Astma-lėtinė kvėpavimo takų liga, pasireiškianti dusulio ar kosulio epizodais bei padidėjusiu bronchų reaktyvumu. Eksperimentiniai bei klinikiniai tyrimai parodė, kad lėtinis neinfekcinis kvėpavimo takų uždegimas- svarbiausia astmos patogenezės grandis, lemianti šios ligos klinikinę eigą, sunkumą bei skiriamo gydymo efektyvumą. Nėra aišku, ar alerginė bei nealerginė astma skiriasi ne tik klinikiniu pasireiškimu, bet ir patomorfologiniais bei patofiziologiniai kvėpavimo takų pakitimais. Rūkymas- svarbus veiksnys, sukeliantis reikšmingus pokyčius kvėpavimo takų gleivinėje. Tačiau kaip rūkymas įtakoja lėtinį neinfekcinį kvėpavimo takų uždegimą ir ar skiriasi rūkymo poveikis sergant fenotipiškai skirtingomis astmos formomis- nėra žinoma. Todėl šio tyrimo tikslas- nustatyti rūkymo sąlygotus imuninio atsako ypatumus sergant alergine ir nealergine astma. Ištirti alergine ir nealergine astma sergantys pacientai, kurie pagal rūkymo įpročius suskirstyti į grupes: rūkorius ir nerūkančiuosius. Įvertinti rūkymo sąlygoti skreplių, bronchoalveolinio lavažo skysčio ląstelių sudėties skirtumai, eotaksinų, IL-5 bei IL-9 koncentracijų ypatumai, jų ryšys su svarbiausiais klinikiniais pacientų duomenimis. Nustatyta, kad alerginė ir nealerginė astma skiriasi patofiziologinėmis savybėmis, o rūkymas sukelia nevienodus imuninių lėtinio kvėpavimo takų uždegimo žymenų pakitimus pacientams, sergantiems skirtingomis astmos formomis. / Asthma is a chronic disorder of the airways, which is characterized by the presence of chronic airway inflammation. Experimental and clinical studies have showed that chronic airway inflammation is the most important part of asthma pathogenesis, which determines the clinical picture and severity of this disease. The data about differences and similarities of allergic and non-allergic asthma are questionable. It was considered that smoking might cause significant changes of bronchial mucosa. It is unclear whether smoking impairs immune response in patients with allergic and non-allergic asthma similarly. The aim of this study was to evaluate tobacco smoke-induced features of immune response in patients with allergic and non-allergic asthma. Subjects, with allergic and non-allergic asthma were investigated. According to their smoking habits, patients were divided into the groups: smokers and non-smokers. Tobacco smoke-induced changes of sputum and BAL fluid cellular composition were evaluated and features of inflammatory mediators (eotaxins, IL-5 and IL-9) were investigated. This study showed pathomorphological and pathophysiological differences between allergic and non-allergic asthma. Smoking impairs lung function and changes the pattern of chronic airway inflammation by decreasing production of cytokines and increasing production of chemokines.

