Bronchoalveolar lavage (BAL) was performed in 7 patients with hypersensitivity pneumonitis (HP), of which 4 patients had farmer's lung disease and the other 3 patients had HP due to home humidifiers. We analyzed their BALF lymphocytes and compared the result with those of 10 normal non-smoking subjects. The serum precipitin antibody to Micropolyspora faeni in 6 patients was positive and in one other patient, the serum percipitin antibody to Trichoderma virile was positive. In the BALF cells of all patients, total cell numbers, and the proportions of lymphocytes and polymorphonuclear leukocytes increased (p<0.01, p<0.01, p<0.1, respectively). The BALF-OKT4/OKT8 ratio had an elevation (p<0.01), that was different from summer type HP. Ia antigen of BALF lymphocytes was investigated in 3 patients with home humidifier lung. The ratio of their Ia⁺ T cells to the pan T cells in BALF lymphocytes was elevated and some relation between Ia⁺ T cells to activated OKT4⁺ T cells was suspected. We investigated changes in BALF cell findings in relation to the clinical course in a case of farmer's lung and a case of home humidifier lung. Abnormal findings of BALF cells were obtained during a clinically asymtomatic period. This means that the abnormal findings of BALF cells continue for a long period.

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Thirty-three autopsied cases with lymphangiosis carcinomatosa of the lung seen at our institution from 1977 through 1987 were reviewed. The patients, 18 men and 15 women, ranged in age from 29 to 86 years, and the mean age was 56 years. The mean duration from the onset of respiratory symptoms to death was 8 weeks. Direct causes of death were respiratory failure in 21 cases, cachexia (3 cases), hepatic failure (2), pericarditis carcinomatosa, metastases to the brain, massive hemorrhage and DIC (1).
The primary sites of carcinomas were the stomach in 19 cases, breast (3), prostate (2), esophagus, rectum colon, lung, bile duct, oral cavity, maxillary sinus and ureter (1). The histological types were adenocarcinoma in 28 cases, squamous cell carcinoma in 4 and transitional cell carcinoma in 1. Pleural effusion was noticed in 27 cases, tumor thrombi were seen in the blood vessels in 13 cases, and the distribution of lymphangiosis was predominant in the lower lobes in 13 cases. Diaphragmatic penetration of tumor cells was microscopically observed in 10 out of 13 cases examined. In areas where changes of lymphangiosis were prominent, alveolar walls showed fibrous thickening in 16 cases and edematous thickening (13), and alveolar ducts were accompanied by hyaline membrane (4).
Macroscopic and microscopic spreading patterns of lymphangiosis in lungs could be classified into four types; subpleural, hilo-bronchial, mixed and intrapulmonary types. The subpleural type in 12 cases showed a spreading pattern mainly in the pleura and subpleural region. The hilo-bronchial type in 4 cases showed a spreading pattern along bronchial trees from metastatic hilar lymph nodes. The mixed type in 15 cases had a spreading pattern of both subpleural and hilo-bronchial types. The intrapulmonary type in 2 cases had a pattern of intrapulmonary spread with neither hilar nodal metastasis nor pleural involvement.
The duration from the onset of respiratory symptoms to death was shorter in cases of the subpleural type than in those of the hilo-bronchial type. The ratio of respiratory failure in the causes of death was 80% of the cases of the mixed type, and occupied 50% of cases of other types. Pleural and subpleural lymphangiosis was prominent in the cases of subpleural and mixed types. Alveolar changes were more frequent in the cases of the mixed type than those of other types. The diaphragmatic penetration was more common in the subpleural (6 out of 7 cases; 86%) and mixed types (4 out of 4 cases; 100%) than in the hilo-bronchial and intrapulmonary types (0 out of 2 cases).

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The adherence of clinically isolated Pseudomonas aeruginosa to human buccal epithelial cells was studied in an invitro system. Buccal epithelial cells were collected for study from patients with primary lung cancer and malignant blood diseases, elderly patients and healthy adult controls.
Adherence of P. aeruginosa to buccal epithelial cells from healthy adult controls correlated to aging, especially those over 50 years old, who demonstrated significantly increased adherence.
Postoperative by under general anesthesia, P. aeruginosa adhered the most significantly to buccal cells one day after the operation, and its value decreased with time, and 3 days after the operaiton, it recovered to the same as that of the preoperative stage.
Adherence of P. aeruginosa to buccal epithelial cells from patients with lung cancer was not significantly different from control values. Neither the clinical stage nor the use of anticancer drugs was significantly associated with P. aeruginosa adherence.
Adherence of P. aeruginosa to buccal epithelial cells from patients with blood diseases was similar to that with lung cancer. In elderly patients, P. aeruginosa adhered to huccal cells from those treated with artificial feedings twice as much as those with oral feeding.
From these results, it is considered that aging, operative damage, and poor nutrition are important factors affecting the adherence of P. aeruginosa to buccal epithelial cells.

