A 68-year-old man consulted our hospital because of a giant cavity in the upper lobe of the right lung, which was detected in a medical examination for asbestosis. Mycobacterium abscessus was cultured from his sputum in 2 separate cultures. Therefore we diagnosed pulmonary Mycobacterium abscessus infection and prescribed amikacin, imipenem/cilastatin, and clarithromycin. After 2 months, lobectomy of the upper lobe of the right lung was performed. The 3 antibiotics were continued for another 6 months, and the patient recovered completely. Mycobacterium abscessus infection is one of the most intractable non-tuberculous mycobacterial infections, and it is important to include surgery in the primary treatment plan.
A 69-year-old man complained of fever in September 2009, after returning from Vietnam where he has been working for 20 years. He had diabetes mellitus and was on diabetic oral medication. He was examined at a nearby hospital, and found out to have pneumonia with cavity formation in the right upper lobe which was found out to be not due to tuberculosis. Although the patient once recovered with antibacterial medicine, after a few months, in January 2010, he was admitted to our hospital because of recurrent fever. Computed tomography revealed multiple pulmonary nodules which were thought to be pulmonary emboli, as well as subcutaneous abscess, spleen abscess, and kidney abscess. Blood test showed that he also had DIC. As Burkholderia pseudomallei was cultured from the subcutaneous abscess and blood, was diagnosed as melioidosis. The patient was treated with meropenem for 8 weeks, and then a maintenance oral antibacterial medicine was continued for the next 6 months. The patient fully recovered after those treatments and has not relapsed since then. This is the ninth case report of melioidosis in Japan which is an imported infectious disease.
BACKGROUND AND OBJECTIVE The origin of frequency dependence of respiratory resistance has been explained by ventilation inhomogeneity, however it is unclear which components in the respiratory system generate the frequency dependence. The author constructed a 4D pulmonary lobule model and analyzed relationships between airflow rate, pressure and airway resistance by the use of computational fluid dynamics (CFD). METHODS The lobule model contained bifurcated bronchioles with two adjacent acini in which deformable inter-acinar septa and alveolar duct walls were designed. Constrictive conditions of respective bronchioles were designed, too. 4D finite element models for CFD were generated and airflow simulations were performed under moving boundary conditions of the arbitrary Lagrangean-Eulerean method. From the simulation results, airway resistances for various conditions were calculated. RESULTS Tissue resistance emerged under the condition of different acinar pressures caused by unequal airway resistances. If the inter-acinar septum was shifted so as to cancel the pressure difference, the acinar pressures were equal in spite of unequal airway resistances, and hence, tissue resistances did not emerge. Therefore, the tissue resistance in the former case is thought to be an index of alveolar pressure inequality (which could be canceled by mechanical interaction of lung parenchyma), rather than a material property of the tissue itself. CONCLUSIONS Inequality of alveolar pressure decreases as the input oscillatory frequency increases. Therefore, frequency dependence of the respiratory resistance should be regarded as a conditional index of the alveolar pressure inequality caused by heterogeneous changes in the intra-pulmonary airway and/or the lung parenchyma.
BACKGROUND:Few reports exist regarding the long-term clinical course of idiopathic pulmonary alveolar proteinosis.PURPOSE AND METHODS:We retrospectively studied the clinical courses of 8 patients. The patients were 4 men and 4 women aged 48.4 +/- 14.0 years (mean +/- SD) with idiopathic pulmonary alveolar proteinosis followed up for a minimum of more than 4 years. Mean follow-up was 13 years and 6 months (4-22 years and 9 months).RESULTS:There were 15 instances of whole-lung lavage and/or bronchoalveolar lavage in 7 patients, and lavage was effective 40% of cases. Spontaneous improvement occurred 16 times and exacerbation occurred 7 times in 8 patients. On chest X-ray films, the shadows disappeared in 5 of 8 (62.5%) patients, and in 4 of 5 patients, shadows disappeared 5 or more years after diagnosis of pulmonary alveolar proteinosis. Pulmonary shadows have not disappeared in the remaining 3 patients at the time of writing but have shown improvement compared with first presentation. There were no deaths.CONCLUSION:As indicated in previous reports, the long-term outcome of idiopathic pulmonary alveolar proteinosis appears to be good.
