Faculty Bibliography

Introduction Measles is a highly contagious viral illness with significant mortality. Despite vaccination efforts, measles continues to occur in the United States. Most cases are associated with importation from endemic countries. Respiratory complications of the virus are one of the leading causes of fatalities. We report a case of measles pneumonia in an immunocompetent, unvaccinated adult with no associated importation from abroad. Case Presentation A 38 year old Caucasian female, with no recent travel history, presented with 3 days of fevers, cough, facial rash, and progressive shortness of breath. Her rash spread inferiorly to her trunk and extremities. On examination she was febrile, tachycardic, and hypoxic with a Pa02 of 55mmHg on room air. An erythematous, maculopapular rash was distributed over her face, trunk, and extremities. Her buccal mucosa had 2 mm white lesions, consistent with koplik spots. A chest x-ray showed a right upper lobe infiltrate and increased interstitial markings. She was placed in isolation and a floroquinolone was empirically initiated for a possible bacterial coinfection. Acute measles serologies returned positive, with an IgM level of 11.04 AU. Over the course of 48 hours, her fever defervesced, her oxygen saturation normalized, and her cough and rash resolved. She was discharged with instructions to have her 2 children receive the MMR vaccination immediately. Her children and she had not been vaccinated previously. Discussion Measles was declared eliminated from the United States in the year 2000, but the virus continues to be imported from endemic regions [1]. Our case represents one of 118 reports of measles in the United States between January 1 and May 20, 2011. Of these 118 cases, 105 (89%) were associated with importations from other countries and only 9 developed pneumonia [2]. Uniquely, our patient had no recent travel to, or contact with, individuals from an endemic region. This case, therefore, represents one of the few instances of measles pneumonia in the United States that was not import-associated. Instead, the risk factor in our presentation was the lack of prior vaccination. This absence of immunity resulted in the potentially life threatening complication of pneumonia. Our case underscores the importance of educating reluctant individuals regarding the safety and efficacy of the measles vaccine in preventing a devastating disease

Introduction: The lung is classically thought to be sterile although molecular techniques for microbial identification are now suggesting the existence of a human airway microbiota. The microbiome of emphysema patients remains largely uncharacterized. We hypothesize that lung microbiota differs in early CT-defined emphysema subjects when compared with normal volunteers and that microbial load is associated with host cytokine production. Methods: Emphysema subjects were identified from the NYU Lung Cancer Center CT-scan screening cohort. Supraglotic and broncho-alveolar lavage (BAL) samples were obtained with bronchoscopy. Bacterial quantificationofepithelial lining fluid (ELF) was determined by qPCR using universal primers for eubacteria 16S rDNA. Bacteria speciation will be performed with 454 sequencing. Alveolar macrophages obtained after centrifugation of BAL were incubated with media alone or lipopolysaccharide (LPS). Thirty-ninecytokines were measured in BAL 24-hr supernatants using Luminex. Cytokine production was clustered based on the protein production post LPS stimulation compared with the media alone. Results: 24 subjects were enrolled (8 healthy normal volunteers and 16 with emphysema). Mean age was 37+/-10 and 62+/-6 yr. (p=0.001). All emphysema subjects were ex-smokers (normal 1+/-0.5 vs. 39+/-20 pack-yr., p=0.019). There were no differences in the %BAL cells between the two groups (Alveolar macrophages 89.5+/-4 vs. 88.1+/-8.2%). Lung function of emphysema subjects was characterized by lower FEV1/FVC (78.9+/-5.1 vs. 69.6+/-6.1, p=0.001) and hyperinflation (TLC=87.7+/-10.3 vs. 104.3+/-15.2% predicted, p=0.016). Bacteria rDNA was higher in the supraglotic area than lower respiratory tract (1.5e9+/-3.2e9 vs. 1e7+/-8.2e6 copies/mL of ELF, p<0.001). Bacterial load was similar in normal volunteers and emphysema subjects (8.4e6+/-8.8e6 vs. 1.1e7+/-8.1e6 copies/mL of ELF, p=ns). Cytokines'response to TLR stimulation grouped all study subjects into two clusters, and those with higher pro-inflammatory cytokine production were associated with higher amounts of bacteria in ELF (1.4e7+/-8.6e6 vs. 5.7e6+/-1.8e6 copies/mL, p<0.03). Conclusions: In the absence of signs or symptoms of infection both emphysema patients and normal controls had significant airway resident bacteria. Surprisingly, bacterial load was not increased in early CT-defined emphysema. Higher bacterial load was associated with higher TLR2/4-induced cytokine production. Next generation rDNA sequence data will define if microbiota is altered by emphysema or associated with TLR response

