Pleural cytokines MIF and MIP-3α as novel biomarkers for complicated parapneumonic effusions and empyema

Abstract

Patients with complicated parapneumonic effusion (CPPE)/empyema have high morbidity and mortality, particularly when adequate management is delayed. We aimed to investigate novel dysregulated cytokines that can be used as biomarkers for infectious pleural effusions, especially for CPPE/empyema. Expression of 40 cytokines in parapneumonic effusions (PPE) was screened in the discovery phase, involving 63 patients, using a multiplex immunobead-based assay. Six cytokines were subsequently validated by enzyme-linked immunosorbent assays (ELISAs). We then used ELISA to further evaluate the diagnostic values and cutoff values of these cytokines as potential biomarkers in an expanded group that included 200 patients with uncomplicated parapneumonic effusion (UPPE), CPPE, empyema, transudates, other exudates, and malignant pleural effusion (MPE). The pleural levels of four cytokines (MIF, MIP-3α, IL-1β, ENA-78) were highest and significantly increased in CPPE/empyema compared with those in other etiologies. According to receiver operating characteristic curve analysis, the four cytokines (MIF, MIP-3α, IL-1β, and ENA-78) had areas under the curve (AUCs) greater than 0.710 for discriminating parapneumonic pleural effusion from noninfectious pleural effusions. In a comparison of nonpurulent CPPE with UPPE, logistic regression analysis revealed that pleural fluid MIF ≥ 12 ng/ml and MIP-3α ≥ 4.3 ng/ml had the best diagnostic value; MIF also displayed the highest odds ratio of 663 for nonpurulent CPPE, with 97.5% specificity, 94.44% sensitivity, and an AUC of 0.950. In conclusion, our results show that elevated MIF and MIP-3α may be used as novel biomarkers for PPE diagnosis, particularly in patients with CPPE/empyema; the findings indicate that dysregulated cytokine expression may provide clues about the pathogenesis of pleural infection.

Figure 1

Pleural levels of six dysregulated cytokines in various types of pleural effusion. The pleural levels of MIF (A), MIP-3α (B), IL-1β (C), ENA-78 (D), Groβ (E), and Groα (F) were measured by ELISA in patients with empyema, complicated parapneumonic effusion (CPPE), uncomplicated parapneumonic effusion (UPPE), other exudates, transudates, and malignant pleural effusion (MPE). The middle lines represent median values. The interval lines represent the 25th and 75th percentile. Statistical analysis was done using the post hoc Tukey test. Bonferroni-adjusted p values < 0.05/30 (6 cytokines and 5 comparisons) = 0.00166 indicate significance.