Search

The clinical effects and tolerability of micafungin sodium in daily practice for the treatment of fungal infection in critically ill patients were evaluated in an open-labeled, non-comparative, observational study. All patients admitted to intensive care units (ICUs) of 3 hospitals in Chiba prefecture between June 2003 and March 2005, who were treated with micafungin because of known or suspected fungal infection, were included in the study. A total of 34 patients received micafungin and 29 cases of them were subjected to analysis. Fungal infections were classified as "proven" in 3 patients (10.3%) and "possible" in 26 (89.7%). Candida was detected in 16 patients, most of them were Candida albicans and 4 cases were non-albicans Candida. Clinical effects of micafungin were "cured" and "improved" in 20 patients (77%), "failure" in 6 (23%), and "undetermined" in 3 cases. Adverse events were reported in 10 patients, but there was no significant event. In conclusion, micafungin was effective in 77% of proven or suspected fungal infections in critically ill patients admitted to the ICU. The drug was well tolerated and discontinuation of its treatment due to adverse events was not experienced during the study period.

A 58-year-old woman was admitted to our hospital for repeated episodes of dry cough, low-grade fever, and gradual development of dyspnea on exertion. Chest computed tomography showed diffuse ground-glass opacities in both lung fields. Bronchoalveolar lavage fluid (BALF) showed an increased number of lymphocytes, and transbronchial lung biopsy revealed alveolitis and epithelioid cell granuloma. The acute onset and the patient's living environment suggested summer-type hypersensitivity pneumonitis. However, anti-Trichosporon antibody was negative and a definitive diagnosis could not be made. The patient's condition improved with corticosteroid treatment and, after discharge from the hospital, she moved to a new home. The following year, however, her symptoms returned, and she was readmitted to our hospital. Recurrence of the disease despite the change in environment ruled out summer-type hypersensitivity pneumonitis. Given the patient's history of budgerigar breeding five years earlier, bird breeder's lung was suspected. Anti-bird excreta antibody found in the patient's serum and BALF, along with a positive lymphocyte stimulation test against pigeon serum, strongly suggested an acute onset of bird breeder's lung. We report a rare case of acute bird breeder's lung with radiologic findings of ground-glass opacities, a one-year disease-free period and an acute relapse.

A 66-year-old woman who had been treated at a nearby hospital since 1977 for rheumatoid arthritis complained of cough. Chest X-ray films disclosed multiple nodular shadows with cavitation in the fields of both lungs. The patient was admitted to our hospital and a thoracoscopic lung biopsy was performed. Histologically, the nodule consisted of necrotizing granuloma, indicating a necrobiotic nodule. Rheumatoid nodule was diagnosed because the patient exhibited rheumatoid arthritis. The chest X-ray shadow disappeared without medication. Rheumatoid nodules without coniosis are uncommon, but should be considered in the differential diagnosis of lung nodular lesions in patients with rheumatoid arthritis.

A 68-year-old woman presented with Sjögren's syndrome. Chest X-ray films disclosed consolidated shadows in the right S2 and an infiltration shadow in the right S8 with small nodules. Pathological examination of transbronchial lung biopsy (TBLB) specimens revealed lymphocytic infiltrations that stained positive with UCHL-1 and L 26 in immunohistochemical studies. Lung tissue specimens obtained by video-assisted thoracic surgery showed lympho-epithelial lesions with dense lymphocytic infiltration. Southern blot hybridization and polymerase chain reaction (PCR) assays demonstrated monoclonality and immunoglobulin heavy chain gene rearrangement. These findings yielded a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma. The detection of rear-ranged genes encoding for immunoglobulin heavy chains is useful for the diagnosis of primary pulmonary lymphoproliferative disorders, especially malignant lymphomas.

We clinically and radiologically examined 8 patients with pulmonary actinomycosis. Their clinical features were slowly progressive, and the most commonly occurring symptom was hemoptysis. Laboratory findings disclosed elevated ESRs, a sign of chronic inflammation. Roentgenographic films showed a higher percentage of lesions in the right lung and on the dorsal side. On chest CT images, the lesions appeared as nodular or consolidated shadows with atelectasis, and spread widely over the parietal pleura in the periphery of the lung fields. The margins of the nodules were irregular, and multiple blood vessels were involved. The internal density of the nodules contained either a low attenuation region or cavity. In relation to the pleural, local pleural thickening adjacent to the nodules was identified in all patients, and the thickened areas were thin and smooth. Although it was difficult to diagnose by transbronchial lung biopsy (TBLB), granulation tissue obtained by TBLB was considered an important finding suggestive of pulmonary actinomycosis. As diagnostic procedures, repeated TBLBs appear to be effective for lesions extending into the hilar region, and video-assisted thoracoscopic surgery, for small nodular lesions located in the periphery of the lung fields.

We investigated the outcome of 12 patients with interstitial pneumonia (IP) associated with polymyositis and dermatomyositis (PM/DM). The mean age of the patients was 53. There were 3 cases of PM/DM preceding the respiratory symptoms (RS), 7 cases of simultaneous PM/DM and RS, and 2 cases of PM/DM delayed with RS. In these 3 groups, there was a tendency for cases with PM/DM preceding RS to be younger. Jo-1 antibody was positive in only one case of the simultaneous group. Patients in whom IP preceded PM/DM or was simultaneous with PM/DM showed a better response to corticosteroid. The chest CT findings and TBLB findings showed a BOOP pattern in these patients. TBLB findings are not useful for diagnosing the pathological type, however they are useful for evaluating the effectiveness of steroid therapy on IP in PM/DM.

