대한비과학회

－ 14 －

Effect of Long-Term Low-Dose Macrolide Therapy in Children with Chronic Rhinosinusitis

Seon Tae Kim, M.D.

, Jung Hoon Lee, M.D.

, Heung Eog Cha, M.D.

, Jin Ho Choi, M.D.

, You Jin Hwang, Ph.D.

and Yoo-Sam Chun, M.D.

ABSTRACT

Backgrounds and Objective s：We studied the effect of long-term low-dose macrolide therapy on the level of IL-8, IL-1

β, and TNF-α in the nasal secretions get from children with chronic rhinosinusitis before and after medication, and investi- gated the association between the changes in the chemical mediator levels and the clinical outcome before and after macrolide treatment. Materials and Methods：The nasal lavage was obtained from 10 patients with nonallergic chronic rhinosinusitis and also from 10 healthy children. Nasal lavage was o btained before and 1 month after full dose (8 mg/kg ) macrolide admi- nistration, and then second lavage was obtained after half dose (4 mg/kg ) administration for 2 month. The level of IL-8, IL-1 β, and TNF-α in nasal lavage were measured by using ELISA kit. The symptoms were also scored by visual analogue scale before and after treatment. Results：The IL-8 concentration was decreased from 317.4 pg/ml to 227.1 pg/ml at 12 weeks after this treatment (p<0.05). The level of IL-1β was decreased from 412.5 pg/ml to 41.5 pg/ml (p<0.05), and TNF-α was also decreased from 49.8 pg/ml to 3.9 pg/ml (p<0.05). The symptoms of most patients with macrolide trea - tment were improved at 3 months after treatment. Conclusion：Macrolide decreased the concentration of inflammatory mediators in nasal discharge, such as IL-8, IL-1β, and TNF-α and this anti-inflammatory effect of macrolide could explain the way of improvement with subclinical dosage of drug.

KEY WORDS

：Macrolide・Rhinosinusitis ・IL-8・IL-1β・TNF-α.

INTRODUCTION

A number of authors have documented the efficacy of long-term low-dose macrolide administration on si- nobronchial syndrome and chronic sinusitis. However, the mechanism involved in the action of the drug is not fully understood. Several lines of evidence indicate that a bactericidal effect is unlikely to be the essential mode of action of this drug in this therapy. It has been revealed by in vitro studies that these drugs modulate

the proliferation, differentiation, cytokine production, and phagocytosis of monocytes and macrophages, im- prove the ciliary movement of airway epithelium, inhi- bition and mucus secretion from epithelial cells, and inhibit bacterial adherence to nasal epithelial cells.

A number of results to effect of macrolides on adults with chronic sinusitis have been reported. However, the efficacy of macrolide use in pediatrics on chronic rhi- nosinusitis have not reported yet.

IL-8, neutrophil elastase, and LTB

have been known to contribute to the neutrophilic inflammation in the airways of chronic lower respiratory tract infection pa- tients. However, it is not certainly known to changes of neutrophil chemotactic factor except for IL-8, which is involved in increase of neutrophils, in addition to clinical effect, after macrolide treatment in the nasal cavity.

Thus, in this study, we examined IL-1β, and TNF- α as well as IL-8 levels in nasal lavage from children with chronic rhinosinusitis before and after macrolide treatment. Additionally we investigated the association between the changes in the chemical mediator levels

1

Department of Otolaryngology Head and Neck Surgery,

Mo- lecular Biology Lab, Gil Medical Center, Gachon Medical School, Incheon,

Department of Otolaryngology Head and Neck Su- rgery, College of Medical, Ulsan University, Asan Medical Center, Seoul, Korea

Address correspondences and reprint requests to Seon Tae Kim, M.D., Department of Otorhinolaryngology Head and Neck Su- rgery, Gachon Medical School, Gil Medical Center 1198 Guwol- dong Namdong-gu, Incheon 405–760, Korea

Tel：82-32-460-3764, Fax：82-32-467-9044

E-mail：[email protected]

Accepted for publication on May 29, 2003

and the clinical outcome before and after treatment.

