancer, t he m anagement of t he p ostoperative a cute e xacerbation of I P (PAEIP) was investigated. Methods: Patients with primary lung cancer were considered to be at risk for PAEIP (possible PAEIP) based on a preoperative evaluation. The early phase of this study was from January 2001 to December 2008, and the late phase was from January 2009 to December 2014. In the early phase, chest computed tomography (CT) was performed for patients for whom PAEIP was suspected based on their symptoms, whereas in the late p hase, chest CT w as r outinely p erformed w ithin a few days p ostoperatively. The n umbers o f possible PAEIP cases, actual PAEIP cases, and deaths within 90 days due to PAEIP were compared between both phases. Results: In the early and late phases, surgery was performed in 712 and 617 patients, 31 and 72 possible PAEIP cases were observed, nine and 12 actual PAEIP cases occurred, and the mean interval from the detection of PAEIP to starting treatment was 7.3±2.3 and 5.0±1.8 days, respectively. Five patients died in the early phase, and one patient died in the late phase. Significantly fewer PAEIP-related deaths were observed in the late phase (p＜0.05). Conclusion: Identifying patients at risk for PAEIP by routine postoperative CT examinations led to the early diagnosis and treatment of PAEIP, resulting in the reduction of PAEIP-related mortality.

Background Primary ciliary dyskinesia (PCD) is a rare genetic disorder caused by functional impairment of cilia throughout the body. The involvement of copy number variation (CNV) in the development of PCD is largely unknown. Methods We examined 93 Japanese patients with clinically suspected PCD from 84 unrelated families. CNV was examined either by exome sequencing of a PCD gene panel or by whole‐exome sequencing (WES). The identified alterations were validated by PCR and Sanger sequencing. Nasal ciliary ultrastructure was examined by electron microscopy. Results Analysis of CNV by the panel or WES revealed a biallelic deletion in the dynein regulatory complex subunit 1 (DRC1) gene in 21 patients, which accounted for 49% of the PCD patients in whom a disease‐causing gene was found. Sanger sequencing of the PCR product revealed a 27,748‐bp biallelic deletion including exons 1–4 of DRC1 with identical breakpoints in all 21 patients. The ciliary ultrastructure of the patients with this CNV showed axonemal disorganization and the loss or gain of central microtubules. Conclusion The deletion of DRC1 is the major cause of PCD in Japan and this alteration can cause various ciliary ultrastructural abnormalities., Analysis of copy number variation revealed a biallelic deletion in the dynein regulatory complex subunit 1 (DRC1) gene in 21 patients, which accounted for 49% of the primary ciliary dyskinesia patients in whom a disease‐causing gene was found. Sanger sequencing of the PCR product revealed a 27,748‐bp biallelic deletion including exons 1–4 of DRC1 with identical breakpoints in all 21 patients. The ciliary ultrastructure of the patients with this copy number variation showed axonemal disorganization and the loss or gain of central microtubules.

Background Sarcoidosis is a systemic granulomatous disease caused by CD4+ cell-dominant inflammation. Meanwhile, diffuse panbronchiolitis is a chronic inflammatory respiratory disease predominantly caused by CD8+ lymphocytes and neutrophils. Herein, we report a rare case of sarcoidosis in which the clinical presentation had become evident as diffuse panbronchiolitis after splenectomy for sarcoidosis. Case presentation A 23-year-old Japanese woman was referred to our hospital due to splenomegaly of unknown etiology. Upon admission, chest computed tomography scan revealed centrilobular and randomly distributed small nodules in both lungs. Bronchoalveolar lavage revealed a high proportion of lymphocytes and a decreased CD4/CD8 ratio. However, the biopsy specimens obtained from both the liver and lungs revealed noncaseating epithelioid granulomas, which confirmed the diagnosis of sarcoidosis. The patient underwent splenectomy due to progressive cytopenia and high risk of splenic rupture. After the surgery, the condition of the patient was consistently good for 3 months. Then, she gradually developed productive cough and dyspnea. Both sinus and chest computed tomography scan revealed chronic paranasal sinusitis and deterioration of centrilobular nodules in both lung fields, respectively. The second bronchoalveolar lavage revealed a high proportion of neutrophils, and the bronchoalveolar lavage fluid tested positive for Hemophilus influenzae. The titer of cold agglutinin was elevated, thereby confirming the diagnosis of diffuse panbronchiolitis. On the basis of the clinical and radiological findings, the condition of the patient improved with low-dose macrolide therapy for 3 months. Conclusions The coexistence of sarcoidosis and diffuse panbronchiolitis has not been previously reported, and the hidden profiles of diffuse panbronchiolitis may have been revealed by splenectomy.

Introduction: Chronic eosinophilic pneumonia (CEP) is easy to relapse, sometimes requiring long-term steroid treatment. Mast cell tryptase is known to be involved in fibrosis and remodeling, but the relevance to eosinophilic pneumonia has not been elucidated. In this study, clinical significance of tryptase in BALF in patients with eosinophilic pneumonia was examined. Method: In the BALF from 16 cases of CEP, 5 cases of acute eosinophilic pneumonia (AEP), 9 cases of drug induced eosinophilic pneumonia (Drug), and 5 cases of angitiis (Angiitis), tryptase concentration was measured by UniCAP method and was compared with clinical characteristics. Results: Nine cases of CEP (56%), 1 case of AEP (20%), and 1 case of Drug (11%) were BALF tryptase-positive. Tryptase levels in CEP were significantly higher than those in the other groups (p Conclusion: Current study showed tryptase levels in recurrent CEP patients were higher than the other groups, associated with high prevalence of asthma. Mast cell tryptase in BALF may be an indicator of chronicity and refractory of CEP.

