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Acute exacerbation (AE) of idiopathic interstitial pneumonia (IIP) is a near-fatal condition with especially high risk following lung surgery. We conducted a nationwide survey concerning prophylactic therapy to prevent possible AE following lung surgery in Japan. We sent a questionnaire concerning prophylactic therapy immediately before and after lung surgery to a total of 701 institutions, including specific questions about anesthesia. Some prophylactic medication was applied in 128 institutions (prophylactic group : P group). In contrast, no prophylactic therapy was utilized in the remaining 92 institutions (non-prophylactic group : N group). In 1 year, 744 operations were performed for lung cancer associated with IIP. In the P group, the prevalence of AE following surgery was 7.8%, and the mortality rate was 48.4%. In the N group, the prevalence was 9.6%, and the mortality rate was 32.2%. In 204 departments (92.7%), certain specific settings for ventilation or surgery were applied. In conclusion, it is necessary to further evaluate the feasibility of such prophylactic therapy, and standard guidelines should be established.

A 64-year-old woman was admitted to our hospital because of cough, bloody sputum and chest pain in January 2007. Chest computed tomography (CT) on admission revealed hyperattenuated mucoid impaction and consolidation in the right S3b. She was given a diagnosis of allergic bronchopulmonary mycosis caused by Schizophyllum commune. Treatment with 200 mg/day itraconazole and 15 mg/day oral prednisolone was begun, and her symptoms and consolidation resolved. In December 2007, consolidation in the left lower lobe appeared after itraconazole was stopped and replaced with oral prednisolone with inhaled fluticasone propionate. She again received 200 mg/day itraconazole and 15 mg/day oral prednisolone, resulting in a reduction in her consolidation. In May 2008, itraconazole was stopped and oral prednisolone was changed to inhaled salmeterol fluticasone propionate. In November 2008, her symptoms appeared again, and chest CT demonstrated hyperattenuated mucoid impaction and consolidation in the right S8. A transbronchial biopsy revealed granulomatosis, Charcot-Leyden crystals, and mucus infiltrated by eosinophils and fungi. Schizophyllum commune was isolated from her bronchial lavage fluid. A recurrence of allergic bronchopulmonary mycosis was diagnosed. Retreatment with itraconazole and oral prednisolone resulted in improvement of her symptoms and chest radiographic findings. To the best of our knowledge this is the first reported case of allergic bronchopulmonary mycosis caused by Schizophyllum commune presenting with hyperattenuated mucoid impaction.

A 53-year-old man with carcinoma (salivary duct carcinoma) ex pleomorphic adenoma was admitted to our hospital because of dyspnea. He received chemotherapy in July 2007, and was subsequently followed up without chemotherapy. A chest CT scan revealed multiple faint ground glass attenuation bilaterally. Contrast-enhanced CT did not reveal any emboli in the large pulmonary arteries. An echocardiogram showed severe pulmonary hypertension. Tc-99m-MAA lung perfusion images showed multiple small defects in both lungs. The serum level of vascular endothelial growth factor (VEGF) was normal. He died of heart failure 23 days after admission. An autopsy was performed, and microscopic examination revealed tumor cell embolism, intimal fibrocellular proliferation of the small arteries, fibrin thrombi and recanalization. A diagnosis of pulmonary tumor thrombotic microangiopathy (PTTM) was made. Immunohistochemical staining of the tumor cells for VEGF was weakly positive. To the best of our knowledge this is the first reported case of PTTM caused by a salivary gland tumor.

A 79-year-old man was hospitalized because of a chest X-ray abnormality. The chest X-ray film revealed infiltration in the left middle lung field. Chest CT scan showed mediastinal lymphadenopathy, and consolidated opacities with ground-glass opacities in the S3 and a part of the S3 segments of the left upper lobe. CT-guided needle biopsy demonstrated caseating epithelioid granuloma with multinucleated giant cells. 18F-fluorodeoxyglucosepositron emission tomography (FDG-PET) showed intense uptake (standardized uptake value (SUV) max 1 hour/2 hours 18.0/21.8) in the left upper lobe. Bronchial lavage fluid culture revealed Mycobacterium tuberculosis. From these findings, we made a diagnosis of caseous pneumonia with intense uptake on FDG-PET. After antituberculosis therapy, chest X-ray images and a CT scan showed improvement of the consolidation, the ground-glass opacities and mediastinal lymphadenopathy. Intense FDG uptake in caseous pneumonia may represent its high activity. This is the first reported case of caseous pneumonia examined by FDG-PET in Japan.

A 55-year-old man was admitted to our hospital because of pyrexia, cough and sputum. He suffered from bronchial asthma. Chest X-ray showed infiltrates in the left upper and right lower lung fields. Chest CT scans showed mucoid impaction and consolidation predominantly in the left upper lobe. Laboratory tests showed peripheral eosinophilia, elevated level of serum IgE, and the increased eosinophils in his sputum. Schizophyllum commune was isolated from the bronchoscopically-removed mucous plug. A diagnosis of allergic bronchopulmonary mycosis (ABPM) due to S. commune was made. Simultaneous daily administration of 400 mg itraconazole (ITCZ) and corticosteroid (prednisolone; 30 mg daily) provided sufficient improvement. However recurrence was recognized on chest CT scan findings one year later. There are not enough case reports concerning S. commune-induced ABPM to establish a therapeutic approach to the condition.

A 47-year-old man was admitted for further examination of uveitis. He had noticed scrotal swelling before his admission. A computed tomographic scan of the chest showed hilar and mediastinal lymphadenopathy, multiple micronodules and thickening of the interlobular septum, and these findings were consistent with sarcoidosis. Bronchoalveolar lavage fluid showed lymphocytosis. Gallium-67 scintigraphy revealed an abnormal accumulation in the hilar and mediastinal lymph nodes and in the bilateral scrotum. The resected and biopsied specimens of the epididymis and testis demonstrated numerous noncaseating epithelioid cell granulomas but no evidence of neoplasm. Therefore, systemic sarcoidosis was diagnosed. A review of the Japanese literature found most cases to be associated with a history of painless scrotal swelling with chest roentgenogram findings of stage I or II, while also indicating it was important to perform biopsy or surgically resect any epididymal and testicular lesion.

