Sekundäre bakterielle Infektionen im Verlauf oder in Folge einer Infektion mit Influenza A Viren (IAV) steigern oftmals die Schwere des Krankheitsverlaufes, was besonders während der IAV Pandemien von 1918, 1968 und 2009 deutlich wurde. Genaue mechanistische Ursachen, welche dieser gesteigerten Kopathogenität zugrunde liegen wurden überwiegend in Tierversuchsmodellen adressiert und sind immunologisch unvollständig. Aufgrund organstruktureller und immunfunktioneller Speziesunterschiede ist ungewiss, inwieweit eine Übertragbarkeit der Daten zwischen Mensch und Maus besteht. Fokus der Arbeit bildete die Analyse potentieller IAV assoziierter Änderungen der angeborenen Immunität, welche sekundäre Pneumokokkeninfektionen in humanem ex vivo Lungengewebe begünstigen. Dafür wurden zentrale Zyto - bzw. Chemokine als Reaktion auf Einzelinfektionen mit dem saisonalen IAV Pan/99(H3N2) sowie Streptococcus pneumoniae D39 mit denen subsequenter viral-bakteriellen Koinfektion verglichen. Ausgelöst durch die antivirale Interferonantwort erfolgte die Reduktion der pneumokokkeninduzierten Bildung von IL-1β und GM-CSF auf translationaler und transkriptioneller Ebene. Vermutlich beeinflussen Typ I und II Interferone die IL-1β Bildung, welches über parakrine Wechselwirkungen an der GM-CSF Regulation beteiligt ist. Auf zellulärer Ebene verursachte IAV die Freisetzung von Typ I, II und III Interferonen aus primären humanen Alveolarepithelzellen vom Typ II. In humanen Alveolarmakrophagen unterdrückten Typ I und II Interferone die pneumokokkeninduzierte IL-1β Freisetzung. Folglich unterblieb die IL-1β-regulierte GM-CSF Sekretion aus Alveolarepithelzellen vom Typ II. Die Ergebnisse zeigen, dass influenzainduzierte Interferone durch die Unterdrückung der IL-1β regulierten Bildung von GM-CSF in humanem Lungengewebe beitragen. Damit unterstützt sie das Verständnis immunologischer Faktoren, welche diesem Krankheitsbild im Menschen pathophysiologisch zugrunde liegen können. / Secondary bacterial infections, which occur during or following an IAV infection, exaggerate the severity of the course of disease up to a lethal outcome, clearly recognizable during the fatal IAV pandemics from 1918, 1968 or 2009. Particular mechanisms underlying this exaggerated viral-bacterial copathogenity were almost solely addressed using animal models and are immunologically incomplete. Due to structural and immunofunctional interspecies differences the transferability of data between human and mice remains indeterminate. The study mainly purposed to investigate IAV associated modulations of innate immunity, which potentially facilitates secondary pneumococcal pneumonia in primary human ex vivo lung tissue. Hence secretion of central cyto- and chemokines initiated by single infection with the seasonal IAV Pan/99(H3N2) or the bacterium Streptococcus pneumoniae D39 were compared to subsequent viral-bacterial coinfection. In context of an antiviral interferon response the pneumococcal induced translation and transcription of IL-1β and GM-CSF were reduced. Probably type I and type II interferons affect generation of IL-1β, which participates in the regulation of GM-CSF by paracrine interactions. On a cellular basis the infection of primary human alveolar epithelial cells type II (AECII) with IAV triggered the release of interferon type I, II and III. In human alveolar macrophages type I and II interferons suppressed the pneumococcal induced release of IL-1β. Consequently, the IL-1β regulated generation of GM-CSF in AECII was impeded. The present study indicates, that influenza related induction of interferons suppresses the IL-1β related release of GM-CSF in human lung tissue. Thereby it takes part in contributing to pathophysiological comprehension of immunological factors underlying this copathogenity.

<p>Akutni respiratorni distres sindrom (ARDS) predstavlja klinički sindrom koji se manifestuje te&scaron;kom respiratornom insuficijencijom sa razvojem akutnog edema pluća u odsustvu znakova popu&scaron;tanja leve polovine srca. S obzirom da ovaj sindrom ima heterogenu etiologiju, progresivan tok i visoku stopu mortaliteta, pravovremena i tačna dijagnoza esencijalna je u primeni efektivne i rane terapije, a samim tim i u pobolj&scaron;anju prognoze bolesti. Cilj ove doktorske disertacije bio je da se ispita povezanost kliničke i patohistolo&scaron;ke dijagnoze ovog sindroma, kao i da se analiziraju i uporede vrednosti kliničkih parametara neophodnih za postavljanje dijagnoze ARDS-a sa patohistolo&scaron;kim parametrima o&scaron;tećenja plućnog tkiva. Studija je obuhvatila 67 pacijenata Instituta za plućne bolesti Vojvodine koji su umrli pod kliničkom slikom ARDS-a i/ili kod kojih je na obdukciji patohistolo&scaron;ki dokazan ARDS. Za postavljanje kliničke dijagnoze ARDS-a kori&scaron;ćeni su kriterijumi The American-European Consensus Conference iz 1994. Nakon semikvantitativne analize patohistolo&scaron;kih parametara difuznog alveolarnog o&scaron;tećenja određivan je histolo&scaron;ki stadijum ARDS-a i svi pacijenti podeljeni su u dve grupe: I grupa - pacijenti u eksudativnoj fazi i II grupa - pacijenti u proliferativnoj fazi difuznog alveolarnog o&scaron;tećenja. Formirane grupe pacijenata upoređivane su u odnosu na vrednosti kliničkih parametara 12h pre smrtnog ishoda. U cilju procene prisustva komorbiditeta analizirani su indeks telesne mase (engl. body mass index- BMI) i podaci o prethodno dijagnostikovanoj