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Humoral and cellular components of bronchoalveolar lavage fluid (ABLF) were examined in atopic asthmatics, by bronchoalveolar lavage. IgE concentration in BALF was higher in atopic asthma cases compared to non-atopic asthma cases, but the difference was not significant. Histamine concentration in BALF was significantly higher in atopic asthma than in non-atopic asthma. Arylsulfactase concentration in the BALF of atopic asthmatics was significantly higher and a correlation between concentration of arylsulfatase and frequency of eosinophils in BALF was observed in atopic asthmatics, but not in non-atopic asthmatics. A significant increase in eosinophil counts in BALF was shown in atopic asthmatics. Eosinophil and neutrophil counts in BALF were more significantly increased in asthmatics, compared to those in healthy subjects.

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Twenty-four positive cases of pleural plaque, were detected on chest X-ray, in the outpatient clinic of the department internal medicine in Kure Kyosai Hospital. However fibrous changes in the lung field were uncommon. Therefore we considered cases exposed to a low dose of asbestos. nineteen of these 24 cases had occupational histories in Japanese naval shipyard and other shipyards. Five other cases also had histories of asbestos exposure. Pleural plaque on the chest X-ray appeared after more than 40 years from the first exposure and the average duration of asbestos exposure was more than 20 years. Cases with calcification had longer intervals after the first exposure and longer duration of asbestos exposure than those without calcification.
Two of 24 cases were complicated by collagen diseases such as rheumatoid arthritis and progressive systemic sclerosis. There fore, the immune competence of 24 cases was also examined. Subsets of lymphocytes, such as CD3 and CD4 decreased, and CD4/8 as an index of immunity also decreased in cases with calcification than in those without calcification. We suggest that a low dose of asbestos exposure might reduce the immune competence.

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In order to investigate the relationship between pulmonary function and disease of the respiratory bronchioles (RB), we measured airway diameter and quantitated airway pathology scores in RB in 35 patients who required surgery for removal of a solitary nodule. The patients had FEV₁ greater than 80% of the predicted value. Measurements of FEV₁, nitrogen washout curve (ΔN₂/L), closing volume as a percentage of vital capacity(CV/VC%), and maximal flow rate at 50% of VC (V₅₀) were made prior to surgery. There were 21 smokers and 14 nonsmokers. There was 0.74 RB per cm² of tissue. The mean internal RB diameter was 0.48±0.10mm. The total pathology scores for all RB were less than those found in North American populations. Inflammation scores were higher in patients with FEV₁ less than 100% predicted (p<0.05). FEV₁ values correlated with fibrosis (p<0.05), pigmentation (p<0.05), and intraluminal macrophages (p<0.05). Tests specific for small airways did not correlate with the pathology scores in RB.
In conclusion, in 35 Japanese patients, some diseases in RB were detected in cases whose average age was 59.5 years (42-78yrs) and FEV₁ was greater than 80% of the predicted value. However, the diseases appeared to be affected little by smoking and changes were relatively minor in comparison with cases in North America. This degree of abnormality was considered to be also found in normal Japanese. Finally, it was supposed that an ordinary pulmonary function test would not reveal the abnormality in RB that we detected.