A 72-year-old man was admitted to our hospital because of a low grade fever and malaise. He had received a middle to lower esophagectomy and proximal gastrectomy with reconstruction of a gastric conduit for esophageal cancer 12 years previously. Chest X-ray and CT scan revealed massive pleural effusion and consolidations on the right side. Candida glabrata was isolated 4 times from pleural fluid specimens. Candida antigen was negative in both serum and pleural effusion. However, while serum beta-D-glucan was negative, the level of beta-D-glucan in pleural effusion was extremely elevated. Thus, the patient was diagnosed as having C. glabrata empyema. He was treated with insertion of a thoracostomy tube followed by intrapleural instillation of amphotericin B and intravenous administration of micafungin. Pleural effusion was reduced and the repeated culture of the pleural effusion became negative after 27 days of treatment. Empyema with C. glabrata is rare and the present case is the second report of the disease in the Japanese literature.

A 41-year-old woman took an EVE-A tablet, which contained ibuprofen, because of pyrexia over 39 degrees C. Due to continued pyrexia, she visited a physician and received cefcapene and acetaminophen under a diagnosis of cold. However, next day, she was admitted to our hospital with severe hypoxemia and pulmonary infiltrates on chest radiograph. Analysis of bronchoalveolar lavage fluid disclosed an increased proportion of 66% eosinophils. All of the lymphocyte stimulation tests for EVE-A tablet, cefcapene and acetaminophen showed positive. After the cessation of these drugs, she was successfully treated with steroids. This case was diagnosed as eosinophilic pneumonia caused by several drugs, and to our knowledge, this is the first report in Japan of ibuprofen (EVE-A tablet)-induced pneumonia.

A case of eosinophilic pneumonia due to Nicolase (serrapeptase) after recovery from acute eosinophilic pneumonia is described. A 32-year-old woman was previously admitted to another hospital because of acute onset of dyspnea accompanied by cough and fever. Chest X-ray films revealed diffuse infiltration in both lungs two days after her symptoms occurred. Her bronchoalveolar lavage fluid showed 13% eosinophils and transbronchial lung biopsy specimen also showed many eosinophils infiltrating in the lesions of the bronchial submucosa and alveolar septa. No infectious causes or related drugs were found. Acute eosinophilic pneumonia was diagnosed, and her condition improved gradually without steroid treatment. Because she recovered clinically and radiologically, she was discharged from hospital. Half a month later she was treated with Nicolase because of pharyngitis. She was admitted to the hospital again because of dyspnea, cough and fever three days after commencing to take Nicolase. Chest X-ray films also revealed diffuse infiltration in both lungs with pleural effusion, and her bronchoalveolar lavage fluid showed 37% eosinophils. When the drug lymphocyte stimulation test was performed, it was positive for Nicolase. Therefore drug-induced eosinophilic pneumonia was diagnosed. This is a very rare case of Nicolase (serrapeptase)-induced eosinophilic pneumonia after recovering from acute eosinophilic pneumonia.

A 34-year-old woman who had been treated with propylthiouracil (PTU) for hyperthyroidism, was admitted because of bloody sputum and pyrexia. The chest CT scan showed some nodules in both lung fields. The serum level of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) was high, but proteinase-3 antineutrophil cytoplasmic antibody (PR-3 ANCA) was negative. A limited form of Wegener's granulomatosis without PR-3 ANCA was ruled out, because of the absence of abnormalities in the upper airway and kidney. No lesions other than the multiple pulmonary nodules of the lung were detected. We diagnosed MPO-ANCA associated vasculitis induced by PTU. After the termination of PTU, bloody sputum, pyrexia, and pulmonary nodules improved spontaneously and the serum level of MPO-ANCA returned to normal gradually. The case of MPO-ANCA positive vasculitis associated with multiple pulmonary nodules following propylthiouracil treatment is very rare.

A 56-year-old man visited another hospital complaining of hemoptysis. A chest radiograph showed expansion of the left upper mediastinum which seemed to be a mass-like lesion. He was referred to our hospital for further investigations. Before further examination, however, he presented to the emergency room with sudden onset of severe back pain. Rupture of a thoracic aortic aneurysm was suspected because of the clinical symptoms and the findings of emergency enhanced CT scanning. Emergency surgery was performed at the other hospital, and frozen section results indicated that the lesion was a non-small cell lung cancer. The pathology report of the surgical specimens revealed poorly differentiated adenocarcinoma of the lung with infiltration of the aortic wall. Postoperative chemotherapy was added, and the patient is doing well 10 months after operation. Some cases of tumor mimicking aortic aneurysm have been reported. We reported this case of lung cancer mimicking the rupture of a thoracic aortic aneurysm.

The chest radiograph of a 57-year-old man, complaining of paroxysmal dyspnea, suggested the probably of a tumor. Chest CT showed a tumor containing calcification, behind the left crus of the diaphragm. Chest MRI suggested lipid components and a cystic lesion within the tumor. Their findings were clinically compatible with posterior mediastinal teratoma. The pathological diagnosis of the surgically resected tumor was mature teratoma with neither malignant components nor thymic tissue. Study of past case reports suggests that posterior mediastinal teratomas should have less malignant characteristics than anterior mediastainal teratomas. Our case is the fifteenth case report in the Japanese literature, and accumulation of more cases is required.

A 46-year-old woman was admitted to our hospital because of bloody and chest pain. Chest X-ray and CT scan revealed a 17-mm nodule in the left upper lobe, consolidations in both lower lobes, and mediastinal and hilar lymphadenopathy. CT-guided lung biopsy from the right lower lobe revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi and recanalization. Embolic tumor cells were adenocarcinoma and immunohistologial staining for TTF-1 was positive. The patient was diagnosed as having pulmonary tumor thrombotic microangiopathy (PTTM) associated with clinical stage IV primary lung adenocarcinoma. Although chemotherapy with carboplatin and paclitaxel resulted in improvement of pulmonary consolidations, multiple bone metastatic lesions appeared. The patient was subsequently treated with docetaxel, and gemcitabine thereafter. This was the first reported case of PTTM associated with lung cancer and diagnosed antemortem by CT-guided biopsy. This suggests that CT-guided lung biopsy may be useful for diagnosis of PTTM, and enable establishment of appropriate cancer chemotherapy.