We report a case of lung abscess caused by Eikenella corrodens and reviewed the literature. A 51-year-old man was hospitalized because of an infiltrative shadow in the left upper lung on chest X-ray. The patient was intravenously given CEZ (2 g/day) followed by CEZ (4 g/day) and AMK (200 mg/day). We nevertheless deteriorated and was subsequently treated with CTM (4 g/day) and LCM (6 g/day), and the shadow improved but remained. Only Eikenella corrodens was isolated from aspiration materials obtained from the resected lung. We examined the susceptibility of 60 strains of Eikenella corrodens to various antimicrobial against. The organisms were very susceptible to PCG, ABPC, PIPC, CTM, CTX and LMOX, but were all resistant to LCM, CLDM, GM and AMK.

We investigated interstitial pneumonia associated with collagen vascular disease (IP-CVD) in association with lung cancer. Seventy-three cases of IP-CVD were included in this study. Nine (12%) of the 73 cases were associated with lung cancer, one of which had double lung cancers. The histological types of the cancers were adenocarcinoma (5 cases), epidermoid carcinoma (2 cases), small cell carcinoma, large cell carcinoma and large cell neuroendocrine carcinoma (one case each). The lesions were located in the central or peripheral lung in 3 and 7 of the ten cancers, respectively. Of the seven cases diagnosed as having IP-CVD followed by lung cancer, five had stage I disease, and one each of the remaining two cases was in stage IIIA and stage IV. Six of the seven peripheral cancer lesions which were resected or autopsied could be analyzed with regard to the topographical relationship between the primary site and fibrotic lesions. Only three cancers were encased by or in close proximity to, honeycomb lung, although most of the lung cancers arose in relation to fibrotic lesions. Moreover, the acute exacerbation of IP-CVD after operation or chemotherapy without thoracic irradiation should be monitored carefully.

The patient, a 59-year-old woman, was admitted for further evaluation after a routine checkup in 1990 revealed an interstitial shadow chronic hypersensitivity pneumonia caused by her pigeons, was diagnosed. The patient later disposed of the pigeons and henhouse, where upon, she experienced dyspnea on exertion. In January 1995, the patient was admitted to our hospital with a progressive pulmonary interstitial shadow. Lung biopsy after thoracoscopic surgery revealed centrilobular fibrotic lesions, as well as, small honeycomb-like and granulomatous lesions. An antibody to the pigeon serum was detected in the patient's serum by the ouchterlony method. Chronic hypersensitivity pneumonia caused by pigeons is rare, and previously documented histological findings are few.

A 52-year-old woman was admitted to the hospital with dyspnea on exertion and a feeling of abdominal fullness. Chest radiographs revealed a moderate bilateral pleural effusion. Examination of the effusion was in conclusive. Thoracoscopy and thoracic computed tomography (CT) failed to provide evidence pertaining to the etiology of the recurrent effusion. Elevation of serum CA-125 levels suggested the presence of an intrapelvic tumor, which was substantiated by pelvic CT. Laparotomy revealed a small amount of ascites. The resected specimen revealed a tumor of the left fallopian tube, which was histologically to be poorly differentiated adenocarcinoma. The pleural effusion disappeared after removal of the tumor and Meigs' syndrome was subsequently diagnosed. Primary fallopian tube adenocarcinoma is a rare cause of Meigs' syndrome.

To gather data about smoking habits among members of the Japan Society of Chest Diseases, a questionnaire was distributed during the 36th annual meeting. A total of 2411 out of 3725 questionnaires were returned (65%). The percentage of smokers was 23%. Smoking was prohibited in the hospitals of 281 respondents (8%). Seventy-nine percent reported that patients smoking areas were separated from patients' non-smoking areas, but only 41% reported that physicians' smoking areas were separated from physicians' non-smoking areas. Tobacco was being solid in over 50% of the hospitals represented, either via vending machines or through hospital retail stores. However, 79% of the respondents indicated that hospitals should be smoke-free. Questions of ethics in medicine are highlighted by this questionnaire. The obvious issues involved are whether or nor both patients and physicians should be required to stop smoking in health-care facilities. The larger issue is the degree and method by which the Japan Society of Chest Diseases should involve itself actively in smoking reform for the sake of society in general.

A 75-year-old woman was admitted to our hospital because of dyspnea and fever. A chest roentgenogram obtained on admission showed cardiomegaly. An echocardiogram, a computed tomogram, and a magnetic resonance computed tomogram revealed a pericardial tumor and a large pericardial effusion. A tumor biopsy was done under echocardiographic guidance, and sarcomatous mesothelioma was diagnosed on the basis of histological and immunohistological studies of biopsy specimens. Pericardial fenestration followed by tumor resection gave relief from cardiac tamponade. The postoperative course was good, and the patient was discharged from the hospital on the 19th postoperative day. Four months later the pericardial mesothelioma recurred and the patient died of constrictive pericarditis. Palliative resection was useful in this case because it allowed the patient to resume activities of daily living by relieving the cardiac tamponade.