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Lysozyme levels in pleural fluid were determined in 77 patients with pleural effusions of various causes: 1) 19 tuberculous cases; 2) 22 carcinomatous; 3) 16 metastatic; 4) 3 parapneumonic; 5) 9 with transudates; 6) 3 with empyemas; and 7) 5 miscellaneous. Mean lysozyme levels of pleural fluid were 1) 26.9±10.7, 2) 7.2±2.4, 3) 12.3±9.4, 4) 14.6±9.5, 5) 9.2±8.8, 6) 22.8±13.9, and 7) 10.6±4.7μg/ml, respectively. The lysozyme level in pleural fluid in tuberculous pleurisy was significantly higher compared with that in carcinomatous, metastatic, parapneumonic and transudative effusion (p<0.001, p<0.001, p<0.05, p<0.001). Similarly serum lysozyme values in tuberculous pleurisy were significantly raised compared with that in carcinomatous pleurisy (p<0.001). Ninety-four percent of patients with tuberculous pleurisy showed a ratio of the lysozyme level of pleural fluid over the serum level of lysozyme (PL/SL) of 1.0 or more. PL/SL in tuberculous pleuritis was meaningfully increased compared with that in carcinomatous, metastatic and transudative effusion (p<0.01, p<0.01, p<0.001). When a PL/SL value of 1.2 is considered, the sensitivity, specificity and diagnostic accuracy were 88%, 89% and 89%, respectively, except for empyemas. All these results suggested that the measurement of lysozyme level in pleural fluid, alone or in combination with that in serum, will be of great value in the differentiation of tuberculous from other causes of pleurisy, especially from carcinomatous effusion.

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Unilateral diaphragm pacing (DP), applied to three patients with central alveolar hypoventilation syndrome (CAH), was effective in improving nocturnal respiratory status for periods of 6 months to 32 months. In one case who died following 32 months DP therapy, no microscopic morphological changes of the phrenic nerve were noted. Although clinical applications of DP have been rarely reported in Japan, long term DP therapy is considered to be useful for ventilatory support in CAH patients.
Some problems concerning diagnosis or DP therapy in CAH patients, such as polysomnographic recording, upper airway obstruciton, neuromuscular fatigue of the diaphragm, respiratory monitoring and tracheostomy, are discussed in this paper.

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Diffuse panbronchiolitis (DPB) is a disease with chronic inflammation located in respiratory bronchiolis lesions, and most DPB patients are distributed in Japan. It is difficult to cure DPB, and these patients are always subject to repeated bacterial infections. The main therapy has been antibacterial drugs against these infections. Recently, however, the efficacy of long term therapy with a low dose of erythromcin (EM) has been reported. Despite the fact that clinical signs are markedly improved, its mechanisms have not been clearly established. In this report, we studied the effects of this therapy on the peripheral blood leukocyte functions.
The objects were 8 patients (6 males and 2 females) who had been diagnosed as DPB from clinical symptoms and histories, chest X-ray findings, and lung function tests. They received 300mg/day of EM for 2 months, and venous blood was sampled before and after this therapy. Blood leukocytes were separated into polymorphonuclear cells (PMN) and mononuclear cells using the density gradient method with Ficoll. We assessed the activities of adhesion to the plastic plate, superoxide generation, cytostasis against tumor cells, and chemotaxis as PMN functions, and the activities of an interleukin-1 and fibroblast growth factors generation as monocyte functions, TB ratio and OKT series as lymphocyte functions.
Therapy for two months did not cause remarkable changes in clinical signs except in vital capacity. However, the most leukocyte functions normalized.
It was reported that the effectiveness of this therapy was observed after at least 3 months. Our data suggested the possibility that firstly EM would affect the blood leukocyte functions, and after that clinical signs improved. It was considered that EM Can normalize such immunological impairments of DPB and Can be an effective therapeutic agent against DPB.

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Two cases, a 52-year-old female patient with Sjögren's syndrome and progressive systemic sclerosis and a 33-year-old female patient with Sjögren's syndrome were admitted because of dyspnea on exertion and were found to have hypoxemia and obstructive respiratory disturbances. On respiratory function tests, both patients were found to have obstructive disturbances which partially responded to bronchodilators. Diffusing capacities were normal for both patients, and neither had episodes of paroxysmal dyspnea. Thus, both patients are unlikely to have had emphysema or bronchial asthma. Some other inflammatory airway diseases were thought to be behind the respiratory disturbances. There were no definite pathological findings on histological specimens. Both patients were treated with corticosteroids and bronchodilators, with little improvement.
Most lung involvements associated with collagen vascular diseases are reported to be interstitial lung diseases, leading to restrictive respiratory disturbances. Recently, however, there have been several reports of collagen disease-associated obstructive lung diseases, most notably rheumatoid arthritis-associated bronchiolitis obliterans. Although few reports make comments on their prognosis, most of them indicate ominous courses. However, our two patients have been able to lead normal lives for 7 to 8 years, despite their nonresponsiveness to therapeutic attempts. Thus, more study on the prognosis of this pathological process is needed, together with its pathophysiology, because most of the currently available diagnostic procedures have failed to pinpoint the responsible region.