BACKGROUND AND OBJECTIVE As part of the enlightenment campaign for COPD and for the introduction of an easy method to assess aging phenomena in respiratory function, the indicator of lung age has been suggested by the JRS Lung-Age-Spread-Promotion Secretariat (original method). In this original method, the lung age was estimated by counting back the regression formula predicting the reference value of FEV1. Since the normal value of FEV1 at a given age is not unique and exists within a certain range defined as the 95% confidence limit, the backward value of lung age calculated with the original method includes various statistical and physiological problems. In the present study, I proposed a novel method allowing estimation of lung age, in which the problems related to the original method were significantly overcome. RESULTS AND CONCLUSIONS Since the 95% confidence limit of FEV1 was not considered in the original method, the lung age of a person with high FEV1 beyond the upper end of the 95% confidence limit would result in the subject being classified as remarkably young (sometimes, the calculated lung age is below zero), while that of a person with reduced FEV1 below the lower end of the 95% confidence limit would be estimated as being very elderly (sometimes, the calculated age is over 100). On the other hand, the novel method reasonably deliberates the 95% confidence limit, leading to the conclusion that it could be applied for estimating the lung age of persons having a wide range of FEV1.
We analyzed the routes of draining veins in 7 cases of intralobar pulmonary sequestration (ILS) and 6 cases of bronchial atresia (BA) by multidetector CT and on 3D reconstructed images. In 2 cases of ILS with systemic venous drainage and 4 of 5 cases with pulmonary venous drainage, the primary veins penetrated the abnormal lungs. In another case, the main vein bypassed the border of the lung, but a small number of branches joined from the normal lung. In all cases of BA, draining veins distributed outside the abnormal lung. The finding that ILS has its own draining veins supports the theory of its congenital origin from an accessory lung bud.
A 44-year-old man was admitted because he had a mass in the right upper lung field showing high uptake of FDG-PET. Although he had already received video-assisted thoracic surgery to remove the mass in another hospital, the procedure had been unsuccessful because of severe adhesion to the superior vena cava. The pathological diagnosis of a specimen obtained in surgery was pleomorphic carcinoma, clinical stage IIIb (c-T4N2M0). We performed concurrent chemoradiotherapy consisting of systemic chemotherapy twice with both cisplatin and vinorelbine, and radiation therapy (60Gy). The tumor size reduced by 46% immediately after chemoradiotherapy. Because there was still no evidence of distant metastasis, we performed a right upper lobectomy and resection of the superior vena cava to remove the tumor completely. We did not detect any microscopic cancer cells in the surgical specimens and the pathological diagnosis was complete response (CR). It is thought that chemotherapy and radiotherapy are ineffective for pulmonary pleomorphic carcinoma. However, in this case, concurrent chemoradiotherapy with surgical therapy was highly effective and no recurrence has been observed 13 months after surgery.
A 69-year-old asymptomatic woman was admitted because of an abnormal chest shadow. Chest X-ray films showed a tumorous shadow behind the heart. Chest CT scans showed an aberrant artery branching from the thoracic aorta and supplying the left basal segment, but the bronchial tree was normal. The left lung vein was normal but wide, and the left lower pulmonary artery could not be observed. Based on these findings, we diagnosed anomalous systemic arterial supply to the normal basal segment of the left lower lobe. Because this patient had a high risk of heart failure and pulmonary hypertension, we decided to perform a left lower lobectomy, but she refused the operation. As this disease is generally found in younger patients, diagnosis in older age, as in the present case, is rare. In this report we also summarize 39 other reports of this disease in Japan.
A 65-year-old man had suffered from systemic erythema from November 2008 and had noticed gradually progressing weakness in the upper and lower limbs. He received medical treatment in another hospital but his symptoms did not improve. He was admitted to our hospital for treatment of diabetes in June 2009, and his chest X-ray images and CT scans showed a mass shadow in the right upper lobe with hilar and mediastinal lymphadenopathy. We performed bronchoscopy, and diagnosed small cell lung cancer (T2N2M1, stage IV). However, he had hand grip weakness and continuing upper and lower limb muscle weakness, and therefore electromyography was performed, which showed the presence of waxing in the right leg. Subsequently, a diagnosis of Lambert-Eaton myasthenic syndrome was made. As he also showed ataxia of the left lower extremity, we also diagnosed paraneoplastic cerebellar degeneration. We gave the patient chemotherapy consisting of carboplatin and etoposide which resulted in the disappearance of his waxing, and his grip strength and erythema immediately improved with regression of the tumor after 1 course of chemotherapy. We report a case of small cell lung cancer associated with Lambert-Eaton myasthenic syndrome, paraneoplastic cerebellar degeneration and erythema which presented as paraneoplastic syndrome, which improved with chemotherapy.