A 53-year-old man was admitted to our department because of interstitial pneumonia found on chest computed tomography when he was given a diagnosis of amyopathic dermatomyositis. Bronchoalveolar lavage (BAL) fluid showed an increased total cell count and lymphocytosis. An acute exacerbation of interstitial pneumonia occurred just after the BAL. Although the administration of corticosteroid and immunosuppressant for the progressive interstitial pneumonia produced temporary improvement, left hemothorax suddenly occurred soon after initiating treatment. The hemothorax was improved by thoracic drainage alone, but the patient died due to progressive worsening of interstitial pneumonia. In this case, we could not clarify the etiological mechanism of the hemothorax, however, there was a possible link with amyopathic dermatomyositis-associated interstitial pneumonia.

A 32-year-old man was referred to our hospital because of a nodular shadow on his chest x-ray film. Chest computed tomography scan revealed multiple nodules in both lungs. Video-assisted thoracoscopic surgery was performed to diagnose the tumor. Microscopic examination of the resected specimen showed tumor connecting of small round cells. Fluorodeoxyglucose positron emission tomography demonstrated strongly increased uptake in the right femur. Subsequently, magnetic resonance imaging showed a well defined mass, approximately 5cm in diameter, in the right lateral femur with isointensity on T1-weighted images and high intensity on T2-weighted images. A needle biopsy of the tumor of the right femur was performed. Pathological examination revealed the same findings of the pulmonary lesions. Immunohistochemical staining was positive for CD99 in the tumor cells. Ewing's sarcoma gene rearrangement was found using fluorescence in situ hybridization on frozen-section specimens. Based on these findings, a diagnosis of Ewing's sarcoma was made. The patient died 13 months after the initial detection of the disease despite intensive chemotherapy. In cases of multiple pulmonary nodular lesions in a young patient, metastatic tumors arising from bone soft tissue should be included in the differential diagnosis.

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.

Objective: The aim of this study was to assess the clinical features and efficacy of domiciliary noninvasive positive pressure ventilation (NPPV) in patients with chronic obstructive pulmonary disease (COPD)., Patients and Methods: We conducted a retrospective study of 16 patients with COPD who received NPPV between March 1996 and April 2005. The patient characteristics, clinical features, a change in arterial PaCO2 and prognoses were evaluated., Results: The study population consisted of 15 males and 1 female, mean age 68.4 +/- 9.9 yrs. The mean values of pulmonary function tests were as follows; FEV1 = 0.73L, FEV1% = 29.8%, VC = 2.49L, %VC = 77.5%, RV/ TLC 55.4%, PaO2 59.8 Torr, PaCO2 71.4 Torr (on admission). Fourteen of 16 patients presented desaturation in the night and 6 patients had sleep apnea syndrome. Eight of the 16 patients received NPPV during acute exacerbation. NPPV yielded dramatic improvement in daytime hypercapnia and clinical symptoms. However, arterial PaCO2 gradually elevated during the long-term clinical course. The duration of treatment was from 2 months to 9 years, with a mean value of 2.3 years. The cause of death of 7 patients was respiratory failure in 5 cases and lung cancer in 2, respectively, and the mortality was significantly higher in patients who received NPPV during acute exacerbation than stable COPD patients receiving NPPV., Conclusions: Long-term improvement in daytime clinical symptoms and arterial blood gas tensions can be achieved by NPPV in patients with COPD.

A 30-year-old man, who had kept a dog for nine years and often ate raw beef liver, visited a hospital because of a chest nodular shadow in the left lung field found on a checkup examination. Chest computed tomography obtained 8 days after the checkup showed no abnormal shadow in the left lung but two nodular shadows with halos in the right upper and lower lobes. Peripheral blood eosinophil counts and serum IgE values were elevated. Immunological examination including microplate ELISA showed a high titer of specific antibody against Toxocara canis in the serum. He was successfully treated with albentazole. Parasitic disease, especially toxocariasis, is an important consideration in the differential diagnosis of migratory nodular shadow with a halo on chest computed tomography, and serology is useful in diagnosis screening.

A 72-year-old man, a Shiitake mushroom grower over fifty years, was admitted to our hospital because of bilateral chest interstitial shadow with chronic cough and breathlessness. Chest computed tomography showed traction bronchiectasis, subpleural micro-cystic changes and partial ground-glass opacities in both lungs, and mild mediastinal lymphadenopathy. A diagnosis of chronic hypersensitivity pneumonitis induced by Shiitake mushrooms was comprehensively confirmed by occupational history, radiological findings, and positive findings of an incidental environmental provocation test and lymphocyte stimulation test for Shiitake mushroom extracts. We reviewed the clinical features in five patients with chronic hypersensitivity pneumonitis induced by Shiitake mushrooms reported in Japan. There was a tendency toward increasing lymphocytes and high CD4/CD8 ratio in bronchoalveolar lavage fluids. Treatment with steroids seems to have a limited effect, while avoidance of the antigen is important.

A 63-year-old man had undergone excision of a growing mass with a wide margin in the left supraclavicular fossa. A diagnosis of fibrosarcomatous variant of dermatofibrosarcoma protuberans (DFSP-FS) was made. Three years later, an abnormal chest shadow was detected on a medical checkup. Chest computed tomography showed a heterogeneously-enhanced 2-cm coin lesion with a distinct border in the right lower lobe and a 3-mm nodule in the left lower lobe. Transbronchial lung biopsy specimens from the right lung revealed a DFSP pattern. We then performed right basal segmentectomy and partial resection of the left lower lobe. DFSP is a relatively rare skin tumor that is considered to be intermediate malignancy. It frequently recurs locally but rarely has systemic metastasis. However, DFSP-FS, a subtype of DFSP, has an increased likelihood of systemic metastasis. The lung is the most common site of metastasis of DFSP-FS. DFSP-FS sometimes recurs even a long time after excision. Therefore, long-term follow-up, including chest X-ray and CT are important in DFSP-FS patients.