We encountered a patient with adenoid cystic carcinoma of a lacrimal gland and multiple pulmonary metastases. The patient underwent resection of a left orbital tumor, which was followed by 60 Gy of radiation therapy. The pathological diagnosis was adenoid cystic carcinoma with a cribriform pattern. About one year after diagnosis, metastases to the lung, liver, bone, and skin were found, but there was ro local recurrence. A chest CT image revealed findings characteristic of hematogenous metastases: multiple discrete tumor shadows distributed over the entire left and right lung fields. We collected 24 reports of similar cases. The cases with pulmonary metastases had poor outcomes.

Malnutritions is one cause of exercise intolerance in patients with chronic obstructive pulmonary disease. We studied the relation between exercise limitation and body composition in 20 clinically stable patients with chronic obstructive pulmonary disease. Maximal work capacity was measured during incremental exercise on a cycle ergometer, along with maximal oxygen uptake. Anaerobic threshold was determined by the V-slope method. Bone mineral content, lean mass, and fat mass were assessed by dual-energy X-ray absorptiometry. Bone mineral content and lean mass were significantly lower in moderately malnourished patients (%IBW < 80) than in well-nourished patients (%IBW > or = 90). Fat mass was significantly lower in mildly malnourished patients than in well-nourished patients. Maximal work capacity, maximal oxygen uptake, and anaerobic threshold correlated significantly with lean mass, but not with fat mass. These data suggest that lean mass is one determinant of exercise capacity in patients with chronic obstructive pulmonary disease.

Reactive oxygen intermediates such as hydrogen peroxide play an important role in the pathophysiology of acute lung injury, not only as terminal effectors, but also as second messengers in signal transduction; we studied their role in adhesion molecule expression and cytokine production. N-acetylcysteine, an antioxidant, decreased the TNF alpha-induced expression of intercellular adhesion molecule-1 on cultured epithelial cells from human bronchi (BEAS-2A), and inhibited IL-8 production by those cells. In vivo, N-acetylcysteine attenuated the sequestration of polymorphonuclear neutrophils in rat lungs caused by intratracheal lipopolysaccharide. These findings suggest that adhesion molecule expression and cytokine production in the lung are mediated by the production of reactive oxygen intermediates. Because adhesion molecules and cytokines play a crucial role in the pathophysiology of neutrophil-mediated acute lung injury, the inhibition of adhesion molecule expression and cytokine production with anti-oxidants such as N-acetylcysteine may be a useful therapeutic strategy.

Thoracoscopy is useful for diagnosis of a number of lung diseases. We report our recent experience with thoracoscopy in 86 patients and with video-assisted thoracic surgery in 105 patients. In 70 patients with pleural effusion, thoracoscopic pleural biopsy was done under local anesthesia. All malignant pleural effusions that were not diagnosed by cytologic examination of pleural effusion fluid were diagnosed by thoracoscopy. Especially in malignant mesothelioma, thoracoscopy yielded correct diagnoses. No complication was observed. In 45 patients with a solitary pulmonary nodular lesion and in 27 patients with diffuse interstitial lung diseases, thoracoscopic lung biopsy was done with an "endo-stapler", under general anesthesia. The diagnostic accuracy of this procedure was excellent. Plasma neutrophil elastase and IL-6 levels were measured after surgery as markers of the invasiveness of the procedure. The results indicated that thoracoscopic lung biopsy is relatively safe and non-invasive. Thoracoscopy has become an indispensable tool in the daily practice of pulmonology.

Levels of KL-6 in serum were measured in 17 patients during acute exacerbations of idiopathic interstitial pneumonia (IIP). The patients were divided into three groups: "effectively" treated (n = 4), "ineffectively" treated (n = 4), and "untreated" with steroid pulse therapy (n = 9). In the "ineffective" group, the level of KL-6 in serum was significantly higher than that in the "effective" group. These results suggest that KL-6 is useful for assessing patients with acute exacerbations of IIP. In a separate study ONO-5046, a specific neutrophil elastase inhibitor, was given in 40 institutions to find out if it is useful in treating IIP. The PaO2/FIO2 ratio after the administration of ONO-5046 was significantly improved in high-dose group, which suggests that this agent is useful in treating patients with IIP.

A 56-year-old man had worked as a furniture painter and had been exposed to tonoko polishing powder for 30 years. He had complained of dyspnea on exertion for 7 years, and was admitted to our hospital in 1991. A chest X-ray film revealed large opacities and emphysematous changes in both lung fields. Tonoko pneumoconiosis was diagnosed after transbronchial lung biopsy. Home oxygen therapy was given because of progressive hypoxemia, but the patient died of respiratory failure. At autopsy, examination of the lungs showed severe emphysematous changes, and collapse of alveoli. Many gray masses resembling coating cement were seen especially in the upper lobes. Microscopical examination showed that the large opacities were composed of hyaline nodules, similar to silicotic nodules, with anthracosis. Scanning electron microscopy with X-ray microanalysis revealed a high concentration of titanium in the gray mass. A low dose of titanium would not be expected to induce fibrotic changes in the lung, but a high dose and long-term exposure might have that effect. Titanium contained in paint might have exacerbated tonoko pneumoconiosis in this patient.