arterijskoj hipertenziji. Kod svih pacijenata uključenih u studiju upoređivane su kliničke dijagnoze sa obdukcionim nalazom. Za klasifikaciju autopsijskih dijagnoza kori&scaron;ćena je Goldman-ova klasifikacija. Na osnovu provedenog istraživanja, do&scaron;lo se do zaključka da slaganje klinički dijagnostikovanih i patohistolo&scaron;ki potvrđenih slučajeva ARDS-a iznosi 68%. Senzitivnost kliničke dijagnoze ARDS-a iznosi 82%, a pozitivna prediktivna vrednost 80%. Pacijenti sa nalazom eksudativne faze DAD-a u plućnom tkivu su u najvećem procentu imali klinički težak ARDS, dok su se pacijenti sa nalazom proliferativne faze sindroma če&scaron;će manifestovali pod kliničkom slikom srednje te&scaron;kog ARDS-a, odnosno utvrđeno je da postoji statistička povezanost između nižih vrednosti PaO2/FiO2 i teže faze ARDSa. Patohistolo&scaron;kom analizom promena u plućnom tkivu nađeno je da najvažnija obeležja eksudativne faze ARDS-a predstavljaju: hijaline membrane, edem i krvarenje, dok su se kao najvažnija obeležja proliferativne faze ARDS-a izdvojili: proliferacija pneumocita tipa II, intersticijalna i mutilantna fibroza i organizirajuća pneumonija. Kod pacijenata sa kliničkom dijagnozom ARDS-a kod kojih ARDS nije i patohistolo&scaron;ki dokazan, najče&scaron;ći nalaz na plućima bila je fibrinozno-purulentna bronhopneumonija. Analizom etiolo&scaron;kih faktora koji doprinose razvoju ovog sindroma otkriveno je da je ARDS najče&scaron;će nastao kao posledica delovanja direktnih/pulmonalnih činilaca: pneumonije i virusa gripa H1N1. Najzastupljeniji komorbiditeti prisutni kod pacijenata sa ARDS-om bili su sistemska hipertenzija i gojaznost. Najzad, kod svih pacijenata uključenih u istraživanje upoređivane su kliničke dijagnoze sa obdukcionim nalazom i na osnovu Goldman-ove klasifikacije kliničke dijagnoze i obdukcioni nalaz slažu se u 72% slučajeva. Rezultati ove studije mogli bi se upotrebiti u daljim istraživanjima kako bi omogućili bolji dijagnostički pristup ovom problemu, a samim tim i bolji terapijski pristup i smanjivanje stope mortaliteta.</p> / <p>Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by severe respiratory failure with development of acute pulmonary edema in the absence of left heart failure signs. Since this syndrome has a heterogeneous etiology, progressive course and high mortality, timely and accurate diagnosis is essential in the implementation of effective and early treatment, and therefore in improving the prognosis of the disease. The aim of this PhD thesis was to examine the association between clinical and pathohistological diagnosis of this syndrome, as well as to analyze and compare the values of clinical parameters necessary for the diagnosis of ARDS with pathohistological parameters of diffuse alveolar damage. The study included 67 patients of the Institute for Lung Diseases who died under clinical picture of ARDS and / or in which, at the autopsy, pathohistological diagnosis of ARDS was set. To set up a clinical diagnosis of ARDS the criteria of the American-European Consensus Conference in 1994 were used. After a semi-quantitative analysis of histopathological parameters of diffuse alveolar damage, all patients were divided into two groups: Group I - patients in the exudative stage and Group II - patients in the proliferative phase of diffuse alveolar damage. Formed groups of patients were compared with respect to clinical parameters values 12 h before death. In order to assess the presence of comorbidities body mass index (BMI) and data on previously diagnosed arterial hypertension were analyzed. In all patients included in the study the clinical diagnosis were compared with autopsy findings according to Goldman&#39;s classification. According to this study, agreement of clinically diagnosed and histologically confirmed cases of ARDS is 68%. The sensitivity of clinical diagnosis of ARDS is 82%, and positive predictive value is 80%. Patients with exudative phase of DAD most frequently had a severe form of ARDS, whereas patients with proliferative phase often manifested with moderate form of ARDS, ie it was found that there is a statistical association between lower values PaO2 / FiO2 and more severe phase of ARDS. Pathological analysis of changes in lung tissue revealed that the most important characteristics of exudative phase of ARDS are: hyaline membrane, edema and bleeding, while the most important features of the proliferative phase of ARDS are: the proliferation of type II pneumocytes, interstitial fibrosis and mutilating and organizing pneumonia. In patients with a clinical diagnosis of ARDS in which ARDS was not pathohistologically proven, the most common finding in the lungs was fibrinous-purulent bronchopneumonia. The analysis of etiological factors that contribute to the development of this syndrome discovered that ARDS usually develop as a result of pulmonary factors: pneumonia and influenza virus H1N1. The most common comorbidities present in patients with ARDS were systemic hypertension and obesity. Finally, in all patients included in the study clinical diagnosis and autopsy findings were compared and based on Goldman&#39;s classification clinical diagnosis and autopsy findings are in agreement in 72% of cases. The results of this study could be used in further research to enable better diagnostic approach to this problem, and therefore a better therapeutic approach and reducing mortality rates.</p>