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

A 43-year-old diabetic man had a productive cough and high fever and was admitted to another hospital. His condition did not improve despite treatment with Cefepime, and he was transferred to our hospital. Chest X-ray films and CT findings showed pulmonary infiltration and diffuse ground-glass opacities in bilateral lung fields, but disseminated nodules were not identified. Since his bronchial lavage fluid (BALF) was bloody, we suspected diffuse alveolar hemorrhage due to vasculitis. Steroid pulse therapy was given, and his fever and chest X-ray findings completely improved. However, 1 week later, he again suffered a high fever and bloody sputum, and a chest X-ray film showed granular shadows in bilateral lung fields. He died of respiratory failure on the 18th hospital day despite treatment and mechanical ventilation. An autopsy revealed many necrotizing epithelioid granulomas in both lungs, the liver, the spleen, both kidneys and both adrenal glands. These findings indicated miliary tuberculosis, and a culture of his sputum and BALF finally revealed mycobacterium tuberculosis. Marked alveolar hemorrhage and a hyaline membrane were also found in both lungs, but vasculitis was not recognized in any organ. We report this case, because to the best of our knowledge diffuse alveolar hemorrhage has not been reported as the primary symptom of miliary tuberculosis.

A 69-year-old man was examined for investigation of a nodular shadow with calcification detected on computed tomography of the chest. He showed no features of allergic bronchopulmonary aspergillosis (ABPA), such as bronchial asthma or eosinophilia. We could not distinguish his disease status from lung cancer and performed upper lobectomy of his right lung. Pathological examination revealed bronchocentric granulomatosis (BCG) with Aspergillus clusters. Subsequent serological testing demonstrated high levels of IgE-RIST and IgE-RAST (Aspergillus) whereas anti-Aspergillus precipitating antibody was not detectable. We believe that Aspergillus clusters may have been present in this patient for several years, and the pathological findings might be manifested as an asymptomatic localized allergic inflammation. BCG is a pathological component of ABPA. This case, of a localized allergic reaction, is considered very valuable for understanding the underlying mechanism of the onset of ABPA.

An 84-year-old man was admitted with paresis of the right lower limb. Hemorrhagic lesions were demonstrated in the left frontoparietal lobe and cerebellum by cranial computed tomography (CT) and magnetic resonance imaging (MRI). Chest CT revealed an ill-defined mass measuring 4 x 6 cm in the left lower lobe of the lung, although bronchoscopic examination failed to obtain pathological diagnosis. Clinical diagnosis of primary lung cancer with multiple brain metastases was made, and he underwent whole brain radiotherapy. The pulmonary and cerebral lesions mimicked abscesses during his clinical course, and he died of respiratory failure due to bilateral pneumonia three months after admission. Autopsy revealed that both the pulmonary and brain lesions were malignant melanomas, but no other melanoma lesions could be identified despite meticulous investigation. Although malignant melanoma with an unknown primary site is rare in Japan, careful evaluation of the CT and MRI findings might be the key to correct diagnosis in this case.

Classic Lemierre syndrome is a septic internal jugular venous thrombophlebitis secondary to oropharyngeal anaerobic infection in adolescents and young adults. Upper respiratory tract infection is the most common antecedent. We report a case of Lemierre syndrome as a rare infectious disease. A 20-year-old man complained of high fever, right neck discomfort and chest pain. Chest X-ray revealed infiltrative shadows, suggesting bacterial pneumonia. Although cefcapene pivoxil hydrochloride hydrate (CFPN-PI) was given in a local clinic, his symptoms did not improve. Then he was referred to our hospital. Chest CT findings showed bilateral multiple nodular shadows with small cavities, suggesting septic embolization. Fusobacterium necrophorum was cultured from specimen of the blood, and an enhanced neck CT scan showed thrombosis in the right internal jugular vein. These findings led us to a diagnosis of Lemierre syndrome. Four weeks of antibiotics and anticoagulants ameliorated inflammatory findings in blood, but internal jugular vein thrombosis remained. Currently, there is no consensus opinion on the use of anticoagulation in patients with Lemierre syndrome complicated by septic internal jugular thrombosis and embolism. Early and effective antibiotics therapy may prevent the development of the syndrome and its associated complication, although it is unclear whether the outcome will be favorable.

The index case was a 71-year-old man with no smoking history. He was given a diagnosis of idiopathic interstitial pneumonia at the age of 65. He was admitted to our hospital because of persistent cough and dyspnea on exertion. Two months after initiation of corticosteroid treatment he died of acute exacerbations of interstitial pneumonia. Among his family, four of seven brothers had interstitial pneumonia and all three sons of his were also found to have interstitial pneumonia, and of these seven patients six had a history of smoking. The average age at diagnosis of his generation was 66.5 and that of his son's generation was 45.3. In proband generation chest CT showed traction bronchiectasis or honeycombing in subpleural lesions. In addition, it revealed centrilobular micronodules and interlobular reticular shadow in the second generation. We found 2 single nucleotide polymorphisms of surfactant protein C gene in all children of the proband.