We studied the relations between preoperative and postoperative lung function in 62 patients with lung cancer who were admitted to our hospital from January 1985 to December 1994. Postoperative pulmonary function, especially vital capacity (VC) and forced expiratory volume in one second (FEV1), could be predicted from the number of unobstructed subsegmental bronchi, and correlations between predicted and measured values of VC and EFV1 were computed. In patients whose pulmonary function was measured more than 4 weeks postoperatively. The predicted and measured VC and FEV1 were found to be strongly correlated (r = 0.892 for VC, and 0.852 for FEV1). Similar correlations were found in patients without obstructive pulmonary dysfunction (FEV1% > or = 70%, r = 0.897 for VC, and 0.884 for FEV1). In one patient who had obstructive lung dysfunction due to pulmonary emphysema (EFV1% < 70%), an error of more than 30% was noted between the predicted and measured FEV1 values. Therefore, patients with lung cancer who have pulmonary emphysema may have postoperative FEV1 valves that are higher than their predicted values. This might be an effect of volume reduction.

A 47-year-old man was admitted to the emergency room in November 1994 with left-sided chest pain. Two days before admission, he had fallen two meters and hit the left side of his chest. A chest roentgenogram showed patchy infiltrative shadows and a pleural effusion confined to the right lung field. Bloody fluid was obtained from the right B3b by bronchoalveolar lavage. Specimens obtained from the right lung by transbronchial lung biopsy revealed deposition of hemosiderin and precipitation of fibrin, which were consistent with lung contusion. The abnormal shadows on the chest roentgenogram disappeared spontaneously within one week. Review of the literature suggests that contra coup pulmonary contusion is rare, and that the mechanism might involve injury of small vessels by high-speed vibration of the contralateral part of the mediastinum.

A 44-year-old man was hospitalized because of exertional dyspnea that had progressed for one month. A chest X-ray film showed bilateral small nodular and reticular shadows. The patient presented with a positive inflammatory reaction and hypoxemia. Bronchoalveolar davage fluid had a high lymphocyte fraction and a low CD4/CD8 ratio. Trichosporon cutaneum antibodies were detected, and a specimen obtained by transbronchial lung biopsy showed alveolitis with granuloma formation. The patient reacted positively on a provocation test that was done by having him stay home for 5 days. Summer-type hypersensitivity pneumonitis was diagnosed, and a steroid was administered because of the prolonged abnormal chest roentgenographic findings. KL-6, a mucinous high-molecular-weight glycoprotein that is expressed on Type II pneumonocytes, was retrospectively used as a marker of pneumonitis. A new kit for enzyme-linked immunoassay (ED046) was used to measure the serum KL-6 level. The serum KL-6 level peaked approximately 10 days after the patient was admitted to the hospital and was thus kept away from antigens, and also after the provocation test. The steroid treatment was started, the KL-6 level decreased gradually. Within 2 months after steroid treatment began, the dose of the steroid was reduced and the KL-6 level decreased below the upper limit of normal. The KL-6 level remained low thereafter; it was not influenced by liver dysfunction or other inflammatory processes. However, the C-reactive protein level decreased rapidly after provocation and thereafter immediately returned to almost zero. The lactate dehydrogenose level peaked 8 days after provocation and decreased rapidly after steroid treatment. These results suggest that the serum KL-6 level provides new information regarding the clinical course and treatment of interstitial pneumonia. In addition KL-6 may be useful form monitoring disease activity, especially while tapering the dose of steroids in patients with interstitial pneumonia.

KL-6 is a mucinous glycoprotein expressed on Type 2 pneumonocytes, and serum levels of KL-6 are reported to be abnormally high in patients with interstitial pneumonia. A new assay kit for serum KL-6 (ED046) was used in the evaluation of patients with pneumonitis. To clarify whether KL-6 is a useful marker of pneumonitis activity, 649 subjects were studied, including 185 healthy controls, 187 patients with 3 types of interstitial lung diseases, and 277 patients with 4 types of non-interstitial lung diseases. The serum KL-6 level was significantly higher in the patients with pneumonitis (1285 +/- 1196 U/ml) than in the patients without pneumonitis (307 +/- 232 U/ml). The KL-6 level was also significantly higher in patients with clinically active pneumonitis (1708 +/- 1338 U/ml) than in those with inactive pneumonitis (820 +/- 796 U/ml) (p < 0.0001). Serum KL-6 levels correlated significantly with serum c-reactive protein, lactic dehydrogenase, and PaO2 values. These results suggest that the ED046 assay is useful for measuring KL-6 as a marker of pneumonitis activity.

A 53-year-old man was admitted to our hospital with a skin eruption, a high fever, and diplopia in April of 1992. He had been given a diagnosis of diffuse panbronchiolitis in 1981. After administration of erythromycin began in 1987, symptoms and chest roentgenographic findings gradually improved. Arteritis of peribronchial muscular arteries with medial destruction was seen in lung biopsy specimens, and periglomerular granulomatous inflammation and necrotizing glomerulitis were seen in renal biopsy specimens. P-ANCA was found, but a test for cytoplasmic ANCA (which is the most specific antigen of Wegener's granulomatosis) was negative. Chronic pulmonary infection due to diffuse panbronchiolitis might have formed ANCA, which may have caused the vasculitis in this patient.