Background: Pulmonary eosinophilia (PE) occurs due to various causes, such as infections, drugs, autoimmune processes, and obstructive lung diseases. Infiltration of eosinophils is found in the airways, interstitium and alveoli, resulting inflammation and tissue injury. The airway secreted mucins MUC5AC and MUC5B may be associated with the pathogenesis of PE; MUC5AC production can be increased by eosinophils, and MUC5B plays a role in an ameliorating pathway for eosinophilia. However, the composition of the airway secreted mucins in PE has not been evaluated yet. Aims: To determine the concentrations of the airway secreted mucins MUC5AC and MUC5B in patients with pulmonary eosinophilia. Methods: Diagnostic BAL was performed via fiberoptic bronchoscopy according to established guidelines. After the BAL, patients who met criteria for PE (elevated BAL eosinophil count greater than 25%, chronic eosinophilic pneumonia with asthma n=5, drug-induced pneumonia n=2, acute eosinophilic pneumonia n=1) and patients who showed no apparent lung disease (control, n=8) were enrolled to this study. The absolute concentrations of MUC5AC and MUC5B in BAL fluids were measured by ELISA. Results: The mean percentage of eosinophils in BAL fluids in PE was 63±24%. The concentrations of mucins in PE with chronic eosinophilic pneumonia were significantly higher with MUC5AC, and significantly lower with MUC5B, respectively, as compared with controls (p Conclusions: The composition of the airway secreted mucins MUC5AC and MUC5B in PE patients was altered, which may be involved in the pathogenesis of eosinophilic airway inflammation, especially with asthma.

Background We previously reported cryobiopsy (Cryo) with endobronchial ultrasonography-guide sheath (EBUS-GS) for peripheral pulmonary lesions (PPLs) provides significantly larger tissues than transbronchial biopsy (TBB) and provides high quantity and quality DNA for gene analysis by next generation sequencing. However, the tumor cell yields and programmed death ligand 1 (PD-L1) expression between each approach have not been compared. Here, we assessed the tumor cell numbers and PD-L1 expression for Cryo with EBUS-GS for PPLs and TBB in patients with lung cancer. Methods Sixteen patients were enrolled in this prospective study from June to November 2017 at Tokyo Women’s Medical University Hospital. The number of tumor cells from a single biopsy, total number of tumor cells, average number of tumor cells, and 22C3 PD-L1 expression (≥ 50% and ≥ 1%) were compared between Cryo and TBB. Results The numbers of tumor cells from a single biopsy, total numbers of tumor cells, and average numbers of tumor cells obtained by Cryo were significantly larger than those obtained by TBB (Cryo [means ± standard errors of the means]: 1321 ± 303.7, 1981 ± 411.7, and 1406 ± 310.3; TBB: 208.8 ± 38.24, 1044 ± 189.0, and 208.8 ± 37.81; P

Background Omalizumab , an anti-IgE antibody , has been widely used in many countries, including Japan. However, some patients do not respond to omalizumab, and the cause of treatment failure has not been fully elucidated. Objective This study aimed to evaluate the characteristics of adult asthma patients who failed to achieve disease control with omalizumab in a real-world setting. Methods We retrospectively reviewed the medical records of patients in Tokyo Women's Medical University Hospital between March 2009 and May 2016. The patient characteristics and factors for treatment failure with omalizumab were evaluated, as were treatment alternatives after discontinuation of omalizumab. Results In total, 59 patients were included in this study. The omalizumab-ineffective group had a significantly higher number of patients with eosinophilic sinusitis (P = 0.001) and eosinophilic otitis media (P = 0.023) than the omalizumab-effective group. A multivariate analysis revealed that both eosinophilic chronic rhinosinusitis (odds ratio: 23.4; P = 0.011) and eosinophilic otitis media (odds ratio: 6.71; P = 0.039) were associated with treatment failure with omalizumab. Most patients with eosinophilic comorbidities of the ear, nose, and throat (ENT) in the omalizumab-ineffective group received mepolizumab or benralizumab as alternative therapy, following which disease control was achieved. Conclusion Eosinophilic comorbidities of the ENT may affect treatment failure with omalizumab in patients with severe asthma. Anti-interleukin-5 antibody or anti-interleukin-5Rα antibody rather than anti-IgE antibody should be considered as an additional therapy for patients with severe asthma who have eosinophilic comorbidities of the ENT.

Background Increased sputum production is an important feature of COPD, in which a large amount of secretions stagnated in the respiratory lumen may aggravate airflow limitation, impair airway mucociliary transport, and cause recurrent respiratory infection and, hence, acute exacerbations of the diseases. There is evidence that airway mucus hypersecretion is associated with the severity and prognosis of COPD, but the symptoms are generally difficult to treat. Methods In an open, non-controlled study, we examined the effect of the anticholinergic agent tiotropium on airway mucus hypersecretion in 22 COPD patients. After a 4-week run-in period, the patients received 18 μg of tiotropium once daily delivered through the handihaler for 8 weeks, while symptoms and their impact associated with sputum were scored according to cough and sputum assessment questionnaire (CASA-Q). At week 0 and week 8, spirometry was performed before and 30 min after the administration of albuterol . To test the effect of tiotropium on airway mucociliary transport, nasal clearance time was measured. To evaluate airway mucus production, solid composition of the sputum (dry/wet weight ratio) was measured. Results Treatment with tiotropium increased both prebronchodilator FEV1 and postbronchodilator FEV1 . Tiotropium decreased cough symptom scores and provided with favorable influences on sputum-related symptoms, and none of the patients complained of worsening of the symptoms judging from the CASA-Q score. Both solid composition of the sputum and mucin contents decreased and nasal clearance time was shortened from 29.4 ± 5.1 to 20.6 ± 4.1min (p Conclusions Tiotropium decreases symptoms associated with sputum in COPD patients, an effect that may be related to the inhibition of airway mucus hypersecretion and improvement of airway mucociliary clearance .

