SESSION TYPE: Miscellaneous Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Lung disease occurs commonly in rheumatoid arthritis (RA) and is associated with significant morbidity and mortality. Recently, Fischer and colleagues demonstrated that anti-cyclic citrullinated peptide (anti-CCP) positive individuals with airways or interstitial lung disease may represent a "pre-articular" RA phenotype.

CASE PRESENTATION:

A 61-year-old Caucasian man, with a 7.5 pack-year smoking history, seasonal allergies, gastroesophageal reflux disease, obstructive sleep apnea, and dyslipidemia presented with pleuritic chest pain and dry cough of five months duration. There was no improvement with two courses of oral antibiotics. There was no evidence of sinusitis, arthralgias, inflammatory arthritis, rash or other symptoms of connective tissue disease. Physical examination was only notable for crackles at the right lung base. His musculoskeletal exam was normal. Cardiopulmonary testing revealed a normal nuclear cardiac stress test, a negative ventilation/perfusion scan and normal pulmonary physiology. Thoracic high-resolution computed tomography (HRCT) images revealed multiple nodules and thick-walled cavities predominantly in the right lung (Figure 1). Latent tuberculosis assessment was negative. Autoimmune serologies demonstrated a high-positive anti-CCP, anti-Ro (SSA) and a weakly positive RF. C-ANCA, P-ANCA, anti-myeloperoxidase, anti-proteinase-3, anti-nuclear and anti-glomerular basement membrane autoantibodies were negative. Surgical lung biopsy revealed necrotizing granulomatous inflammation with geographic necrosis, vasculitis and lymphocytic pleuritis. The patient was started on oral corticosteroids with rapid clinical improvement. Two months after lung biopsy, as corticosteroids were tapered, he developed symmetric inflammatory arthritis involving the small joints of the hands, wrists, and feet with synovitis His arthritis responded to dose escalation of corticosteroids and injectable methotrexate which was initiated and rapidly titrated to 25 mg weekly. Corticosteroids were tapered off over the subsequent 3 months, while synovitis symptoms, pleurisy, and cough remained quiescent. Follow-up HRCT has demonstrated that the pulmonary cavitary nodularity is improving.

DISCUSSION:

In this report we demonstrate that pulmonary vasculitis may be a presenting feature of RA. Although vasculitis is a well recognized extra-articular manifestation of RA, it is usually considered to be associated with long-standing, severe, erosive, nodular, and sero-positive disease. RA-vasculitis may manifest with pyoderma gangrenosum, mononeuritis multiplex, or pulmonary vasculitis. Our findings highlight that severe pulmonary vasculitis may also occur as the first clinical feature of RA.

CONCLUSIONS:

A wide spectrum of lung disease, including pulmonary vasculitis, may be the presenting manifestation of RA.1) Genta M.S, Genta R.M, Gabay C. Systemic Rheumatoid Vasculitis: a review. Semin Arthritis Rheum 2006. 36:88-98DISCLOSURE: The following authors have nothing to disclose: Salvador de la Torre Carazo, Olga Tourin, Daniel Smith, Fischer AryehNo Product/Research Disclosure InformationHospital 12 de Octubre, Madrid, Spain.

SESSION TYPE: Pleural Cases IPRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION:

Inflammatory bowel disease can affect airways and parenchyma of lung as first reported by Kraft. Rarely does it involve the pleura and pericardium causing recurrent serositis. (1)

CASE PRESENTATION:

