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

We report a case of a 41-year-old woman admitted to our hospital for dyspnea on exertion and nonproductive cough. High-resolution computed tomography (HRCT) revealed central ground-glass opacities surrounded by ring-shaped areas of consolidation (reversed halo sign), predominantly in the lower lobes. Bronchoalveolar lavage fluid revealed an increase of the total number of cells (35 x 10(4)/ml), including elevated lymphocyte level (69%) and decreased CD4/CD8 ratio (0.45). Histopathological examination by transbronchial lung biopsy showed polypoid masses of granulation tissue filling the lumens of a respiratory bronchiole and alveolar ducts, consistent with organizing pneumonia. After admission the patient complained of dry eyes and dry mouth. The serum anti-SS-A antibody level was also elevated (65.0 U/ml). Labial salivary gland biopsy specimens revealed focal lymphocytic infiltration of more than 50 per 4 mm(2). There were no findings of rheumatoid arthritis or other collagen diseases. We diagnosed primary Sjögren syndrome with secondary organizing pneumonia with a reversed halo sign. She was treated with prednisolone (0.5 mg/kg body weight, 35 mg/day). After treatment, the chest CT showed improvement through consolidation.

We recently experienced one each of 2 types of recurrent respiratory papillomatosis (RRP). Case 1 (juvenile-onset type): A 30-year-old woman presenting with bloody sputum and large tumors with cavities on her chest Xray film, was referred to our hospital. She had been diagnosed with laryngeal papillomatosis when she was three years old. According to our bronchoscopical examination biopsy, she was diagnosed with squamous cell carcinoma of the lung in addition to papillomatosis of the trachea and bronchus. Although chemotherapy was performed, she died 2 years after the diagnosis of lung cancer without any distinct treatment efficacy. Case 2 (adult-onset type): A 43 year-old woman presenting with fever and dry cough visited our hospital. Chest CT revealed that there was narrowing of bilateral main bronchi and hilar lymphadenopathy. Bronchoscopic examination revealed diffuse papilloma distributed extensively from the trachea to bilateral main bronchi. However, she recovered spontaneously in 6 months and has remained stable without recurrence. Both cases were diagnosed with RRP based on the separation of HPV in case 1 and pathological findings of koilocytosis in case 2. Case 1 was complicated with squamous cell carcinoma of the lung in the clinical course, presumably due to occurrence of malignant conversion of papillomatosis. Since RRP is a rare but refractory disease, novel effective treatment is necessary.

A 76-year-old man was admitted to our hospital because of increasing size of lung nodules, while he was under observation for silicosis at another hospital. As the result of bronchoscopic biopsy, it was confirmed that they were silicotic nodules. However, he was hospitalized again about one month later due to left spontaneous pneumothorax. The pneumothorax improved immediately by persistent drainage of the thoracic cavity, but he developed a fever on day 9, and ground-glass opacities in both lungs also became exacerbated in spite of our administration of antibiotics. In addition, the level of MPO-ANCA increased markedly and multiple 3-10mm sized purpurae was seen on the right thigh on day 29. Skin biopsy specimens revealed infiltration of histiocytes and lymphocytes around medium-sized vessels in lower dermis. We diagnosed microscopic polyangiitis, then treated with steroid and immunosuppressive therapy. Fever and radiological findings improved significantly from the day after initiation of steroid administration. The patient was discharged on day 92 because of the improvement of his respiratory condition. We report a case of microscopic polyangiitis with silicosis, which markedly improved by steroid and immunosuppressive therapy.

A 60-year-old man was admitted because of fever, headache, and difficulty in walking. Respiratory symptoms included only mild cough, but crackles were present on auscultation at the right lung base, the chest roentgenogram and computed tomography scans showed consolidation in the right lower lobe. Laboratory findings revealed hyponatremia, elevated liver function test values and creatine phosphokinase, and Legionella pneumophila antigen in urine. Neurological examination revealed mild mental status change, dysmetria, dysarthria, and ataxic gait. Diffusion-weighted magnetic resonance imaging (MRI) of the brain, performed at the time of admission, revealed regions of high intensity in the splenium corpus callosum. We diagnosed Legionnaires' pneumonia accompanied by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), and started treatment with ciprofloxacin and methylprednisolone at 1 mg/kg/day. Neurological symptoms gradually improved. On day 6 after admission, mild dysarthria and ataxic gait remained, a 123-IMP single photon emission computed tomography revealed no abnormality. On day 15 after admission, the only neurological symptom was mild ataxic gait; the MRI scans showed no abnormalities. On day 29 after admission, neurological symptoms were completely resolved. This is the first reported case of Legionnaires' pneumonia accompanied by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) was treated with not only antibiotics but also corticosteroid.

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.

