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

An 80-year-old woman visited her family physician because of back pain. A chest X-ray film showed a mass in the left middle lung field. She was referred to our hospital for further examinations. A computed tomography-guided lung biopsy revealed a solitary fibrous tumor, and a whole body examination demonstrated multiple metastases, including in the spine, ribs, femurs and pubis. Considering her age, chemotherapy was not given, but we administered radiotherapy for the metastatic lesions. Subsequently detected metastases of the left orbit, liver, scapula and humerus were also then irradiated, but she died 11 months after the initial diagnosis due to the complication of bacterial pneumonia. A case of a solitary malignant fibrous tumor with multiple metastases was reported.

A 51-year-old man visited a local physician because of a chest radiographic abnormality which had been pointed out in October 2009 and March 2010. His chest CT images revealed a nodular lesion in the right middle lobe. Since the nodular lesion showed abnormal FDG accumulation on FDG-PET, the physician suspected lung cancer, but was unable to make a definitive diagnosis by CT-guided lung biopsy. The patient was thus referred to our hospital for detailed investigations. A nodular lesion with spiculation and pleural indentation was recognized in the S4 region on chest CT scans which was strongly suspected to be lung cancer. Since various examinations did not provide a definitive diagnosis, we performed surgery. The histological findings of the extirpated tumor were considered to be bronchocentric granulomatosis (BCG), because necrotic granulomatous lesions with epithelioid cells centered on the bronchioles and there was no evidence of fungus or acid-fast bacterium infection.

A 71-year-old man underwent pleural biopsy due to left pleural effusion and pleural thickening in August, 2001. An inflammatory pseudotumor (IPT) was diagnosed, and therefore systemic oral steroid therapy (prednisolone [PSL] 30 mg/day) was initiated. However, after tapering PSL to 7.5 mg/day, a complication of secondary central diabetes insipidus due to hypophysitis developed in 2008. As his pulmonary condition deteriorated over time and he began to experience exertional dyspnea, he was admitted to our hospital for re-evaluation of the disease in October, 2010. High-resolution CT (HRCT) revealed pulmonary involvements distributed in the interstitium and a high serum IgG4 level (240 mg/dl). Upon re-evaluating the pleural biopsy specimens of the first visit, we found lymphoplasmacytic-type IPT with approximately 10% IgG4-positive plasma cells in the affected areas. After increasing the PSL dose up to 0.6 mg/kg/day, his serum IgG4 levels decreased, his dyspnea improved, and the radiological findings of his pulmonary and pituitary involvements improved. This case was diagnosed as lymphoplasmacytic type IPT which appeared to be highly homologous with IgG4-related disease due to high serum levels of IgG4, pituitary involvements and the observed efficacy of PSL.

We report the case of a 67-year-old man with a diagnosis of stage IV stomach cancer in May 2010 who was treated with outpatient chemotherapy using TS-1, paclitaxel and lentinan. Dyspnea and coughing developed after drug administration in November and the patient was hospitalized on day 5 after the appearance of symptoms due to hypoxemia and the presence of ground-glass opacities in the right middle and lower lung fields. On the same day, bronchoscopy was performed for differentiation from infection and lymphangitic carcinomatosis. A transbronchial lung biopsy suggested drug-induced pulmonary toxicity, and a drug lymphocyte stimulation test was highly positive for TS-1. Discontinuation of TS-1 alone improved his respiratory status and imaging findings. TS-1 is available only in Japan, and because it is administered orally and its toxicity is minimal, its use has been expanded to treat a variety of malignancies. Drug-induced pulmonary toxicity due to TS-1 occurs in only 0.03% of all cases, and there are few reports regarding the histopathological findings of TS-1-related pulmonary toxicity. Although it can be difficult to diagnose drug-induced pulmonary toxicity because it demonstrates a variety of imaging findings, the present case suggests that it is important to proactively perform transbronchial lung biopsy at the early stage of diagnosis and promptly determine a course of treatment.

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.

The aim of this study was to investigate the effects of inspiratory negative pressure by biphasic cuirass ventilation on tidal volume and the relationship between pressure level and tidal volume in 15 normal subjects. We measured tidal volume during inspiratory negative pressures of -5, -10, -20 and -30 cm H2O. An inspiratory negative pressure of -30 cm H2O was necessary to increase tidal volume. We conclude that -30 cm H2O of biphasic cuirass ventilation significantly increases tidal volume in normal subjects.