A 73-year-old woman was admitted to our hospital because of dyspnea on effort and diffuse ground-glass opacities in bilateral lower lung fields on a chest radiograph. CT scans demonstrated a spiculated nodule measuring 9 mm in diameter in the right S3 and diffuse ground-glass opacities in bilateral lower lobes. Right upper lobectomy and lung biopsy of the right lower lobe were performed using video-assisted thoracoscopic surgery. Histological examination revealed adenocarcinoma in the right S3 and an accumulation of pigmented macrophages in the alveolar spaces of the lower lobe, which was compatible with desquamative interstitial pneumonia (DIP). Five months' cessation of smoking was not sufficiently effective for DIP. Therefore, corticosteroid therapy was started, and resulted in rapid improvement in symptoms, pulmonary function and CT findings had been achieved. It is unlikely that the lung cancer and DIP were closely associated etiologically, because the adenocarcinoma was located far from the area of DIP.

We report a rare case of Sweet's syndrome (acute febrile neutrophilic dermatosis) with a variety of chest radiological findings. A 73-year-old man, who had been treated with corticosteroid for Sweet's syndrome for 2 years, was admitted to our hospital because of pyrexia with a infiltrative chest shadow. Chest CT scans showed consolidation and ground-glass opacities with air-bronchogram in the right lower lobe. Treatment with antibiotics seemed to be effective but there was no improvement of chest shadows. Simultaneously with his pyrexia, diffuse centrilobular-micronodular shadows and a mass-like shadow appeared on chest CT after 2 months and after the next 2 months, respectively. Bronchoalveolar lavage fluid contained increased neutrophils but not any infectious pathogen. Transbronchial lung biopsy specimens revealed chronic interstitial infiltrate with alveolar wall thickening and neutrophil accumulation in the airspace. A diagnosis of pulmonary involvement in a patient with Sweet's syndrome was finally made and he was successfully treated with corticosteroid.

We retrospectively evaluated the results of low-dose helical CT screening as an option for health examinations. From November 2002 to October 2005, CT screening was performed in 2,306 individuals (men 1,766, women 540, mean age 56.1 years). Among them, 71 individuals (3.1%) were diagnosed as having active thoracic diseases consisting of 14 neoplasms and 57 non-neoplastic diseases. Of 14 patients with neoplastic lesions, 13 had lung cancer, 1 of whom had double primary lung cancer, and 1 had atypical adenomatous hyperplasia. The mean diameter of the 14 lung cancers was 14.4 mm. The histology of these lesions was adenocarcinoma in 13 and squamous cell carcinoma in 1. The pathological stage was IA in 12 patients and IIA in 1. All patients underwent surgical resection. On the other hand, emphysema was diagnosed in 40 asymptomatic individuals based on CT and spirometry, and smoking cessation was strongly implemented for those who were current smokers. CT screening is useful for detecting not only early lung cancer but also non-neoplastic lung diseases.

We report a rare case of pulmonary lymphomatoid granulomatosis radiologically mimicking interstitial pneumonia. A 57-year-old man was admitted to our hospital because of chest bilateral reticular shadow with sustained cough and breathlessness for 10 years. Chest CT scans showed multiple ground-glass opacities, traction bronchiectasis and cystic change in both lungs, in addition to hilar and mediastinal lymphadenopathy. A histopathologically diagnosis of pulmonary lymphomatoid granulomatosis (angiocentric immunoproliferative lesion, grade 1) was made by thoracoscopic lung biopsy. In this case, serological and immunohistochemical analyses did not show Epstein-Barr virus infection. No clinical or radiological deterioration has been observed thereafter despite no medication.

We report a 56-year-old man with pulmonary large cell neuroendocrine carcinoma (LCNEC) incidentally found at the surgery for pulmonary aspergillosis. In 1991, an abnormal chest radiographic shadow was found on a mass screening. A diagnosis of pulmonary aspergillosis was made by bronchoscopic examination. The patient was then followed up without treatment. He had hemoptysis in 2005, and was referred to our hospital. Chest CT scan revealed a cavitary lesion with an air crescent sign and an irregularly shaped nodule in the right apex. Wedge resection of these lesions was performed under video-assisted thoracoscopic surgery. Pathological examination revealed not only aspergilloma, but also an LCNEC 11 x 7 mm in size, which was located close to the aspergilloma. Microscopically, nests of tumor cells were distributed peribronchially. Right upper lobectomy and mediastinal lymph node dissection was performed, and the pathological stage was IIIA (T1N2M0). The patient received four cycles of adjuvant chemotherapy with carboplatin and paclitaxel. No recurrence has been observed since surgery. This is the first report describing co-existence of pulmonary aspergilloma and LCNEC.

A 61-year-old woman who had been followed up after resection of lung cancer (adenosquamous cell carcinoma), was admitted to our hospital because of recurrence. She received systemic anticancer chemotherapy and the chief adverse event was leukopenia (Grade 3). Nineteen days after initiating chemotherapy, she suffered painful vesicular eruption on the right upper limb and the right upper hemithorax which was diagnosed as herpes zoster. After treatment with anti-viral drugs the vesicular eruption disappeared, but chest X-ray film revealed a right diaphragmatic relaxation. Although herpes zoster virus usually affects sensory nerves and causes painful vesicular eruption, it can also damage motor nerves. Herpes zoster virus almost affects cranial nerves, but it should be considered as the cause of diaphragmatic paralysis in this case.

A 36-year-old man, a worker exposed to tungsten and cobalt compounds, was admitted because of chest bilateral micronodular shadow with chronic cough and sputum. Chronic sinusitis, mild hypoxemia, obstructive respiratory impairment and chest radiological findings fulfilled the Japanese diagnostic criteria for diffuse panbronchiolitis, while atypical bronchoalveolar lavage fluid and pathological findings were seen. The surgical lung biopsy specimens showed patchy centrilobular inflammatory change with monocytic infiltrations and particulate deposition inside the area of bronchiolitis, but neither tungsten nor cobalt was found. Treatment with a macrolide antibiotic had no effect on the patient's symptoms, hypoxemia and lung function, suggesting bronchiolitis associated with inhalation of hard metal.

