Centriacinar emphysema (CAE) is in principle defined and diagnosed pathologically. However, recently, computed tomography (CT) has been advocated in the diagnosis of emphysema because of the high degree of anatomic details it can provide. In order to assess the reliability and detectionability of CT in CAE detection, as well as evaluation of the severity, a CT-pathologic correlative study of CAE was performed.
To study direct one-to-one CT (in vivo)-pathologic correlation, 20 lung lobes with CAE from autopsies and resections were inflated and fixed by the method of Heitzman et al and then sectioned along the plane equivalent to the CT images. The degree of CAE was graded pathologically by the point-counting method. The CT scans were assessed visually for low-attenuation areas by 3 independent physicians.
A significant correlation was found between the CT and pathologic scores of the studied lobes (r=0.94). Detectionability of CAE on lung slices by CT were 74%, 91%, and 100% for mild, moderate, and severe cases respectively. The smallest size of the diameter of emphysematous spaces which could be detected by CT with 10mm collimation was 3-4mm.
We concluded that CT extremely useful in assessing the extent of CAE, however there are limitation in the diagnosis of mild cases. Moreover, visual scoring of low-attenuation areas on CT images was found to be clinically useful in the quantitative evaluation of CAE.

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The X-ray CT findings of two cases of pulmonary lymphangioleiomyomatosis were reported. The correletion between high-resolution CT findings and inflated biopsy specimens was studied. The X-ray CT findings are 1) multiple low attenuation areas, 2) diffuse areas of slightly increased density and 3) irregular enlargement of pulmonary vascular images.
Each low attenuation area turned out to correspond to emphysematous lesions. Slightly increased densities on CT images seemed to be caused by a summation of many small nodules of a proliferation of smooth muscle cells located in the wal of respiratory broncioles and alveolar ducts, with or without intraalveolar hemosiderosis. Some nodular lesions in bronchiolar walls were so close to neighboring vessels that they could not be separated from vascular images on CT, so peripheral vascular images were irregulary thickened. X-ray CT reflected more actual pathological findings than routine chest radiographs.
As low attenuation areas on CT images have been reported to be representive of pulmonary emphysema, it is thought that the above CT findings must be differentiated from those of pulmonary emphysema. While pulmonary vascular images were thin and stretched on the CT in patients with emphysema, they were irreguarly thickned on the CT of patients with LAM. Furthermore, while CT of emphysema often revealed overinflation or decreased density, diffuse areas of slightly increased density were never found in emphysema.

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Recent studies have shown that nasal CPAP is very effective in the treatment of patients with obstructive sleep apnea syndrome (OSA). To clarify the characteristics of pulmonary function testing and to evaluate the effect of short term nasal CPAP therapy in 13 cases of OSA patients, nasal CPAP was used for 10 to 14 days and polysomnography was performed on two consecutive nights without nasal CPAP and at one night with nasal CPAP. Pulmonary function tests and the Uchida-Kraepelin test were performed before the initiation of nasal CPAP therapy and also 7 to 14 days after the nasal CPAP therapy. Apnea index reduced significantly in all cases from 51.0±19.6 episodes/hour without therapy to 3.1±3.5 with nasal CPAP (p<0.001). Nasal CPAP significantly reduced the frequency of obstructive (p<0.001) and mixed apnea (p<0.01), but the frequency of central apnea did not change with nasal CPAP. During the nasal CPAP, mean nadir SaO₂ rose from 87.3±2.9% to 92.7±1.1% (p<0.001) and the lowest SaO₂ rose from 73.3±6.4% to 92.0±2.1% (p<0.001). Before the nasal CPAP therapy, daytime PaO₂ was 80.6±6.4 Torr and closing capacity (CC)/FRC ratio was higher when patients were in a supine than in a sitting position. After short term nasal CPAP therapy, daytime PaO₂ increased significantly (p<0.001), and FRC/TLC in a supine position increased and CC/FRC in a supine position decreased in some patients. It can be postulated that the increase in daytime PaO₂ associated with short term nasal CPAP therapy can be attributed, at least in part, to an increase in FRC and also to the reduction of CC/FRC. The Uchida-Kraepelin test revealed significant increment of average result after short term treatment of nasal CPAP (p<0.001). We conclude that nasal CPAP therapy during sleep is an effective and non invasive therapy for patients of OSA, and may lead to rapid recovery of mental function after short term treatment.