A rinossinusite crônica (RSC) é uma doença inflamatória da mucosa nasal, e pouco tem sido relacionada à exposição no ambiente de trabalho, em especial ao algodão. Atualmente, uma série de citocinas e quimiocinas tem sido estudada para elucidação das características imunológicas que levam ao desenvolvimento da doença. Objetivos: Caracterizar a exposição ao algodão como indutora de RSC e determinar o padrão de resposta inflamatória imuno-histoquímica da mucosa nasal de indivíduos expostos ou não ao algodão e que desenvolveram RSC. Casuística e Metodos: Por meio de questionário baseado no EPOS e SNOT-22 foi realizado diagnóstico clínico de RSC em indivíduos expostos ao algodão no ambiente de trabalho. Após a confirmação diagnóstica com tomografia computadorizada e nasofibroscopia flexível foi realizada biópsia na mucosa de concha média de pacientes com diagnóstico clínico de RSC para análise da expressão de IL-4, IL-5, IL-10, IL-17 e IL-33. A análise foi realizada também em grupo com RSC sem exposição ao algodão e controle sem RSC. Resultados: Todos os indivíduos expostos ao algodão com sintomatologia sugestiva de RSC apresentaram padrão histológico com aumento da expressão de IL-4, IL-5, IL-10, IL-17 e IL-33. Conclusões: O presente estudo comprovou a estreita relação entre a exposição ao algodão no ambiente de trabalho e o surgimento de uma resposta inflamatória com aumento da expressão das interleucinas estudadas. A possível instituição de terapias/medicamentos que inibissem a expressão dessas citocinas poderia auxiliar na diminuição do processo inflamatório presente na RSC e/ou no desencadeamento da doença / The chronic rhinusinusitis (CRS) is an inflammatory disease of the nasal mucosa, and has been little related to exposure in the work environment, especially to cotton. Currently, a number of cytokines and chemokines have been studied to elucidate the immunological characteristics that lead to the development of the disease. Objectives: To characterize exposure to cotton as an inducer of CRS and to determine the pattern of inflammatory immune-histochemical response of the nasal mucosa of individuals exposed or not to cotton and who developed CRS. Casuistic and Methods: Using a questionnaire based on EPOS and SNOT-22, a clinical diagnosis of CRS was performed in individuals exposed to cotton in the work environment. After diagnostic confirmation with computed tomography and flexible nasofibroscopy, biopsy was performed on the middle concha mucosa of patients with clinical diagnosis of CRS to analyze the expression of IL-4, IL-5, IL-10, IL-17 and IL- 33. The analysis was also performed in a group with CRS without exposure to cotton and control without CRS. Results: All individuals exposed to cotton with symptoms suggestive of CRS had a histological pattern with increased expression of IL-4, IL-5, IL-10, IL-17 and IL-33. Conclusions: This study confirms the close relationship between exposure to cotton in the workplace and the appearance of an inflammatory response with increased expression of interleukins studied. The possible institution of therapies / drugs that inhibit the expression of these cytokines could help in the reduction of the inflammatory process present in CRS and in the onset of the disease

Contexte : La polypose naso-sinusienne (PNS) est une maladie inflammatoire chronique multifactorielle dont l’étiologie reste imprécise. Les acteurs de l’immunité innée et acquise sont diversement impliqués avec un rôle central joué par l’éosinophile(EO). L’asthme associé à la PNS est un facteur de résistance à la corticothérapie constituant à l’heure actuelle la seule option thérapeutique médicale.Objectifs : Caractériser sur le plan histologique, biologique et cellulaire les patients atteints de PNS afin de définir des profils phénotypiques inflammatoires en relation avec l’asthme et de préciser les mécanismes d’immuno-modulation de l’EO.Matériel: Une étude prospective était menée incluant les patients atteints de PNS réfractaires au traitement médical. Après recueil du consentement éclairé et accord institutionnel, les sécrétions nasales et les polypes étaient prélevés au bloc opératoire. Les corticoïdes locaux et généraux étaient au préalable arrêtés pendant 1 