MATERIAL AND METHODS

Samples were collected from 10 children with nona- llergic chronic rhinosinusitis. The subjects consisted of 6 males and 4 females, ranging in age from 6 to 15 years, with an average age of 9.3 years. The diagnosis was made based on the clinical symptoms, rhinoscopic findings, paranasal sinus radiographs, skin test, and negative RAST for specific IgE for dust mite. All patients suffered more than 3 months from the follo- wing symptoms：chronic nasal congestion, chronic rhinorrhea, and chronic coughing. The patients did not receive antibiotics, antihistamines, antiallergic medicine, or corticosteroids for at least 4 weeks before sample collection. Patients were given macrolides, roxithro- mycin for 12 weeks. Full dose (8 mg/kg) was given for the first 4 weeks, and half dose (4 mg/kg) for next 8 weeks. Nasal lavage was collected before treatment and at 1, and 3 months after the beginning of the trea- tment. Nasal lavage was also obtained from 10 healthy subjects (5 males and 5 females). Control group ages ranged from 7 to 14 years, with an average age of 8.5 years.

Method of collecting nasal lavage was that 5 ml of normal saline was delivered into each nostril of the su- bject, and after 10 seconds, the wash fluid was collected in a tube. After centrifugation, the supernatants were transferred to other tube and stored at -20℃. IL-8, IL-1β, and TNF-α levels of the nasal lavage were measured using an ELISA kit (BD PharMingen

).

To investigate the effect of macrolides on clinical symptoms between before and after treatment, sympt- oms were scored by parents using visual analog method.

A score of 0 was given when a symptom was not pre- sent, and numbers up to 3 were given when a symptom was present, with 3 indicating greatest severity. Sym- ptoms to be scored were nasal obstruction, rhinorrhea, nasal blowing, and chronic coughing. Actual scoring was always performed by the same person in each child. We defined improvement as reduction of score by more than 4 after treatment.

Data values were expressed as mean±standard de- viation, and statistical significane of differences was te- sted by using a paired t-test. Differences were estimated to be significant when p value was less than 0.05.

RESULTS

We examined the levels of three chemical mediators in nasal lavage from 10 chronic rhinosinusitis children and 10 normal controls. IL-8 levels in nasal lavage from children with chronic rhinosinusitis (317.4±78.9 pg/

ml) were significantly higher than normal controls (36.5±28.9 pg/ml)(Fig. 1). IL-1β levels from chr- onic rhinosinusitis (412.51±121.5) were higher than normal controls (11.0±4.4)(Fig. 3). TNF-α levels in chronic rhinosinusitis children (49.8±27.1 pg/ml) were also higher than normal controls (3.8±0.2 pg/ml) (Fig. 5).

IL-8, IL-1β, and TNF-α levels were decreased si- gnificantly at 3 months after the beginning of the ma- crolide treatment, but not at 1 month (Fig. 1, 3, 5). The IL-8 concentrations in the nasal lavage from children

400 350 300 250 200 150 100 50

1

0 (Month)

Concentration of IL-8 (pg/ml)

0 Control 3

*

Control CRS

**

Fig. 1. The effects of macrolide on IL-8 in nasal lavage. The IL-8 levels in nasal lavage of normal controls (n=10) and of children with chromic rhinosinusitis before treatment and at 1, and 3 months after the beginning of the treatment (n=10) are shown respectively (*：p<0.05, **：p<0.001).

450 400 350 300 250 200 150 100 50

0 0 3 (Month)

*

Concentration of IL-8 (pg/ml)

Fig. 2. The IL-8 changes in children (n=7) with improvement of symptom. The IL-8 levels were decreased significantly at 3 mo- nths after the beginning of the macrolide treatment (*：p<0.05).

with chronic rhinosinusitis decreased significantly from 317.4 pg/ml to 227.10 pg/ml at 3 months after the beginning of this treatment (p<0.05)(Fig. 1). The IL- 1β concentrations decreased from 412.51 pg/ ml to 41.53 pg/ml (p<0.05)(Fig. 3). The TNF-α conce- ntrations decreased from 49.8 pg/ml to 3.90 pg/ml (p<0.05)(Fig. 5).