Background The purpose of this study was to evaluate the diagnostic accuracy of Cryo with endobronchial ultrasonography using a guide sheath (EBUS-GS) for peripheral pulmonary lesions (PPLs) to assess the volume of specimen, determine DNA sequencing analysis, and evaluate the utility of rapid on-site evaluation (ROSE). Methods Out of 30 patients assessed for eligibility, 23 were enrolled in this prospective study. The histological diagnostic yield of Cryo was evaluated and the volume was compared to that of trans-bronchial biopsy (TBB). DNA analysis of Cryo was performed using next generation sequencing (NGS). ROSE was compared with the final diagnosis. Results The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy rate was 85%, 100%, 100%, 50%, 87% for Cryo and 80%, 100%, 100%, 42.9%, 82.6% for TBB, respectively. The mean volume was 0.078 cm3 for Cryo and 0.003 cm3 for TBB (p Conclusions Cryo with EBUS-GS for PPLs is a safe and potentially useful diagnostic strategy. It has a high diagnostic yield, and provides significantly larger specimens than TBB. It also provides high quantity and quality of DNA for NGS and high concordance rate between ROSE and the final diagnosis.

Background Transmembrane protein 16A (TMEM16A) is associated with mucus secretion and ion transport in asthma. Clarithromycin (CAM) is reported to inhibit IL-13-induced goblet cell metaplasia. However, the effect of CAM on TMEM16A function and expression remains unclear. Methods Tracheal epithelial cells from guinea pigs were cultured for ~14 days at an air-liquid interface in medium containing IL-13 (10 ng/ml) in the absence or presence of CAM (20 µg/ml) or a TMEM16A inhibitor, T16Ainh-A01 (10 µg/ml). Electrophysiological studies were performed by Ussing׳s short-circuit technique. The cells were used for immunofluorescence staining with antibodies against TMEM16A, MUC5AC, and α-tubulin. The cells were also examined by transmission electron microscopy. TMEM16A protein levels in the cell lysates were determined by ELISA. For the in vivo study, guinea pigs were treated intratracheally with IL-13 in the absence or presence of CAM or T16Ainh-A01. Results CAM decreased the MUC5AC-positive cells and reduced TMEM16A expression in them and increased the α-tubulin-positive cells. CAM inhibited TMEM16A protein levels in a dose-dependent manner, and decreased UTP-induced Cl ion transport. In cells treated with IL-13 for 24 h, TMEM16A appeared prior to MUC5AC protein expression, and was inhibited by CAM. In the in vivo study, CAM inhibited IL-13-induced goblet cell metaplasia and TMEM16A expression. The inhibitory effects of CAM were similar to those of T16Ainh-A01. Conclusions CAM inhibited IL-13-induced TMEM16A expression, Cl ion transport and goblet cell metaplasia both in vitro and in vivo. CAM may thus improve airway mucociliary differentiation by attenuating TMEM16A expression in IL-13-related asthma.

A 38-year-old woman with sustained right chest pain was referred to our hospital. She showed pleural effusion and peripheral blood eosinophilia. Thoracentesis revealed eosinophilic pleural effusion in which the smear, culture and cytological examinations were all negative. Although she had no notable dietary history, chest CT revealed linear opacities, which suggested the migration tracks of paragonimiasis. The diagnosis was confirmed using enzyme-linked immunosorbent assays, which showed elevated Paragonimus westermani and Paragonimus miyazakii antibody levels. After the initiation of praziquantel therapy, all clinical findings were promptly improved. The detection of a migration track may therefore be useful in the diagnosis of paragonimiasis.

Asthma and COPD overlap (ACO) is an important clinical phenotype, due to the low-health-related quality of life (QOL), rapid decline in lung function, frequent exacerbation, and high economic burden. However, no large-scaled therapeutic trials of ACO have been conducted. At present, ACO is treated according to asthma/COPD guidelines. The goals of ACO treatment are to relieve symptoms and improve QOL and lung functions. Treatment must also prevent disease progression, airway remodeling, exacerbation, complications, and comorbidities. To achieve these goals, ACO needs first to be assessed based on pathophysiological findings. Comprehensive long-term management includes medication, reduction of risk factors, environmental improvement, patient education, rehabilitation, and vaccination. Drug treatment for ACO employs a combination of inhaled corticosteroids (ICSs) and long-acting bronchodilators; long-acting muscarinic antagonists and/or long-acting β2-agonists. The dose of ICS is determined according to ACO severity. Leukotriene receptor antagonists and theophylline are used as add-on drugs. Macrolides and expectorants are recommended for reduction of mucus hypersecretion. Anti-IgE and anti–IL-5 antibodies, oral corticosteroids, and oxygen therapy are additional treatments for the most severe ACO. The therapeutic effects are evaluated using lung function tests, eosinophil counts in sputum and blood, FeNO, and symptom questionnaires. ACO exacerbation is treated by inhalation of short-acting β2-agonist and systemic corticosteroids. The doses of corticosteroids are determined based on the asthma/COPD component of the exacerbation. Administration of antibiotics is recommended if sputum is purulent. Referral to specialists is necessary in cases of inability to control symptoms by medication, uncertain diagnosis with atypical features, or severe complications and comorbidities. Keywords: Inhaled corticosteroids, Long-acting bronchodilators, Long-term management of ACO, Severity of ACO, Treatment of ACO exacerbation

Lymphangioleiomyomatosis (LAM) is characterized by cystic lung disease, abdominal tumor and involvement of the axial lymph nodes. We report a very rare case of LAM with malignant lymphoma. A 51-year-old female had medical history of recurrent pneumothorax and nephrectomy for a left renal angiomyolipoma and was diagnosed with LAM by video-assisted thoracoscopic surgery at the age of 30. She presented with left neck mass. Computed tomography and magnetic response imaging showed multiple enlarged cervical lymph nodes. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal uptake in the mass. We suspected a malignant tumor or extrapulmonary lesion of LAM, and performed surgical biopsy. Pathologically, diffuse large B-cell lymphoma was diagnosed, but LAM was not detected. After she received six cycles of R–CHOP chemotherapy, FDG-PET turned negative and complete metabolic response was achieved. As LAM is reported to be silent for FDG-PET, unusual uptake of FDG is useful for identifying other neoplasms. For this case, FDG-PET was useful for the differential diagnosis and therapeutic evaluation. Keywords: Diffuse large B-cell lymphoma (DLBCL), FDG-PET, Lymphangioleiomyomatosis (LAM)