In this report we describe a 49 year old female with history of Crohn's disease who presented with chest pain, pleurisy and SOB. On physical examination, she was afebrile, tachycardic and hypotensive. The breath sounds were decreased at the lung bases. The abdomen was tender to palpation in the upper quadrants, without peritoneal signs. The laboratory data revealed normal blood counts and a negative autoimmune and infectious panel. The chest radiograph demonstrated small bilateral pleural effusions and a CAT scan of her chest/abdomen revealed moderate sized pericardial effusion, fluid filled distal small bowel loops and small bilateral pleural effusions. A TTE revealed a large pericardial effusion and early tamponade. A therapeutic pericardiocentesis was performed and exudative, sterile neutrophil predominant fluid was drained. A diagnostic thoracentesis revealed a neutrophil predominant sterile effusion. She was readmitted multiple times with pleurisy and pericardial tamponade and eventually underwent pericardiectomy, the pathology of which revealed fibrosis and chronic inflammation with lymphoid aggregates. As no definite etiology was identified, the recurrent effusions were attributed to Crohn's disease. The patient was started on prednisone which resolved the pleuritis.

DISCUSSION:

Thoracic Serositis in patients with IBD can cause pleuritis, pericarditis, pleuropericarditis or myopericarditis. Although these respiratory symptoms develop in patients at any time in the history of the IBD, most do so following the onset of bowel disease by days to decades. The reason for the wide range of time-to-onset of the respiratory disease is unknown, as are the reasons why only few patients develop the disease. The respiratory manifestations are unusual as they may develop in the quiescent phase. Although the specific pathophysiology of this remains unclear, the response to systemic steroids is usually adequate similar to our patient.

CONCLUSIONS:

In conclusion, Serositis is an uncommon extraintestinal complication which should be considered in the differential diagnosis of IBD patients presenting with similar symptoms. Such manifestations are probably underrecognized and underreported due to the routine use of anti-inflammatory drugs in the acute and maintenance management of IBD.1) Kraft SC, Earle RH, Rossler M, Estarly JR. Unexplained bronchopulmonary disease with inflammatory bowel disease. Arch intern Med 1976; 136: 454-459.2) Camus Ph, Plard F, Ashcraft T, Gal AA, Colby TV. The lung in inflammatory bowel disease. Medicine (Blatimore) 1993; 72:151-183.3) Muhanned Abu-Hijleh, Samuel Evans, Bassam Aswad. Pleuropericarditis in a Patient with Inflammatory Bowel Disease: A Case Presentation and Review of the Literature. Lung (2010) 188:505-510.DISCLOSURE: The following authors have nothing to disclose: Sowjanya DuthuluruNo Product/Research Disclosure InformationUniversity of Kansas Medical Center, Kansas City, KS.

Chickenpox is a viral infection usually benign and practically mandatory of the childhood. In the adult, it may know multivisceral complications as pneumonia in relationship with chickenpox which is the most frequent. One case of varicella pneumonia with a bilateral pleurisy has been noticed in a 38-year-old adult. The definite diagnosis has been based on clinical, biological and radiological arguments. Under an antiviral treatment, the evolution is favourable.

We have previously shown that human memory-like NK cells were persistent in tuberculous pleurisy but it was unclear how NK cells migrated into the pleural fluids. At present, we found that NK cells from TB pleural fluid cells (PFCs) expressed significantly higher levels of CXCR3 and CXCR4 than NK cells from PBMCs. Migration assay demonstrated that IP-10 and SDF-1 induced more migration of NK cells from PFCs than PBMCs. CD45RO(+) or CD45RO(-) NK cells from PFCs were co-cultured with autologous monocytes and stimulated with BCG. The results showed CD45RO(+) but not CD45RO(-) NK cells produced significantly higher levels of IFN-γ, which was IL-12-dependent since anti-IL-12Rβ1 mAbs could significantly inhibit the IFN-γ by NK cells. Collectively, our data demonstrated that human Mycobacterium tuberculosis-specific NK cells were migrated into the local site of TB infection mainly via IP-10/CXCR3 and SDF-1/CXCR4 axis, memory-like NK cells might display an important role against M. tuberculosis infection.