Macrolide treatment improved symptoms in 70% (7 of 10) of children. We have defined improvement as reduction of score by more than 4 after treatment. The average score decreased from 9.1 to 3.5. We observed no patients with increase of quantitative score. Most children experienced the improvement of clinical out- come, and the parents agreed on this point (Table 1).

In case 3, after the macrolide treatment, all of IL-8, IL- 1β, and TNF-α levels increased, and also we did not observed the particular change of symptoms. In case 4, after the treatment, only IL-8 levels increased. In case 7, IL-8, IL-1β, and TNF-α levels were all decreased significantly after this treatment. Also case 4 and 7 had

less change of symptoms (Table 1). In the improve- ment group, IL-8, IL-1β, and TNF-α levels were de- creased significantly at 3 months after the beginning of the macrolide treatment (p<0.05) (Fig. 2, 4, 6).

Table 1. The clinical symptoms and IL-8 levels

Symptom score IL-8 levels Case

Before After 3 mon Before After 3 mon

01 10.1 1.5 I 291.5 103.5

02 10.1 3.5 I 366.5 051.5

03 09.1 8.5 N 153.5 372.5

04 11.1 8.5 N 231.5 298.5

05 10.1 2.5 I 280.5 256.5

06 11.1 0.5 I 382.5 109.5

07 10.1 7.5 N 412.5 246.5

08 11.1 0.5 I 344.5 232.5

09 09.1 3.5 I 363.5 339.5

10 10.1 3.5 I 352.5 265.5

Average 09.1 3.5 317.4 227.1

I：improved, N：no change

600 500 400 300 200 100

1

0 (Month)

*

Concentration of IL-1β (pg/ml)

0 Control 3

* *

Control CRS

Fig. 3. The effects of macrolide on IL-1β in nasal lavage. The IL-1β levels in nasal lavage of normal controls (n=10) and of children with chronic rhinosinusitis before treatment and at 1, and 3 months after the beginning of the treatment (n=10) are shown respectively (*：p<0.05).

2000

3

0 (Month)

*

Concentration of IL-1β (pg/ml) 1800 1600 1400 1200 1000 800 600 400 200 0

Fig. 4. The IL-1β changes in children (n=7) with improvement of symptom. The IL-8 levels were decreased significantly at 3 mo- nths after the beginning of the macrolide treatment (*：p<0.05).

100 90 80 70 60 50 40 30 20 10

1

0 (Month)

*

Concentration of TNF-α (pg/ml)

0 Control 3

* *

Control CRS

Fig. 5. The effects of macrolide on TNF-α in nasal lavage. The TNF-α levels in nasal lavage of normal controls (n=10) and of children wit h chromic rhinosinusitis before treatment and at 1, and 3 months after the beginning of the treatment (n=10) are shown respectively (*：p<0.05).

180 160 140 120 100 80 60 40 20

0 0 3 (Month)

*

Concentration of TNF-α (pg/ml)

Fig. 6. The TNF -α changes in children (n=7) with improvement of symptom. The TNF -α levels were decreased significantly at 3 mo- nths after the beginning of the macrolide treatment (*：p<0.05).

DISCUSSION

Macrolide treatment was first reported to be very effective for diffuse panbronchiolitis in Japan.

Long- term macrolides have previously been reported to improve 10-year survival from 12.4% to over 90% in patients with diffuse panbronchiolitis, and improve lung function in those with bronchiectasis.

Chronic rhinosinusitis is characterized by mucosal neutrophil infiltration. Various mediators including IL- 8, IL-1β, LTB4 and neutrophil elastase, a neutrophil chemotactic factor, may be involved in the recruitment and activation of neutrophils in patients with airway infections.