Since the avian antigen is one of the important causative antigens in hypersensitivity pneumonitis, measurement of bird-specific antibody should be readily available. We measured IgG and IgA antibodies against pigeons and budgerigars by the ImmunoCap system in bird-related hypersensitivity pneumonitis (BRHP) to evaluate their diagnostic utility. In acute BRHP, antibodies markedly increased and showed high sensitivity and specificity ranging from 75-100% based on the cut-off values determined by ROC analysis. In chronic BRHP, antibody reactivity slightly increased, showing a sensitivity of 27-73% and specificity of 45-100%. Pigeon antibodies evaluated by the ImmunoCap system showed a good correlation with anti-pigeon dropping extract antibodies measured by ELISA. In conclusion, measurement of antibodies against pigeons and budgerigars are helpful for the diagnosis of BRHP.
Primary effusion lymphoma is a rare type of lymphoma which is confined to those body cavities associated with human herpes virus 8 infection in its development. We describe a 93-year-old man with primary effusion lymphoma in the pleura, but who was negative for herpes virus 8 infection. Chest computed tomography revealed bilateral pleural effusion, but did not show any evidence of a tumor mass or lymph node enlargement. Cytological analysis of his pleural effusion revealed atypical lymphoid cells with immunophenotypes which were positive for CD10, CD19 and CD20. Clonal rearrangement of the immunoglobulin-heavy chain gene was detected by Southern blot analysis, and a diagnosis of primary effusion lymphoma was made. Although dyspnea and severe hypoxia developed, accompanied with increased pleural effusion, chemotherapy was not indicated because of his age. We thus tried oral corticosteroid therapy for palliation which resulted in a dramatic, long-term decrease of his pleural effusion. We present a rare case of primary effusion lymphoma effectively controlled by corticosteroid therapy.
A 78-year-old man with COPD was admitted in August 2010 complaining of productive cough and fever of 38 degrees C for 2 days. He was admitted with septic shock and pneumonia of the right upper lobe. Despite antibiotic administration, infiltration progressed to the right lung and lower left lung after 24 hours, and he developed acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation. All cultures from both sputum and blood grew Acinetobacter baumannii. He recovered following intensive care. Although some community-acquired pneumonias by A. baumannii are reported in Japan, this is the first report concerning a successfully treated patient.
We report a case of myeloid sarcoma in the anterior mediastinum. The patient was a 33-year-old man with a chief complaint of right shoulder pain, right upper limb edema, and cough. Chest contrast-enhanced computed tomography (CT) revealed a partially enhanced anterior mediastinal tumor. A CT-guided biopsy was then performed, and a Hematoxylin-eosin (HE) stain revealed mitosis of tumor cells and other cells, including eosinophils. Immunohistochemical stains with myeloperoxidase, CD34, CD43, CD68 and c-Kit tests were positive for tumor cells. Due to a pathological diagnosis of myeloid sarcoma, he was treated with chemotherapy based on a diagnosis of acute myelogenous leukemia. After complete remission was obtained, the patient visited another hospital to receive an unrelated bone marrow transplantation. Although it rarely occurs as a mediastinal tumor, the prognosis of myeloid sarcoma is unfavorable, and thus should be taken into consideration as a differential diagnosis.
A 63-year-old male smoker with left chest pain was admitted for examination of an abnormal chest shadow. A chest computed tomography (CT) scan revealed a tumor in S6 of the left lung, and left pleural effusion. Histological examination by CT-guided needle biopsy revealed a proliferation of spindle-shaped tumor cells with sarcomatous features. Immunohistochemical staining confirmed the tumor cells to be of epidermal origin, indicating a diagnosis of sarcomatoid carcinoma of the lung. No distant metastases were found, and his disease was judged to be clinical stage IV (T3N2M1a). He received 5 courses of systemic chemotherapy consisting of carboplatin, paclitaxel and bevacizumab, and the tumor shrank. Systemic chemotherapy is generally ineffective for sarcomatoid carcinoma of the lung. However, in the present case this chemotherapy was effective with the addition of bevacizumab.
A 23-year-old man was admitted for examination of an abnormal shadow in the right lower lung field. A chest CT scan revealed a nodule in the right lower lobe and a calcified nodule in the right upper lobe. A diagnosis of lung adenocarcinoma in the right lower lobe was made by transbronchial cytology. After resection of the right lower lobe and partial resection of the nodule in the right upper lobe were performed, we diagnosed lung adenocarcinoma in the right lower lobe (pathological stage IIIA) and hamartoma in the right upper lobe. Although several authors have reported cases of synchronous pulmonary hamartoma and lung cancer, it is uncommon in young patients. Since patients with hamartoma could also have lung carcinoma, careful observation is needed.
