Nihon Kokyuki Gakkai zasshi = the journal of the Japanese Respiratory Society最新文献

A 72-year-old man was admitted to the intensive care unit of our hospital with acute respiratory distress syndrome (ARDS). A chest CT scan showed diffuse consolidations and ground-glass opacities in both lungs. We diagnosed ARDS secondary to community-acquired pneumonia. We then started mechanical ventilation with airway pressure release ventilation and treated him with antibiotics, peramivir, and corticosteroids, despite negative results for a rapid antigen test for influenza. Bronchial lavage on day 10 showed blood-tinged fluid and hemosiderin-laden macrophages, but no bacteria or fungi. Real-time reverse-transcriptase polymerase chain reaction testing yielded a positive result for pandemic influenza A (H1N1). The mechanical ventilator was removed on day 15, corticosteroid administration was discontinued on day 22 and antibiotics were discontinued on day 23. However, he had a fever on day 28, pleural pain and dyspnea on day 29, and exacerbation of the infiltration as demonstrated on chest CT on day 30. On day 31, repeat bronchoalveolar lavage showed an increase in the number of total cells which were lymphocyte-predominant, but there were no pathogens. We believed that this clinical exacerbation might have occurred due to the re-exacerbation of pandemic influenza A (H1N1) pneumonia due to the cessation of corticosteroids. The re-administration of corticosteroids was effective, and were eventually tapered. Currently, the use of corticosteroid therapy for severe pandemic influenza A (H1N1) pneumonia is controversial, but even the late administration of corticosteroid therapy may be effective. However, this case also suggests that the early administration of corticosteroid therapy as immunomodulation might be effective in selected cases, and that cessation of such therapy during the early phase of ARDS may cause exacerbation of clinical symptoms.

Pleuritis is a rare complication associated with nontuberculous mycobacteriosis of the lung and its etiology remains to be clarified. We investigated pleuritis associated with nontuberculous mycobacteriosis of the lung in 304 patients who visited our hospital. Of these, 9 patients (3%) had pleural effusion not attributable to any factor other than pleuritis; these cases were diagnosed as pleuritis. Massive pleural effusion requiring drainage was rare (1 patient, 0.3%) and pleuritis accompanied by pneumothorax was also rare (2 patients, 0.7%). The lung lesions in the patients with pleuritis were often extensive or contained a cavity. All these patients showed infection with Mycobacterium avium complex (MAC). Although it is difficult to diagnose MAC-induced pleuritis, patients with this condition often present with at least 1 of the following signs: the presence of nontuberculous mycobacterium in pleural effusion, a predominance of lymphocytes among the cells detected in pleural effusion, a high adenosine deaminase level, and the disappearance of pleural effusion following treatment. Recognizing these signs may aid the diagnosis of MAC-induced pleuritis.

Background: Detailed investigation of the cause of chylothorax and its treatment should be performed by thoracoscopy under general anesthesia, but if this is difficult due to multiple complications it is possible to perform a detailed investigation by combining thoracoscopy under local anesthesia and thoracic duct scintigraphy.

Case presentation: A 74-year-old woman presented with exertional dyspnea. Chest X-ray films showed right pleural effusion, and thoracocentesis yielded a milky white pleural effusion, meeting the criteria of chylothorax, after excluding conditions such as malignant lymphoma, amyloidosis and trauma. Since the patient's medical history included pacemaker insertion, dialysis and diabetes, thoracoscopy was performed under local anesthesia rather than general anesthesia, to investigate the cause in detail. The pleural cavity was visualized, but no obvious tumor or other cause was present in the parietal pleura. There was partial adhesion of the lower lobe and chest wall, and the leakage of a milky white pleural effusion from this site was confirmed. We then performed thoracic duct scintigraphy, which revealed an area of enhancement corresponding to the leakage site near the right pulmonary hilum.

Conclusion: We describe a case in which thoracoscopy under local anesthesia and thoracic duct scintigraphy were useful for determining the leakage site in chylothorax.

A 62-year-old man with left chest pain had left pleural effusion pointed out on a chest radiograph. Chest CT scans showed multiple nodules on the left parietal pleura and pleural effusion. He was referred to our hospital and we performed thoracoscopic examination. Malignant pleural mesothelioma (biphasic type) was diagnosed, based on the pathological findings of a parietal nodular mass, including immunohistological analysis. Chemotherapy using carboplatin and pemetrexed reduced the size of tumor and left pleural effusion. This is a rare case with atypical CT findings of malignant pleural mesothelioma.

A 78-year-old man was referred to our hospital because of pyrexia in October 2008. Chest X-ray films and chest computed tomography (CT) indicated chronic tuberculous empyema in the right hemithorax. His general condition was not improved by antibiotic treatment, and CT showed pyothorax with a niveau and bronchial fistulas in May 2009. We subsequently performed open window thoracostomy and decortication of the residual dead spaces, but the bronchial fistulas remained. As this approach makes it difficult to ensure the sterility of the cavity, we therefore performed fiberoptic bronchoscopy and occluded the bronchus with an endobronchial Watanabe spigot (EWS). However, the bronchial fistula recurred, and therefore we performed this treatment again. We continued to carefully wash the cavity and the leakage stopped, whereupon the cavity became sterile. We then performed omental pedicle and muscle flap closure and thoracoplasty in April 2010. The empyema was cured without any complications. These findings suggest that using an EWS before surgery can be highly effective in controlling chronic tuberculous empyema with fistulas.