We previously reported the expression of cyclooxygenase (COX)-2 in draining lymph nodes during carrageenin-induced pleurisy of rats. Here, we analyzed histological and immunohistochemical characteristics of COX-2-expressing cells. After carrageenin administration into the pleural cavity of rats, parathymic lymph nodes were enlarged beginning at 8h and peaking from 24 to 48h. Lymphatic follicles disappeared 16h after injection, and numerous macrophages and fibroblasts were observed in the cortical region. COX-2-expressing cells in the cortical region showed characteristic dendritic processes from 16 to 48h and primarily co-localized with stromal fibroblastic reticular cell markers, α-smooth muscle actin (α-SMA), and desmin. Expression of α-SMA increased following COX-2 expression. Nimesulide, a COX-2 inhibitor, increased the dendritic processes of COX-2-expressing cells as well as expression of both COX-2 and α-SMA. These results suggest that COX-2-expressing cells may be stromal fibroblastic cells, which negatively self-regulate their proliferation and modulate tissue remodeling of draining lymph nodes at inflammatory sites.

Pleural effusion is a rare complication in non-tuberculous mycobacterial infection. We report a case of Mycobacterium intracellulare pleuritis with idiopathic pulmonary fibrosis in a 69-year-old man presenting with dyspnea. Pleural effusion revealed lymphocyte dominant exudate. M. intracellulare was identified using a polymerase chain reaction-restriction fragment length polymorphism method and liquid cultures of pleural effusion and pleural biopsy. After combination therapy for M. intracellulare pulmonary disease, the patient was clinically well at a 1-month follow-up.

Abstract

Context:

Despite the many biological activities reported for essential oils, their anti-inflammatory ability is relatively underexplored considering the wide variation in plant sources and in their volatile composition. Oils from Syzygium cumini Skells (SC) and Psidium guajava L. (PG) (Myrtaceae) have been described as having diverse pharmacological activities.

Objective:

The current study seeks to evaluate the anti-inflammatory activity of the essential oils from the leaves of SC and PG, as well as some of their terpene-enriched fractions (+V = more volatile and -V = less volatile) obtained by vacuum distillation. Both the pharmacological responses and chemical compositions were correlated. Materials and methods: The relative contents of the oils and their fractions were evaluated by gas chromatography. Individual constituents in the oils were characterized by gas chromatography coupled to mass spectrometry. Anti-inflammatory activity was accessed in the lipopolysaccharide-induced pleurisy model, by measuring the inhibition of total leukocyte, neutrophil and eosinophil migration in the mice pleural lavage, after oil treatment with the oils at 100 mg/kg.

Results:

Eosinophil migration was inhibited by SC (67%), SC (+V) (63%), PG (76%), PG (+V) (67%) and PG (-V) (74%). This efficacy was correlated with the presence of β-pinene and β-caryophyllene in the oils, a result that was reinforced by evaluating both these pure components (38 and 50% inhibition, respectively). Synergistic effects associated with the presence of α-pinene were speculated. Discussion and conclusion: Essential oils from SC and PG may be useful to treat inflammatory diseases by mechanisms that include the inhibition of eosinophil migration.

OBJECTIVES:

Differential diagnosis of exudative pleural effusions can be difficult, despite the use of several biomarkers. Serum procalcitonin (s-PCT) is a well-known biomarker for systemic bacterial infections. However, the usefulness of pleural fluid procalcitonin (pf-PCT) in clinical practice has not been established. This study evaluated the usefulness of PCT measurements in differentiating parapneumonic effusion (PPE) from tuberculous (TB) pleurisy or malignant effusion.

DESIGN AND METHODS:

Ninety eight adult patients diagnosed with exudative pleural effusion were enrolled and allocated into the PPE group (n=32), TB pleurisy group (n=40), or malignant effusion group (n=26). Both s-PCT and pf-PCT concentrations were measured at admission using an immunoluminometric assay.

