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

We evaluated the consistency of the A-DROP system for community-acquired pneumonia (CAP) and its outcomes, and developed a new severity classification of community-acquired pneumonia using nonlinear discriminant analysis. A total of 615 patients with CAP were enrolled between 2004 and 2009. A poor outcome was defined as patients requiring ventilation and/or death from CAP. We investigated the influence of prognostic factors on CAP severity and outcome using a logistic regression model to obtain the coefficient, and a contingency table. The optimal cutoff points for age and BUN were calculated from receiver-operating characteristic (ROC) curves. The influence of respiratory failure was approximately twice that of other prognostic factors. The optimal cutoff point for age was 83 years old, and that for BUN was 23mg/dl. We found inconsistencies in the equivalence of all prognostic factors and the addition-scoring method in predicting outcome. To ensure consistency between the A-DROP system and outcome, we believe that the weight of respiratory failure, threshold of classification, and cutoff points for age and BUN should be revised.

A 50-year-old woman was admitted because of chest pain and lumbago. A chest X-ray film showed a 4-cm mass in the left lower lung field. Computed tomography scans revealed a nodule with spicule formation in the left lower lobe, and therefore we strongly suspected lung cancer. Fiberoptic bronchoscopy yielded a diagnosis of adenocarcinoma. However, since she had metrorrhagia we performed an endometrial biopsy. Histologically, the endometrium was similar to the lung lesion, with positive staining for thyroid transcription factor-1 (TTF-1), and lung cancer with endometrial metastasis was therefore diagnosed. Although lung cancer with endometrial metastasis is rare, it should be included in the differential diagnosis in patients with gynecological symptoms such as metrorrhagia.

A 64-year-old man, who had been treated with valsartan for hypertension since about 2 months previously, was admitted with exertional dyspnea. A chest X-ray film on admission showed infiltrative shadows in bilateral lower lung fields. Chest computed tomographic images showed diffuse ground-glass opacities, consolidation and traction bronchiectasis. His serum KL-6 level was markedly elevated, to 7,360 U/ml. Despite the withdrawal of valsartan, his symptoms deteriorated, and a drug lymphocyte stimulation test was positive for valsartan. Based on these findings, we diagnosed valsartan-induced pneumonitis. Glucocorticoids were administered, and his symptoms, chest radiograph findings and serum KL-6 level all improved. Currently, angiotensin II receptor blockers (ARBs), including valsartan, are often used as the first drug of choice to treat hypertension, but they can cause drug-induced pneumonitis. It has been previously reported that serum KL-6 levels may reflect the clinical activity of drug-induced pneumonitis. In cases of drug-induced pneumonitis with a high level of serum KL-6, glucocorticolds should be started at an early stage.

A 69-year-old asymptomatic woman was admitted because of an abnormal chest shadow. Chest X-ray films showed a tumorous shadow behind the heart. Chest CT scans showed an aberrant artery branching from the thoracic aorta and supplying the left basal segment, but the bronchial tree was normal. The left lung vein was normal but wide, and the left lower pulmonary artery could not be observed. Based on these findings, we diagnosed anomalous systemic arterial supply to the normal basal segment of the left lower lobe. Because this patient had a high risk of heart failure and pulmonary hypertension, we decided to perform a left lower lobectomy, but she refused the operation. As this disease is generally found in younger patients, diagnosis in older age, as in the present case, is rare. In this report we also summarize 39 other reports of this disease in Japan.

A 65-year-old man had suffered from systemic erythema from November 2008 and had noticed gradually progressing weakness in the upper and lower limbs. He received medical treatment in another hospital but his symptoms did not improve. He was admitted to our hospital for treatment of diabetes in June 2009, and his chest X-ray images and CT scans showed a mass shadow in the right upper lobe with hilar and mediastinal lymphadenopathy. We performed bronchoscopy, and diagnosed small cell lung cancer (T2N2M1, stage IV). However, he had hand grip weakness and continuing upper and lower limb muscle weakness, and therefore electromyography was performed, which showed the presence of waxing in the right leg. Subsequently, a diagnosis of Lambert-Eaton myasthenic syndrome was made. As he also showed ataxia of the left lower extremity, we also diagnosed paraneoplastic cerebellar degeneration. We gave the patient chemotherapy consisting of carboplatin and etoposide which resulted in the disappearance of his waxing, and his grip strength and erythema immediately improved with regression of the tumor after 1 course of chemotherapy. We report a case of small cell lung cancer associated with Lambert-Eaton myasthenic syndrome, paraneoplastic cerebellar degeneration and erythema which presented as paraneoplastic syndrome, which improved with chemotherapy.