mois. Etaient réalisés un dosage des marqueurs d’inflammation (interleukine 5 (IL-5), Immunoglobulines E (IgE), eosinophil-derived neurotoxin (EDN), IL-9), une analyse histologique du polype sous microscopie optique et une analyse cytométrique des récepteurs d’adhésion (béta(β) intégrines, CD44), d’activation (CD69) et du récepteur alpha à l’IL-5 (IL-5Rα) sur les EOs purifiés sanguins et tissulaires. Ces paramètres étaient comparés à la présence d’un asthme.Résultats: Une classification histologique des polypes en 3 sous-types était établie: le polype œdémateux riche en EOs (64% des cas), le polype fibreux riche en collagène et glandes sous-muqueuses (9%) et le polype intermédiaire à composante mixte fibreuse et œdémateuse mais à prédominance éosinophile (27%). Il n’existait pas de corrélation entre cette classification et le statut clinique. L’asthme était associé à une plus forte éosinophilie tissulaire (p=0.026). Cette infiltration cellulaire était associée à la présence d’une plus forte concentration en IL-5, IgE et EDN dans les sécrétions nasales et dans le polype chez les patients asthmatiques (p≤0.04). La domiciliation des EOs dans le polype était favorisée par une diminution de l’expression membranaire des βintégrines et du CD44 après migration tissulaire (p≤0.02). Cette migration s’accompagnait d’une activation cellulaire CD69+ et d’une augmentation de l’expression membranaire de l’IL-5Rα sur les EOs purifiés quel que soit le statut clinique des patients. L’expression de l’IL-5Rα sur les EOs tissulaires était relativement plus faible en cas d’asthme associé (p≤0.04). Les analyses fonctionnelles par mise en culture d’EOs purifiés confirmaient le rôle anti-apoptique de l’IL-5 à forte concentration chez les patients asthmatiques. La co-culture IL-5/IL-9 permettait de renforcer cette action anti-apoptotique IL-5 dépendante en induisant l’expression membranaire de l’IL-5Rα chez les patients asthmatiques.Discussion: Ces résultats confirment le rôle majeur de l’EO en particulier chez les patients asthmatiques. L’architecture du polype conséquence du remodelage tissulaire ne détermine pas la cortico-résistance habituellement associée à l’asthme dans la mesure où les sous-types histologiques sont distribués de manière équivalente quel que soit le statut clinique des patients. Le profil inflammatoire (IL-5, IgE, IL-9) conditionne la domiciliation tissulaire des EOs en modulant l’expression des protéines d’adhésion et d’interaction. Il influence aussi la survie tissulaire des EOs en contrebalançant une diminution d’expression de l’IL-5Rα IL-5 dépendante par une synergie d’action IL-5/IL-9 anti-apoptotique [...] / Background: The chronic rhinosinusitis with nasal polyps (CRSwNP) is a plurifactorial inflammatory disease whose etiology is still unknown. Innate and acquired immune agents are key factors with a pivotal role of the eosinophil (EO). Asthma is recognized as a major factor of medical failure. Objectives: Setting histological, biological and cellular patterns of inflammation in CRSwNP in accordance with the asthmatic status of the patient and describing the membrane immune phenotype of EOs both in blood and polyp compartments. Materiel: A prospective study was conducted enrolling patients with medical refractory CRSwNP. With institutional review board agreement, nasal secretions and polyp specimens were harvested through endoscopic surgical procedure. A 1-month corticosteroid wash-out was required prior to surgery. Inflammatory biomarkers measurements (interleukin-5 (IL-5), Immunoglobulins E (IgE), eosinophil-derived neurotoxin (EDN), IL-9), histological study on microscopic slides and cytometric analyses of adhesion receptors (beta(β) integrins, CD44), activation proteins (CD69) and of the IL-5 receptor alpha (IL-5Rα) were performed on purified EOs collected from the blood and the polyp. Data were compared with the asthmatic status of the patients.Results: A histological classification was established. Three subtypes were observed. The edematous polyp with huge EO infiltration (64%), the fibrous polyp with a collagen framework and a large amount of seromucous glands (9%) and the intermediate polyp with mixed fibro-edematous stroma and EO infiltration (27%). No correlation