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Lymph nodes obtained from 19 patients with sarcoidosis were classified into four groups according to their histological maturation stages, which were the early stage, the former mature stage, the late mature stage and the healing stage. Immunohistochemical analsyis of CD4 positive cells and CD8 positive cells were performed using monoclonal antibodies to these lymph nodes. Then the number of the positive cells per square millimeters of a granuloma was estimated using a computerized analytic system for light microscopic figures. The number of CD4-positive cells per square millimeter of a granuloma was almost constant from the early stage to the mature stage, but inclined to decrease in the healing stage; on the other hand, the number of CD8-positive cells per square millimeter of granuloma decreased extremely in the mature stage, compared with the early stage and the healing stage. Moreover the CD4/CD8-positive cell ratio in granulomas, calculated from these data, was elevated in the mature stage, compared with the early and the healing stages. From the above results, the CD4/CD8-positive cell ratio in a granuloma was demonstrated to be a valuable index for evaluating the histological activity of the granuloma of sarcoid lymph nodes. Furthermore, the decrease of CD8-positive cells in mature stage granuloma was considered to be related to the maturation of the epithelioid cell granulomas in sarcoidosis.

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To evaluate acute lung injuries and their persistence in patients with summer-type hypersensitivity pneumonitis, repeated bronchoalveolar lavage (BAL) and pulmonary function tests were performed. BAL was performed on 36 occasions in 17 patients with hypersensitivity pneumonitis. Nineteen BAL procedures in 16 cases were done during the active phase within the three hospital day and BAL was repeated in 8 cases during inactive phase. Anti-Trichosporon cutaneum antibodies were detected in all of 15 cases examined using the Ouchterlony method and indirect immunofluorescent methods.
The number of total BAL cells, lymphocyte and neutrophils were increased in the active phase, and OKT4/OKT8 was quite low (0.39). As the disease became inactive, the number of total BAL cells, lymphocytes and neutrophils decreased. On the other hand OKT4/OKT8 increased quickly. Significantly negative correlations were recognized between the number of BAL lymphocytes and %VC, and lymphocytes and %DL_CO4. More improvements in BAL findings, %VC and %DL_CO one year after acute episodes were seen in cases that moved house than cases that did not move, and these often relapsed.
We concluded that complete clearing of the patient's house or moving out, if necessary, were needed to avoid relapse and persistent lung injuries.

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Alveolar macrophage (AM) function was investigated in 4 cases of pulmonary alveolar proteinosis (PAP). Therapeutic bronchoalveolar lavage (BAL) with a flexible bronchofiberscope was done 7-13 times during periods of 4-24 weeks.
In the initial BAL, the total cell count was only 0.18-0.92×10⁵/ml. Also low AM, lymphocytosis and eosinophilia values were noted.
The phagocytic activity of AM was only 3-14% and nitroblue tetrazonium (NBT) reduction of AM was under 5% before therapeutic BAL. However, the phagocytic activity was from 25-63% and NBT reduction from 15-35% after therapeutic BAL, AM function with periods of remission of PAP was normal but AM function decreased during relapse and exacerbation of PAP.
After therapeutic BAL, two patients have been in remission for three years, one patient with incomplete restoration of AM function relapsed after one year, and one patient without restoration of AM function showed further deterioration after developing pulmonary tubeculosis.
These findigns indicate that the defect in AM function found in PAP is revesible with therapeutic BAL, and that the severity of PAP is closely associated with AM function.

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Hypergammaglobulinemia is a frequent complication of tuberculosis. Serum levels of each class of immunoglobulin were analyzed among tuberculosis patients. Adult patients had high levels of IgG and IgA, but IgM levels were not elevated. These data suggested that antibody responses to mycobacterial antigens might be influenced by individual immune responses.
In order to analyze the specific antibody responses to mycobacterial antigens, IgG class antibodies reactive with BCG proteins were enumerated by an enzyme-linked immunosorbent assay (ELISA). Patients were shown to have significantly higher a mount of IgG antibodies than healthy controls. Sera from patients with active tuberculosis had high consistently titers of antibodies. Antibody titers returned to a normal range after effective treatment, suggesting that the measurement of IgG anti-BCG antibodies would be useful for the diagnosis and follow-up of tuberculosis.
In addition, serum antibody profiles were analyzed by immunoblotting. Sonicated whole BCG proteins were electrophorased and transferred to nylon sheets by Western blotting.
Then the sheets were developed with sera from patients or controls. Mycobacterial cell wall contains a vast array of proteins so that comparison of the antibody profiles from different sera revealed striking individual variations. However two kinds of proteins, whose molecular sizes were 65KDa and 16KDa, were considered to be significant.
The 65KDa protein was recognized in most sera from both patients and controls. The protein may be related to a “common antigen” present in a wide variety of bacteria. These observations may shed a new light on the role of 65KDa protein in the regulation of the immune systems, for example a individual highly primed to 65KDa protein may amount an exaggerated and potentially harmful response to cross-reactive antigens from other essentially non-pathogenic bacteria.
Antibodies to 16KDa protein were detected significantly more often in sera from tuberculosis patients than those from controls, which suggested that 16KDa protein might be relatively unique in tuberculosis. Although more detailed studies are still necessary concerning 16KDa protein, it is suspected that antibodies to 16KDa protein have a potentially diagnostic value for tuberculosis and it is necessary to develop a component-vaccine.