A 41-year-old man with fever, diarrhea and skin rash received a diagnosis of drug-induced lupus. He was given corticosteroids for 3 months and was subsequently admitted to a local hospital due to dyspnea. Pneumonia was then diagnosed and he was given a new quinolone antibacterial agent. Despite this treatment, his symptoms and signs gradually worsened and he was referred to our hospital. High resolution CT (HRCT) of the chest showed diffuse ground-glass opacities, reticular shadows, parenchymal abnormalities, traction bronchiectasis, a subpleural curvilinear shadow and septal lines. Serological examinations were positive for anti-myeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA) and subsequent HRCT findings were consistent with ANCA-related lung disease. However, the patient had complications such as previous syphilis infection, oral candidiasis, herpes zoster, hepatitis B virus and cytomegalovirus infection. Additionally, his serum was positive for HIV antibody and HIV-1 RNA, and therefore we diagnosed AIDS. His bronchoalveolar lavage fluid revealed Pneumocystis jirovecii. It is known that HIV infection is associated with many types of autoantibodies including MPO-ANCA. Therefore, in HIV/AIDS patients with interstitial lung diseases, it is important to differentiate opportunistic Pneumocystis pneumonia infection from collagen vascular disease-associated interstitial lung diseases.

A 52-year-old man noticed hardening and swelling of his salivary glands in the summer of 2009. We suspected Mikulicz disease and performed several work-ups. His serum IgG4 level was elevated, and a chest computed tomography scan demonstrated marked thickening of the bronchial wall. A histopathologic examination of a bronchial mucosa biopsy specimen revealed diffuse infiltration of IgG4-positive cells in the submucosal layers, and on this basis we diagnosed IgG4-related disease. After the administration of corticosteroids, the patient's symptoms, his serum IgG4 level and bronchial wall thickening all improved. When encountering a patient with thickening of the bronchial wall, IgG4-related disease should be considered.

A 58-year-old man presented to a local physician with cough, fever, myalgia and dyspnea. His chest X-ray film showed abnormal shadows and therefore he was admitted to our hospital. Chest computed tomography showed bilateral ground-glass opacities and bilateral consolidation. We suspected influenza pneumonia, but the results of both an influenza rapid antigen test and reverse transcriptase-polymerase chain reaction test for novel influenza (H1N1 2009) were negative. Transbronchial lung biopsy showed diffuse alveolar damage patterns. We diagnosed acute interstitial pneumonia and initiated corticosteroid therapy. Moreover, because influenza pneumonia could not be excluded according to his clinical picture, oseltamivir was administered. His condition improved and he was discharged. After discharge, the levels of antibody titers for influenza A virus significantly increased. We therefore re-evaluated his transbronchial lung biopsy specimen and found that immunohistochemical staining was positive for influenza A antigen in his bronchial and bronchiolar cells. We re-diagnosed his condition as influenza pneumonia. The possibility that influenza pneumonia may present in cases originally diagnosed as acute interstitial pneumonia must be considered.

A 40-year-old man was admitted to our hospital with a 1-month history of dyspnea and appetite loss. Chest computed tomography and echocardiography showed moderate pericardial effusion and pericardial thickening. The patient had no history of exposure to asbestos. We created a pericardial window in order to make a diagnosis and to relieve the symptoms using video-assisted thoracoscopic surgery and performed biopsies of the pericardium and the pleura. Immunohistologic analysis of the pericardium confirmed a diagnosis of biphasic pericardial mesothelioma. We gave the patient two cycles of chemotherapy, including pemetrexed and platinum, but his condition did not improve and he died 3 months after onset.

A 49-year-old man consulted our hospital several days after the onset of dyspnea and was admitted because it rapidly exacerbated 9 days after presentation. Diffuse centrilobular micronodular shadows and diffuse opacities in all lung fields were noted on high-resolution computed tomography of the chest. Severe pulmonary hypertension and dilatation of the right ventricle was observed on echocardiography. Although there was no evidence of thrombus in the central portion of the pulmonary artery or deep veins of the lower limbs, the patient's respiratory insufficiency rapidly progressed and he died about 14 hours after admission. A postmortem examination revealed widespread gastric cancer and tumor emboli in the pulmonary arterioles, complicated with intraluminal organization, which is consistent with pulmonary-tumor thrombotic microangiopathy (PTTM). His serum level of vascular endothelial growth factor-D (VEGF-D) was elevated, but VEGF-D was not detected by immunohistological staining. A possible pathophysiological association with PTTM and VEGF-D should be examined in future studies.