Erlotinib is a potent drug used for treating epidermal growth factor receptor (EGFR) mutation positive lung cancer. In this study, we report a case of erlotinib induced cutaneous vasculitis. The patient was a 69-year-old woman with a history of left lower lobe resection for lung cancer. Two years after the resection, she had metastasis in the adrenal glands for which we initiated erlotinib therapy at a dose of 150 mg/day. The patient developed multiple purpurae with a partially necrotic region on both lower thighs at 8 weeks after initiating therapy. The skin biopsy results revealed cutaneous vasculitis. We stopped erlotinib therapy after this diagnosis because of this adverse effect as well as because it exacerbated the cancer. The patient's skin manifestation disappeared 2 weeks after stopping therapy, with no recurrence of any symptoms of systemic vasculitis. We reviewed the literature on drug-induced vasculitis due to oral EGFR inhibitors and found 13 such cases. In most cases, the symptoms appeared 1-2 months after initiating therapy. In all the cases, the symptoms resolved within 2-6 weeks after stopping drug therapy. Erlotinib-induced cutaneous vasculitis is rare but may cause fatal systemic vasculitis. Therefore, the skin of patients who are undergoing erlotinib therapy should be carefully examined at regular intervals during the course of therapy for drug-induced adverse effects.

Background: The importance of the home care of patients with chronic respiratory failure has been emphasized, but the status of the patients and their caregivers have not been comprehensively evaluated.

Methods: We performed a cross-sectional analysis of 242 patients treated at home with long-term oxygen therapy (LTOT) and/ or non-invasive positive pressure ventilation (NPPV) and of their caregivers, using a questionnaire survey.

Results: A total of 176 patients responded. The patients' mean age was 74.5 years, and 80.7%, 16.5%, and 1.7% of them were treated with LTOT, LTOT and NPPV, and NPPV, respectively. Of these, 29 patients lived alone, and 11 of whom had no caregivers. The SF-8 questionnaire, a health-related quality of life (HRQOL) scale, showed that the patients' HRQOL was lower than the Japanese standard. Patients with severe dyspnea were not all designated as requiring a high care level according to the Long-Term Care Insurance System. A total of 155 caregivers responded to the questionnaire, and their mean age was 64.7 years; 81% of them were women and 67.7% were the patients' spouses. The Burden Index of Caregivers (BIC-11), which is a multidimensional short care burden scale, showed that they bore the burden of patient care, comparable to the caregivers of patients with intractable neurological diseases. The patients and their caregivers required several services including a family doctor, public aid, and short-term hospitalization.

Conclusions: This study highlighted the poor HRQOL of patients provided with LTOT and/or NPPV, and the considerable burden on their caregivers. Current respiratory home care should be reviewed thoroughly, and further measures to support the patients and their caregivers should be implemented.

A 70-year-old woman with rheumatoid arthritis received treatment with corticosteroids and methotrexate for 4 years, followed by an additional TNF-alpha antagonist (infliximab) for about 3 years. She presented with a several-week history of persistent cough, and CT images of the lung showed a thin-walled cavitary lesion abutting the pleural surface of the left upper lobe. While we investigated the cause of this lesion, we admitted her because of acute chest pain. Chest radiography demonstrated moderate left-sided pneumothorax with pleural effusion. After further investigation, we suspected that her pneumothorax and pleuritis had been caused by a ruptured cavitary lesion arising from a Mycobacterium avium infection. Despite multi-drug therapy, chest tube drainage and surgical pulmorrhaphy her pleural complications were intractable. This is a rare case of pneumothorax and pleuritis caused by Mycobacterium avium infection induced by a TNF-alpha antagonist. Physicians should be aware of nontuberculous mycobacterial infections in patients treated with TNF-alpha antagonists.

An 81-year-old woman was admitted to our hospital for hyponatremia and impaired consciousness after unsuccessful antibiotic treatment for pneumonia-like symptoms by a previous doctor. A chest X-ray film revealed unilateral infiltration. Mycobacterium tuberculosis was detected on a sputum smear and pulmonary tuberculosis was diagnosed. Based on the diagnostic criteria, we believed that her hyponatremia a consequence of syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication of pulmonary tuberculosis. Sodium loading and water restriction quickly improved her serum sodium level and impaired consciousness. Anti-tuberculosis therapy reduced the abnormal shadows noted on chest X-ray films, and the sputum smear became negative for Mycobacterium tuberculosis. Her serum sodium level remained normal after the discontinuation of sodium loading. Previous reports have associated SIADH with severe types of tuberculosis such as miliary tuberculosis, tuberculosis meningitis, and pulmonary tuberculosis with massive bacterial excretion. However, this complication can also occur in mild tuberculosis, as in this case, thus SIADH should also be considered in mild cases of tuberculosis.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become widespread, but reports of complications are rare.

Case: An enlarged mediastinal lymph node (4R) was detected in a 67-year-old man 33 months after surgery for rectal cancer, and we performed EBUS-TBNA to confirm the diagnosis. He was then admitted to hospital 13 days after the procedure, with cough, a swollen mediastinal fatty area around the 4R lymph node, and elevated WBC and CRP levels. After a diagnosis of acute mediastinitis was confirmed we gave him antibiotics, which improved his symptoms, the mediastinal fatty area and his WBC and CRP levels.

Conclusion: We have to be aware of the possibility of acute mediastinitis after EBUS-TBNA of necrotic lymph nodes.