A 70-year-old man injured his spinal cord at the fourth cervical vertebra due to a fall and became quadriplegic. Following emergency treatment, the patient was admitted to our hospital for rehabilitation. On admission, respiratory function tests indicated a percent vital capacity value (%VC) of 58.6%, revealing restrictive ventilatory impairment. After admission, we observed difficulty breathing at night and extreme snoring and thus performed a simple full-night polysomnography. Results showed an apnea-hypopnea index (AHI) of 46.5/hr and serious obstructive sleep apnea syndrome (OSAS). Based on these results, we conjectured that a preexisting OSAS condition was exacerbated by the cervical spinal cord injury, and thus administered nasal continuous positive airway pressure (NCPAP) in addition to respiratory rehabilitation. A speedy disappearance of clinical symptoms was found with the application of NCPAP. Compared to a 3% oxygen desaturation index (ODI 3%) of 31.0 dips/hr prior to treatment, the ODI 3% dropped to 3.5 dips/hr after 14 days, and 0 dips/hr after 60 days, indicating an obvious improvement in nocturnal oxygen desaturation.

A 34-year-old man was admitted with dyspnea and low grade fever. Chest radiograph and computed tomography (CT) showed bilateral, ground glass opacities and perihilar consolidation. Bronchoalveolar lavage (BAL) was performed. The percentage of eosinophils in the BAL fluid (BALF) was elevated (20.5%). BALF smear and culture showed normal flora. Acute eosinophilic pneumonia was diagnosed and steroid therapy was performed. Afterwards he was transferred to our hospital. The HIV antibody was positive and peripheral blood CD-4 positive lymphocytes decreased to 10/microl, cytomegalovirus (CMV) antigenemia was positive and beta-D-glucan increased. CMV infection and pneumocystis pneumonia (PCP) complicated with AIDS was diagnosed. Trimethoprim/sulfamethoxazole, ganciclovir, and antifungal drugs were administered, but he suffered pneumothorax on the 18th day after admission and died. Histopathologic findings from an autopsy lung specimen revealed CMV infection and PCP. It is known that the percentage of eosinophils in the BALF increases in some cases of PCP complicated with AIDS. We emphasize that it is necessary to consider PCP when the percentage of eosinophils in the BALF increase.

Some microbes, including the Bacteroides species, Staphylococcus aureus and Streptococcus milleri groups, can cause pulmonary abscess. Haemophilus parainfluenzae is usually categorized as one of the normal flora which colonizes in the ears and the nasopharynx, and it has been long considered that H. parainfluenzae has little pathogenicity in the lower respiratory tract and lung parenchymal. In this report, we present a case of pulmonary abscess caused by both H. parainfluenzae and Streptococcus intermedius. The patient was a 75-year-old man who had had total esophageo-gastrectomy because of esophageal cancer. He presented with purulent sputum, and chest X-ray film showed a dense consolidation in the right upper lung field. CT-guided transcutaneous fine needle aspiration was performed as a diagnostic procedure. Since both H. parainfluenzae and S. intermedius had been isolated from the lesion, pulmonary abscess caused by these two pathogens was diagnosed. The patient was treated with panipenem/betamipron, and his symptoms and pulmonary infiltrates on the chest X-ray film improved thereafter. So far, very few cases have been reported in which H. parainfluenzae caused lower respiratory tract infection. Although S. intermedius is known as one of the pathogens of pulmonary abscess, it is possible that H. parainfluenzae could also be pathogenic in infectious diseases of the lung.

Large cell neuroendocrine carcinoma (LCNEC) is a newly recognized clinicopathologic entity. The clinical features of advanced LCNEC are still unclear, because most of the previous reports have described resected cases. The aim of this study was to clarify the clinical characteristics and response to chemotherapy in patients with advanced LCNEC. From June 2002 to July 2004, nine patients (seven men and two women, median age 61) with advanced LCNEC were admitted to our hospital. We reviewed the clinical manifestations, tumor markers, and treatment of these patients. Seven of nine patients (78%) were current or ex-smokers. As for tumor markers, the levels of progastrin-releasing peptide (proGRP) and neuron-specific enolase (NSE) were elevated in six patients (67%) and five patients (56%), respectively. The diagnosis of LCNEC was made based on the resected specimens in 8 patients including resection of brain metastasis in 1 and CT-guided needle biopsy in 1. One patient was stage IIIA, 1 was stage IIIB, 3 were stage IV, and 4 had postoperative recurrence. Treatment included chemotherapy alone in 7 patients, chemotherapy plus whole brain radiation in 1, and postoperative radiotherapy in 1. Of 7 patients treated by chemotherapy alone who had received carboplatin-based chemotherapy. 5 showed partial response, yielding response rate of 71.4%. The proGRP level was frequently elevated in patients with advanced LCNEC and the response rate of LCNEC to carboplatin-based chemotherapy was comparable to that of small cell lung cancer.

A 59-year-old woman was admitted with dyspnea. A chest X-ray film revealed a large amount of pleural effusion at the both sides. No malignant cells were found in bilateral pleural effusions. Computed tomography (CT) of the abdomen showed a huge mass of the right ovary with a small amount of ascites, suggesting a diagnosis of Meigs syndrome. The ovarian mass and the neighboring organs, including the uterus and the greater omentum, were surgically removed, and then both the bilateral pleural effusion and ascites disappeared after the surgery. The histopathological examination revealed that the mass was clear cell adenocarcinoma of the ovary (stage IIc), indicating that the disease was pseudo-Meigs Syndrome. This is the second report of pseudo-Meigs Syndrome caused by clear cell adenocarcinoma of the ovary in Japan.

Pneumothorax associated with idiopathic pulmonary fibrosis (IPF) is intractable and often fatal because the patients are usually under a long-term steroid therapy, and are associated with severely impaired lung function. Further, pneumothorax itself recurs frequently, and acute exacerbation of IPF may develop after a surgical intervention. Here, we describe a case of intractable pneumothorax developed in a patient with IPF who was successfully treated with repeated talc pleurodesis combined with video-assisted thoracoscopic surgery under local anesthesia. A 67-year-old male with IPF who was under a long-term treatment with steroid, developed right-sided pneumothorax. A chest drainage tube was placed in the right pleural cavity, and repeated pleurodesis with minocycline or fibrinogen was challenged, but the outcome turned out to be unsuccessful. Then, talc slurry was applied repeatedly, resulting in a high-grade fever associated with reactive accumulation of pleural effusion. However, air leakage did not cease completely despite the eight-times pleurodesis with talc using 16 g in total. Finally, video-assisted thoracoscopic surgery under local anesthesia was undertaken and the pulmonary fistula was successfully closed.

