Jpn. J. Infect. Dis., 54, 225‑228, 2001

Original Article

Non‑Specific Interstitial Pneumonia and Chlamydia pneumoniae Infection
Jiro Fujita*, Shuji Bandoh, Michiaki Tokuda, Yuji OhtsukiI, Ichiro Yamadori2,
Takeo Yoshinouchi3 and Toshihiko IshidaFirst Department ofJnternal Medicine, Kagawa Medical Universiol,
Miki‑cho I 750‑1, Kita‑gun, Kagawa 761‑0793.
1Department of Pathology, Kochi Medical School,
Kochi 783‑8505,

2Department of Pathology, National 0kayama Medical Center:
Okayama 700‑8558 and3Department oflnternal Medicine, Nagoya CioJ University,
Nagoya 467‑8602, Japan(Received August 14, 2001. Accepted November 6, 2001)

SUMMARY: Recently, the clinical features ofnon‑specific interstitial pneumonia (NSIP) have been described.
We hypothesize that recurrent infection caused by Chlamydiapneumoniae may play a role in the pathogenesis of
NSIP･ To prove this, we quantified serum lgA and lgG antibodies agalnSt C pneumoniae using the enzyme
linked‑immunosorbent assay kit･ The study included 1 5 patients diagnosed with NSIP, 20 patients with chronic

obstructive pulmonary diseases (COPD) as disease group, and 27 control subjects. IgA antibody against C.

pneumoniae was positive in 12 of 15 patients with NSIP, in 16 of20 patients with COPD, and in 14 of27 control
subjects･ 1gG antibody against C･ pneumoniae was positive in 14 of 15 patients with NSIP, in 17 of20 patientswith COPD, and in 16 of 27 control subjects. If the cut offvalue (mean ± 2SD, index more than 3.0) was

introduced, IgA and/or lgG antibodies against Cpneumoniae were positive in 8 of 1 5 patients with NSIP (53.3%),
in 9 of20 patients with COPD (45%), and in 2 of27 control subjects (7.4%). These results suggest that infectionof C. pneumoniae might play a role in the pathogenesis ofNSIP.

pneumoniae are positive in 70. 1% and in 96. 1%, respectively(14). These findings may indicate a significant role for C.
pneumoniae in the acute exacerbation of COPD.
McConnell et al ･ have described the radiographic appearanceof C･pneumoniae (15)･ ln Figure 3 oftheirarticle,they den?n‑

INTRODUCTION
In 1 994, Katzenstein and Fiorelli reported the histologlCfeatures and clinical significance of non‑specific interstitial

pneumonia (NSIP) ( 1 ). The histologic features ofNSIP include
a varylng degree of interstitial innammation and fibrosis

strated a chest X‑ray diagnosed as recurrent C. pneumonlae

which appear to develop over a specific time frame (i.e., theinfection in a 68‑year‑old woman (15). We considered thatprocess is temporarily uniform). Recently, Park et al. reported
the radiographic and CT findings (2) and clinical features (3)the figLue resembled a chest X‑ray Image OfNSIP,and therefore
hypothesized that chronic C･ pneumoniae infection might beof seven patients with NSIP. In addition, Bjoraker et al.

one orthe causes ofNSIP. With this in mind, we measured

reported that patients with usual interstitial pneumonia (UIP)
have a shorter survival than patients with other types ofanti‑C･ pneumoniae IgA as well as IgG antibodies in patientswith NSIP and patients with COPD, as a disease group, andidiopathic chronic interstitial pneumo.nia including NSIP (4)･

compared the resultswith those of control subjects.

More recently, Cottin et al. (5), Nagal et al. (6), and Fujita etal. (7) have described the clinical features ofNSIP. However,the pathogenesis of NSIP remains unclear. Since the term
"NSIP" refers to a histopathologlC Pattem and not a disease

PATIENTS ANJ) METHODSPatients: Between March 1990 and November 1997, 15

entlty, NSIP can result from a number of causes including
Chlamydia pneumoniae is a frequent cause of acute respi‑

patients (12 females and 3 males, median age 59; range from39 to 70) were diagnosed with NSIP confirmed histologi‑
cally (Table I). Ofthese, 4 had idiopathic NSIP and 1 1 hadratory infection and the most common species of Chlamydia

polymyositis (PM) or dermatomyositis (DM). PM/DM wasin humans (8). Primary infection by C. pneumoniae may cause

diagnosed according to the criteria of Bohan and Peter ( 1 6):

symptoms ranglng from severe to mild or may even be(i) syrr‑etric muscle weakness; (ii)typical histologic丘ndings

asymptomatic (8)･ In addition, the role of C. pneumoniae inon muscle biopsy; (iii) increased levels of muscle enzymes

infections, environmental insults, and drugs ( 1).

the exacerbation of chronic obstructive pulmonary diseases

in the sera; (iv) Compatible electromyographic findings; and(CO㌣D) has been studied (9‑13). In these studies, serology(V) characteristic dematologic manifestations.

revealed acute C. pneumoniae infection in 4 to 18% of thesubjects･ ln addition, Miyashita et al. have reported that in 77

The diagnoses ofNSIP were made by open‑lung biopsy.
All pathologlC Specimens were analyzed by lung pathologlStS(IY and YO) according to the criteria orNSIP described bypatients with CO㌣D, IgA and lgG antibodies agalnSt C.