We studied the effect of sensory nerve peptide substance P (SP) and neurokinin A (NKA) in isolated perfused guinea pig lungs. SP and NKA increased pulmonary arterial pressure, capillary pressure, pulmonary venous resistance, and lung weight, but they did not change pulmonary arterial resistance or pulmonary vascular permeability. The effects of SP on pulmonary vascular dynamics were greater than those of NKA. Ozagrel hydrochloride, a thromboxane synthase inhibitor, partially attenuated the effect of SP. This indicates that thromboxane contributes to SP-induced pulmonary vasoreactivity. However, ozagrel hydrochloride did not change the effects of NKA. FK224, an NK-1/NK-2 receptor antagonist, abolished both SP- and NKA-induced pulmonary vasoconstriction. This indicates that SP and NKA acted on the pulmonary vasculature through the NK-1 or NK-2 receptor, or both. Papaverine, a smooth muscle relaxant, abolished the effects of SP. The SP-induced increase in lung weight was caused by a rise in pulmonary hydrostatic pressure, especially that caused by pulmonary venoconstriction.

A 55-year-old man who complained dyspnea on exertion was given a diagnosis of interstitial pneumonia associated with mixed connective tissue disease, based on symptoms and on physical and laboratory findings. Soon afterward, he experienced an acute exacerbation of the interstitial pneumonia. He was given three courses of steroid pulse therapy and cyclophosphamide, but his condition worsened. After administration of azathioprine in addition to corticosteroids, his respiratory status improved. The dose of corticosteroids was tapered and the patient has been free of disease for two years. Pulmonary involvement in mixed connective tissue disease has been considered to be relatively benign and easily treated with corticosteroids. Recently, however, many cases of corticosteroid-resistant disease with poor outcome have been reported. Azathioprine was very effective against the interstitial pneumonia in this case, but general conclusions about the most effective type of immunosuppressive agent and the timing of its administration must await the results of further study.

We examined clinical characteristics of patients with primary lung cancer associated with clubbing of the fingers or pulmonary hypertrophic osteoarthropathy. Clubbing was observed in 12.5% of patients with lung cancer. Squamous cell carcinoma was frequently associated with clubbing. Clubbing was found in all clinical stages. PaO2 and PaCO2 were normal in patients with lung cancer, which suggests that neither hypoxemia nor hypercapnia caused the clubbing in these patients. Pulmonary hypertrophic osteoarthropathy was found in three patients with lung cancer (two men and one woman, mean age 49 years). The incidence was 2.9% among lung cancer patients with clubbing, 0.22% in all lung cancer patients, and was apparently lower than those in reports from outside Japan. One of these patients has stage IIIA squamous cell carcinoma, one had stage IV large cell carcinoma, and one had stage IV adenocarcinoma. In all cases bone scans were useful for diagnosis and for following the clinical course.

A 33-year-old man was admitted complaining of a fever, dyspnea, and a dry cough almost every night since December of 1992. He had been using an ultrasonic humidifier at home. The chest CT scan and roentgenogram showed bilateral reticulonodular shadows. After admission, the symptoms resolved spontaneously. These findings were suggestive of hypersensitivity pneumonitis. After analysis of fluid obtained by bronchoalveolar lavage and of a specimen obtained by transbronchial biopsy, "humidifier lung" was diagnosed. Ten species of microorganisms were isolated from the water left in the patient's humidifier. On precipitation and complement fixation tests of the patients serum, the results were positive for three of those microorganisms: Flavobacterium multivorum, Yersinia pseudotuberculosis, and Aureobacterium liquefaciens. The titer on the complement fixation test increased immediately after a provocation test. The laboratory results suggest that at least one of these three microorganisms was the causative antigen in this case.

A 64-year-old woman complained of multiple blisters in 1990. She had had a productive cough since 1975. Immunofluorescence study of a specimen obtained from a skin biopsy showed staining in a linear pattern for both IgG and C3 in the epithelial basement membrane zone (BMZ) of the dermal-epidermal junction, and a high titer of anti-BMZ antibody. These findings led to the diagnosis of bullous pemphigoid. Corticosteroid therapy was started, and resulted in some stabilization of the skin lesion. Exertional dyspnea and a productive cough developed gradually, and the patient was referred to our department in 1992. Chest X-ray film and CT findings revealed a diffuse granular shadow and bronchiectatic change, predominantly in the lower lung fields. Laboratory tests showed a high titer of cold hemagglutinin and a high level of serum immunoglobulin A. Pulmonary function tests showed a combined destructive-restrictive defect and hypoxemia (PaO2 = 58.5 Torr). From these findings diffuse panbronchiolitis was diagnosed. A low dose of erythromycin alleviated the patient's pulmonary symptoms and improved the chest radiographic findings.

A 61-year-old woman was admitted for evaluation of an abnormal shadow found incidentally on a chest radiograph. A 35 x 20 mm nodule with an ill-defined margin was found at the left hilum on conventional CT. Thin-slice (2 mm) CT was done, and a fine granular zone was found around the lesion. Left upper lobectomy was done and the lesion proved to be a primary pulmonary non-Hodgkin's lymphoma (small cell type, B-cell). The granular pattern seen on CT was found to correspond to intraseptal micronodules scattered along the lymphatic vessels, a finding which is considered to be pathognomonic of pulmonary lymphomas by many pathologists. We know of no previous description of how these histologic characteristics can appear on high-resolution thin-slice CT. These findings will be helpful for the CT diagnosis of pulmonary lymphoma.