We describe a case of catamenial pneumothorax caused by diaphragmatic endometriosis and histologically confirmed thoracoscopically. The patient was a 33-year-old woman who had had recurrent right chest pain starting on the day preceding each menstruation since she was 26 years of age. In June 2001, at the age of 33, she felt right chest pain and developed dyspnea, and so came to our hospital. Chest radiography showed bilateral pneumothorax. Timely thoracoscopy revealed the characteristic appearances of catamenial pneumothorax such as a blueberry spot on the central tendon of the right diaphragm and a purplish-red locus in the right apex. Histopathological examination further confirmed the presence of endometrial tissue on the diaphragm as well as in the lesion of the right lung. Despite resection of the endometrial tissues from the right hemidiaphragm and the lung under thoracoscopy, right pneumothorax recurred after one month. Since then, the patient's condition has been well controlled by therapy with gonadotropin releasing hormone, with no recurrence of catamenial pneumothorax.

We evaluated the efficacy of pleurodesis using OK-432 (Picibanil) for the treatment of pneumothorax associated with pulmonary lymphangioleiomyomatosis (LAM). Seven episodes of pneumothorax in five patients with LAM were treated with pleurodesis using OK-432. First, all patients underwent tube thoracostomy drainage. After drainage, 5 or 10 KE of OK-432 was administered via the tube. If incomplete lung expansion or a continuous air leak occurred, an additional 5 KE of OK-432 was administered. Of the five patients, two developed pneumothorax for the first time and three had a history of previous pneumothorax. The mean total dose of OK-432 administered was 13.6 KE, and the mean period of tube drainage was 11 days. The only recurrence of ipsilateral pneumothorax after OK-432 pleurodesis was observed seven years and eight months later in association with chronic respiratory failure in one patient. This patient was successfully treated with repeated pleurodesis using OK-432 during mechanical ventilation, and no recurrence has developed in the eight years since then. The main side effects of the procedure with OK-432 were fever and chest pain, which were well controlled by non-steroidal anti-inflammatory drugs. The study concluded that pleurodesis with OK-432 was an effective and safe treatment for intractable and recurrent pneumothorax associated with LAM.

A 72-year-old woman had been diagnosed as having organizing pneumonia at another hospital. She was treated with antibiotics, bronchodilators and prednisolone, but her cough, fever and inflammatory signs were not resolved completely. She was admitted to our hospital for further evaluation of the lung lesion. The chest CT scan revealed narrowing of the segmental bronchus and the serum samples showed elevated MPO-ANCA but negative PR 3-ANCA levels. Physical examination also revealed marked bilateral episcleritis and eyeground angitis. Fiberoptic bronchoscopy showed bilateral marked stenotic segmental bronchi associated with mucosal erosions and small nodular lesions. Bronchial and renal biopsy specimens demonstrated marked angitis in the bronchial arteries and glomeruli. A generalized form of Wegener's granulomatosis (WG) was diagnosed and was treated with 60 mg/day of prednisolone, 50 mg/day of cyclophosphamide and 4 g/day of sulfamethoxazole-trimethoprim, which resulted in a marked improvement of the clinical symptoms and endobronchial lesions. In WG, the incidence of endobronchial involvement is 16 to 55% and that of positive serum MPO-ANCA alone is only 14.3%. The present case of WG was considered a rare case with WG which because of the MPO-ANCA-positive but PR 3-ANCA-negative findings associated with marked endobronchial lesions and systemic angitis.

To assist in making prognoses for patients with interstitial pneumonia (IP) who were treated with cyclosporin A (CsA), we conducted a review of forty-nine patients (32 men and 17 women with a mean age of 62 yrs) with progressive IP during the period from 1997 through 2001. All patients were steroid-resistant or acutely exacerbated cases. They received a low dosage of CsA (100-130 mg/day) combined with corticosteroids. Before and after the CsA therapy, blood gas analysis and HRCT scans were evaluated. Twenty-five patients underwent video-assisted thoracoscopic surgery (VATS) or autopsy for a histopathological evaluation. Among the 49 patients with IP, the documented underlying systemic diseases were of unknown etiology (IPF or IIP) in 26 and were collagen vascular diseases (CVD) in 23. The chest CT pattern and underlying systemic diseases of IP were classified as a usual interstitial pneumonia (UIP) pattern/IPF in 16 cases, a non-UIP pattern/IIP in 10 cases, a UIP pattern/CVD in 7 cases, and a non-UIP pattern/CVD in 16 cases. The prognoses after CsA treatment were improved or unchanged in 27% of cases with a UIP pattern/IPF, 78% of cases with a non-UIP pattern/IIP, 71% of cases with a UIP pattern/CVD and 75% of cases with a non-UIP pattern/CVD; deteriorated in 73%, 22%, 29% and 25% of cases, respectively, with these patterns and underlying diseases. At present, four out of thirteen (31%) patients with acute exacerbation of UIP pattern/IPF have survived for four to twelve months (mean: 7.5 months). Four patients revealed re-exacerbation of IP after the dose of CsA was tapered. Among the 25 patients with IP, the histopathological patterns of IP were classified as usual interstitial pneumonia (UIP) in 10 cases, nonspecific interstitial pneumonia (NSIP) in 14 cases (group I, 2; group II, 5; group III, 7) and diffuse alveolar damage (DAD) in 1 case. The prognoses were improved or unchanged in all cases of NSIP group I, in 80% of cases with NSIP group II, in 29% of cases of NSIP group III and in 20% of cases of UIP; and deteriorated in the case of DAD, in 80% of cases of UIP, in 71% of cases of NSIP group III, and in 20% of cases of NSIP group II. It should be emphasized that CsA combined with corticosteroids may be effective for the treatment of steroid-resistant or acute exacerbation cases of IP. Further studies are required to determine long-term outcome with this treatment.