Katzenstein.and Fiorelli ( 1 )･ Briefly, NSIP represented a pa伏em*Corresponding author: Tel: +8 I‑87‑891‑2145, Fax: +8 1187‑891‑

of chronic lnterStitial pneumonia that lacked characteristic

2 147, E‑mail: jiro@kms.acjp

features of other specific entities such as UIP, desquamative

225

Table 1. Patient characteristics

Case AgcandScx Background Rhcumatoidfactor J0‑I

58M

1 2 3 4 5 ′0 7 0 9 1 2 つJ 4 5DM

IgAindcx

Judge IgGindex Judge

<0･9

(‑)

70F

DM

3.02

(++)

39F

DM

L27

(+)

65F

PM

56F

PM

62F

PM

58M

PM

55F

DM

59F

PM

57F

DM

66M

DM

1
一一一一 + L

･62

<0
+

+

(i)

1

(+)

,95
2.43

(+)

,9

2,16

(‑)

L

(｣

2.3

(+)

(+)

77

(+)
(+)

2.09

(+)

5.98

(++)

3.49

(++)

3.34

(++)

4.14

(++)

0,9

2.75

(+)

1

67F

idiopathic

70F

idiopathic

(+)

1.99

53F

idiopathic

(++)

L

69F

idiopathic

(++)

1.5

+ 一一 +

(+)

1.77

(+)

<0.9

(++)

2.69

(+)

2.55

2.33

4,4

3.49

(‑)

(++)
(+)

8

(+)
1

(+)

DM: dcmatomyositis

PM : polymyositis

interstitial pneumonia (DIP), hypersensitivity pneumonitis,
bronchiolitis obliterans organizlng PneuntOnia (BOOP),

by HITAZYME C. pneumoniae kit (Hitachi Chemical Co.,

Langerhans'cell granulomatosis, or chronlC eOSinophilic

defined as follows:Ltd., Tbkyo) as described previously (18). The index was

pneumonia. Lung biopsleS in this group were characterizedby varying Proportions of chronic interstitial inflammation

Absorbance corrected by the referred serum

Absorbance of the cut off(0.2)

and fibrosis which were temporarily uniform.

Anindex ofmorethan 1.0 was considered to be positive (+),

We also evaluated 20 patients with COPD (1 female and19 males, median age 72; range from 49 to 78) and 27 control

and an index of more than 3.0 (mean± 2SD of the indexes ofsubjects (14 females and 1 3 males, median age 57; range &om

healthy persons) was considered to be strongly positive (++)

40 to 65). COPD was diagnosed as described previously (1 7).
Blood samples: Peripheral venous blood samples wereas described previously ( 1 8).

obtained before the subjects ate breakfast. After centrifuga‑

RESULTStion at 1,000 g for lOmin at4oC, the serum was frozen andstored at ‑700C until used.

lgAantibody agalnSt C. pneumoniae was positive in I 2 of

Measurement of lgA and lgG antibodies against C.

15 patients with NSIP (80%), in 1 6 of20 patients with COPD

pneumon,lap by eTIZ:yme‑linked immunosorbent assay(ELISA): IgA and/or IgG antibodies in sera were measured(80%), and in 14 of27 control subjects (51.9%) (Fig. lA).
lgGantibody agalnst C. pneumoniae was positive in 14 of 1 5(A) ZgA(BI ZgG●●●

L T 4 3 つ○▲】つ一2

｡ ･ ･ ･ 一一･●●(76Z) H CJtH(○申H) H etH●●●･･‑> 一･A●●●･･･〜I･IJ

●●■■
●●

i:?
I++

●

●…

a
■■‑‑

COy℡RO工.
StnJEC℡SCOmL tTS I P COEDNS I P COED(J)≡15)(h=20 )

StnJEC℡S tn=15〉

th=27)(JZ≡20I

tn=27)

Fig･ 1 ･ Titcrs ofanti‑Chlamydia pneumoniae lgA (A) and lgG (B) antibodies in patients with NSIP, COPD, and control subjects.

An index ofmorethan 1 ･O is considered to be positive (+), and an index ofmorcthan 3.0 is considered strongly positive (++).

226

Table 2, Strongly positive rates of IgA antibody, lgG antibody, andSince four patients with NSIP had a rheumatoid factor, theIgA and/or IgG antibodies agalnSt Chlamydia pneumoniae in NSIP,

possibilityof false positive results caused by HITAZYME C.

COPD, and control subjects
IgA

NSIP

5/15 (33%)*

COPD

3/20 ( 1 5%)

Contro1

IgG

2/27 ( 7%)

lgA

an〟or

lgG

8/15 (53%)***

anti‑C. pneumoniae IgM immunonuorescence assay (24), we

9/20 (45%)**

evaluated only lgA and lgGantibodies against C. pneumoniae.

