Elastase-Positive Neutrophils Are Associated With Refractoriness of Chronic Rhinosinusitis With Nasal Polyps in an Asian Population

Purpose: Various immune cells, including eosinophils and neutrophils, are known to contribute to the development of chronic rhinosinusitis with nasal polyps (CRSwNP). However, the current understanding of the role of neutrophils in the development of CRSwNP still remains unclear. Therefore, we investigated risk factors for refractoriness of CRSwNP in an Asian population. Methods: Protein levels of 17 neutrophil-related mediators in nasal polyps (NPs) were determined by multiplex immunoassay, and exploratory factor analysis using principal component analysis was performed. Immunofluorescence analysis was conducted to detect human neutrophil elastase (HNE) or myeloperoxidase (MPO)-positive cells. Tissue eosinophilic nasal polyp (ENP) and tissue neutrophilia (Neu(high)) were defined as greater than 70 eosinophils and 20 HNE-positive cells, otherwise was classified into non-eosinophilic nasal polyp (NENP) and absence of tissue neutrophilia (Neu(low)). Results: In terms of disease control status, NENP-Neu(low) patients showed the higher rate of disease control than NENP-Neu(high) and ENP-Neu(h)(igh) patients. Linear by linear association demonstrated the trend in refractoriness from NENP-Neu(low) to NENP-Neu(high) or ENP-Nee(low) to ENP-Neu(high). When multiple logistic regression was performed, tissue neutrophilia (hazard ratio, 4.38; 95% confidence interval, 1.76-10.85) was found as the strongest risk factor for CRSwNP refractoriness. Additionally, exploratory factor analysis revealed that interleukin (IL)-18, interferon-gamma, IL-1Ra, tumor necrosis factor-alpha, oncostatin M, and MPO were associated with good disease control status, whereas IL-36 alpha and IL-1 alpha were associated with refractory disease control status. In subgroup analysis, HNE-positive cells and IL-36 alpha were significantly upregulated in the refractory group (P= 0.0132 and P= 0.0395, respectively), whereas MPO and IL-18 showed higher expression in the controlled group (P= 0.0002 and P= 0.0009, respectively). Moreover, immunofluorescence analysis revealed that IL-36R(+)HNE(+)-double positive cells were significantly increased in the refractory group compared to the control group. We also found that the ratio of HNE-positive cells to alpha 1 anti-trypsin was increased in the refractory group. Conclusions: Tissue neutrophilia had an influence on treatment outcomes in the Asian CRSwNP patients. HNE-positive cells and IL-36 alpha may be biomarkers for predicting refractoriness in Asians with CRSwNP. Additionally, imbalances in HNE and alpha 1 anti-trypsin may be associated with pathophysiology of neutrophilic chronic rhinosinusitis.