A 25-year-old Chinese man visited our institution due to fever and left chest pain. A chest CT showed infiltrative shadows with pleural effusion. Despite antibiotics treatment, his symptoms gradually worsened. The contrast CT showed deterioration of infiltrative shadows with thromboembolism in pulmonary arteries, suggesting pulmonary infarction. Thereafter, his HIV test turned out to be positive. His symptoms and radiological findings improved after initiation of an anticoagulant therapy. No known risk factors for thromboembolism were identified except HIV infection. The possibility of pulmonary thrombosis should be noted when the HIV patient with acute chest pain and pneumonia-like infiltrative shadow is seen.

Rationale: Cottin first described CPFE and there is accumulating evidence that respiratory dysfunction is more severe and the prevalence of pulmonary arterial hypertension (PAH) is higher in patients with CPFE than in patients with COPD alone. It has recently been reported that relative pulmonary artery (PA) enlargement, defined as a PA to ascending aorta (A) diameter ratio greater than one (PA:A>1) is associated with severe exacerbations in COPD patients, but there is little information about clinical features of CPFE. Therefore, in the present study, we compared clinical characteristics between patients of CPFE and COPD, including the evaluation of PA/A ratio and the cardiovascular disease. Methods: We conducted a retrospective observational study of patients with COPD (n=41) and CPFE (n=24) in our outpatient clinic. We compared the two groups in terms of age, sex, smoking history, severity, comorbidity, and pulmonary function. We also evaluated a ratio of PA/A in predicting PAH, according to the measurement by CT. Results: There were no differences between the two groups in terms of age, sex, and smoking history. FEV 1 /FVC ratio in the CPFE group was significantly higher than that in the COPD group (72.6% vs. 53.1%, p Conclusions: These results suggest that, in patients with CPFE, coronary artery diseases which require PCI are often comorbid, but influences of this comorbidity in the development of CPFE remain to be elucidated.

A 25‐year‐old Japanese woman suffered from repeated respiratory tract infections. Because of her characteristic medical history and imaging findings, we suspected primary ciliary dyskinesia (PCD) and performed a transbronchial biopsy. The biopsy revealed complex abnormalities of the ciliary structure including cleavage of the B‐subfibers observed by transmission electron microscopy analysis and the complete loss of ciliary motion by video analysis. Genetic examinations to diagnose PCD have progressed in recent years. However, in this case, the well‐known genetic mutations in causal genes of PCD were not detected via whole‐exome sequencing of the blood. Cleavage of the B‐subfibers in patients with PCD has never been reported. This case appears to be the first report of this PCD subtype in humans.

Background Emphysema and chronic obstructive pulmonary disease (COPD) are well known independent risk factors for lung cancer. However, the developmental mechanisms between emphysema/COPD and lung cancer remain unknown. The purpose of this study was to evaluate PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression in squamous cell carcinoma (SCC) associated with emphysema/COPD. Methods A total of 59 patients with squamous cell lung carcinoma (SCC) resected between 2008 and 2012 were retrospectively reviewed. Emphysema was assessed according to the Goddard score. Total severity was divided into none-mild (0–7), moderate (8–15), and severe (≥ 16). Local severity around the existing tumor was divided into no emphysema (0) and presence of emphysema (1–4). COPD severity was based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression were evaluated by immunohistochemistry (IHC). Expression level was classified as tumor cells (TC) 3 (≥ 50%), TC2 (5–49%), TC1 (1–4%), or TC0 (

Cough variant asthma (CVA) is a common cause of chronic persistent cough, in which allergic airway inflammation may play a role. Although current guidelines recommend bronchodilators and anti-inflammatory drugs for the treatment, comparison of the efficacy of these medications has not been investigated. This study was designed to evaluate the effectiveness of pranlukast, a leukotriene receptor antagonist, and salmeterol, a long-acting beta₂-adrenergic agonist, in the treatment of CVA. The study was a randomized, controlled, parallel-group, multicenter trial. After a 4-week run-in period, 49 patients with newly diagnosed CVA were assigned to receive oral pranlukast (225 mg, b.i.d.) or inhaled salmeterol (100 μg, b.i.d.) for 4 weeks. Primary outcome measure was cough symptom and secondary outcome measures were pulmonary function and eosinophilic airway inflammation. Treatment with pranlukast and salmeterol each decreased cough symptom scores, where the changes from baseline values were significantly greater in the pranlukast group than in the salmeterol group. Forced expiratory volume in 1 second and peak expiratory flow (PEF) increased in the two treatment groups with the same magnitudes, but significant decreases in diurnal variation of PEF and eosinophil counts and eosinophil cationic protein contents in the peripheral blood and induced sputum were observed only in the pranlukast group. In view of antitussive and anti-inflammatory actions, the leukotriene receptor antagonist pranlukast seems to be more effective than the long-acting beta₂-adrenergic agonist salmeterol in the treatment of CVA.