was described between this classification and the clinical status. CRSwNP with concomitant asthma was depicted with a major eosinophilia (p=.026). High IL-5, IgE and IL-9 concentrations in nasal secretions and polyp were also associated with asthma (p≤.04). EO homing into the polyp was partly promoted by the β integrins and CD44 membrane downregulation observed during tissular migration (p≤.02). CD69 activation process and IL-5Rα surface enhancement on EOs were observed in CRSwNP with or without asthma during tissue migration. The IL-5Rα expression was slightly reduced in asthmatic CRSwNP patients by comparison with the non-asthmatic counterparts (p≤.04). In vitro analyses showed the anti-apoptotic function of IL-5 in EOs of the asthmatic patients. The co-culture with IL-5 and IL-9 led to the up-regulation of the IL-5Rα surface expression. Discussion: Our results stress the major role of the EO in particular in asthmatic CRSwNP patients. The remodeling process implied in the polyp formation is not directly involved in the corticosteroid resistance as the 3 subtypes of polyps were evenly observed whatever the clinical status. High IL-5, IgE and Il-9 environment promotes EO polyp migration and activation by the regulation of adhesion and activation proteins on the EO membrane. The synergistic action of pro Th2 cytokines (IL-5/IL-9) balances the IL-5Rα downregulation observed in high IL-5 rate conditions. Conclusion: The cellular and inflammatory phenotype profiles in CRSwNP are correlated to the asthmatic status of the patients. Taken together, our results suggest that processes of immune modulation are key factors of inflammatory homeostasis in CRSwNP. Intricate mechanisms of up and down regulation of cytokines receptors expression could be involved in the incomplete efficacy of targeted therapies whose evaluation is still pending.

付記する学位プログラム名: 京都大学卓越大学院プログラム「メディカルイノベーション大学院プログラム」 / 京都大学 / 新制・課程博士 / 博士(薬科学) / 甲第24547号 / 薬科博第164号 / 新制||薬科||18(附属図書館) / 京都大学大学院薬学研究科薬科学専攻 / (主査)教授 生田 宏一, 教授 橋口 隆生, 教授 木村 郁夫 / 学位規則第4条第1項該当 / Doctor of Pharmaceutical Sciences / Kyoto University / DFAM

O veneno do T.nattereri induz uma resposta de memória com a diferenciação de células B B220neg, indicativo de células produtoras de anticorpos de vida longa (ASC). Para avaliar o efeito do veneno na diferenciação de ASCs, camundongos BALB/c foram imunizados e sacrificados nos dias 21, 28, 48, 74 e 120 para avaliação de anticorpos plasmáticos e células B no peritônio, baço e medula óssea. O veneno induziu intensa esplenomegalia, formação de centros germinativos e persistentes níveis de anticorpos específicos IgG1, IgG2a e IgE anafilática. Células B1a e ASC apareceram rapidamente e a população de ASC CD138pos foi dividida em três subtipos (B220highCD43high, B220lowCD43low, e B220negCD43high) que persistiram em diferentes níveis em todos compartimentos. Finalmente, por métodos de neutralização nós sugerimos um papel importante da IL-5 e IL-17 A no desenvolvimento de ASC B220neg e na população B1a e mais ainda, a produção de TNF-a, IL-1b, IL-6, KC bem como a retenção do veneno nas células dendríticas foliculares parece promover os mecanismos para manutenção das ASCs. / T. nattereri fish venom induces a memory immune response with the differentiation of B cells B220neg, an indicative of long-lived antibody-secreting cells - ASC. To assess the effect of the venom on differentiation of ASCs, BALB/c mice were immunized with venom and sacrificed at days 21, 28, 48, 74 and 120 to evaluate plasmatic antibodies and B cell subtypes in peritoneum, spleen and bone marrow. The venom promoted splenomegaly, germinal centers formation and persistent levels of specific antibodies IgG1, IgG2a and anaphylactic IgE. B1a cells and ASC emerged rapidly and CD138pos ASCs can be divided into three subsets (B220high CD43high, B220low CD43low, and B220neg CD43high) that persist at different levels in all compartments. Finally, by neutralization methods we suggested an important role for IL-5 and IL-17A on development of B220neg ASCs and B1a population and moreover the production of TNF-a, IL-1b, IL-6, KC as well as the venom retained in follicular dendritic cells seem to provide mechanisms to explain the maintenance of ASCs.