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A 49-year-old man was admitted with complaints of fever and diarrhea. Biochemical findings on admission showed increased acute phase reactants and elevated alkaline phosphatase, LAP and γ-GTP. Extensive laboratory studies and radiologic examinations yielded no new information concerning the elevated ALP, LAP and γ-GTP. Chest X-ray films and chest CT scans showed a tumor posterior to the left pulmonary artery in the mediastinum. By the 20th hospital day diarrhea disappeared. Left pneumonectomy was performed because the tumor could not be separated from the left pulmonary artery. The mediastinal lymph nodes were excised. The histopathological diagnosis of the tumor was a primary malignant fibrous histiocytoma in the mediastinum. After operation this patient became afebrile and the levels of ALP, LAP and γGTP decreased, suggesting that their elevations originated from drug-induced liver injury combined with cholangitis of unknown cause.
This is a report of a rare case of primary malignant fibrous histiocytoma in the mediastinum with fever.

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A 65-year-old woman was referred to our hospital because of bilateral pleural effusion on chest X-ray. Lower abdominal tumor was palpable on physical examination and the titer of CA125 in serum (1793U/ml) and pleural effusion (1815U/ml) was increased. MRI showed ascites and intra-pelvic tumor. Abdominal total hysterectomy and bilateral salpingo-oophorectomy was performed. Histological examination of the resected specimen revealed ovarian thecoma and the titer of CA125 in ascites collected during operation was also increased (638U/ml). Two weeks after the operation, chest roentgenogram demonstrated no pleural effusion, and the disease was diagnosed as true Meigs' syndrome with ovarian thecoma.

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A 57-year-old patient was admitted to Iwamizawa Rosai Hospital, because of back pain, right hypochondralgia and body weight loss. Chest X-ray revealed multiple, thin-walled cavities in both lung fields. Diagnosis of adenocarcinoma of unknown primary origin was made by open lung biopsy. He died of respiratory failure, in spite of treatment, including chemotherapy. At autopsy, cancer of the body of the pancreas was found, the histology of which was mucinous adenocarcinoma, and the multiple cavitary lesions were metastatic from the pancreas carcinoma. The pathology of the cavitary wall of the lungs revealed a mucin-producing carcinoma cell layer. The cavities were dilated spaces composed of alveolar sacs, alveolar ducts and terminal bronchiole, containing air and mucin inside. Various mechanisms of cavity formation of this case were speculated. Bacause of no necrotic mass in the abnormal air space, no evidence of tissue destruction, and rapid changes of its diameter, it was thought that the cavitary shadows were formed by check valve mechanisms.

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A case of mediastinal cystic lymphangioma with niveau formation is reported. An 18-year-old man visited a hospital because of right anterior chest pain and back pain. The chest X-ray film showed a mass-like shadow with niveau formation in the right mediastinum. He was admitted to our hospital on Jan. 8 1987. Bronchography and esophagography showed no communication between the mass and the bronchus or esophagus. It was unclear why niveau was formed in the mass. Mediastinal cystic lesion was suspected, and right thoracotomy was performed. A large multilocular, thin walled cystic structure was present in the right anterior and middle mediastinum. It extended from just above the subclavian artery to the diaphragm. Histological examination showed that the cyst wall consisted of fibrous tissue and smooth muscle fiber and that the cysts were lined by endothelium. It was thought that these findings suggested cystic lymphangioma.

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A case of posterior mediastinal primary myelolipoma was reported. The patient was a 63-year-old male, complaining of chest compression, with a history of tuberculosis, cystic kidney, hypertension and diabetes mellitus. There was no evidence of anemia. Chest X-ray film showed a right posterior mediastinal mass. On computerized tomogram the mass was located in the right paravertebral lower mediastinum. The density of the mass varied, ranging a CT-number of -26 to 36. Right thoracotomy was performed. The tumor was well encapsulate dand soft in consistency. It was easily resected and the size was 32×30×8mm. The patient's potoperative course was uneventful. Microscopically the tumor was composed of fat cells and mature bone marrow cells including normoblastic, granulocytic and megakaryocytic series. This case was diagnosed as primary myelolipoma because of no evidence of hematopoietic stimuli which brought about extramedullary hematopoiesis, namely secondary myelolipoma. Although primary myelolipoma of mediastinum is very rare, knowledge of this tumor is important for the differential diagnosis of mediastinal tumors.

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