Allergy Asthma Immunol Res.  2019 Sep;11(5):664-676. 10.4168/aair.2019.11.5.664.

Immunological Characteristics in Refractory Chronic Rhinosinusitis with Nasal Polyps Undergoing Revision Surgeries

• Ryu G
• Kim DK
• Dhong HJ
• Eun KM
• Lee KE
• Kong IG
• Kim H
• Chung SK
• Kim DY
• Rhee CS
• Cho SH
• Hong SD
• Kim DW

• KMID: 2452757
• DOI: http://doi.org/10.4168/aair.2019.11.5.664

Abstract

PURPOSE
Despite medical and surgical treatments, some cases of nasal polyps (NP) exhibit recidivism. However, the endotype of refractory chronic rhinosinusitis with NP (CRSwNP) remains unclear. Therefore, the objective of this study was to characterize the immunological profile of refractory CRSwNP.
METHODS
The control (n =23), primary NP group (pNP, n =70) and refractory NP group (rNP, n =86) were enrolled in this study. Patients who underwent revision surgeries due to failed maximal medical treatment after primary surgery were defined as the rNP group. A total of 18 inflammatory markers were investigated in nasal tissues using multiplex cytokine assay or enzyme-linked immunosorbent assay.
RESULTS
The clinical characteristics of rNP included more extensive disease and worse clinical course after surgery. Additionally, rNP subjects showed higher infection rate (mucopurulence and culture-positive rate), more frequent use of antibiotics and suffered from symptomatic bacterial infection, increased asthma morbidity compared to pNP. Cytokine profile analysis showed that levels of Th17-associated mediators (myeloperoxidase, interleukin (IL)-8, IL-17A and IL-23), B-cell activating factor (BAFF) and Th1 cytokine (interferon-γ) were up-regulated in rNP compared to controls and pNP. Human neutrophil elastase-positive cells were also enhanced in rNP compared with pNP. Upregulation of Th17/Th1mediators and BAFF were observed in rNP, regardless of tissue eosinophilia or asthmatic comorbidity. Interestingly, eosinophilic markers, such as eosinophil cationic protein and C-C motif chemokine ligand 24, were up-regulated in asthmatic rNP compared to pNP and controls. Levels of anti-dsDNA immunoglobulin (Ig) G and IgA were up-regulated in rNP and highest in asthmatic eosinophilic rNP among subtypes of rNP.
CONCLUSIONS
Our results suggest that Th17/Th1-associated mediators and BAFF may play a role and be a potential therapeutic target in refractory CRSwNP. Additionally, eosinophilic markers and autoantibodies may contribute to refractoriness in asthmatic rNP.

Keyword

Nasal polyps; sinusitis; refractory; neutrophil; Th17 cells; B cell activating factor

MeSH Terms

Anti-Bacterial Agents
Asthma
Autoantibodies
B-Cell Activating Factor
Bacterial Infections
Comorbidity
Enzyme-Linked Immunosorbent Assay
Eosinophil Cationic Protein
Eosinophilia
Eosinophils
Humans
Immunoglobulin A
Immunoglobulins
Interleukin-17
Interleukins
Nasal Polyps*
Neutrophils
Sinusitis
Th17 Cells
Up-Regulation
Anti-Bacterial Agents
Autoantibodies
B-Cell Activating Factor
Eosinophil Cationic Protein
Immunoglobulin A
Immunoglobulins
Interleukin-17
Interleukins

Figure

• 

  Fig. 1 Inflammatory mediators in rNP. (A) Eosinophils-associated inflammatory markers, (B) Neutrophils-associated inflammatory markers and (C) Remodeling markers. Data were evaluated by Kruskal-Wallis test and Dunn multiple comparison test. A P value < 0.05 was considered statistically significant. ECP, eosinophil cationic protein; CCL, C-C motif chemokine ligand; IL, interleukin; IFN, interferon; MPO, myeloperoxidase; TGF, transforming growth factor; MMP, matrix metalloproteinase; TIMP, tissue inhibitor of metalloproteinase; BAFF, B-cell activating factor; pNP, primary nasal polyps; rNP, refractory nasal polyps.

• 

  Fig. 2 Principal component analysis in rNP. Component 1 (Th1/Th17 and BAFF) can help to discriminate between pNP and rNP in both eosinophilic and non-eosinophilic subtypes. ECP, eosinophil cationic protein; CCL, C-C motif chemokine ligand; IL, interleukin; IFN, interferon; BAFF, B-cell activating factor; rNP, refractory nasal polyps; p, primary; r, refractory; NP, nasal polyps; ENP, eosinophilic nasal polyps; NENP, non-eosinophilic nasal polyps.

• 

  Fig. 3 Neutrophilic infiltration in rNP. (A) Enhanced neutrophilic infiltration in rNP, refractory ENP, refractory non-ENP. (B) Immunohistochemical staining using anti-HNE. (C) Increased eosinophilic infiltration in primary and rNP compared to control tissues. rNP, refractory nasal polyps; p, primary; r, refractory; ENP, eosinophilic nasal polyps; NENP, non-eosinophilic nasal polyps; HNE, human neutrophil elastase; HPF, high power field.

• 

  Fig. 4 Inflammatory mediators in rNP with asthma vs. without asthma. Data were evaluated by Kruskal-Wallis test and Dunn multiple comparison test. A P value < 0.05 was considered statistically significant. ECP, eosinophil cationic protein; CCL, C-C motif chemokine ligand; IL, interleukin; MPO, myeloperoxidase; IFN, interferon; BAFF, B-cell activating factor; TGF, transforming growth factor; pNP, primary nasal polyps; rNP, refractory nasal polyps; A: asthmatic, NA: non-asthmatic.

• 

  Fig. 5 Autoantibodies production in rNP. (A) Anti-dsDNA IgG and IgA in primary and rNP. (B) Anti-dsDNA IgG and IgA according to asthma comorbidity. (C) Anti-dsDNA IgG and IgA according to each phenotype of rNP. Ig, immunoglobulin; pNP, primary nasal polyps; rNP, refractory nasal polyps; A, asthmatic; NA, non-asthmatic; ENP, eosinophilic nasal polyps; NENP, non-eosinophilic nasal polyps.

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