A 62-year-old Japanese man visited our hospital for the examination of a middle-posterior mediastinal lesion noted on a chest CT image. Magnetic resonance imaging (MRI) showed swelling of the hypophysis, bilateral orbital muscles and bilateral lacrimal and submandibular glands. CT subsequently showed a middle-posterior mediastinal lesion, centrilobular nodules in the lung fields, swelling of the pulmonary hilar lymph nodes and soft tissue tumor around the bilateral ureteropelvic junctions. The patient's serum IgG4 level was elevated, and biopsy specimens from the lacrimal gland showed abundant IgG4-positive plasma cells. These findings were consistent with systemic IgG4-related disease. Following steroid treatment, the lesions reduced. To the best of our knowledge, there are only 2 case reports regarding systemic IgG4-related disease accompanied with a middle-posterior mediastinal lesion.

Distigmine bromide is a cholinesterase inhibitor widely used for the treatment of hypotonic neurogenic bladder. However, this drug is also known to cause cholinergic crisis, a rare but serious adverse reaction. Cholinergic crisis is an excessive amount of acetylcholine due to the systemic inhibition of cholinesterase activity, characterized by parasympathetic symptoms such as sweating, salivation, miosis, bradycardia, diarrhea and circulatory and respiratory failure. The incidence of cholinergic crisis has been estimated at approximately 0.2%, and the majority of the patients are elderly with underlying conditions such as cerebrovascular disease. Since 2004, we have encountered 5 cases of acute respiratory failure associated with cholinergic crisis induced by the administration of a normal oral dose of distigmine. We present these cases here and review an additional 23 cases from the literature in Japan. In these 28 cases, mechanical ventilation was required for 57%, with a mean duration of 5.1 days and a mortality rate of 11%. Pneumonia was observed in half of the cases in the acute phase, and relapse due to the readministration of distigmine was reported in 20% of cases. It is important to remember that cholinergic crisis in the elderly is often misdiagnosed and is occasionally treated as simple aspiration pneumonia.

We present a case of postural hypoxemia with a final diagnosis of myasthenia gravis (MG). A 62-year-old man experienced double vision in his left eye from December 2008 and received a diagnosis of diabetic neuropathy. From mid-December he began to experience breathing difficulties at night when in a supine position and was admitted to our hospital. Bilateral diaphragmatic elevation was observed on a chest X-ray film, and lower lung atelectasis and an anterior mediastinal tumor were observed on chest CT. However, his breathing difficulties only occurred when he was in a supine position. Therefore, we performed blood gas analysis in supine and sitting positions. Hypoxemia, hypercapnia and an increase in A-aDO2 were observed in the supine position, leading to a diagnosis of postural hypoxemia. Due to the exacerbation of his double vision, the patient was referred to the ophthalmology and neurology departments where he tested positive for anti-acetylcholine receptor antibodies and also on a tensilon test, resulting in a final diagnosis of MG. During the tensilon test, the patient's breathing difficulties in the supine position improved, and therefore his postural hypoxemia was thought to have resulted from diaphragmatic muscle weakness as a result of MG. MG respiratory failure is typically of the acute fulminating type and is considered to be a critical condition. However, it should be noted that there are cases, such as the present one, in which MG presents as postural hypoxemia.

We report a case of secondary amyloidosis with pleural involvement in a patient with rheumatoid arthritis. A 77-year-old man had received a diagnosis of rheumatoid arthritis 10 years previously. Bilateral pleural effusion of unknown etiology was noted 2 years prior to admission. A biopsy of the left pleura by video-assisted thoracic surgery did not reveal any evidence of the cause of his pleural effusion. The histological findings revealed chronic inflammation of the pleura on a hematoxylin-eosin (HE) stain, but treatment with an increased dose of corticosteroid did not improve his effusion. Right pneumothorax then developed. Based on the histological findings of a Congo red stain, the diagnosis was changed to pleural amyloidosis. An initial attempt at pleurodesis with OK-432 and a pleural patch with the patient's own blood was attempted but was not successful. Subsequently, pleurodesis with OK-432 and the patient's own blood improved his pleural effusion and pneumothorax. Pleural involvement in amyloidosis is extremely rare and is difficult to treat.