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

A 76-year-old man who was taking prednisolone and methotrexate for rheumatoid arthritis presented with gastric ulcers. Chest X-ray images showed multiple pulmonary nodules. Transbronchial lung biopsy specimens showed lymphocytic infiltrates but no malignant cells. The radiographic findings gradually ameliorated over a month, but then deteriorated 5 months later. We performed video-assisted thoracoscopic biopsy of the left lung, and the biopsy specimens showed lymphocytic infiltration with necrosis, in which the atypical lymphocytes were positive for Epstein-Barr virus-encoded small RNAs in situ hybridization (EBER-ISH). A diagnosis of lymphomatoid granulomatosis was determined. One year before this diagnosis, the patient was found to have an inflammatory liver tumor that had disappeared spontaneously within a month. A new pathological review of the liver and stomach lesions demonstrated EBER-ISH-positive lymphocytes, and therefore we assumed that they were pathological features of lymphomatoid granulomatosis. The chest radiographic findings improved gradually after the discontinuation of methotrexate. We therefore suggest that methotrexate treatment may be associated with the development of lymphomatoid granulomatosis in patients with rheumatoid arthritis. Lymphoproliferative disorders, including lymphomatoid granulomatosis, should be considered in patients with rheumatoid arthritis who are receiving methotrexate.

An 82-year-old woman with a past history of a colectomy for colon cancer was admitted to our hospital because of fever and cough. Her chest radiologic images on admission showed bilateral pulmonary infiltration, which suggested community-acquired pneumonia. However, the results of gram and acid-fast staining demonstrated branching acid-bacilli, which suggested pulmonary nocardiosis. We administered sulfamethoxazole-trimethoprim, and her condition and radiology findings promptly improved. Nocardia cyriacigeorgica was identified from her sputum. One of the nocardial isolates, formerly identified as Nocardia asteroides, has recently been reclassified as Nocardia cyriacigeorgica by the 16S rRNA gene amplification method. Pulmonary nocardiosis may be misidentified as "aspiration pneumonia", especially in elderly people. It is important for patients with community-acquired pneumonia to be evaluated with sputum gram staining for accurate diagnosis.

We report a case of pulmonary carcinomatous lymphangitis and multiple pulmonary infarctions from gastric cancer. A 58-year-old housewife presented with a complaint of a worsening cough over the previous 6 weeks. Chest radiography and CT scans revealed infiltration and diffuse ground-glass opacities in both lung fields, and she was hospitalized for further examination. No specific findings were found upon screening examination, including bronchoscopy with bronchoalveolar lavage (BAL). However, a CT scan showed mediastinal, hilar and paraaortic lymph node swelling, and therefore we suspected the presence of a malignant tumor. On the 11th hospital day, she suddenly developed severe hypoxia and went into cardiogenic shock. Although there was no sign of a filling defect in the vessels on CT with an intravenous contrast, we diagnosed pulmonary thromboembolism based on other examination findings and began thrombolysis and anticoagulant therapy. Treatment with heparin and urokinase did not improve her condition, and she died on the 14th hospital day. The autopsy findings revealed widespread gastric cancer with pulmonary lymphangitis carcinomatosa and thrombus formation in arterioles throughout the pulmonary lobes: 'Trousseau syndrome'.

A 75-year-old woman received a diagnosis of small-cell lung cancer (T1N2M0, stage IIIA, limited disease) in January 2009. She received 4 cycles of chemotherapy with etoposide and carboplatin and concurrent radiotherapy (50 Gy/25 Fr) which yielded a complete response. However, recurrence of her small-cell lung cancer occurred in a mediastinal lymph node and the ribs in November 2009. During the 2nd cycle of second-line chemotherapy with nogitecan, she was readmitted to our hospital complaining of amnesia, periods of unconsciousness and convulsions. Her laboratory data on admission revealed normal serum electrolyte and cerebrospinal fluid levels, and electroencephalogram findings. Her neurological symptoms, which mimicked limbic encephalitis improved after steroid pulse therapy plus third-line chemotherapy with amrubicin. The final diagnosis was paraneoplastic limbic encephalitis by positive serum voltage-gated calcium channel antibodies. We hereby report a rare case of small-cell lung cancer associated with paraneoplastic limbic encephalitis during chemotherapy.