We report a case of primary pulmonary cryptococcosis. A 20-year-old woman was admitted to the hospital complaining of coughing, fever, and dyspnea on exertion. She had no underling disease or immunological abnormality. Chest X-ray film revealed bilateral diffuse infiltrative shadows, which were first believed to have been caused by a community-acquired pneumonia. Pulmonary cryptococcosis was diagnosed from the results of a transbronchial lung biopsy. After 2.5 years of anti-mycotic chemotherapy with amphotericin B and flucytosine, pneumothorax occurred in the left lung. Thoracotomy and open lung biopsy were done. Histological findings of the open lung biopsy specimens showed numerous broken cryptococcal organisms within alveolar macrophages. Diffuse fibrosis accompanied by multiple bullae may have punctured bullae or blebs and thus led to pneumothorax.

Twenty nine patients with superior sulcus tumors (26 men and 3 women) were studied. The incidence was 2.1% of 1350 patients with lung cancer. The mean age was 66.2 years, and 27 patients (93.1%) had a history of smoking (B.I. = 1193.7). There were 10 adenocarcinomas, 9 squamous cell carcinomas, 5 large cell carcinomas 4 small cell carcinomas, and 1 that could not be classified. Fifteen patients (51.7%) had Stage IV disease on admission. Eight patients (27.6%) presented with symptoms outside the chest. Pancoast syndrome was recognized in 9 patients (31.0%). In 15 patients (51.7%) the diagnosis was made by transbronchial biopsy and in 10 patients (34.5%) it was made by echoguided needle biopsy. Tumors were located in a posterior lesion in 13 patients (44.8%). Twenty patients were given radiation therapy. Clinical staging, irradiation, and surgical treatment were related to the length of survival. The median survival time was 7 months.

A 24-year-old woman who had suffered from pulmonary alveolar proteinosis for eight years was admitted to Jichi Medical Hospital with severe pneumonia. She was mechanically ventilated, and her condition markedly improved after repeated bronchoalveolar lavage with surfactant replacement therapy. This method was used because she had been resistant to the conventional unilateral lung lavage method for 12 months. During the bronchoalveolar lavage procedure, she became progressively hypoxic, but recovered immediately after the instillation of surfactant. The combination of bronchoalveolar lavage with surfactant replacement via a fiberoptic bronchoscope may be useful in treating other patients with pulmonary alveolar proteinosis.

The frequency of chronic sinusitis among the family members of 26 patients with diffuse panbronchiolitis were analyzed, and were compared with the frequency in 127 control families. In the diffuse panbronchiolitis group, 50% of families suffered from chronic sinusitis, in contrast to 18.9% of families in the control group. The difference was significant. Analysis of HLA antigens in families of patients with diffuse panbronchiolitis revealed that family members with chronic sinusitis had the same HLA haplotype as these patients with diffuse panbronchiolitis in the same family. These results indicate that patients with chronic sinusitis only and those with diffuse panbronchiolitis have similar genetic background. They also suggest that the patients with chronic sinusitis may be seen as a mild or incomplete type of diffuse panbronchiolitis.

We retrospectively analyzed the clinical presentation of non-insulin-dependent diabetes mellitus (NIDDM) in patients with idiopathic interstitial pneumonia (IIP). Between 1977 to 1993, 75 patients with IIP were admitted to our hospital. None had previously received corticosteroids. To compare the incidence of NIDDM with other pulmonary diseases and the degree of obesity, we randomly selected 200 patients without IIP who were admitted to our hospital in 1992 and 160 healthy subjects. We analyzed weight indices using two methods, body mass index and weight as a percentage of ideal body weight. Eighteen patients (24.0%) with IIP and 9 patients (4.5%) in the disease control group had NIDDM (p < 0.001). As the incidence of NIDDM is approximately 10% in Japan, it was suggested that these IIP patients showed a high prevalence of accompanying NIDDM. Among females, patients with IIP showed a strong tendency toward obesity compared with the healthy control subjects (p < 0.001), but this was not noted among males. Female patients with NIDDM showed a strong tendency toward obesity compared to those without NIDDM, but this was not noted among males. Although the correlation between IIP and NIDDM is unclear, we noted recent reports that advanced glycation and products can stimulate macrophages to secrete tumor necrosis factor and interleukin-1 in vitro, and can stimulate free radical generation by early glycation products in vitro. These cytokines and oxygen radicals may play a role in the pathogenesis or induction of IIP.

A 71-year-old woman was admitted to our hospital for evaluation of a chest X-ray abnormality. Heart murmur was not heard. Chest X-ray showed a bulge with calcification at left third arch. Chest computed tomography revealed contrast enhancement of masses, which appeared to originate from the vascular system. Coronary angiography demonstrated multicystic aneurysmal dilatation of a coronary artery fistula originating from the proximal left descending and right coronary artery. Electrocardiography showed no remarkable findings and a treadmill exercise test showed no significant ST-T change. The size of the mass of 3 cm in diameter on chest X-ray remained the same for two years. We concluded that surgery was not necessary immediately. In Japan, nineteen cases of coronary-pulmonary artery fistula with multicystic saccular aneurysms have been reported in the literature, including our case. The majority of these cases are elderly women from fifty to sixty years old.

A case of primary pulmonary cryptococcosis is reported. A 76-year-old man, without underlying disease or immunological abnormalities, was admitted to the hospital. Chest X-ray revealed diffuse infiltrative shadows considered at first to be community-acquired pneumonia. A diagnosis of pulmonary cryptococcosis was performed using fluconazole, miconazole and transbronchial inhalation of amphotericin B. Cryptococcal antigen detection was performed by two latex agglutination methods: Crypto-test and Sero-direct test (Eiken-test). Comparing the results of the two tests, sensitivity was superior with the Sero-direct test, but the correlation between the titers of the two tests was good.

