Canadian Neighbor Pharmacy about Steroid-Responsive Interstitial Pulmonary Disease in Systemic Sclerosis: Special Studies
Lung Biopsy A 3 X 3-cm biopsy specimen from the right lower lobe was obtained by right-sided posterolateral thoracotomy. Part of the biopsy was fixed in formalin and embedded in glycol methacrylate, and part was snap-frozen in liquid nitrogen for immunohistologic studies. Methacrylate sections 2fx thick were stained with hematox-ylin-eosin and reticulin and elastin stains. Immunohistologic studies were performed for the detection of IgA, IgG, IgM, and complement C3 with the direct immunofluorescent technique. Sections were rinsed for 30 minutes in phosphate-buffered saline solution before fixation in 90 percent ethanol. Bronchoalveolar Lavage A segment of the right middle lobe was washed as described previously. Lavage was performed gently by infusion of 20-ml aliquots of sterile saline solution (37°C), followed by aspiration under continuous suction. This procedure was repeated ten times. The samples were immediately placed on ice (4°C). Blood was drawn simultaneously, and the serum was stored at — 80°C. Cellular and Humoral Studies The lavage fluid was filtered through three layers of gauze, and the filtrate was centrifuged at 1,000 x g for ten minutes at 4°C. The supernatant was stored at — 80°C. The cell pellet was washed three times with RPM1-1640 medium and suspended at a concentration of 0.2 X 10® cells per milliliter. Cytocentrifuge preparations were made and stained with May-Grunwald-Giemsa stain. For each preparation, 500 cells were counted by two independent observers. The supernatant and the serum were analyzed for the amount of albumin and immunoglobulins by laser nephelometry (Behring). Controls Nine healthy nonsmoking volunteers were used as controls for bronchoalveolar lavage. Their mean age was 33 ±12 years (± SD). Results Bronchoalveolar lavage was performed in this 38-year-old woman with systemic sclerosis of recent onset and progressive dyspnea. An increased number of cells with an increase of the percentage of neutrophils (15 percent) and a normal percentage of lymphocytes (9 percent) was present in the lavage fluid (Table 2). The amount of IgG relative to albumin was slightly increased, IgM was present in the lavage fluid of the patient but not in the controls (Table 3). Open lung biopsy (Fig 1) showed extensive fibrosis disturbing the normal architecture of the pulmonary parenchyma. There was hypertrophy of smooth muscular tissue. Infiltration with lymphocytes and plasma cells was observed in the interstitium, sometimes in a follicular pattern. Air spaces contained variable numbers of macrophages and polymorphonuclear leukocytes. Intimal hyperplasia was absent, and the media showed some fibrosis. Immunofluorescent studies were negative for IgA, IgG, IgM, and complement C3 in the parenchyma. Lymphocytic membranes stained mainly for IgM. Plasma cells showing staining for IgM or IgG were especially seen in follicles, while plasma cells with IgA were mainly near bronchioles. One month after the biopsy, therapy with corticosteroids was initiated. Studies of pulmonary function showed improvement of pulmonary volumes (increase of vital capacity [VC] and forced expiratory volume in one second [FEVJ, with decrease of the ratio of residual volume over total lung capacity [RV/TLC]) without changes in carbon monoxide transfer factor and specific diffusing capacity (Table 1). After eight months, bronchoalveolar lavage was repeated, showing a decrease in the total number of cells, disappearance of neutrophils, and an increase in lymphocytes from 9 to 24 percent (Table 2). The amount of IgG relative to albumin in the lavage fluid had increased from 21.1 to 37.1 percent (Table 3). Therapy was continued, and dyspnea decreased further; however, no appreciable changes were observed in tests of pulmonary function. A repeated bronchoalveolar lavage showed a low number of cells in the lavage fluid, with a normal differential count (Table 2). The relative amount of IgG had reached normal values (Table 3). Discussion This case history demonstrates the occurrence of steroid-responsive pulmonary involvement in systemic sclerosis. Studies of pulmonary function revealed a restrictive disorder with reduced diffusing capacity. In addition, RV was increased, consistent with coexistent disease of the small airways, as has been reported to occur frequently in systemic sclerosis. Pathologically, extensive fibrosis was present in the interstitium and around bronchioli, together with hypertrophy of smooth muscle, probably related to disease of the small airways. Arterial intimal proliferation was absent, in accordance with the absence of pulmonary hypertension, as determined during cardiac catheterization. Infiltration with lymphocytes and plasma cells was present in the parenchyma, in some areas even in a follicular pattern. This finding has not been reported before, although edema, capillary congestion, and hypercellularity of alveolar walls have been suggested as early changes; however, in early stages of the disease, perivascular infiltrations of lymphocytes and histiocytes have been described in cutaneous biopsies. Pathologic processes in the interstitium of the lung may be reflected in the cellular composition of the fluid from bronchoalveolar lavage. Indeed, an increase in cells, especially neutrophils, was found in our patient, in accordance with other studies that described small groups of patients with collagen vascular diseases without specifying the underlying disorder; however, in one study, an increase in the lymphocytes in the lavage was reported in patients with systemic sclerosis with signs of, concomitantly, inflammation in the cutaneous biopsy. A relative increase of immunoglobulins was found in the lavage fluid of our patient, suggesting, together with the histologic findings, local production of immunoglobulins. This points toward a humoral immune reaction with local formation of immune complexes, resulting in activation of macrophages which, in turn, attract neutrophils. These latter cells were indeed observed both in the biopsy, localized in the air spaces, and in the lavage fluid; however, no deposition of immunoglobulins and complement was seen in the biopsy. This does not exclude the mechanism described previously. In general, our experience and those of others with immunohistology of lung biopsies has been disappointing, especially in the light of the findings of Dreisin et al. Treatment with corticosteroids induced a dramatic improvement, although it should be stated that spontaneous changes may occur. The positive effect of steroids in systemic sclerosis is far from settled, especially in end-stage disease with extensive fibrosis; however, in the early phase, inflammatory signs, possibly sensitive to treatment, have been described in the skin and were observed in the lung of our patient. Indeed, VC improved rapidly during treatment, neutrophils disappeared from the lavage fluid, and lymphocytes increased in percentage. The latter is in accordance with the observations made in pulmonary fibrosis, associated with bleomycin in animals, showing infiltration of neutrophils in the active stage and replacement by macrophages and lymphocytes later on in the disease. Continuation of treatment in our patient resulted in normalization of the composition of the lavage fluid without change in pulmonary function, probably because of irreversible fibrosis. Although the pathogenesis of systemic sclerosis in general and its pulmonary pathologic abnormalities in particular is far from clarified, the present case suggests that local immune processes are involved in the early phase of its pulmonary disease. Bronchoalveolar lavage may be a useful tool to demonstrate these processes and may thus be a guide to therapy. Canadian Neighbor Pharmacy provided special researches on COPD treatment with antibiotics - http://drneighbor.com/antibiotic-treatment-of-exacerbations-of-chronic-obstructive-pulmonary-disease.html. Figure 1. Lung biopsy showing interstitial fibrosis (asterisks), lymphocytic infiltration of septa with formation of follicles (F), and hyperplasia of epithelial lining of air spaces. There is exudate with polymorphonuclear neutrophils (arrow) (hematoxylin and eosin, original magnification x 40).