A 53-year-old man who had been suffering from asthma presented to our hospital because of abnormal shadows detected on a chest X-ray film during a routine medical examination. A biopsy specimen of a mucus plug obtained by bronchoscopy showed fungal hyphae, eosinophils, and Charcot-Leyden crystals, with evidence of lung tissue eosinophilia. Schizophyllum commune and Aspergillus fumigatus were isolated from his sputum, bronchial washing specimens and the mucus plug. We detected specific immunoglobulin E anti-Aspergillus fumigatus responses and precipitating antibodies against Schizophyllum commune and Aspergillus fumigatus, which led to the diagnosis of allergic bronchopulmonary mycosis caused by both fungi. We gave him fluticasone/salmeterol and itraconazole; thereafter, his symptoms of cough and sputum production and his radiological findings all improved.

We present a case of pulmonary varices in a 44-year-old man. The patient's chest X-ray films revealed well-delineated shadows in the right lower lung field. An enhanced chest CT scan with three-dimensional volumetric imaging demonstrated a vascular malformation in the right lower lobe. Both the arterial and parenchymal phases of digital subtraction of the right pulmonary angiography were normal. However, the venous phase showed serpiginous right lower pulmonary veins draining into the left atrium, and a delayed pooling of contrast in dilated pulmonary veins confirmed a diagnosis of pulmonary varices. No echocardiographic findings of valvular disease were recognized. He remained asymptomatic and returned to work, but radiological follow-up was continued annually.

We treated 8 cases of autoimmune pulmonary alveolar proteinosis (APAP) with whole lung lavage (WLL) in our hospital and evaluated the disease severity of APAP before and after WLL, adverse events (AEs) and recurrence-free survival in those cases who improved. In all cases, unilateral WLL was performed in both lungs. The median of total lavage volume in unilateral WLL was 17.9 L, and the median procedure time of unilateral WLL was 105 min. Fever was the most frequently observed AE (87.5% of all procedures). Pulmonary function tests (percentage of predicted value of VC, FEV1 and diffusing capacity of carbon monoxide), serum markers (KL-6, surfactant apoprotein (SP)-D, SP-A and carcinoembryonic antigens), arterial blood gas analyses (PaO2, AaDO2) and disease severity score all significantly improved after WLL. The serum levels of anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibody temporarily decreased after unilateral WLL, but returned to previous levels (before WLL) in 7 cases. The radiological findings improved in 6 cases. In the 7 improved cases in whom AaDO2 decreased more than 10 Torr, the median recurrence-free survival of APAP after WLL was 17.5 months. We concluded that WLL is an effective and safe method for the treatment of APAP, and all parameters except for anti GM-CSF antibody are useful to evaluate the effect of WLL.

A 66-year-old man was found to have a very small ground-glass opacity in the apex of the left lung. Because the ground-glass opacity had slightly enlarged after 2 years, video-assisted thoracic surgery (VATS) biopsy was performed. The histological findings showed the alveolar spaces to be filled with PAS-positive granular materials, so pulmonary alveolar proteinosis was diagnosed. Although his bronchoalveolar lavage fluid (BALF) did not have a milky appearance, his serum and BALF GM-CSF autoantibody and serum KL-6 levels were elevated. Asymptomatic pulmonary alveolar proteinosis may appear as very small ground-grass opacities.

A 64-year-old diabetic man was admitted because his general condition had not improved despite the admini stration of voriconazole in another hospital, and his condition had become critical. Chest CT demonstrated a large fungus ball and consolidation around a cavity in the right lung. Aspergillusfumigatus was detected on a sputum culture. Based on these findings, we diagnosed invasive aspergillosis and administered high-dose (5mg/kg) liposomal amphotericin B (L-AMB) for 8 weeks, which resulted in the improvement of his general condition and the disappearance of the fungus ball, without severe adverse events.

Although drug-induced interstitial pneumonitis caused by gefitinib is well recognized in Japan, reports of alveolar hemorrhage caused by gefitinib are very rare. We encountered a case of alveolar hemorrhage thought to be caused by gefitinib. A 74-year-old woman with non-small cell lung cancer (adenocarcinoma; cT4NOM0, stage IIIB) had been receiving gefitinib as second-line therapy from January 2009. However, bloody sputum and nasal bleeding were observed 2 weeks after the initiation of gefitinib therapy. Chest radiography and computed tomography revealed ground-glass opacities predominantly in the lower lung fields. Bronchoscopy was performed, and the bronchoalveolar lavage fluid obtained from the right B8 was bloody. Her symptoms and chest ground-glass opacities improved after the withdrawal of gefitinib. Based on these clinical findings, we diagnosed alveolar hemorrhage caused by gefitinib. If chest radiography or computed tomography findings of gefitinib-treated patients show ground-glass opacities, the possibility of not only interstitial pneumonitis, but also alveolar hemorrhage should be considered in the differential diagnosis.