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Levels of Interleukin-2, Interferon- , and Interleukin-4 In Levels of Interleukin-2, Interferon-␥, and Interleukin-4 in Bronchoalveolar Lavage Fluid From Patients With Mycoplasma Pneumonia: Implication of Tendency Toward Increased Immunoglobulin E Production Young Yull Koh, MD*; Yang Park, MD*; Hoan Jong Lee, MD*; and Chang Keun Kim, MD‡ ABSTRACT. Objective. In connection with the possi- ABBREVIATIONS. IgE, immunoglobulin E; TH1, T helper type 1; ble relationship between Mycoplasma infection and the TH2, T helper type 2; IFN, interferon; IL, interleukin; BAL, bron- onset of asthma, several studies have shown not only a choalveolar lavage; FB, fiber-optic bronchoscopy; SD, standard high level of serum total immunoglobulin E (IgE) but deviation. also the production of IgE specific to Mycoplasma or common allergens during the course of Mycoplasma in- fection. It has been suggested that the balance of T helper esults of several studies over the past decade type 1 (TH1)/T helper type 2 (TH2) immune response have provided evidence linking Mycoplasma may regulate the synthesis of IgE. The objective of this Rinfection with asthma exacerbation and have study was to investigate the pattern of cytokine response raised the possibility that Mycoplasma infection is a (TH1 or TH2) during an episode of acute lower respira- factor in the pathogenesis of asthma. An acute exac- tory tract infection caused by Mycoplasma pneumoniae. erbation of wheezing in asthmatic participants in Study Design. Using a bronchoalveolar lavage (BAL) association with Mycoplasma infection has been well- with flexible bronchoscopy procedure, this study deter- 1,2 mined the levels of interleukin (IL)-2, interferon (IFN)-␥ documented. In addition, Mycoplasma pneumoniae (TH1), and IL-4 (TH2) in the supernatant of BAL fluid as has been found in the lower airways of chronic, well as the BAL cellular profiles of patients with Myco- stable asthmatics with a greater frequency than in -These results were com- control participants,3 suggesting a pathogenic mech .(14 ؍ plasma pneumonia (n pared with those of patients with pneumococcal pneu- anism in chronic asthma. It has even been suggested or those of children with no identifiable that Mycoplasma infection may be responsible for the (12 ؍ monia (n ؍ airway infections (control group: n 8). subsequent development of asthma. In a follow-up Results. The BAL cellular profile in the Mycoplasma study of 50 children with Mycoplasma respiratory pneumonia group was characterized by a high percent- age of neutrophils and lymphocytes. A significantly in- illness, 5 developed clinical signs of asthma for the 4 creased level of IL-2 was found in both pneumonia first time. There is also a report that describes a groups, compared with the control group. In contrast, the previously healthy participant who had an initial IFN-␥ level was not different for the 3 groups. The level asthmatic attack after recovering from Mycoplasma of IL-4 and ratio of IL-4/IFN-␥ were significantly elevated pneumonia.5 in the Mycoplasma pneumonia group, but not in the Several studies support the theory of a possible pneumococcal pneumonia group, compared with the relationship between Mycoplasma infection and the controls. onset of asthma. It has been reported that Myco- Conclusions. IL-4 levels and IL-4/IFN-␥ ratios in BAL plasma infections could induce transient or persistent fluid are significantly higher in patients with Myco- 5–7 plasma pneumonia than in patients with pneumococcal airway hyperresponsiveness. The level of serum pneumonia or control participants. The BAL cytokine total immunoglobulin E (IgE) has been shown to data suggest a predominant TH2-like cytokine response increase in the acute phase of Mycoplasma infection.8 in Mycoplasma pneumonia, thus representing a favor- As has been reported for virus infection, wheezing able condition for IgE production. Pediatrics 2001;107(3). during Mycoplasma infection may be related to higher URL: http://www.pediatrics.org/cgi/content/full/107/3/ serum IgE levels.9 Mycoplasma-specific IgE10 and IgE ␥ e39; interleukin-2, interferon- , interleukin-4, bronchoal- specific to common allergens unrelated to the infec- veolar lavage, Mycoplasma, pneumococcus, pneumonia. tious agent8 have been detected during the course of Mycoplasma infection. Although the baseline IgE lev- els have not been presented to be certain that the increase in IgE is caused by Mycoplasma infections, these observations raise the possibility that Myco- From the *Department of Pediatrics and Clinical Research Institute, Seoul National University Hospital, Seoul, Korea; and the ‡Department of Pedi- plasma infections may stimulate an inflammatory re- atrics, Inje University Sanggye Paik Hospital, Seoul, Korea. sponse that promotes IgE production. Received