O veneno do T.nattereri induz uma resposta de memória com a diferenciação de células B B220neg, indicativo de células produtoras de anticorpos de vida longa (ASC). Para avaliar o efeito do veneno na diferenciação de ASCs, camundongos BALB/c foram imunizados e sacrificados nos dias 21, 28, 48, 74 e 120 para avaliação de anticorpos plasmáticos e células B no peritônio, baço e medula óssea. O veneno induziu intensa esplenomegalia, formação de centros germinativos e persistentes níveis de anticorpos específicos IgG1, IgG2a e IgE anafilática. Células B1a e ASC apareceram rapidamente e a população de ASC CD138pos foi dividida em três subtipos (B220highCD43high, B220lowCD43low, e B220negCD43high) que persistiram em diferentes níveis em todos compartimentos. Finalmente, por métodos de neutralização nós sugerimos um papel importante da IL-5 e IL-17 A no desenvolvimento de ASC B220neg e na população B1a e mais ainda, a produção de TNF-a, IL-1b, IL-6, KC bem como a retenção do veneno nas células dendríticas foliculares parece promover os mecanismos para manutenção das ASCs. / T. nattereri fish venom induces a memory immune response with the differentiation of B cells B220neg, an indicative of long-lived antibody-secreting cells - ASC. To assess the effect of the venom on differentiation of ASCs, BALB/c mice were immunized with venom and sacrificed at days 21, 28, 48, 74 and 120 to evaluate plasmatic antibodies and B cell subtypes in peritoneum, spleen and bone marrow. The venom promoted splenomegaly, germinal centers formation and persistent levels of specific antibodies IgG1, IgG2a and anaphylactic IgE. B1a cells and ASC emerged rapidly and CD138pos ASCs can be divided into three subsets (B220high CD43high, B220low CD43low, and B220neg CD43high) that persist at different levels in all compartments. Finally, by neutralization methods we suggested an important role for IL-5 and IL-17A on development of B220neg ASCs and B1a population and moreover the production of TNF-a, IL-1b, IL-6, KC as well as the venom retained in follicular dendritic cells seem to provide mechanisms to explain the maintenance of ASCs.

<p>In this thesis the oxidative metabolism by blood eosinophils from birch pollen allergic subjects was studied and compared to that by eosinophils from healthy controls, during and out of the pollen season. The effects and mechanisms of <i>in vitro</i> IL-5 priming on blood eosinophils were investigated and compared to the effects of <i>in vivo</i> priming during pollen exposure.</p><p>The main findings of this work were that the oxidative metabolism by blood eosinophils taken from pollen allergic subjects is reduced during the pollen season. The eosinophils taken from asymptomatic allergics have a reduced capacity to produce oxygen free radicals as compared to non-allergic controls. The oxidative metabolism by blood eosinophils from allergic subjects is primed <i>in vivo</i> during the pollen season, as compared to the healthy controls and as compared to out of season. IL-5 primed the oxidative metabolism by eosinophils from allergic subjects in a similar way as eosinophils from healthy controls, both during and out of pollen exposure. The total and tyrosine phosphorylation patterns obtained were identical in eosinophils from allergic subjects and non-allergic controls during the pollen season. Spontaneous phosphorylation was the same in both groups and different from that after IL-5 priming. The oxidative metabolism of blood eosinophils is composed of different stages. The initial stage, measured as the t_½rises of the CL curves, is an indication of the state of priming of the cell, while the end stage, measured as the peaks of the CL curves, is an estimate of the total radical production by the cells. IL-5 priming affected these two stages differently and the two stages are regulated by different signal transduction pathways and IL-5 priming causes a by-passing of MEK.</p><p>In conclusion, in this thesis it is shown that blood eosinophils from allergic subjects are primed <i>in vivo</i> during exposure to their allergen. This <i>in vivo</i> priming leads on one hand to a reduced oxidative metabolism during the pollen season, but also to a faster onset of radical production as a response to certain stimuli. Our data do not provide any evidence of IL-5 involvement in the <i>in vivo</i> priming of blood eosinophils from allergic patients during pollen exposure.</p>