RATIONALE: The World Trade Center (WTC) destruction exposed ~13,000 FDNY rescue workers to aerosolized particulate matter. A subset of these patients developed obstructive lung disease. Matrix metalloproteinases(MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are important in tissue remodeling and are implicated in the development of airflow obstruction. Our work is focused on quantifying serum levels of these protease/antiproteases and determining their potential role in WTC-Lung Injury (WTC-LI). METHODS: In a nested case-control study of symptomatic non-smoking male firefighters with pre and post-9/11 spirometry data(N=1720), we defined cases (N=68) as having an FEV₁ at subspecialty pulmonary evaluation(SPE) in the lowest 12.5% of the cohort. Controls (N=119) were chosen from a random population stratified on BMI and FEV1at SPE. Serum drawn within six months of 9/11/2001, prior to the development of advanced WTC-LI, was assayed for MMP-1, MMP-2, MMP-3, MMP-7, MMP-8, MMP-9, MMP-12, MMP-13, TIMP-1, TIMP-2, TIMP-3, and TIMP-4 by commercially available multiplex assays for Luminex(R&D Systems; Affymetrix). FEV₁ at SPE was correlated with serum MMP and TIMP. RESULTS: Cases and controls were compared by Pearson Chi-Square and Mann-Whitney U test where appropriate. Cases and controls were not significantly different in age, years of service, and WTC exposure intensity. Cases had significantly lower MMP-1 and MMP-3 than controls; Cases had elevated MMP-7, MMP-12, and MMP-13. MMP-2, MMP-8, MMP-9, TIMP-1, TIMP-2, TIMP-3, and TIMP-4 were not significantly different between cases and controls. At the time of SPE, cases had FEV_1%pred median(IQR) of 72(66-74), whereas controls had 96(88-104). Cases had a significantly lower DLCO, higher methacholine slope, and a greater number of subjects with a bronchodilator response compared to controls. There was no difference between cases and controls in airtrapping or in bronchial wall thickening by CT. Logistic regression modeling was used to determine the potential biomarkers' ability to predict WTC-LI. Elevated levels of MMP-12 had an odds ratio(OR) of being a case of 3.89, whereas elevated levels of MMP-3 and TIMP-3 had OR of being a control of 3.75 and 2.37. The model had Sensitivity of 48.5%, Specificity of 85.7% and a ROC Curve AUC of 0.757(95%CI:0.687-0.827), Figure 1. CONCLUSIONS: Serum levels of MMP and TIMP soon after 9/11 predicted lung function decline seven years later. The study finds that elevated MMP-12 is a risk factor for lung injury, whereas elevated MMP-3 and TIMP-3 are protective factors. These biomarkers of future lung injury may identify those most at risk for obstructive lung disease. (Figure Presented)

RATIONALE: The destruction of the World Trade Center (WTC) led to the exposure of over 300,000 rescue workers and residents to particulate matter (WTC-PM) and other products of combustion. Victims have suffered from a wide array of adverse health effects. Particulates up to 50 microns have been recovered from the airways of rescue workers 10 months after the event. Our study focuses on understanding the cytokine and chemokines elaboration from the ex-vivo exposure of human alveolar macrophages (AM) from 15 subjects exposed to WTC-PM₅₃ and PM_2.5. METHODS: AM from 15 volunteers with normal chest radiographs were incubated in media alone (MA) to measure spontaneous cytokine release, LPS 40 ng/ml as a positive control, or suspensions of WTC-PM₅₃ and WTC-PM_2.5 at concentrations of 10, 50 and 100 mug/mL to assess the impact of WTC dust. Supernatants were assayed for 39 pro-inflammatory chemokines and cytokines 24 hours after exposure. RESULTS: PM₅₃ and PM_2.5 produced dose dependent analyte induction for a majority of the chemokines and cytokines. WTC-PM53 induced significantly more GM-CSF, G-CSF, IL-6, TNF-alpha, IL-10, IL-1beta, IP-10 and GRO than fine WTC-PM_2.5, Table 1. PM₅₃ 100mug/mL induced more GM-CSF than LPS 40ng/ml. For all other cytokines and chemokines tested PM₅₃ induced less analyte than LPS. Baseline GM-CSF and MDC elaboration varied in AM preparations; the median GM-CSF concentration was 16.4(IQR: 7-66) pg/mL, and MDC was 1803(483-3348). There was a strong correlation between baseline elaboration and dust induced GM-CSF and MDC; the correlation coefficients between baseline and dust-induced GM-CSF and MDC expression are shown in Table 2. CONCLUSIONS: Ex-vivo exposure of human AM to coarse WTC-PM53 stimulated production of significantly more inflammatory mediators than fine WTC-PM_2.5, suggesting that inhalation of coarse PM at the WTC produced high incidence of lung injury in those exposed. There was patient specific variation in response to dust that may contribute to individual susceptibility to lung injury after irritant dust exposure. (Table presented)

