© Borgis - New Medicine 3/2008, s. 64-66
*Małgorzata Dębska1, Joanna Peradzyńska2, Mieczysław Chmielik1, Marek Kulus2
EXAMINATION OF THE ULTRASTRUCTURE OF THE RESPIRATORY EPITHELIUM CILIA IN CHILDREN WITH RECURRENT INFECTION OF THE RESPIRATORY TRACT
1Department of Paediatric Otorhinolaryngology, Medical University of Warsaw
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
2Department of Child Pneumonology and Allergology, Medical University of Warsaw
Head of Department: Prof. Marek Kulus, MD, PhD
Summary
Introduction: The article presents the comprehensive diagnostics of recurrent infections of the respiratory tract in children. The indications for examination of the ultrastructure of the cilia in the respiratory epithelium were analysed.
Aim: To analyse the clinical value of selected diagnostic methods used for recurrent respiratory tract infections.
Material and methods: Patients with recurrent respiratory tract infections hospitalized in the Clinic of Pulmonology and Allergology and the Clinic of Paediatric Laryngology in 2006 and 2007. All the patients underwent basic tests, several of CT of the sinuses, spirometry and bacteriological examination.
Results: In all patients (except one) the results of the basic exams as well as of the chloride levels of sweat were correct. The results of the chest radiography were positive in 18 cases. In all patients the respiratory epithelium was sampled for examination of the cilium ultrastructure. It was sampled from the nose in 27 cases and from the trachea in 4 cases. The most common pathology in the cilium ultrastructure was missing dynein arms.
Conclusions: In almost 100% of cases of children with recurrent infections of the respiratory tract, no cilia or very few of them were present in the respiratory epithelium. Sampling of the respiratory epithelium is a valuable diagnostic method in children with recurrent infection of the respiratory tract.
INTRODUCTION
The article presents the comprehensive diagnostics of recurrent infections of the respiratory tract in children. The indications for examination of the ultrastructure of the cilia in the respiratory epithelium were analysed.
The diagnosis of recurrent infections of the upper and lower respiratory tract requires an interdisciplinary approach. Children with this condition seek consultation of a paediatrician, an allergologist, a laryngologist or an immunologist (6, 11,1 3). The diagnostics includes the following tests (3, 4, 7, 10, 12):
– basic: blood count, blood sedimentation, CRP,
– immunological: levels of IGA, IgG, IgM, IgA; examination of the subpopulation of lymphocytes; chemiluminescence in granulocytes, etc.,
– allergological: allergy tests, total and specific IgE levels, spirometry,
– radiological: chest radiography, nasopharyngeal radiography, CT scan of the sinuses and the chest, examination of the gastrointestinal tract and ultrasound of the abdominal cavity,
– infectious factors: IgG and IgM antibodies to Mycoplasma pneumoniae, Chlamydia pneumoniae, RS virus, Cytomegaly virus, Ebstein-Barr virus, adenoviruses; tests for Mycobacterium tuberculosis,
– tests for cystic fibrosis.
AIM
An attempt to analyse the clinical value of selected diagnostic methods used for recurrent respiratory tract infections.
Patients with recurrent respiratory tract infection hospitalised in the Clinic of Pulmonology and Allergology and the Clinic of Paediatric Laryngology of the SPDSK in 2006 and 2007 were included. The analysis concerned 31 patients, 19 boys and 12 girls aged 1 to 15 (8 years old on average). The largest group (18 patients) consisted of children aged 6 to 10; seven children were 6 to 10 years old, and six children were over 10. The children were healthy during the hospitalisation. Only individual cases of acute infections were observed.
METHODS
An analysis of the diagnostic methods in recurrent respiratory tract infections in children presenting diagnostic difficulties was carried out. All the patients underwent basic tests: peripheral blood count, blood sedimentation, CRP, total immunoglobulin A, G, M and E levels, chloride levels of sweat, chest radiography, allergic examination of the mucous membrane of the nose or bronchi in order to analyse the ultrastructure of the respiratory epithelium cilia. 14 patients underwent a CT of the sinuses, and several of them underwent spirometry and bacteriological examination of the nasal, pharyngeal or bronchial secretions (also for tuberculosis infection).
RESULTS
In all patients but one (who had anaemia), the results of the basic exams as well as of the chloride levels of sweat were correct. In 3 cases the level of IgA was lowered and in one case the level of IgM was lowered.
Three children had positive Chlamydia pneumoniae serology, one positive Mycoplasma pneumoniae serology, two positive RSV serology, one positive Adenovirus serology, and one positive EBV serology.
