Mechanisms in organic dust related airway diseases Antalya April 29 th 2005

2. Mechanisms in organic dust related airway diseasesAntalya April 29th 2005 Torben Sigsgaard; Professor, MD, PhD Department of Environmental & Occupational Medicine, Institute of Public HealthUniversity of Aarhus, DENMARK

3. If you thresh mouldy Barley you should bind a Cloth before your Mouth, that is dipped in Cider of good Quality. Otherwise You might loose your Life. Olaus Magnus, De Gentibus Nordicus, Vatican 1546

4. Farming Swine confinement buildings Hen houses, pigeon houses…. Grain elevators Feed elevators Silage containers Straw - hay Forestry Wood Woodchips Bark Fishing Industry fish Fish meat Consum fish Occupations with exposureto organic dust

5. Diseases in organic dust exposed • Toxic pneumonitis (ODTS) • Extr. allergic alveolitis HP • Asthma • Allergic • Inflammatory • COPD • Work related cough • Byssinosis • Mucus membrane irritation

6. Respiratory symptoms in 4,793 European farmers Monso & al; m J Respir Crit Care Med 2000 Oct;162(4 Pt 1):1246-50

7. Atopy, allergic and non-allergic asthma in Norwegian farmers (Eduard et al., Allergy 2004)

8. Microorganisms, etiologic agents, markers and effects

9. Endotoxin (Lipopolysaccharide [LPS]) • First described by Pfeiffer in 1892 (Zf f Hygiene) as heat stable, cell associated material from Vibrio cholerae • part of the outer membrane of all gram negative bacteria and some blue algae • Commonly present in many occupational environments but also in the general environment

10. Endotoxin levels in various agricultural environments

11. some well designed observational studies on acute respiratory effects suggest LOELs/NOELs below 100 EU/m3 (Milton 1994, 1995; Zock 1998) Dutch recommended OEL is set at 50 EU/m3 based on a challenge study with endotoxin containing cotton dust (LOEL  90 EU/ m3) (DECOS 1998) Dose response relationship for endotoxin 5 sessions with 20 persons (Castellan et al NEJM 1987)

12. Normal Valic et al 75 Beck et al Zuskin et al Berry et al Iversen et al 21-31 ml/yr 48 fem 45 vs 25 59 fem 68 male 54 60 smoking swinefarmers Lung functionFollow up studies of FEV1

13. Main - Exposure (Anamnesis, measurements precipitins) Criteria Symptoms (Cough dyspnoea tiredness ...) X-ray signs (thorax) -------- ------------------------- Bi- Lowered diffusion capacity Criteria Lowered PaO2 Lowered lung function Basal crepitations Positive provocation tests Positive lungbiopsy Allergic Alveolitis

14. Bagassosis Sugar cane Jamison 41 T.Vulgaris T.saccari Pepy Lacey et al Vallery-Radot 28 Malt worker Barley A. clavatus Riddle 69 et al lung Wood Wood workers l Towey 32, Emanuel 62 Paper prod. C. corticale A. alta Schlueter 72 et al Cork Cancella 59 Suberosis P. frequentans Avila 74 et al Etc. Allergic Alveolitis

15. Main- Exposure (Anamnesis, measurements precipitins) criteria Symptoms (Cough dyspnoea tiredness etc.) -------- ------------------------- X-ray changes (thorax) -------- ------------------------- Bi- Diffusion capacity low criteria PaO2 low Lung function reduction Basal crepitations Positive provocation test Changes in lung biopsy Toxic Alveolitis (ODTS) X

16. Agent Mill fever Cotton Schilling Endotoxin Rylander - Dried sewage sludge Mattsby & Rylander Gr neg bacteria Garbage Sigsgaard Endotoxins Composting (sludge) Manzdorf et al bacteria Humidifier-fever Endotoxins Rylander et al Bacteria Hansen Toxic Alveolitis (ODTS)

17. ODDS RATIO FOR CHEST TIGHTNESS& TOXIC PNEUMONITIS AMONG PAPER WORKERS Sigsgaard et al Occupational Hygiene; 1994 177-189 LIGHTLY EXPOSED <= 25 NG ENDOTOXIN/M3HEAVILY EXPOSED > 25 NG ENDOTOXIN/M3

18. Mould spore concentration in association with Allergic Alveolitis & Toxic Pmeumonitis Spore count*/m3 Rask Andersen et Malmberg Am J Ind Med 1990 116-117 *; Direct counting method

19. Toxic alveolitis in cotton mills after the WW2 • In a mill with app 400 workers cotton was reintroduced after the embargo in September 1945. • In a report from the Labour inspection 1945-46 the medical officer states: • ”Almost all workers suffered from fever and chills – However most people recovered within the first 3 months”