Airway occlusion by mucus in chronic obstructive disease (COPD) is associated with a poor prognosis. We hypothesised that tiotropium has the ability to inhibit neutrophil elastase (NE)-induced goblet cell metaplasia in mice and mucin production in vitro. On days 1, 4, and 7, tiotropium or vehicle was administered to C57BL/6 mice by inhalation and they were allowed to intranasally aspirate human NE. Bronchoalveolar lavage fluid (BALF) and lung sections were analysed on days 8, 11 and 14. The effect of late administration of tiotropium on the goblet cell metaplasia by NE aspiration was also assessed. NE-induced MUC5AC production by NCI-H292 cells was measured with ELISA. Repeated NE aspiration induced marked goblet cell metaplasia. The grading of goblet cell metaplasia, neutrophil count and eosinophil count in BALF, keratinocyte-derived chemokine level and leukotriene B(4) level in BALF, and M(3) receptor expression by immunohistochemistry, were lower in the tiotropium group than in the vehicle group. Late administration of tiotropium inhibited the established goblet cell metaplasia. Tiotropium inhibited NE-induced MUC5AC production. Tiotropium inhibited NE-induced goblet cell metaplasia and mucin production, probably mediated by suppression of inflammation and a direct action on epithelial cells. This result suggests that tiotropium may be useful for the treatment of mucus overproduction in COPD.

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with poor prognosis. Leukotrienes play an important role in IPF, and leukotriene (LT)B(4) is one of the key eicosanoids in IPF. In this study, we investigated whether ONO-4057, a LTB(4) receptor (BLTR) antagonist is capable of preventing bleomycin-induced pulmonary fibrosis. On day 1, C57BL/6 male mice were given a single intratracheal injection of bleomycin (2.5 mg x kg(-1)), and ONO-4057 (1.0 mg x kg(-1)) or vehicle alone, administered by intraperitoneal injection on days 1-5 each week for 3 weeks after the bleomycin injection. ONO-4057 reduced the total cell count in bronchoalveolar lavage fluid (BALF) on days 7, 14 and 21 and the Ashcroft score and the lung hydroxyproline content on days 14 and 21. The LTB(4), interleukin (IL)-6, IL-13, transforming growth factor (TGF)-beta levels in BALF and the TGF-beta expression in lung tissue, assessed by immunohistochemistry were decreased on day 7, whereas interferon (IFN)-gamma level in BALF was increased on day 14. The results of this study indicated that the BLTR antagonist inhibited the development of bleomycin-induced pulmonary fibrosis in mice by decreasing inflammation and altering TGF-beta, IL-6, IL-13 and IFN-gamma.

Background: The existence of antineutrophil cytoplasmic antibody (ANCA)-positive pulmonary fibrosis (PF) has recently been recognized. Objectives: The aim of this study was to clarify whether there is any difference in the clinical features between ANCA-positive PF and ANCA-negative PF. Methods: A retrospective study was carried out on 53 patients with idiopathic PF whose myeloperoxidase (MPO)- and proteinase 3 (PR3)-ANCA levels were measured. After dividing the patients into ANCA-positive and ANCA-negative PF, we compared their symptoms, pulmonary function tests, chest CT findings, bronchoalveolar lavage findings, the effects of therapy and survival rates. Results: 17 of the 53 patients with idiopathic PF were MPO-ANCA-positive, 2 were PR3-ANCA-positive and 34 were negative for both ANCA types. Lactate dehydrogenase was lower in ANCA-positive PF than in ANCA-negative PF. However, there was no significant difference in the symptoms, lung function tests, CT findings and bronchoalveolar lavage findings. Corticosteroid therapy tended to be more effective in ANCA-positive PF, but the overall survival rate in ANCA-positive PF was not different from that in ANCA-negative PF. However, the low-titer (Conclusions: Our studies showed little difference in the clinical features between ANCA-positive and ANCA-negative PF. However, it may be important to measure ANCA when idiopathic PF is diagnosed, because a high titer of ANCA suggests a poor prognosis and the association with microscopic polyangiitis.

Background TMEM16A, a Ca-activated Cl channel, regulates various physiological functions such as mucin secretion. However, the role of TMEM16A in hypersecretion in asthma is not fully understood. Objective The aim of this study is to evaluate Cl ion transport via TMEM16A and determine the localization of TMEM16A in a guinea pig asthma model. Methods Guinea pigs were sensitized with OVA ip. on Day 1 and Day 8. On Day 22, we assessed OVA challenge-induced Cl ion transport in the sensitized tracheas ex vivo in an Ussing chamber, compared with the non-sensitized tracheas. We then examined the effect of T16Ainh-A01, a TMEM16A inhibitor, on the increase in Cl ion transport. The tracheal epithelium was immunostained with an anti-TMEM16A antibody. Epithelial cells from guinea pig tracheas were cultured at the air-liquid interface in the presence of IL-13 for in vitro study. We studied the effect of TMEM16A inhibitors on Ca-dependent agonist, UTP-induced increases in Cl ion transport in the cultured cells. The cells were immunostained with an anti-TMEM16A antibody, an anti-MUC5AC antibody, and an anti-α-tubulin antibody. Results OVA challenge induced an increase in Isc within 1 min in the OVA-sensitized tracheas but not in the non-sensitized tracheas, which was inhibited by pretreatment of T16Ainh-A01. Sensitized tracheas showed goblet cell metaplasia with more positive TMEM16A immunostaining, particularly in the apical portion compared with the non-sensitized tracheas. The in vitro UTP-induced increase in Cl ion transport was strongly inhibited by pretreatment with T16Ainh-A01, benzbromarone, and niflumic acid. TMEM16A was positively immunostained at the apical portion and in the MUC5AC-positive area in IL-13-induced goblet cell metaplasia. Conclusions Antigen challenge and Ca-dependent agonist treatment increased Cl ion transport via the overexpression of TMEM16A in goblet cell metaplasia in a guinea pig asthma model. TMEM16A inhibitors may be useful for the treatment of hypersecretion in asthma. This article is protected by copyright. All rights reserved.