RESULTS:

Both s-PCT and pf-PCT were significantly increased in the PPE group compared with the TB pleurisy or malignant effusion groups (p<0.001). The optimal cut-off value for s-PCT in the diagnosis of PPE was 0.18ng/mL (sensitivity 83.3%, specificity 81.0%). The pf-PCT cut-off value was 0.16ng/mL (sensitivity 81.5%, specificity 72.1%). Serum PCT exhibited better diagnostic accuracy than pf-PCT, with areas under the receiver operating characteristic curves of 0.842 for s-PCT and 0.784 for pf-PCT (p=0.015). In addition, s-PCT and pf-PCT showed better diagnostic accuracy than serum C-reactive protein (p=0.005 and p=0.023, respectively).

CONCLUSIONS:

Measurement of s-PCT and pf-PCT is useful in differentiating PPE from TB pleurisy and malignant effusion. Both s-PCT and pf-PCT may be useful biomarkers in the differential diagnosis of exudative pleural effusions.

To assess anti-psoriatic activity of the methanol extract and the isolated flavonoid quercetin from the rhizome of Smilax china (S. china) Linn.Mouse tail test was used for the evaluation of anti-psoriatic activity. Methanol extract (100 and 200 mg/kg b.w.) and isolated flavonoid quercetin (25 and 50 mg/kg b.w.) were tested in Swiss albino mice. Parameters studied in the mouse tail test were changes in epidermal thickness and percentage orthokeratotic values. The anti-inflammatory role of the methanol extract and isolated flavonoid quercetin was evaluated using carrageenan-induced pleurisy in rats. In vitro antiproliferant assay on HaCaT cell lines was also carried out.The isolated flavonoid quercetin from the rhizome of S. china produced significant orthokeratosis (P<0.01) in the mouse tail test. In epidermal thickness, a significant reduction with respect to control was observed in groups treated with retinoic acid and isolated flavonoid quercetin. The methanol extract (200 mg/kg) and isolated flavonoid quercetin (50 mg/kg) showed anti-inflammatory effect in terms of significant inhibition (P<0.001) in leukocyte migration. Maximum antiproliferant activity was shown by isolated flavonoid quercetin (IC50, 62.42±10.20 µg/mL).From the above data, the flavonoid quercetin shows significant orthokeratosis, anti-inflammatory and maximum antiproliferant activities. To our knowledge, this is the first report on the anti-psoriatic effect of the flavonoid quercetin which is promising for further investigations to prove its anti-psoriatic activity.

Casearia sylvestris Sw. is widely used in popular medicine to treat inflammatory conditions.To investigate the anti-inflammatory and antioxidant properties of hydroalcoholic crude extract (HCE) taken from Casearia sylvestris Sw. (Salicaceae).The effect of the HCE from this plant (3-300mg/kg) on the reduction of inflammatory response to carrageenan was investigated in pleurisy in rats (intrapleural, 2% in 0.2mL) or paw edema in mice (intraplantar, 300μg/20μL, right hind paw). The plant anti-inflammatory action was assessed by its capability in inhibiting cell migration, enzymatic activity of myeloperoxidase (MPO) and production of nitrite/nitrate or edema. The in vitro antioxidant activity of this extract against lipid peroxidation and damage to proteins was assessed as possible pathways to contribute as anti-inflammatory mechanisms. Carrageenan-induced hind paw edema (739.3±11.9μm) was reduced by HCE (30mg/kg: 462.8±28.38μm) to similar extents as dexametasone (365.1±16.7). In pleurisy, treatment of the animals with HCE (100mg/kg: 0.010±0.001mU/mg of protein) also reduced MPO activity augmented by carrageenan (0.020±0.001mU/mg of protein) as well as leukocytes migration (carrageenan: 17.8890±2.3900leukocytes/mL, HCE 100mg/kg: 7.0880±9631leukocytes/mL). Significant effects were also observed in animals treated with different doses of HCE in biochemical tests for oxidative stress analysis.The anti-inflammatory and antioxidant effects of HCE from Casearia sylvestris Sw. suggests a potential therapeutic benefit of this plant in treatment of inflammatory conditions.