for publication Jul 5, 2000; accepted Sep 26, 2000. The development of cellular or humoral immune Reprint requests to (Y.Y.K.) Department of Pediatrics, Seoul National Uni- responses will depend on a repertoire of cytokines versity Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea. E- produced by numerous cells, including CD4ϩ helper mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- T cells. These lymphocytes can be subdivided into 2 emy of Pediatrics. subsets, T helper type 1 (TH1) and T helper type 2 http://www.pediatrics.org/cgi/content/full/107/3/Downloaded from www.aappublications.org/newse39 by guestPEDIATRICS on September 24, Vol. 2021 107 No. 3 March 2001 1of7 (TH2), based on their cytokine profiles.11 TH1 cells Olympus, New Hyde Park, NY) for children Ͻ8 years old and a are characterized by the secretion of interferon 4.8-mm flexible bronchoscope (Olympus BF-1T10) for older chil- ␥ dren. Premedication consisted of intramuscular atropine sulfate (IFN)- and interleukin (IL)-2 and promote cell-me- (0.01–0.02 mg/kg and Ͻ1 mg) and intravenous midazolam (0.1– diated immunity. TH2 cells selectively produce IL-4 0.2 mg/kg). During bronchoscopy, oxygen and epinephrine were and IL-5, and they are involved in the development readily available, and patients had an intravenous infusion to of humoral immunity. It has been suggested that the provide venous access. Heart rate and transcutaneous oxygen balance of TH1/TH2 immune response may regulate saturation were monitored throughout the procedure and contin- ued for 1 hour. Topical anesthesia of the upper and lower airways the synthesis of IgE, because IL-4 is the critical stim- used 2% lidocaine. BAL was performed either in an area most ulus that induces the isotype switch to IgE antibody prominently affected on the chest radiographs (pneumonia production, whereas IFN-␥ inhibits the switch.12 groups) or in the right middle lobe (control group) by gently The aim of this study was to investigate the pattern wedging the tip of the bronchoscope in a segmental or subseg- mental bronchus. Three 1-mL/kg aliquots of sterile, nonbacterio- of cytokine response (TH1 or TH2) during an episode static saline at room temperature were instilled through the in- of acute lower respiratory infection caused by M strumentation channel. Each aliquot was immediately aspirated pneumoniae. To perform the study, we determined into a sterile specimen container using a wall suction pressure of the levels of IL-2, IFN-␥ (TH1), and IL-4 (TH2) in the 100 to 150 mm Hg. BAL fluid aspirated after each instillation was supernatant of bronchoalveolar lavage (BAL) fluid as pooled together into a single specimen and immediately placed on ice. well as the BAL cellular profiles in patients with Mycoplasma pneumonia. These results were com- Processing and Analysis of the BAL Fluid pared with those of patients with pneumococcal The total amount of recovered fluid was measured and the pneumonia or those of children with no identifiable recovery was calculated as a percentage of the volume instilled. airway infections (control group). Pooled BAL fluid was placed into 2 aliquots. One aliquot of the pooled BAL fluid was submitted for viral (respiratory syncytial METHODS virus, adenovirus, influenza A and B, parainfluenza 1 and 3, and cytomegalovirus) and bacterial cultures to the hospital microbiol- Study Population ogy department. The remainder of the pooled BAL fluid was taken The study participants included 14 patients with Mycoplasma to the laboratory for analysis of the cellular and fluid fractions. pneumonia, 12 patients with pneumococcal pneumonia, and 8 The fluid was centrifuged at 400 g for 10 minutes at 4°C to controls who underwent fiber-optic bronchoscopy (FB) with BAL separate fluid from cells. Total cell count was measured using a between January and July of 1999 as part of an approved study hemocytometer (Weber, Teddington, United Kingdom). Differen- protocol or for clinical indications. Complete history taking, phys- tials were obtained from cytospin (Shandon, Pittsburgh, PA) slide ical examination, and routine laboratory testing were performed preparations, using a May-Grunwald-Giemsa stain and by figur- on all participants. Serum total IgE was measured on the day of FB ing a percentage of 400 cells. The cell-free fluid was frozen at with BAL. None of them had previously suffered from allergic Ϫ70°C until required for cytokine assay. disease or experienced asthma-like syndrome. The Mycoplasma pneumonia group consisted of 8 boys and 6 girls (mean: 7.1 years old; range: 3.2–12.9 years) who had a clinical Concentration of the BAL Fluid condition that necessitated hospitalization. The diagnosis of My- Because of the large dilution effect of the instilled fluid and the coplasma pnuemonia
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