A 76-year-old woman with a 20-year history of chronic hepatitis C was referred to our hospital for worsening exertional dyspnea. She had been given a diagnosis of interstitial pneumonia based on chest computed tomography findings 5 years previously. Contrast-enhanced echocardiography confirmed an intrapulmonary right-to-left shunt, and therefore we diagnosed hepatopulmonary syndrome comorbid with interstitial pneumonia. In July 2009 she was admitted to our hospital with a low grade fever, headache, and vomiting. We diagnosed a left cerebellar brain abscess caused by Streptococcus intermedius. She underwent stereotactic burr-hole drainage and received vancomycin, piperacillin and cefotaxime. Cases of brain abscess secondary to hepatopulmonary syndrome are rare. Nevertheless, we should be aware of this complication of hepatopulmonary syndrome.

A 62-year-old woman with Sjogren syndrome was admitted for computed tomographic (CT) evaluation of a thickened trachea and parotid tumor. She had been given a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma 6 years previously, and had undergone surgical resection of the parotid tumor. Endoscopic examination revealed an annular tumor that had formed a stricture in the mid-trachea. Pathologic specimens were obtained by surgical resection of the parotid tumor and bronchoscopic biopsy of the tracheal tumor. Both histological examinations revealed MALT-type marginal zone B-cell lymphoma. Because CD20 immunostaining was positive, the patient received 6 cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) without any signs of major toxicity. All lesions disappeared after treatment, and this patient remained disease-free for 40 months.

Unlabelled: Chronic obstructive pulmonary disease (COPD) is treated primarily with inhalation therapy. However, as many COPD patients are elderly, whether or not patients inhale dry powder at an adequate inspiratory flow rate requires investigation. We therefore conducted a multicenter investigation of the effects of height, body weight, age, disease severity, and other factors on inspiratory flow rate in COPD patients.

Methods: We measured inspiratory flow rates and forced expiratory volume in the first second (FEV1) with the In-Check Dial (Clement Clarke) fitted with a discus adapter in 175 COPD patients of 40 years old and over (mean age 71.3, men 89.1%, women 10.9%).

Results: A total of 98.9% of the patients had an inspiratory flow rate exceeding 30L/minute. Two patients had a rate of 30L/minute or less. The mean inspiratory flow rate was 98 +/- 30L/minute overall, 104 +/- 27L/minute in mild COPD, 109 +/- 28L/minute in moderate COPD, 91 +/- 26L/minute in severe COPD, 71 +/- 24L/minute in very severe COPD, and 83 +/- 28L/minute in patients 75 years and older. Inspiratory flow rates significantly correlated with body mass index and FEV1.

Conclusion: Most elderly patients with COPD maintained a sufficient inspiratory flow rate when inhaling dry powder.

Among conventional oxygen therapies there are currently no devices which can supply a high oxygen level of over 60%. The HighFO nebulizer (Koike Medical) is a new device which is able to supply an oxygen flow rate of over 35l/min, and a high concentration of oxygen. We report 2 cases of type I respiratory failure managed by the HighFO nebulizer. Case 1: A 70-year-old man with lung cancer had an acute exacerbation of radiation pneumonitis during chemoradiotherapy. We gave him an oxygen mask with a reserve bag, but his condition worsened. We then used the HighFO nebulizer followed by non-invasive positive pressure ventilation. He began to recover and we again used the HighFO nebulizer during the weaning period. Case 2: A 74-year-old man presented with acute exacerbation of interstitial pneumonitis. We started steroid pulse therapy, HighFO nebulizer treatment and physiotherapy to prevent disuse syndrome. We were able to raise his exercise stress levels due to the high concentration of oxygen provided by the HighFO nebulizer. We believe that the HighFO nebulizer is useful for type-I respiratory failure as well as interstitial pneumonia. However, oxygen toxicity is a potential problem, so we must accumulate more cases in order to fully assess the risks and benefits of this new modality.

We encountered 2 cases of drug-induced intrathoracic lesions caused by allergic reactions to mesalazine in patients with ulcerative colitis. Case 1: A 26-year-old man had a fever, cough and exertional dyspnea after 1 month of mesalazine treatment. He was hospitalized because of bilateral pulmonary infiltrates on a chest X-ray film. Case 2: A 27-year-old woman complained of fever and left back pain that exacerbated after 2 weeks of mesalazine treatment. She was hospitalized because of bilateral pulmonary effusions on chest CT. Both patients showed a positive reaction to a drug lymphocyte stimulation tests (DLST) for mesalazine. The first case was given a diagnosis of eosinophilic pneumonia by bronchoscopic examination, and responded to steroid therapy after discontinuation of mesalazine. The second case was given a diagnosis of pleuritis and improved on cessation of Mesalazine treatment.