Leukotrienes are lipid mediators of inflammation derived from the 5-lipoxygenase pathway of arachidonic acid metabolism, and recent evidence suggests that they play an important role in pulmonary fibrosis. Montelukast is a cysteinyl-leukotriene 1 receptor antagonist that has been found to reduce airway remodeling, including subepithelial fibrosis, in a murine model of asthma, but the therapeutic effect of montelukast on pulmonary fibrosis remains unclear. In this study, we investigated whether montelukast is capable of preventing bleomycin-induced pulmonary fibrosis in mice. On day 1, C57BL/6 mice were given a single intratracheal injection of bleomycin (2.5 mg/kg), and montelukast (1.0 mg/kg) or vehicle alone subcutaneously 2 h later and on days 1-5 of each week for two weeks. The total number of cells in bronchoalveolar lavage fluid (BALF) was reduced in the montelukast group on day 7 and on day 14, and cellular inflammation and fibrosis were attenuated on day 14 as indicated by significant decrease in the Ashcroft score and lung hydroxyproline content. Although cysteinyl-leukotriene level in BALF was not significantly different, transforming growth factor beta (TGFbeta) level in BALF by ELISA and TGFbeta expression in lung tissue by immunohistochemistry was reduced on day 14 in the montelukast group. The results of this study show that montelukast inhibits the inflammatory process and development of bleomycin-induced pulmonary fibrosis in mice and that these effects may be associated with a decrease in TGFbeta expression. They also suggest that montelukast may serve as a new therapy for patients with interstitial pulmonary fibrosis.

Changes in ionic composition of airway surface fluid may modulate airway epithelial functions. We tested the hypothesis that fluctuations of ambient ionic composition could affect airway epithelial Ca(2+) dynamics and Ca(2+)-dependent cellular functions, including NO release and PGE(2) production in vitro. The responses of intracellular Ca(2+) concentration ([Ca(2+)](i)) to changes in extracellular Cl(-) and Na(+ )concentrations ([Cl(-)](e), [Na(+)](e)) in the human bronchial epithelial cell line, 16HBE cells, were measured by the fura-2 method. The NO release to the medium after lowering [Cl(-)](e) was measured by an amperometric NO sensor. PGE(2) production was measured by radioimmunoassay. Changing to isotonic low [Cl(-)](e) solution by substitution with gluconate caused a sustained increase in [Ca(2+)](i) in a concentration-dependent manner, with the maximal [Ca(2+)](i) increase from the baseline level being 243 +/- 110 nM with Cl-free solution. The effect was not altered by thapsigargin but abolished by EGTA and by Cl channel blockers, including diphenylamine-2-carboxylate, disodium 4,4'-diisothiocyanatostilbene-2,2'-disulfonate, and disodium cromoglycate. In contrast, the effect of reduction of [Na(+)](e) by substitution with N-methyl-D-glucamine(+) on [Ca(2+)](i) was less than that of reduction of [Cl(-)](e). The reduction of [Cl(-)](e) caused a concentration-dependent rise in NO contents in the medium and PGE(2) production. This release of NO was inhibited by EGTA but not by dexamethasone pretreatment. These results suggest that the decrease in ambient [Cl(-)] induces Ca(2+) mobilization probably through Ca(2+) influx, followed by the release of NO and PGE(2), thereby modulating various cellular functions.

Rationale: Approximately 10% of the patients with asthma are complicated with eosinophilic otitis media (EOM). Although pathogenesis of EOM is supposed to be associated with local production of Th2 cytokines, as with allergic asthma, the relationship between asthma and EOM remains unclear. We therefore investigated the clinical features of asthma patients with EOM and the effect of omalizumub therapy. Method: Of 41 patients with chronic rhinosinusitis were included in this study, 14 patients revealed to have EOM based on full examinations by otolaryngologists, and 27 patients did not have EOM. We compared these two groups in terms of age, sex, atopic factors, smoking history, severity of asthma, pulmonary function and lung image findings including airway wall thickness based on high-resolution CT. In addition, we studied the effect of omalizumab on asthma with EOM. Results: There were no significant differences between two groups in terms of age, sex, atopic factors and the level of serum IgE. Asthma severity, the number of blood eosinophils, Brinkman index and airway wall thickness were each significantly greater in patients with EOM than in those without EOM. Treatment with omalizumab at least for 4 months caused improvements in symptoms of both asthma and EOM. Conclusions: These results suggest that smoking, in concert with eosinophilic airway inflammation, and the resultant airway wall thickness possibly play roles in the pathogenesis of EOM with asthma. Thus, cessation of smoking might be important in preventing development of EOM, and furthermore, early initiation of omalizumab therapy seems to inhibit progression of both diseases.

Background: Exercise-induced hypoxia is a characteristic feature of interstitial pneumonia. Although the patients are not hypoxic at rest, oxygen saturation tends to drop abruptly during exercise. Objectives: The aim of this study is to evaluate the frequency and severity of hypoxia during daily life in the patients with interstitial pneumonia. Methods: Thirteen subjects (male 11, age 68.2 ± 10.4) were recruited from the outpatient clinic of our institute. SpO2 was monitored for 24 hours using ambulatory pulse oximeter, Pulsox-Me300 (Konica-Minolta, Tokyo, Japan). All data were downloaded to a computer for the analysis. While being monitored, patients recorded detailed diary including activities and events. Results: The patients consisted of 6 IPF, 3 NSIP and 4 CVD. The pulmonary function tests were %DLCO 39.0 ± 13.6% and %VC 76.6 ± 16.8%. Average of SpO2 during 24 hours was 93.8 ± 1.6%. Minimal SpO2 was 70.4 ± 17.1%. The frequency of >4% dip was 9.31 ± 5.4 /hour. All patients showed hypoxia during exercise. Two patients played tennis and golf in spite of severe exercise-induced hypoxia. Furthermore, four patients with pulmonary hypertension showed more severe hypoxia with minimal SpO2 59.1 ± 12.6% and the frequency of >4% dip 13.1 ± 4.5 /hour, although two of them had already received home oxygen therapy. In contrast, most of the patients did not show hypoxia during sleep. Conclusions: 24hr continuous monitoring of SpO2 could detect severe exercise-induced hypoxia during daily life in the patients with interstitial pneumonia. Intermittent severe hypoxia may be associated with the progression of pulmonary hypertension.