A 68-year-old female was admitted because of an abnormal shadow on chest X-ray film. Chest CT showed a nodular shadow in right S3a. Right upper lobectomy with mediastinal lymph node resection was performed under a diagnosis of lung cancer made by TBLB. Pathological examination of the resected lung revealed well differentiated adenocarcinoma. In addition, examination of the resected lymph nodes showed granulomas, some of which contained numerous cryptococci and showed central caseous necrosis, and others showed non-caseating epithelioid cell granulomas suggesting sarcoid reaction. No cryptococcal infection was found in the resected lung. Mediastinal lymph node involvement of cryptococcus in this case was considered to be the lymph node component of the primary pulmonary complex of cryptococcosis. Such a primary complex was demonstrated in 1% of the cases of cryptococcosis in previous reports.

We reported two cases of idiopathic interstitial pneumonia (IIP) who developed acute exacerbation after bronchoalveolar lavage (BAL). One case was a 67-year-old male who presented with dry cough and exertional dyspnea. He was diagnosed as IIP and transbronchial lung biopsy revealed alveolitis. BAL was performed after administration of prednisolone. He complained of severe dyspnea after BAL and was diagnosed as having an acute exacerbation of IIP. In spite of extensive treatment including pulse therapy with methylprednisolone, he died. The other case was a 57-year-old male noted to have a chest X-ray abnormality who presented with dry cough and dyspnea on exertion. He was diagnosed as having IIP and primary lung cancer. BAL was performed to evaluate the activity of IIP, and respiratory distress subsequently became severe. After BAL, he developed an acute exacerbation of IIP and died in spite of treatment. In both cases, peripheral white blood cell counts were increased just before BAL. It was suggested that this condition might participate in acute exacerbation of IIP. It should be kept in mind that some patients with IIP may develop acute exacerbation after BAL.

A case of sarcoidosis with a high level of SCC antigen in the serum and broncho-alveolar lavage fluid (BALF) which was difficult to distinguish from lung cancer is reported. A 66-year-old female was admitted with a fever, sputum and coughing. Chest X-ray on admission showed bilateral hilar swelling and infiltrative shadows in the left lower lung. Chest CT showed bilateral lymph node enlargement and a localized nodular mass. The level of SCC antigen in the serum and BALF was high. Initially she was suspected of having lung cancer, but she was subsequently diagnosed as having sarcoidosis from a bronchial biopsy specimen, BALF and gallium scintigraphy. It was difficult to distinguish this case showing lymph node enlargement and mass shadow from lung cancer. Although this is a rarely reported case of sarcoidosis with a high level of SCC antigen in the serum and BALF, it is possible that SCC antigen may be elevated in patients with benign inflammatory lung disease due to various interactions of cytokines.

We studied the effects of erythromycin (EM) in diffuse panbronchiolitis (DPB) with chronic respiratory failure. Seventeen patients with DPB or sinobronchial syndrome receiving home oxygen therapy (HOT) were treated with EM of 400-600 mg/day for twelve months. Five patients discontinued HOT, and hypoxemia was improved in five other patients. Clinical effects were evident at one month after the start of EM administration, and a stable state was achieved after six months of EM therapy. FEV1 was significantly increased in pulmonary function tests. Factors which influenced the effects of EM included the period between onset of clinical symptoms and commencement of HOT and/or between commencement of HOT and administration of EM. EM was effective for patients with obstructive, but not constrictive impairment in pulmonary function tests. These findings indicate that EM is effective for DPB even in patients with chronic respiratory failure.

A 38-year-old woman was brought to hospital in an unconscious condition due to hypoglycemic coma. At 23 years of age she was diagnosed as having insulin-dependent diabetes mellitus. She had been treated with insulin but the control of her blood sugar was inadequate. Emergency endotracheal intubation was performed and she began to breathe spontaneously. Two days later, sore throat, swelling of the neck and fever appeared. She was therefore transferred to our hospital. CT showed a continuous abscess with multiple air bubble from the pharynx to the mediastinum. Cervical incision was performed and treatment with ampicillin, cefmetazole, and clyndamicin was started. Culture of the pus revealed alpha-streptococcus. The abscess decreased in size and her blood sugar was controlled by insulin and diet. She was discharged after 11 weeks of hospitalization. At that time CT showed only emphysematous change.

A 33-year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray film. Chest X-ray film and chest CT showed a round tumor in the left infrahilar area. Bronchoscopic findings revealed narrowing of left B5 and B8, with extraluminal compression. A preoperative diagnosis was not obtained and tumor resection was performed. The tumor was located in the parenchyma of left S8. Histological examination showed nuclear palisading and loosely textured spindle cells within myxomatous tissue, compatible with neurilemoma. Intrapulmonary neurilemoma is extremely rare and only 23 cases have been previously reported in Japan.