2/27 ( 7%)

In addition, it has been reported the rheumatoid factor does not

4/15 (27%)+
8/20 (40%)**I/27 ( 4%)pneumoniae should be discussed. Although it has beenreported that the rheumatoid factor affects the results of theamect these lgAand lgG ELISAs( 1 8). Therefore, fTalse positive

NSIP: non‑specific intcrstitialpncumonia
COPD: chronic obstructive pulmonary discasc

results caused by the rheumatoid factor will be overlooked in*P< 0.05, **P< 0.01, ***P< 0.00l comparcdwith control

our study.

The pathogenesis of C. pneumoniae infection is still largely

unknown. 1n an animal model of C. pneumoniae infection, amild peribronchial and perivascular lymphoid infiltration andpatients with NSIP (93.3%) and in 17 of20 patients with
COPD (85%), and in 16 of27 control subjects (59.3%) (Fig.

nodular hyperplasia characterize the prlmary infection in thelungs (25). Reinfection results in a significant increase in themagnitude of the lymphoid reaction (25). Overall, 1ymphoidlB). Strongly positive lgA antibody was obseⅣed in 5 of 15

patients with NSp (33･3%; P < 0･05 by I‑sqpare test comparedwith control subjects) and in 3 of 20 patlentS With COPD

reactions remain detectable up to 61 days after pnmary
challenge and rechallenge (25). This evidence may explain(1 5%), and in 2 of27 control subjects (7.4%) (Table 2). Strongly
positive lgG antibody was observed in 4 or 15 patients with
NSIP (26･7%; P < 0･05 by I:square test compared withcontroI
subjects) and in 8 of20 patlentS With COPD (40%; P < 0.01

the increase of lymphocytes in bronchoalveolar lavagefluidin patients with NSIP and its clinical course (usually subacuteonset).

by x‑square test compared with control subjects), and in 1 of

Our study included 1 1 patients with NSIP complicated with27 control subjects (3･7%) (Table 2)･ In total, strongly pos.itive

PM/DM. Therefore, the relationship between C. pneumoniae
and the onset orPM/DM should be discussed. ln the mouseand rabbit models of C. pneumoniae pneumonitis,the organismlgA and/or lgG antibodies were obseⅣed in 8 or 1 5 patlentSwith NSIP (53.3%; P < 0.001 by I‑square test compared with
control subjects) and in 9 of20 patients with COPD (45%; P

has been shown to spread from the resplratOry tract tO Other< 0.01 by I‑square test compared with control subjects), andorgans fわllowing intranasal inoculation (26,27). In addition,in 2 of27 control subjects (7.4%) (Table 2).

it has been postulated that systemic dissemination of C.
pneumoniae occurs by infection of monocytes/macrophages

and consequently spreading of the organism via the blood or

DISCUSSION

lymphatic circulation (28). In humans, C. pneumoniae has

ln our present study, we demonstrate that the anti‑C.

been detected by polymerase chain reaction in the liver, spleen,

pneumoniae lgAand lgG antibodies detemined by HITAZYME

and lymph nodes during systemic disease (29). This evidence

C. pneumoniae in patients with NSIP were high compared tosuggests that C. pneumoniae infected through the resplratOrythe values of the control subjects. In addition, the levels oftract could spread to several organs and could cause systemicthese antibodies were comparable with those or patients withdiseases. Interestlngly, it has also been reported that the 60‑

COPD.
ln the present study, IgA and/or lgG antibodies deteminedkilodalton cysteineィich outer membrane proteins of C.

pneumoniae has sequence homology to a peptide kom theby HITAZYME C. pneumoniae were positive in all patientswith NSIP. HITAZYME C. pneumoniae is a diagnostic

murine heart muscle‑specific a myosin heav.y chain (30)･

reagent that has been recently developed by adopting anfrom C. pneumoniae cross‑react to muscle proteins and/or

ELISA method for the detection of anti‑C. pneumoniae anti‑

skin proteins, resulting in the onset of PM/DM･

bodies (18). ln addition, Kishimoto et al. have established a
new diagnostic standard for HITAZYME C. pneumoniae by

available, future studies to detect C. pneumoniae antigen by

settlng uP Special cut‑offvalues for a slngle serum for diagno‑

immunohistochemistry, or to detect C. pneumoniae DNA

sis of C. pneumoniae infection (1 8). They reported that if auslng ln Situ hybridization or polymerase chain reaction,

special cut‑off value at index 3.0 fb∫ both lgA and lgG isshould be perf♭med.

Therefore, it can be speculated that other antlgenS derived

Since surglCal lung specimens from patients with NSIP aredefined (the calculation of "mean + 2SD" of healthy persons),

In summary, we describe the first evidence that lgA and/or

most healthy persons fall within the range of the negativelgG anti‑C. pneumoniae antibodies were elevated in patientswith NSIP. Recurrent C. pneumoniae infection might play azone, and when this cut‑off value is applied, the rate of> index 3.0 for either lgA or lgG is 7.6% for healthy persons,and 64.9% for infected patients. They determined that ifrole in the pathogenesis or NSIP.

index is 3.0 0r greater for lgA and/or lgG, it is highly likely

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228