The largest epidemic outbreak of legionnaires' disease occurred in Japan, where there were 45 cases, including three deaths. There was a high degree of homology at the genetic level between Legionella pneumophila sero-group 1 isolated from two patients and water samples collected from a public bath, and this highlighted the public bath visited by the patients as the source of the infection. We report our clinical observations of 34 cases with a pneumonia type (20 definite and 14 probable) of the 42 cases for whom a diagnosis was made and follow-up care was subsequently provided at our hospital or hospital-affiliated facilities, out of the initial total of 45 cases. Twenty-one cases had underlying diseases, but the disease was mild in all patients. Three cases showed different neuropsychiatric symptoms such as reduced capacity for memorization, somnolence or delirium. Diarrhea was found in three cases, and relative bradycardia in ten. Clinical laboratory test results indicated that a severe inflammatory reaction, renal or hepatic dysfunction, an electrolyte abnormality and abnormal urinalysis were common in the 34 cases. Chest radiography showed a shadow suggestive of infection of the pulmonary parenchyma with multilobar involvement in most cases and pleural effusion in nine cases.

We report a rare combination of pulmonary cryptococcosis and pulmonary tuberculosis in a diabetic patient. A 63-year-old man was admitted to our hospital in January 2002 for evaluation of an abnormal chest radiograph. In 1999, the abnormality had first been detected by mass screening radiography. In 2000, an abnormality in a chest radiograph was again detected in a mass screening, and he visited another hospital. A chest CT scan revealed a cavitating lesion and several nodules in the left lower lobe. Fiberoptic bronchoscopy was performed, but was not diagnostic. The patient was referred to our hospital. He had a history of diabetes mellitus starting in 1984. The chest CT scan revealed solid nodules in the left lower lobe and several micronodules in both upper lobes. Video-assisted thoracoscopic surgery was performed and specimens were obtained from the left S8 and left S1 + 2. Histologically, cryptococci were detected in the resected left S8. In addition, mycobacterium tuberculosis was cultured from the resected left S1 + 2. A diagnosis of combined pulmonary cryptococcal and tuberculous infections was made and treatment with itraconazole, isoniazid sodium methansulfonate, rifampicin, and ethambutol hydrochloride was given.

We reviewed a clinicopathological study of pulmonary eosinophilic granuloma focusing on the evolution of pulmonary lesions in chest CT scans. Between 1990 and 2002, five patients with pulmonary eosinophilic granuloma were admitted to our hospital. Clinical features, chest radiographs, pathological characteristics and treatments were evaluated. The scans were repeated in four patients at intervals of at least eight months. All patients were men who smoked. The age at onset of the pulmonary disorders ranged from 22 to 45 years, with a mean of 33 years. Most of the initial chest CT scans showed nodular lesions and thin-walled cysts, but the nodular lesions disappeared or were transformed into cystic lesions in the later scans. Most of the final scans revealed thin-walled cysts and emphysematous lesions. The histopathological characteristics of the nodular lesions in the chest CT were correlated with cellular granulomas mainly composed of Langerhans cells and eosinophils, and small granulomas were also seen in the thin fibrous walls of the cysts. All patients quitted smoking and three showed improvement of the pulmonary lesions within three months.

We describe a case of bilateral chylothorax with malignant pleural mesothelioma. A 41-year-old woman was admitted to our hospital because of dyspnea. She had no history of exposure to asbestos. A chest radiograph and chest computed tomogram (CT) on admission revealed massive bilateral pleural effusion and a large tumor with pleural thickening in the left lateral and anterior parts of the pleura and mediastinum. Biochemical tests of pleural fluid revealed chyle. Two years before, she had been diagnosed through histological and histochemical examinations as having diffuse malignant pleural mesothelioma of the epithelial type. Chest-tube drainage was performed, and pleurodesis was induced by the intrathoracic injection of OK-432 at 10 KE per dose. The chylothorax disappeared after pleurodesis. To date, reports of malignant mesothelioma with nontraumatic chylothorax have been rare.

In this case, a 30-year-old man had been treated for chronic sinusitis and bronchiectasis since 2000, and presented at our outpatient clinic in May 2001 with chief complaints of massive yellow sputum expectoration and dyspnea. After he was admitted by our hospital, Pseudomonas aeruginosa bacteria were isolated at the rate of 10(8)/ml from his sputum culture. In electron-microscopic observation, the cilia of the bronchial epithelium were found to lack dynein arms. Semen examination revealed decreased sperm motility. Thus, the following diagnosis was made: diffuse bronchiectasis associated with the immotile-dyskinetic cilia syndrome, complicated with a P. aeruginosa infection. After the airway infection was ameliorated, 40 mg/day of clenbuterol hydrochloride was administered in combination with 250 mg of azithromycin, which was given twice a week, and which led to a markedly decreased frequency of exacerbation of airway infection. Moreover, chest CT scanning and respiratory function testing also indicated improvements. It was hypothesized that the decreased cilia motility due to P. aeruginosa-produced pyocyanin would be ameliorated with a b2 stimulant, and the inhibitory effect of a macrolide on the P. aeruginosa biofilm and production of pyocyanin would also be involved in the improvement of this case.

NTx and I CTP, a metabolite of type I collagen, were compared as to their usefulness as indicators of bone metastasis in lung cancer. The NTx level was significantly higher in lung cancer patients with bone metastasis (107.9 +/- 56.1 nM BCE/mM) than in those without it (p < 0.0001), as was the I CTP level (10.0 +/- 6.5 ng/ml; p < 0.0001). The Z scores of NTx and I CTP were 2.37 and 2.04, respectively, indicating that NTx is superior to I CTP in sensitivity to bone metastasis because of its higher Z score and its higher area under the ROC curve. The cutoff values of these markers were set to produce the highest accuracy/sensitivity rates and to make possible the highest diagnostic efficiency, and then the odds ratios at these cutoff values were calculated. The odds ratios of NTx and I CTP at cutoff values for the highest accuracy were 66.3 and 12.6, respectively; those offering the highest diagnostic efficiency were 46.5 and 10.0, respectively. These results indicated that NTx offers better prediction of bone metastasis in lung cancer than does I CTP.

We encountered a case of pulmonary eosinophilic granuloma complicated with pneumothorax. A 24-year-old man was admitted to our department because of respiratory difficulty. Chest radiography on admission showed a right pneumothorax. A thoracic catheter was therefore inserted, and the pneumothorax was improved. A chest radiograph obtained after treatment showed diffuse linear reticular shadows; and a chest CT scan showed starlike nodular lesions and multiple cysts in the lungs, and a large nodule in the left rib. Because an ulcer had been diagnosed in the oral cavity 1 year previously, a mandible biopsy was performed, and a granulomatous lesion consisting of eosinophils was recognized. Taken together with the pulmonary findings, an eosinophilic granuloma was diagnosed. The patient was instructed not to smoke and the clinical course was observed. The pulmonary, mandibular, and costal lesions improved.