We examined the role of lipopolysaccharide binding protein (LBP) in the airspace and the CD14 receptor on alveolar macrophages in TNF alpha production and neutrophil (PMN) sequestration in lungs induced by intratracheal injection of lipopolysaccharide (LPS). LPS alone (Salmonella minnesota wild-type; 20 ng) or LPS + LBP complex [LPS (20 ng) + rabbit LBP (500 ng); preincubated for 30 min at 37 degrees C] was injected intratracheally into isolated rabbit lungs perfused with lactate-Ringer-albumin solution. Human PMN (5 x 10(7)) were added to the perfusate after 2 hr perfusion. Samples of lung perfusate were collected every 30 min for 180 min, after which bronchoalveolar lavage (BAL) was also performed. TNF alpha concentration in the perfusate and BAL fluid were determined using a bioassay with L-929 fibroblasts. PMN accumulation in the lung was determined by myeloperoxidase assay of the lung homogenate. LPS alone did not significantly increase TNF alpha production or PMN accumulation in lungs, whereas LPS/LBP complex increased TNF alpha concentration in the perfusate and PMN accumulation. Intratracheal injection of anti-CD14 antibody (40 micrograms) with LPS/LBP complex prevented TNF alpha production and subsequent PMN sequestration. We conclude that LBP in the airspace enhances the effect of LPS on TNF alpha production via a CD14-dependent pathway, and this subsequently contributes to PMN sequestration in the lungs. Airspace accumulation of LBP secondary to increased vascular and epithelial permeability may play a critical role in the development of septic shock and lung injury by promoting TNF alpha production via a CD14-dependent mechanism.

It is important to evaluate hilar and mediastinal lymph node metastasis accurately, since the findings are used to determine the indications for therapies and to estimate the patient's prognosis. Computed tomography (CT) is a useful method for this purpose, but it is known that healthy people may also have lymphadenopathy up to 10 to 15 mm, and metastasis is sometimes observed in lymph nodes less than 10 mm in cases of adenocarcinoma. For this reason, it is necessary to establish an optimal criteria for measured values of lymph nodes on CT images. In this study, we compared the size of mediastinal lymph nodes on CT images and histological findings in 425 lymph nodes of 153 primary lung cancer patients resected in our hospital from 1984 to 1991. Criteria were expressed as possible criteria which can be obtained from ROC analysis with compatibility of sensitivity and specificity, and definite criteria which offer highest efficiency. We analyzed these two criteria by minor axis, major axis, their sum, and their product. As a result, minor axis offered the best criteria. The value of possible criteria was 8.7 mm (sensitivity: 73%, specificity: 70%) and definite criteria was 13 mm (efficiency: 88%) in 425 lymph nodes. Analyzed by histological type, the criteria of epidermoid carcinoma (possible criteria: 9.5 mm, definite criteria: 13 mm) were larger than those of adenocarcinoma (possible criteria: 8.3 mm, definite criteria: 11 mm). Analysed by anatomical region and histological type, the criteria of epidermoid carcinoma varied by with the location of lymph nodes, but those of adenocarcinoma were almost constant.(ABSTRACT TRUNCATED AT 250 WORDS)

Intralobar pulmonary sequestration is a congenital disease characterized by nonfunctioning lung tissue with an anomalous blood supply stemming from the systemic circulation. We report a rare case of anomalous systemic arterial supply to the lung without demonstrable pulmonary changes. It is controversial whether this abnormality, systemic arterialization of lung without sequestration, should be a subtype of sequestration complex or not. We discuss the spectrum of sequestration complex.

A 58-year-old man was referred for the evaluation of a lung nodule on chest X-ray. On admission, chest X-ray showed a solitary nodule with cavitation in the left lung field. Histological examination revealed epithelioid cell granulomas and the diagnosis of pulmonary tuberculosis was made. He was treated with INH, ethambutol (EB), and rifampicin (RFP). On the 16th day of treatment, he developed dry cough and high fever. On the 20th day, dyspnea developed and PaO2 was decreased to 38.2 Torr. Chest X-ray showed new widespread infiltrates in both lung fields and bilateral pleural effusions. The size of the cavitary lesion was decreased. Transbronchial biopsy specimen showed slight interstitial thickening, lymphocyte infiltration, and multiple granulomas. Drug lymphocyte stimulation test was positive only with INH (230%). INH-induced pneumonitis was highly suspected. All drugs was discontinued and hydrocortisone 2400 mg daily was started. He soon became afebrile, and dyspnea and dry cough resolved. Chest X-ray film showed resolution of infiltrative shadows. He was subsequently successfully treated with streptomycin, EB, and RFP without any adverse effects. To our knowledge, this is the sixth reported case of INH-induced pneumonitis.

Various kinds of chemical mediators have been implicated in the pathogenesis of bronchial asthma. PGD2 is a cyclooxygenase product which has various physiological effects. In this experimental study, we investigated the role of PGD2 in the pathogenesis of bronchial asthma. In a bioassay system, PGD2 caused dose-dependent contractile responses in non-sensitized guinea pig trachea and lung tissue strips. The subthreshold concentration of PGD2 in both strips was 25 ng/ml. Acetylcholine-induced contractile responses in both strips were significantly increased by continuous infusion of PGD2. In the experimental model of bronchial asthma, the levels of PGD2 were significantly increased in serum, bronchoalveolar lavage fluid (BALF) and lung tissue of sensitized guinea pigs after antigen challenge. We have also reported that the levels of PGD2 in BALF were elevated in patients with stable state bronchial asthma. These results suggest that PGD2 may be a key substance that increases airway responsiveness and induces asthmatic attacks.