<p>Otitis media with effusion (OME) is the major form of chronic relapsing inflammatory disease of the middle ear, constitutes the most common diagnosis for children under 15 years old and is the major cause of auditory dysfunction in pre-school children. OME is a disease more commonly found in allergic children. These studies sought to investigate the inflammatory response in the middle ear of patients and test the hypothesis that an allergic-like response might occur in the ear. Atopy was diagnosed by standard in vitro tests. Immunochemical techniques used to study classic allergic rhinitis and asthma were extrapolated to the evaluation of OME children whose effusion persisted beyond 2 months. Not only eosinophil cationic protein (ECP), tryptase, CD3-positive and IL-5 producing cells, but also myeloperoxidase (MPO) was found in middle ear fluid and/or mucosa in the majority of patients with OME and atopy. </p><p>Initially, levels of ECP, MPO, and tryptase were measured in effusions from 97 random OME patients whose atopic status was determined by in vitro testing to 12 inhalants and 5 foods. The response of eosinophils, neutrophils and mast cells in the middle ear was distinctly different between atopic and non-atopic patients (p<0.001) with higher levels of the cell markers in the atopic group of patients. This suggested that 1) perhaps OME was predominantly a disease of atopics and that 2) they differed in their response from non-atopics.</p><p>Tryptase was measured in middle ear effusions from 38 patients with OME, 94.7% of whom were atopic by in vitro testing. Tryptase was elevated only in the effusion of atopic patients as compared to 5 controls (p<0.01). Biopsies stained histochemically for tryptase showed evidence of mast cells in the mucosa and submucosa from 6 of 8 OME ears but absent in 4 normals.</p><p>Middle ear biopsies, embedded in a plastic resin to improve the structural preservation, from 5 patients with OME and 5 normals were evaluated for the presence of eosinophils and neutrophils with monoclonal antibodies against 4 specific granule proteins. Eosinophils and neutrophils were present in the mucosa and mucus in significantly higher numbers than in the control group.</p><p>In an effort to determine whether the middle ear itself might be involved in allergic disease, evidence that some of the cells, mediators and cytokines associated specifically with a Th-2 response were sought for in the middle ear mucosa of these children. Middle ear biopsies from 7 atopic patients with OME and 4 controls demonstrated the presence of activated eosinophils, CD-3+ T cells and IL-5 mRNA cells only in the mucosa from atopic OME children. </p><p>Conclusion: Effusion and mucosal biopsies containing ECP, tryptase, and/or IL-5 mRNA cells, CD3+ T cells, eosinophils, and mast cells indicate that many of the mediators and cells essential to the production of a Th-2 immune mediated response are present in ears with chronic effusion. The increased levels of MPO in atopic patients further suggest that the general inflammatory response to putative inciting agents such as bacterial and viral products may be altered in atopy. These studies support the hypothesis that the exaggerated inflammation within the middle ear associated with most cases of OME is possibly the result of an atopic response within the middle ear itself.</p>

In this thesis the oxidative metabolism by blood eosinophils from birch pollen allergic subjects was studied and compared to that by eosinophils from healthy controls, during and out of the pollen season. The effects and mechanisms of in vitro IL-5 priming on blood eosinophils were investigated and compared to the effects of in vivo priming during pollen exposure. The main findings of this work were that the oxidative metabolism by blood eosinophils taken from pollen allergic subjects is reduced during the pollen season. The eosinophils taken from asymptomatic allergics have a reduced capacity to produce oxygen free radicals as compared to non-allergic controls. The oxidative metabolism by blood eosinophils from allergic subjects is primed in vivo during the pollen season, as compared to the healthy controls and as compared to out of season. IL-5 primed the oxidative metabolism by eosinophils from allergic subjects in a similar way as eosinophils from healthy controls, both during and out of pollen exposure. The total and tyrosine phosphorylation patterns obtained were identical in eosinophils from allergic subjects and non-allergic controls during the pollen season. Spontaneous phosphorylation was the same in both groups and different from that after IL-5 priming. The oxidative metabolism of blood eosinophils is composed of different stages. The initial stage, measured as the t½rises of the CL curves, is an indication of the state of priming of the cell, while the end stage, measured as the peaks of the CL curves, is an estimate of the total radical production by the cells. IL-5 priming affected these two stages differently and the two stages are regulated by different signal transduction pathways and IL-5 priming causes a by-passing of MEK. In conclusion, in this thesis it is shown that blood eosinophils from allergic subjects are primed in vivo during exposure to their allergen. This in vivo priming leads on one hand to a reduced oxidative metabolism during the pollen season, but also to a faster onset of radical production as a response to certain stimuli. Our data do not provide any evidence of IL-5 involvement in the in vivo priming of blood eosinophils from allergic patients during pollen exposure.