We report a case of subacute pulmonary hypertension caused by microscopic pulmonary tumor embolism due to the dissemination of gastric cancer cells. The patient, a 61-year-old man with no history of malignant diseases, was admitted to our hospital on October 14 in 1998 because of cough and dyspnea on effort, that had developed since the previous month. On admission, chest radiography including CT scans showed slight cardiomegaly and disseminated reticulonodular shadows predominating in the lower lung fields of both lungs, and arterial blood gas analysis disclosed severe hypoxemia. Lung perfusion scintigraphy revealed multiple irregular defects in both lungs. Echocardiography indicated right ventricular overload, and the pulmonary artery systolic pressure was estimated to be higher than 80 mmHg. Disseminated intravascular coagulation (DIC) developed on the 6th day of hospitalization. Multiple pulmonary embolism with DIC of unknown cause was diagnosed, and the patient was given anticoagulant therapy with heparin. However, he died of respiratory failure on the 7th day of hospitalization. At autopsy, an invasive cancer was found in the stomach, resembling type IIc early gastric cancer. The lumens of the pulmonary arterioles were significantly narrowed by fibrocellular proliferation and thrombi accompanying tumor cell clusters, and some of the microvessels were completely occluded. Disseminated microscopic pulmonary metastasis of malignant tumors should be included in the differential diagnosis of subacute pulmonary hypertension due to multiple pulmonary embolism of unknown cause.

While Nocardial infections are being diagnosed with increasing frequency, infection with Nocardia otitidiscaviarum remains relatively uncommon. We report a case of pulmonary Nocardia otitidis-caviarum infection in a 35-year-old man with Cushing's disease. This work describes the first case of nocardiosis in Japan caused by Nocardia otitidis-caviarum in Cushing's disease. The patient was admitted to our department because of edema. A diagnosis of Cushing's disease was made on the basis of elevated serum levels of cortisol and adrenocorticotropic hormone (ACTH) and pituitary adenoma was found in a cranial CT scan. One month after admission, chest radiographs showed a large bilateral mass on the lung fields. Nocardia otitidis-caviarum was isolated from the sputum. The patient responded poorly to intravenous PAPM/BP, but later improved after treatment with trimethoprim-sulfamethoxazole, but he died of heart failure and respiratory failure after the initiation of this therapy. This case demonstrated that nocardiosis must be considered in differential diagnosis as an opportunistic infection.

We reviewed the clinicopathological features in 12 patients (7 males and 5 females; mean age 54 yr) with pulmonary cryptococcosis. Eleven of the patients were asymptomatic and the disease was detected by chest radiograph abnormalities. The underlying systemic disease had been diagnosed as diabetes mellitus in two. Chest CT scans showed a solitary nodule in 9 of the 12 patients, multiple nodules in 2, and infiltration in 1. The nodular diameter was less than 2 cm in 10 of the 12. All nodules were located in the subpleural region. On the chest CT, cavitary nodules, scattered nodules, or both, and spiculated nodules were difficult to distinguish from pulmonary tuberculosis and primary lung cancer, respectively. According to McDonnell's pathological classification of pulmonary cryptococcosis, the resected 8 lungs revealed peripheral pulmonary granuloma in 5 and granulomatous pneumonia in 3. It is important to perform a pathological examination for the diagnosis of pulmonary cryptococcosis to avoid misdiagnosis as lung cancer or pulmonary tuberculosis.

A 59-year-old woman was admitted to our hospital with exertional dyspnea. Linear and reticular opacities in the middle and lower fields of both lungs were observed on chest roentgenograms and chest computed tomograms (CT). The presence of anti RNP-antibody and Raynaud's phenomenon, sclerosis of the fingers, and leukopenia yielded a diagnosis of mixed connective tissue disease associated with interstitial pneumonia. The symptoms and lung involvement were alleviated after the administration of prednisolone (40 mg/day). However, the patient experienced the sudden onset of dyspnea during pulmonary function tests. A chest X-ray film disclosed mediastinal air around the left pulmonary artery, and a chest CT scan demonstrated some blebs in the left lower lung field. After tapering the dosage of prednisolone in 5 mg increments per week, the pneumomediastinum disappeared without treatment. The clinical features and laboratory data findings suggested the patient's interstitial pneumonia was associated with systemic lupus erythematosus rather than with progressive systemic sclerosis or dermatomyositis. The pneumomediastinum may have been due to the rupture of blebs secondary to interstitial pneumonia during pulmonary function tests or as a result of steroid therapy.

Sarcoidosis is known to be a disease characterized by high familial aggregations. We reported on the genealogy of sarcoidosis in a man and his identical twin sons. The patient we encountered was a 49-year-old man admitted to our hospital because of abnormal chest X-ray findings observed during a medical checkup. Cervical and hilar lymph nodes were swollen on both sides, and lesions were observed in the right lung field. Biopsy specimens from cervical lymph nodes disclosed epithelioid cell granuloma without caseous necrosis. A diagnosis of sarcoidosis was made. The disease had also been diagnosed in the patient's identical twin sons 2 years earlier. They had been successfully treated and no recurrence has been observed. HLA typing disclosed that the father and his twin sons had identical A 33 (19), B 44 (12), DR 2, and DR 12 genes. This finding suggested that genetic factors are involved in the onset of this disease.

We reported a case of chronic cough due to gastroesophageal reflux (GER). The patient was a 29-year-old woman who had suffered from persistent chronic cough for more than 3 years. She had been treated with high doses of inhaled steroids, oral bronchodilators, and oral corticosteroids on a presumed diagnosis of asthma. However, her cough was not alleviated by these treatments, and the patient was referred to our hospital. She did not exhibit typical GER symptoms except for belch. Although esophagoscopy did not disclose reflux esophagitis, esophageal pH monitoring revealed acid reflux 7 to 8 times higher than the reference value. The patient was treated with a proton-pump inhibitor, which markedly alleviated her cough. Chronic cough due to GER was diagnosed. Although the incidence of chronic cough due to GER was thought to be rare in Japan, the findings in our case report underscored the importance of this association to the differential diagnosis of chronic cough.