20. Allergic alveolitis

21. Allergic Alveolitis H&E, 47x Necrotising granulomas Tcell infiltration Type4?? H&E, 160x

22. Mechanism Organic Dust Alveolar macrophages Epithelial cells IL-1 TNF- Fever IL-6 IL-8 proliferation Chemotactic factor B cells Activation T cells Eosinophils PMN’s Plasma cells

23. Allergic Inflammatory Byssinosis Chest tightness +++ +++ +++ Mondays tightness + +++ Wheezing +++ +++ ++ Cough + ++ ++ Start delayed quick after years Duration after exposure short yrs gr < 3 short gr 3 yrs AsthmaPeriodic decline in lung functionDifferent types

24. Occupational Type I Allergens Cat, dog, horse and cow dander Wheat, rye flour proteins; Soy proteins? Amylase and other industrial enzymes Rat and mouse urinary proteins

25. TOLL-like receptors TLR10 TLR11 TLR12 Imidazoquinolinamines TLR8 TLR7 T-cell activation

26. Innate receptors for PAMPs related to respiratory toxicology • LPS • CD14 Rietschel • LBP Wright, Ulevitch • BPI • PLUNC Lindblad • TLR4 • Peptidoglycan • Tomasic • B-Glucans • DECT1 Brown & Gordon • TLR2 Czop Goldman

27. Effect of mediators Toxic alveolitis (Organic Dust Toxic Syndrome) 4–8 hours after the exposurea generalised reaction is seenwith fever and flue like feeling An inflammatoric reaction is also seen inthe lung tissue, caracterised by transientchanges in histamin reactivity and gas transfer(Rylander 90)

28. Cytokines TNF-a IL-1b IL-6 IL-8 LBP LBP LPS LPS TNFR1 MyD88 TRAF6 NIK IKK TRAF2 NFkb LPS & inflammation LPS + PLUNC ?? BPI LPS LPS LPS LPS LPS LPS BPI/Plunc Superfamily LPS LPS LPS LPS LPS HDL LPS BPI Lp C D 1 4 S C D 1 4 T L R 4 IL1R1 LPS AcP r CD14 neg celler MACROPHAGE

29. MyD88 TRAF6 NIK IKK NFkb Receptors for b-Glucan TLR6/2 TLR1/2 DECT Y DECT1 Oxidative burst TNFa IL12

30. Experimental setup in swine confinement buildings Gumboot immunology

31. AIBAL exposure protocol Baseline Exposure Follow-up Spirometry Blood Exercse Blood Exercise Blood Exercise Spirometry Blood NO AR NAL PD20 Blood Blood Blood -1wk 0 1 2 34 6 12 24 +1 +2 wk hours Blood Box BAL NO AR NAL PD20 Prick test NO AR NAL Blood PD20 NO AR NAL Blood PD20 NO AR NAL Blood Box BAL 8 cases with asthma like symptoms when working with swine 8 controls without symptoms when working with swine

32. Serum and BAL Il-1b are reduced in cases *

33. BAL neutrophil numbers increase more in controls than in cases

34. Differential regulation of Serum and BAL Il-8 during the study period

35. BAL IL-8 concentration ratio and BAL neutrophil response *

36. Smokers Lower IgG levels, increased decline in FEV1 Sigsgaard et al AJIM 1992, 163-84 Sigsgaard et al AJIM 2004 Atopics Greater decline in FEV1 independently of disease Show ”exhaustion” effect in ex vivo analyses Krüger et al 2004 TLR4 pmp  hyporesponsiveness to LPS in a farming population Arbour et al; Nature Genetics, 2000,187-91 TLR2 pmp  loss of beneficial effect of farming exposure Lauener et al; Lancet, 2002, 465-466 Glucan reactivity ??? A-1-Antitrypsin Pi-M pmp  increased reactivity to org dust Sigsgaard et al; Pharmacogenetics 1994 Sigsgaard et al; ERJ 2000 TLR10 PMP Associated to asthma phenotype Lazarus et al. AJRCCM 2004 Susceptibility

37. Odds ratio$ (95% c.i.) for bronchial hyperreactivity according to Pi-phenotype among 2000 farming school attendants Sigsgaard et al ERJ 2000p56-61 * PD20 < 1.44 mg histamine $ adjusted for FEV1

38. PMN’s in nasal lavage after LPSAmong symptomatic and asymptomatic garbage workers Asymptomatic P < 0.05 MW Symptomatic Sigsgaard et al Eur Respir J; 2000, vol 16; 140-145

39. Lung response to LPS exposure among asthmatics and non-asthmatics Normal 13 Asthmatics 38 FEV1 Equal effect on FEV1 and FVC FVC Subjects with BHR and/or asthma are more sensitive to develop symptoms (Michel 1989, 1992, 1997)

40. Thank you for your attention