Previous reports have indicated complex interactions between these mediators both in vivo and in vitro. The mRNA of IL-8 is highly expressed in maxillary mucosa of chronic rhinosinusitis,

and the levels of IL-8 in the nasal discharge of patients with chronic sinusitis is significantly higher. This is thought to result from induction of IL-8 from nasal epithelial cells, gland duct cells, and neutrophils from the conti- nuous inflammation.

Correlated with previous study, we also could find that IL-8, IL-1β, and TNF-α levels in nasal lavage from children with chronic rhinosinusitis were significantly higher than those from the normal controls. The associated increase in this chemical me- diators, neutrophil chemotactic factor indicates that all this chemical mediators play an important role in the activation of inflammation in chronic rhinosinusitis.

Yamada et al.,

reported that the IL-8 levels in nasal lavage from patients with nasal polyps were reduced during macrolide treatment. There was significant co- rrelation between decreased IL-8 levels in nasal lavage and the clinical effect of macrolides on the size of the nasal polyps. And they thought that IL-8 may be a use- ful prognostic marker to predict the effectiveness of macrolide therapy for nasal polyps, because the IL-8 levels before macrolide treatment in the improvement group were significantly higher than those in the no change group. In another study, using roxithromycin for 3 months, the subjective and objective symptoms have disappeared or decreased markedly, especially po- stnasal drip and nature of discharge in more than 80 % of the cases.

It was suggested that roxithromycin produced some clinically beneficial effect through an immunological and, or anti-inflammatory mechanisms

in addition to its antibiotic effect.

Erythromycin have been the drug of choice for in- fants and children with Legionnaire’s disease, pertussis, diphtheria, lower respiratory tract infections, and ente- ritis.

To our best knowledge, there is no report re- garding the efficacy of macrolide use in pediatrics have not reported yet, especially in chronic rhinosinu- sitis children. In our study, 70% of patients experienced improvement of clinical outcome. This study demons- trates that long-term, low-dose macrolide treatment can improve symptoms of children.

IL-8 is produced from nasal gland duct cells and epithelial cells, and attracts neutrophils.

Additionally, IL-8 induces further secretion of IL-8 from accumulated neutrophils, followed by further neutrophil accumula- tion in chronic rhinosinusitis.

The previous study reports that low -dose erythromycin may act as a bio- logic modulator that inhibits this IL-8 secretion from exudative neutrophils and thereby reduces neutrophil recruitment in the inflammatory site in chronic sinu- sitis.

This results in the block of the vicious cycle of IL-8 generation and neutrophil exudation, which is an essential mechanism in the prolongation of sinus infla- mmation.

Our results demonstrated significant decrease in IL-8 level at 3 months after the beginning of this treatment. In previous study, at 2 to 3 moths after the beginning of long-term low -dose clarithro- mycin treatment, the IL-8 concentrations in the nasal discharge decreased significantly.

And this study indicated that until 1 month after clarithromycin trea- tment, it did not play an effective role in decrease of IL-8 levels.

We examined the concentrations of chemical medi-

ator such as IL-1β, TNF-α and IL-8 in the nasal

secretions get from children with chronic rhinosinusitis

before and after macrolide treatment. We found that

the IL-8, IL-1β, and TNF-α levels in nasal lavage

from the improvement group were significantly dec re-

ased after macrolide treatment. In the no-improvement

group, there was no difference in the IL-8, IL-1β, and

TNF-α levels before and after treatment. The differe-

nce of IL-8, IL-1β, and TNF-α levels between im-

provement group and no-improvement group before

macrolide treatment was absent, and this suggests that

the concentration of these chemical mediators cannot

be prognostic marker to predict the effectiveness of

macrolide therapy for improvement of symptoms. Our

findings show that the clinical effectiveness of macrolide treatment for children with chronic rhinosinusitis was reflected by the decrease in such mediators (Fig. 1, 4, 6).

CONCLUSION

Our findings indicate that long-term, low-dose ma- crolide therapy is effective in children with chronic rhinosinusitis by the decrease of IL-8, IL-1β and TNF-α concentrations.

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