Background: Foxc2 is one of the forkhead transcriptional factors, which are expressed in mesenchymal cells and influence their migration. Recently, there are some reports on the relationship of mesenchymal cells and pulmonary fibrosis. We therefore hypothesized that Foxc2 gene may also be related to the pulmonary fibrosis. Objective: To elucidate the role of Foxc2 gene in pulmonary fibrosis, we investigated Foxc2 mutant mice exposed with bleomycin to induce pulmonary fibrosis. Materials & methods: ICR- Foxc2 heterozygotes (n=3) and wild type (7-14 weeks) (n=5) mice were injected a single dose of bleomycin hydrochloride (1mg/kg bodyweight) into the trachea using 28G needle under anesthesia, histologically examined after 14 days. Lungs were fixed with 4% paraformaldehyde, and their paraffin-sections and cryo-sections (5µm) were made. immunohistochemically. We performed hematoxylin-eosin staining on paraffin sections for estimating the fibrosis grade by Ashcroft9s score (AC). To estimate the epithelial cell renewal processes, we examined the expressions of podoplanin and prosurfactant protein-C (proSP-C), as markers for type1 and type2 alveolar cells, respectively. Results: We found significant difference (P Foxc2 +/- (AC: 2.84) mice. Although some of proSP-C+ cells became squamous shape in both groups, there was no difference in the expression and the shape of podoplanin+ cells. There was no numerical difference in the two types of alveolar cells, either. Conclusions: These data suggest that Foxc2 may control the severity of lung fibrosis, but have little effect on the alveolar cell renewal.

Background: Pulmonary alveolar proteinosis (PAP) occurs in association with impairment of macrophages, which leads to alveolar surfactant accumulation and opportunistic infections. Recently, MUC5B, one of the major mucins in airways is reported to be required for airway defense; MUC5B deficiency caused dysfunction of macrophages, resulting chronic infections. However, mucin composition of airway mucus in patients with PAP is unknown. Aims: To determine whether abnormality of mucin composition is present in patients with PAP, we measured major secreted airway mucins, MUC5AC and MUC5B in bronchoalveolar lavage fluids (BALF) of the patients with PAP. Methods: Diagnostic BAL was performed via fiberoptic bronchoscopy according to established guidelines. After BAL, patients who met criteria for PAP and patients who showed no apparent lung disease were enrolled to the study. The MUC5AC and MUC5B protein levels in BALF were measured by enzyme-linked immunosorbent assay. Results: The mean percentage of lymphocytes in BALF was significantly higher in patients with PAP. The MUC5AC levels were similar in both groups, whereas the MUC5B levels were significantly lower in patients with PAP compared with control (Fig. 1). Conclusions: MUC5B production in airways is decreased in patients with PAP. Alteration of mucin composition may lead to the dysfunction of macrophages, resulting opportunistic infections in patients with PAP.

An air-liquid interface culture system accelerates cell differentiation and growth in airway epithelial cells. In this study, the authors investigated whether glutathione (GSH) affects cell growth in an air-liquid interface culture. Various components of the cellular GSH system were measured and the number of cells was counted after conversion from an immersed feeding to an air-liquid interface. The effect of medium supplementation with cystine, a precursor of GSH, on cell growth was also examined. After conversion to an air-liquid interface, the cellular GSH level increased by 4 to 5-fold. The increase in GSH preceded the rise in cell number. The glutathione disulfide (GSSG)/total GSH ratio (an indicator of oxidative stress) increased initially and reached a plateau (time 0: 0.379%+/-0.054%; day 2: 0.824%+/-0.063%; day 6: 0.806%+/-0.093%). The level of glutathione reductase activity in the cells increased in a time-dependent manner, whereas the glutathione peroxidase activity level declined. When the amount of cystine in the medium was varied after conversion, the cellular GSH level was closely correlated with the rate of cell growth. In conclusion, air exposure causes oxidative stress in cultured cells and produces a change in the cellular glutathione system, resulting in the promotion of cell growth.

The Th2 cytokines, interleukin (IL)-4 and IL-13, bind to IL-4R, that IL-4 inhibited mucus secretion and attenuated the gene and cause goblet cell metaplasia/hyperplasia with increased expression of MUC5AC and MUC5B in primary human mucin expression in vivo. However, there is not enough evi- bronchial epithelial cells (8), and that IL-4 did not induce dence that these cytokines directly induce mucin production in MUC5AC gene expression in mucoepidermoid carcinoma vitro. In this study, primary epithelial cells from guinea pig cell line, NCI-H292 (9). Concerning IL-13, Longphre and cotrachea were cultured at an air–liquid interface, and immedi- workers (10) reported that IL-13 did not increase MUC5AC ately after achieving confluence at Day 7 they were treated gene expression in NCI-H292 cells, but it is uncertain with human recombinant IL-4 or IL-13 for 14 d. IL-13–treated whether IL-13 induces mucin production and MUC5AC cells consisted of a large number of fully mature goblet cells expression in primary culture of lower airway epithelium. with a smaller number of ciliated cells. Secretory granules of the goblet cells were positive for both periodic acid-Schiff and We studied the effects of IL-4 and IL-13 on airway epitoluidine blue, and showed exocytosis. By contrast, IL-4 failed thelial differentiation using air–liquid interface culture, a to induce goblet cell differentiation. The electric resistances of procedure that induces high levels of differentiation (11–13), IL-13–treated cells were lower than those of IL-4–treated cells with airway epithelial cells differentiating into both ciliated and nontreated cells, suggesting leaky epithelia. MUC5AC pro- and goblet cells. In this study, we focused on the numbers of tein level in cell lysates measured by ELISA was several-fold goblet cells and ciliated cells, because goblet cell hyperplasia higher in IL-13–treated cells than in nontreated cells, whereas along with correspondingly fewer ciliated cells may cause the level in IL-4–treated cells was not changed. These data the impairment of mucociliary clearance that is found in suggest that human recombinant IL-13, but not IL-4, can induce the airways of patients who die of asthma (14). We also

