Effect of budesonide transnasal nebulization in patients with eosinophilic chronic rhinosinusitis with nasal polyps Chengshuo Wang, MD, Hongfei Lou,

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Effect of budesonide transnasal nebulization in patients with eosinophilic chronic rhinosinusitis with nasal polyps Chengshuo Wang, MD, Hongfei Lou, MD, Xiangdong Wang, MD, Yang Wang, BS, Erzhong Fan, BS, Ying Li, BS, Hong Wang, BS, Claus Bachert, MD, Luo Zhang, MD Journal of Allergy and Clinical Immunology Volume 135, Issue 4, Pages 922-929.e6 (April 2015) DOI: 10.1016/j.jaci.2014.10.018 Copyright © 2014 The Authors Terms and Conditions

Fig 1 Study patients' flow diagram. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig 2 Clinical improvements in the budesonide transnasal nebulization–treated group compared with the placebo transnasal nebulization–treated group. Reductions in NP size and symptom improvements were used as primary end points. A, NP size. B, Nasal congestion. C, Rhinorhea. D, Loss of smell. E, Headache. F, TNSS. VAS, Visual analog scale. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig 3 Inflammatory cytokines and mediators in tissue homogenates were determined by using the cytometric bead array (eotaxin, IL-5, IL-10, IL-17, and IFN-γ) and ELISA (TGF-β). A, Eotaxin. B, IL-5. C, IL-10. D, TGF-β. E, IL-17. F, IFN-γ. NS, Not significant. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig 4 Inflammatory cells in NP tissue were analyzed before and after treatment by using H&E staining (eosinophils) and flow cytometric analysis (T-cell subsets). A, Eosinophils. B, TH2 cells. C, TH1 cells. D, TH17 cells. E, TR1 cells. F, nTreg cells. HPF, High-power field; NS, not significant. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig 5 Picrosirius red–stained sections of polyp tissues from the same patient before and after budesonide transnasal nebulization were assessed for total collagen by using bright-field microscopy (A and B) and for collagen fibers by using polarized light microscopy (C and D) at ×200 magnification. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig 6 Remodeling pattern shifts of NP tissues were evaluated in the budesonide transnasal nebulization–and placebo transnasal nebulization–treated groups. A, Collagen. B, Albumin. C, MMP-2. D, MMP-7. E, MMP-8. F, MMP-9. G, TIMP-1. H, TIMP-2. I, TIMP-4. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig E1 Representative gating figures in flow cytometric analysis of TH1, TH2, TH17, TR1, and nTreg cells in tissue homogenates. A, CD4+ T cells (scatter dots in the semicircle) were gated. B, Isotype control of TH1 and TH2 cells (left lower quadrant). C, TH1 cells (IFN-γ+IL-4−CD4+ T cells, right lower quadrant) and TH2 cells (IL-4+IFN-γ−CD4+ T cells, left upper quadrant) were gated in CD4+ T cells. D, Isotype control of TH17 cells (left upper quadrant). E, TH17 cells (IL-17+CD4+ T cells, right upper quadrant) were gated in CD4+ T cells. F, Isotype control of TR1 cells (left lower quadrant). G, TR1 cells (IL-10+IL-4−CD4+ T cells, left upper quadrant) were gated in CD4+ T cells. H, Isotype control of CD25+Foxp3+ cells (left lower quadrant). I, nTreg cells (CD4+CD25+Foxp3+ T cells, right upper quadrant) were gated in CD4+ T cells. Values in dot plots indicate percentages of different cell subsets in total CD4+ T cells. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig E2 Eosinophil infiltration in polyp tissues (×400 magnification) decreased from before (A) to after (B) treatment in the budesonide transnasal nebulization group. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions

Fig E3 Correlation between the change in TGF-β levels and the change in nTreg cell numbers from baseline in the budesonide transnasal nebulization–treated group. Journal of Allergy and Clinical Immunology 2015 135, 922-929.e6DOI: (10.1016/j.jaci.2014.10.018) Copyright © 2014 The Authors Terms and Conditions