Otitis media with effusion (OME) is the major form of chronic relapsing inflammatory disease of the middle ear, constitutes the most common diagnosis for children under 15 years old and is the major cause of auditory dysfunction in pre-school children. OME is a disease more commonly found in allergic children. These studies sought to investigate the inflammatory response in the middle ear of patients and test the hypothesis that an allergic-like response might occur in the ear. Atopy was diagnosed by standard in vitro tests. Immunochemical techniques used to study classic allergic rhinitis and asthma were extrapolated to the evaluation of OME children whose effusion persisted beyond 2 months. Not only eosinophil cationic protein (ECP), tryptase, CD3-positive and IL-5 producing cells, but also myeloperoxidase (MPO) was found in middle ear fluid and/or mucosa in the majority of patients with OME and atopy. Initially, levels of ECP, MPO, and tryptase were measured in effusions from 97 random OME patients whose atopic status was determined by in vitro testing to 12 inhalants and 5 foods. The response of eosinophils, neutrophils and mast cells in the middle ear was distinctly different between atopic and non-atopic patients (p&lt;0.001) with higher levels of the cell markers in the atopic group of patients. This suggested that 1) perhaps OME was predominantly a disease of atopics and that 2) they differed in their response from non-atopics. Tryptase was measured in middle ear effusions from 38 patients with OME, 94.7% of whom were atopic by in vitro testing. Tryptase was elevated only in the effusion of atopic patients as compared to 5 controls (p&lt;0.01). Biopsies stained histochemically for tryptase showed evidence of mast cells in the mucosa and submucosa from 6 of 8 OME ears but absent in 4 normals. Middle ear biopsies, embedded in a plastic resin to improve the structural preservation, from 5 patients with OME and 5 normals were evaluated for the presence of eosinophils and neutrophils with monoclonal antibodies against 4 specific granule proteins. Eosinophils and neutrophils were present in the mucosa and mucus in significantly higher numbers than in the control group. In an effort to determine whether the middle ear itself might be involved in allergic disease, evidence that some of the cells, mediators and cytokines associated specifically with a Th-2 response were sought for in the middle ear mucosa of these children. Middle ear biopsies from 7 atopic patients with OME and 4 controls demonstrated the presence of activated eosinophils, CD-3+ T cells and IL-5 mRNA cells only in the mucosa from atopic OME children. Conclusion: Effusion and mucosal biopsies containing ECP, tryptase, and/or IL-5 mRNA cells, CD3+ T cells, eosinophils, and mast cells indicate that many of the mediators and cells essential to the production of a Th-2 immune mediated response are present in ears with chronic effusion. The increased levels of MPO in atopic patients further suggest that the general inflammatory response to putative inciting agents such as bacterial and viral products may be altered in atopy. These studies support the hypothesis that the exaggerated inflammation within the middle ear associated with most cases of OME is possibly the result of an atopic response within the middle ear itself.