RATIONALE: The World Trade Center(WTC) collapse exposed over 300,000 rescue workers and residents to high amounts of particulate matter from debris. WTC-exposed FDNY rescue workers with pulmonary symptoms had primarily obstructive physiology. WTC exposure has also been linked to cardiovascular disease(CVD). Both CVD and COPD are characterized by systemic inflammation. Subjects with COPD are at greater risk for developing CVD. However the mechanism that links these two disease processes is poorly understood. Our goal was to quantify serum biomarkers of CVD present within six months of WTC-PM exposure. We then developed a predictive model that determines the odds of having WTC-Lung Injury(WTC-LI) within seven years after exposure. METHODS: A nested Case-Control design was used to identify the association of CVD biomarkers and development of WTC-LI post-9/11. All patients were non-smoking males, had normal pre-9/11 lung function, and had heart rate recorded at serum draw. Cases (N=61) were defined as FEV1%Pred in the lowest 12.5 percentile at the time of subspecialty pulmonary evaluation(SPE). Controls (N=109) were defined from a random sample that was enriched for those in the top octile of FEV1%Pred at SPE. We assayed serum collected within six months of 9/11 for biomarkers of CVD: Apolipoproteins(AI, AII, B, CII, CIII, E); C-Reactive Protein; Serum Amyloid A(SAA); Serum Amyloid P(SAP); Macrophage Inflammatory Protein-4(MIP-4, CCL18, PARC). RESULTS: Cases had significantly elevated Apolipoproteins(AI, AII, CII, CIII), SAA, and heart rate compared to controls. Controls had significantly elevated Apo E and MIP-4 compared to cases. Cutpoints were defined to optimize model parameters. The final logistic regression model determined the odds ratio(OR) of being a case using elevated heart rate (OR=3.5), elevated Apo AII(OR=6.8), CRP>3mg/L(OR=5.8), and lower levels of SAA(OR=17.9). Elevated levels of MIP-4 were seen as protective, and had an OR of being a control of 66.7. The model was adjusted for BMI at SPE, age at 9/11, exposure intensity and Pre-9/11 FEV1%Pred. The model had sensitivity of 74% and specificity of 85%. A ROC analysis determined an AUC of 0.891(95%CI:0.840-0.942), Figure 1. CONCLUSIONS: CVD biomarkers present in serum six months post-9/11 predict accelerated decline in lung function after exposure to WTC dust. The strong predictive ability of the model suggests that CVD biomarkers can also be used to predict lung injury. This suggests potential overlapping pathways of inflammation in CVD and lung injury in response to irritant exposure. (Figure Presented) Macrophage Inflammatory Protein-4; 3mg/L for CRP. The final logistic regression model used the cut points as predictors of airflow obstruction at subspecialty pulmonary evaluation. The models were adjusted for age, BMI, exposure intensity, and pre-9/11 FEV1% Predicted. The AUC of the final model was 0.891 (CI: 0.840-0.942). Sensitivity of the model is 74%; Specificity is 85%

The development of lung cancer in humans can be divided into three steps: initiation, promotion and progression. This process is driven by alterations in related signal transduction pathways. These pathways signal the aberrant activation of NF-kappaB, a transcription factor that regulates the expression of genes important for lung tumorigenesis. Our current knowledge about the role of the NF-kappaB signaling pathway in the development of lung cancer has been bolstered by animal models demonstrating the connection between K-ras and tobacco induced lung transformation with NF-kappaB. Activation of downstream genes leads to cell proliferation, inhibition of apoptosis, angiogenesis, inflammation, invasion, and metastasis.

PURPOSE: To characterize the interactions of non-small cell lung cancer (NSCLC) tumors with the immune system at the level of mRNA and microRNA (miRNA) expression and to define expression signatures that characterize the presence of a malignant tumor versus a nonmalignant nodule. EXPERIMENTAL DESIGN: We have examined the changes of both mRNA and miRNA expression levels in peripheral blood mononuclear cells (PBMC) between paired samples collected from NSCLC patients before and after tumor removal using Illumina gene expression arrays. RESULTS: We found that malignant tumor removal significantly changes expression of more than 3,000 protein-coding genes, especially genes in pathways associated with suppression of the innate immune response, including natural killer cell signaling and apoptosis-associated ceramide signaling. Binding sites for the ETS domain transcription factors ELK1, ELK4, and SPI1 were enriched in promoter regions of genes upregulated in the presence of a tumor. Additional important regulators included five miRNAs expressed at significantly higher levels before tumor removal. Repressed protein-coding targets of those miRNAs included many transcription factors, several involved in immunologically important pathways. Although there was a significant overlap in the effects of malignant tumors and benign lung nodules on PBMC gene expression, we identified one gene panel which indicates a tumor or nodule presence and a second panel that can distinguish malignant from nonmalignant nodules. CONCLUSIONS: A tumor presence in the lung influences mRNA and miRNA expression in PBMC and this influence is reversed by tumor removal. These results suggest that PBMC gene expression signatures could be used for lung cancer diagnosis. Clin Cancer Res; 17(18); 5867-77. (c)2011 AACR

Lung cancer is the leading cause of cancer deaths, with an overall survival of 15% at five years. Biomarkers that can sensitively and specifically detect lung cancer at early stage are crucial for improving this poor survival rate. Sputum has been the target for the discovery of non-invasive biomarkers for lung cancer because it contains airway epithelial cells, and molecular alterations identified in sputum are most likely to reflect tumor-associated changes or field cancerization caused by smoking in the lung. Sputum-based molecular biomarkers include morphology, allelic imbalance, promoter hypermethylation, gene mutations and, recently, differential miRNA expression. To improve the sensitivity and reproducibility of sputum-based biomarkers, we recommend standardization of processing protocols, bronchial epithelial cell enrichment, and identification of field cancerization biomarkers.