A 69-year-old man, who had been followed up for sarcoidosis at another hospital from 10 years previously, was referred to our hospital because of a new lesion in the left upper lobe. A chest CT scan revealed a nodular lesion at the orifice of the left B3b and mediastinal lymphadenopathy. Bronchoscopic biopsy established a diagnosis of squamous cell carcinoma. Because there had been no distant metastasis and no change in size of the mediastinal lymph nodes over the previous 5 years, left upper lobectomy with lymph node dissection was performed. The histology of the resected tumor indicated a moderately-differentiated squamous cell carcinoma, and the dissected lymph nodes contained non-caseous epithelioid cell granuloma without metastasis. Thus, we made a final diagnosis of squamous cell carcinoma (pT1N0M0, stage IA) that complicated the sarcoidosis. Surgical resection can be the first option for lung cancer complicating sarcoidosis with mediastinal lymphadenopathy, because making a preoperative assessment of N status is difficult.
Multiple pulmonary nodular lesions were noted on a chest X-ray film of a 56-year-old man. Partial resection of the left lung via thoracoscopy was performed, yielding a pathological diagnosis of leiomyosarcoma. Positron emission tomography/computed tomography (PET/CT) and other examinations revealed that the lesions originated in the lung. Chemotherapy with adriamycin and ifosfamide was performed but was ineffective. It is reported that leiomyosarcoma with multiple pulmonary nodules often derives from a uterine primary lesion. Primary pulmonary leiomyosarcoma with multiple nodular lesions is rare, but it should be considered in the differential diagnosis in cases with multiple lung nodules.
A 72-year-old man visited our hospital due to persistent cough, fever and weight loss. A chest X-ray film revealed a round tumor in the left lower lung field. A specimen obtained by transbronchial lung biopsy demonstrated histiocytic and lymphocytic infiltration in the alveolar space, with spindle myofibroblasts and plasmacytes in the interstitium, Those findings were consistent with inflammatory pseudotumor. Four weeks later, a chest X-ray film showed only scars of the primary lesion, and his symptoms resolved dramatically. He has had no recurrence of symptoms and pulmonary tumor since then. Although spontaneous remission is uncommon in inflammatory pseudotumor of the lung, there are several case reports about spontaneous remission of hepatic inflammatory pseudotumor and autoimmune pancreatitis, parts of IgG4-related sclerosing disease. Recently, inflammatory pseudotumor is thought to be IgG4-related sclerosing disease. We speculate that IgG4 may be associated with spontaneous remission of inflammatory pseudotumor of the lung, and we discuss this issue in relation to the pertinent literature.
An 80-year-old Japanese male was admitted to our hospital because of bloody sputum. He had a history of malignant melanoma of the left fourth digit, which was surgically excised 16 years previously. On hospital admission, chest computed tomography revealed several nodules in the lower lobes. He underwent thoracoscopic lung biopsy and amelanotic malignant melanoma was histologically diagnosed by immunohistochemical staining. The staining pattern with several antibodies was similar to that of the melanoma excised 16 years previously. Therefore, we concluded that the nodules in the lung were metastases of the malignant melanoma of the digit. Despite treatment with interferon, the nodules progressed rapidly, and the patient died 4 months later. This case suggests that the risk of recurrence with rapidly progressive distant metastasis should be considered in patients with malignant melanoma, even after a long disease-free interval. In addition, this case suggests that immunohistochemical stains with several antibodies are useful in the diagnosis of malignant melanoma.
BACKGROUND:To investigate the relationship between the prognosis of chronic interstitial pneumonia (IP) and its comorbidities, we conducted a retrospective study for clinically and radiologically diagnosed IP. We assessed comorbidities by using the Charlson Comorbidity Index (CCI).METHODS:We classified 224 patients given clinical diagnoses of chronic IP (excluding the patients who had clear causes such as collagen disease, infection, drugs or radiation) in our institution between April 2000 and June 2010, into 2 groups; those with clinical diagnoses of idiopathic pulmonary fibrosis (IPF:108 cases) and those with other chronic IP but without honeycomb lung (116 cases); and analyzed their backgrounds and comorbidities. We also classified them into survival and non-survival groups to assess their prognostic factors.RESULTS:Although the smoking status of patients with clinically diagnosed IPF was higher, and SpO2 was lower than those with other chronic IP without honeycomb lung, the mean age, comorbidities and CCI did not differ between them. The 5-year overall survival of the clinically-diagnosed IPF group was lower than that of the other chronic IP without honeycomb lung group (50.8% vs. 76.3%, p<0.01). In cases of other chronic IP without honeycomb lung, the CCI of non-survival cases was higher than that of survival cases (4.05 vs. 2.47, p<0.01), although patient backgrounds did not differ between survival and non-survival cases in those with clinically diagnosed IPF (CCI : 2.32 vs. 2.98, p = 0.70).CONCLUSIONS:Our analysis revealed the possibility that comorbidities and CCI were prognostic factors in other chronic IP cases without honeycomb lung, although the prognosis of IPF was not affected by their comorbidity.