Study objective: Long-term administration of macrolide antibiotics reduces sputum production in patients with chronic airway diseases, probably by inhibiting airway inflammation. The objective of the present study was to determine the acute effects of a macrolide on airway chloride secretion and sputum production. Methods: We first investigated the effect of erythromycin treatment on chloride diffusion potential difference (CPD) across tracheal mucosa in vivo. Next, we conducted a double-blind, parallel-group study examining the effect of 7 days of treatment with clarithromycin (400 mg/d), amoxicillin (1,500 mg/d), or cefaclor (750 mg/d) in patients with chronic bronchitis or bronchiectasis without apparent respiratory infection. Results: IV administration of erythromycin decreased the CPD of rabbit tracheal mucosa in a dose-dependent manner. Treatment of patients with clarithromycin decreased sputum production, whereas amoxicillin and cefaclor treatment had no effect. The percentage of patients whose sputum decreased > 30% from baseline (responders) was 38% in the clarithromycin group, 7% in the amoxicillin group, and 0% in the cefaclor group. During treatment with clarithromycin, the sputum solid composition increased and chloride concentration decreased in responders, but these changes were not observed in nonresponders. Conclusion: Short-term administration of 14-membered macrolide reduces chronic airway hypersecretion, presumably by inhibiting chloride secretion and the resultant water secretion across the airway mucosa. (CHEST 2002; 122:213–218)

To examine the effect of adenosine A3receptor stimulation on airway mucociliary clearance, we measured transport of Evans blue dye in rabbit trachea in vivo and ciliary motility of epithelium by the photoelectric method in vitro. Mucociliary transport was enhanced dose dependently by the selective A3agonist N6-(3-iodobenzyl)-5′- N-methylcarbamoyladenosine (IB-MECA) and to a lesser extent by the less-selective N6-2-(4-amino-3-iodophenyl)ethyladenosine, whereas the A1agonist N-cyclopentyladenosine (CPA) and the A2agonist CGS-21680 had no effect. The effect of IB-MECA was abolished by pretreatment with the selective A3antagonist MRS-1220 but not by the A1antagonist 1,3-dipropyly-8-cyclopentylxanthine or the A2antagonist 3,7-dimethyl-l-propargylxanthine. Epithelial ciliary beat frequency was increased by IB-MECA in a concentration-dependent manner, the maximal increase being 33%, and this effect was inhibited by MRS-1220. The IB-MECA-induced ciliary stimulation was not altered by the Rp diastereomer of cAMP but was greatly inhibited by Ca2+-free medium containing BAPTA-AM. Incubation with IB-MECA increased intracellular Ca2+contents. Therefore, A3agonist enhances airway mucociliary clearance probably through Ca2+-mediated stimulation of ciliary motility of airway epithelium.

A 65-year-old man was diagnosed with granulomatosis with polyangiitis (GPA) at the age of 47, when cytoplasmic anti-neutrophil cytoplasmic antibody (C-ANCA) serology was positive, and he had multiple nodular shadows in both lungs. He had been treated with prednisolone, cyclophosphamide (CPA) and plasma exchange. At the age of 64, a nodular shadow was newly detected in the right lower lung field and serum tumour marker increased. Subsequent positron emission tomography/computed tomography scan demonstrated accumulations of fluorodexyglucose (FDG) in the same area, mediastinum lymph nodes, thoracic wall, right iliac bone, and right retroperitoneum. The diagnosis of squamous cell lung cancer cT2bN2M1b Stage4 was made with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). There are no reports of cases that lung cancer has developed with GPA during the long-term treatment with CPA. We suggest that in such patients, the differential diagnosis should include not only the relapse of GPA, but also the rare possibility of development of carcinomas.

Tryptase is a specific marker of mast-cell activation and plays a part in the pathophysiology of various allergic diseases including asthma, but little is known of the spillover of this enzyme into the systemic circulation. Therefore, we measured serum levels of mast-cell-derived tryptase in 21 patients with mild to moderate asthma and 20 healthy, subjects, using a B12 monoclonal antibody-based immunofluoroassay that detects both monomers and tetramers of alpha- and beta-tryptases. There was a good correlation between serum and sputum tryptase levels, and, compared with healthy subjects (1.68 +/- 0.31 ng/ml), asthma patients had higher concentrations of serum tryptase (atopic asthma, 4.18 +/- 0.95 ng/ml, p = 0.022; nonatopic asthma, 3.93 +/- 0.82 ng/ml, p = 0.031). Although serum tryptase levels did not correlate with asthma symptom scores, peak expiratory flow, or forced expiratory volume in 1 s, they positively correlated with mast-cell and eosinophil counts (p = 0.041 and p = 0.025, respectively) and eosinophil cationic protein contents (p = 0.029) in induced sputum. These results suggest that serum tryptase detected with B12 antibody is a marker of allergic airway inflammation in asthma.

The peripheral blood from healthy subjects and asthma patients was stimulated with phorbol 12-myristate 13-acetate and ionomycin, and the cells were stained with anti-CD4 antibody, permeabilized, stained with anti-IFN-gamma and anti-IL-4 antibodies, and analyzed by flow cytometry. Compared with healthy subjects, asthma patients showed a greater percentage of both IL-4(+) IFN-gamma(-) CD4 cells (Th2 cells) and IFN-gamma(+) IL-4(-) CD4 cells (Th1 cells). The percentage of Th2 cells was correlated with serum IgE level. After treatment with inhaled corticosteroid, Th2 cells decreased at week 24, but not week 4. Long-term therapy with inhaled steroid may thus be required for improvement in lymphocytic inflammation.