Results of the chest radiography were positive in 18 patients, and in four cases bronchiectasis was suspected (and confirmed by chest CT scan in 3 cases and excluded in one). Four patients presented with situs inversus, two with inflammatory changes and one with atelectatic changes. Lung cavity distention was observed in two patients, but additional tests excluded a TB aetiology.
Allergic tests showed food allergy in 9 cases and inhalation allergy in 7 cases. In 8 patients allergic rhinitis was diagnosed or confirmed, in 13 bronchial asthma, in 1 atopic dermatitis. A therapy was initiated or modified in accordance with the findings.
In all patients the respiratory epithelium was sampled for the examination of the cilium ultrastructure. It was sampled from the nose in 27 cases and from the trachea in 4 patients when the previous nasal sample had not determined a diagnosis.
In 9 patients the examination by the electron microscope (carried out by Dr Rowińska from the Institute of Anatomopathology of the Warsaw Medical University, head – Prof. A. Wasiutyński) showed no cilia on the epithelium, only microvilli, and in three cases neither cilia nor microvilli were observed. In one case no respiratory epithelium was present. This shows that in 13 children the exam did not determine any diagnosis.
In 18 cases it was established that the epithelial cells did not have cilia, only microvilli, but individual cells with cilia were found. The examination consisted of several to around a dozen transverse sections of one to a few dozen cilia. In 10 cases the ultrastructure of the cilium was correct, and in 8 it was incorrect. The most common pathology in the cilium ultrastructure was missing dynein arms; less common features were missing central tubules or radial spokes, asymmetry of the central tubules or the presence of additional tubules. In several sections correct and pathological cilia coexisted. In 8 cases the exam of the cilia ultrastructure allowed for a diagnosis of cilia dyskinesia.
In the 4 cases where the tracheal epithelium was
examined, cilia for the exam were always found. In the case of the nasal epithelium examination, in 8 cases (29%) no cilia were found, and in one patient no epithelium was present.
DISCUSSION
Recurrent infections of the respiratory tract in children are a frequent cause of medical consultation. Diagnostic methods include numerous paediatric, allergological, laryngological and immunological examinations and the analysis of the ultrastructure of the respiratory epithelium cilia is one of the most important among them (1, 2, 3, 4, 10). It is an invasive method and should therefore be used only in selected cases (1, 2, 9). The exam consists either in sampling the mucous membrane from the nasal concha with tweezers performed in local anaesthesia, or in sampling the mucous membrane from the trachea during bronchoscopy in general anaesthesia (1, 2, 9). In the present study in 30 (almost 100%) cases no cilia, only microvilli, were observed in the epithelial cells, and sometimes not even microvilli were found. One patient did not present with respiratory epithelium in the section. This condition of the respiratory epithelium may be caused by the recurrence of nonspecific infections of the respiratory tract, by an allergy or a local therapy of an allergy or an infection (1, 3, 4, 5). Damage of the respiratory epithelium increases the frequency of infections which leads to a „vicious circle”.
The moment of sampling must be chosen carefully. It should be performed in between infections to increase the chance of finding any parts of cilia in the section. The regeneration of the respiratory epithelium after an infection can take up to several weeks, and meanwhile the child is at risk of new infections which would disrupt regeneration and give cells with no cilia in the sections, with or without microvilli (1, 2, 3, 8, 9).
This is why the optimal moment to sample cilia is in summer, when the number of infections is relatively lower.
In 8 cases cilia dyskinesia was confirmed. These children also required pulmonological care due to chronic bronchitis and bronchiectasis (3 cases) and laryngological care due to chronic sinusitis (5 cases), otitis with effusion (1 case) and tonsil hypertrophy (1 case).
The relatively low number of children with humoral and cellular immunity disorders is conspicuous – only 4 cases in 31 (12.9%) – as well as the lack of children with cystic fibrosis, even though the patients suffered from recurrent infections of the upper and lower respiratory tract (3, 4).
CONCLUSIONS
In almost 100% of cases of children with recurrent infections of the respiratory tract, no cilia or very few of them were present in the respiratory epithelium.
The respiratory epithelium of 40% of patients did not contain cilia, with or without microvilli.
Sampling of the respiratory epithelium is a valuable diagnostic method in children with recurrent infection of the respiratory tract.
The sampling of nasal respiratory epithelium does not always determine a diagnosis. Tracheal epithelium is more reliable.
Dyskinetic and correct cilia can coexist in one patient and give an incomplete clinical picture of the dyskinesis.
In the present study in the examined group of children with recurrent infections of respiratory tract rarely humoral immunological disorders were observed.
Piśmiennictwo
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