Three cases of organizing pneumonia (OP) that occurred after planned radiation therapy for postoperative breast cancer are reported. All patients received tangential radiation therapy and adjuvant tamoxifen (TAM) for postoperative breast cancer. Two patients developed fever and cough; one was asymptomatic. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field. Bronchoalveolar lavage showed an elevated total cell count with a high percentage of lymphocytes, as well as elevated eosinophil levels in two cases. Transbronchial lung biopsy revealed a histologic pattern consistent with organizing pneumonia. For the two symptomatic cases, treatment with corticosteroids reduced clinical symptoms promptly and improved imaging findings. The single asymptomatic case improved without treatment. The number of such reported cases has increased in recent years, but the etiology is unclear. In the three cases presented, TAM combined with radiation therapy may have been the cause of the OP.

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.

Mycobacterium kansasii pulmonary diseases account for 20% of cases of non-tuberculous mycobacteria. Most patients are male. However, a recent study has found that radiological examinations in female patients often reveal nodular, bronchiectatic opacities. We describe 3 young women with cavitary opacities. Patient 1 was a 35-year-old woman in whom thin-walled cavitary opacities were detected in the upper lobe during a routine checkup. Sputum examination and fiberoptic bronchoscopy led to a diagnosis of M. kansasii pulmonary disease. Patient 2 was a 23-year-old woman who presented with hemoptysis. Thin-walled cavitary opacities were detected in the right upper lobe. Infection with M. kansasii was diagnosed after a sputum examination. Patient 3 was a 43-year-old woman in whom thin-walled cavitary opacities were detected in the left upper lobe during a routine checkup. Infection with M. kansasii was diagnosed after a fiberoptic bronchoscopic examination. Patient 1 was successfully treated with rifampicin, ethambutol, and levofloxacin, and patients 2 and 3 were successfully treated with isoniazid, rifampicin, and ethambutol. The possibility of M. kansasii pulmonary diseases should be considered in a previously healthy young woman with thin-walled cavitary opacities in the upper lobe.

A 42-year-old Japanese woman was referred to our university hospital due to progressive anemia and bilateral hilar lymphadenopathy with diffuse ground-glass attenuation on chest computed tomography in December 2009. She had suffered from exertional dyspnea and fatigue for several months. Laboratory findings on admission demonstrated leukocytosis (10,950/ul), elevation of C-reactive protein (4.7 mg/dl), IL-6 (19.9 pg/ml), IgG4 (567 mg/dl) and polyclonal hyper gamma-globulinemia. Chest computed tomography represented mediastinal and bilateral hilar lymphadenopathy with diffuse centrilobular fine nodules and intralobular septal thickening. Histopathological findings of the specimens obtained by thoracoscopic lung and mediastinal lymph node biopsies revealed massive infiltration of IgG4-positive plasma cells in lung tissue and lymph nodes. Pathological findings and high levels of C-reactive protein and interleukin-6 suggested a diagnosis of multicentric Castleman's disease (MCD). In addition, pathological findings of peribronchiolar infiltration of IgG4-positive plasma cells and lymphoid follicles with infiltration of IgG4-positive plasma cells with a high level of IgG4 were indicative of the complication of IgG4-related lung disease. Radiological and serological findings improved rapidly soon after the initiation of oral corticosteroid treatment. It was speculated that this case indicated the close relationship between MCD and IgG4-related lung disease.

Objective: We examined the educational usefulness of lung auscultation training with an auscultation simulator "Mr. Lung".

Methods: Auscultation training was conducted for fifth-year students of the Medical Department of the University of Miyazaki, and consisted of a lecture by a pulmonologist (Board Certified Member of the Japanese Respiratory Society) and skill training using Mr. Lung for a total of 90 min. We compared the percentages of students who correctly identified 4 adventitious sounds before and after training. We also investigated the responses to a self-report questionnaire on self-evaluation after training, auscultation experiences before training, and opinions regarding medical education with the simulator.

Results: The subjects' correct answer rate before training was 40% or less and that for the correct identification of rhonchi was the lowest (5%). The correct answer rate, which was not influenced by previous experience of auscultation, significantly increased after training (80% or more). In the self-report questionnaire, about 90% of the students answered that the ability to identify lung sounds by auscultation was necessary for all doctors and that the simulator was effective for acquiring this skill.

Conclusion: The auscultation simulator may be useful for medical students not only to enhance auscultatory skills but also to realize the importance of auscultation in clinical examination.