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Forty-two lung cancer patients with COPD (7.9% of 534 lung cancers), and 84 age- and sex-ratio-matched controls who were randomly selected from lung cancer patients without COPD were examined. Lung cancers with COPD consisted of 25 cases of squamous cell carcinoma (59.5%), 11 of adenocarcinoma (26.2%), 2 of small-cell carcinoma (4.8%), and 4 of large-cell carcinoma (9.5%). Squamous cell carcinoma occurred more in patients with COPD than in controls (35.7%) (p<0.01). In squamous cell tumors with COPD, 12 cases (48.0%) were centrally located and 13 cases (52.0%) were peripherally located. Squamous cell carcinoma of peripheral origin occurred more in patients with predominant emphysema (76.9%) than controls (36.7%) (p<0.05). Our results suggest that the COPD patients with predominant emphysema may be at greater risk for squamous cell tumors of peripheral origin.

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The respiratory burst of murine alveolar macrophages (AM) was compared with that of peritoneal macrophages (PM). Superoxide anion (O₂^-) released from resident AM was similar to that of resident PM. That is, resident AM or PM exposed to phorbol myristate acetate (PMA) released only a small amount of O₂^-, whereas both macrophages released a large amount of O₂^- when stimulated with zymosan particles. AM as well as PM obtained from mice injected with Mycobacterium bovis BCG 3 weeks previously (abbreviated to BCG-AM and BCG-PM, respectively) showed an enhanced killing actibity to Candida parapsilosis. O₂^- release of BCG-AM stimulated with zymosan was similer to that of BCG-PM. In both BCG-AM and BCG-PM, maximal O₂^- response was obtained by stimulation with a lower concentration of zymosan than the concentration which required for resident macrophages to release maximal amount of O₂^-. There was however, a remarkable difference between the ability of BCG-AM and BCG-PM to release O₂^- when stimulated with PMA. Markedly enhanced O₂^- release of BCG-PM was observed. In contrast, O₂^- release of BCG-AM exposed to PMA was almost the same as that of resident AM. Hydrogen peroxide release of BCG-AM, when stimulated with PMA or zymosan, was compatible with O₂^- release. Isoquinolinylsulfonyl piperadine (H-7), an inhibitor of protein kinase C, inhibited O₂^- release of PMA-stimulated BCG-AM and BCG-PM in a dose-dependent manner and the extent of inhibition was greater in O₂^- release of PM than that of AM. Superoxide anion release in response to zymosan was slightly inhibited by H-7. Dioctanoyl glycerol (DOG), a synthetic diacylglycerol, elicited a larger amount of O₂^- release from BCG-PM than that of resident PM, whereas O₂^- release of BCG-AM was no more than that of resident AM. These findings indicate that reactive oxygen intermediates (ROI) generation of AM differs significantly depending on the stimulant employed and O₂^- response to PMA does not always correlate with the activation state of AM. Furthermore, these results suggest that more than two signal transduction pathways for the O₂^--forming enzyme system may be present, and the activity of transduction pathway through protein kinase C might be low in murine AM. Since surfactant is an important environmental factor within the alveolar space, effect on O₂^- release of AM was examined. Surfacten was purified from bovine alveolar lining material. When BCG-AM were incubated with various concentrations of surfacten, O₂^- release of AM stimulated with PMA or zymosan was suppressed depending on the concentration of surfacten. Such inhibitory effect was greater in macrophages stimulated with PMA than with zymosan. Murine AM did not release a large amount of ROI to all stimuli, and even when activated, their responses were not enhanced uniformly. Taken together, such characteristics might release to a kind of host defense that protects lung tissue from possible delecterious effects of ROI.

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Thirty seven patients with sarcoidosis were examined using ultrasound (US) to determine the size of the spleen. A Spleen Index (SI) was employed to evaluate splenomegaly and the SI was calculated using long (a) and short (b) dimensions on the sectional splenotomogram (SI=a×b). In 21 (57%) of these patients the spleen was judged ultrasonographically to be enlarged (SI 30), but in only 3 was it palpable.
The clinical records of patients with and without splenomegaly dectected by US were compared. There were no differences between patients with or without splenomegaly in hematologic findings (peripheral blood and bone marrow) or blood chemistry; furthermore no patients with hypersplenism were seen. In immunological parameters, the serum immunosuppressive acid protein level was significantly (p<0.05) higher in patients with splenomegaly than in those without splenomegaly; however, there were no differences in serum angiotenisn converting enzyme activity, serum lysozyme level, PPD skin test or bronchoalveolar lavage fluid analysis. The patients with splenomegaly had significantly higher evidence of increased uptake of 67-Gallium in lung fields and positive lung infiltrates in chest X-ray than those without splenomegaly (p<0.01, p<0.05).
These data suggest that ultrasound is a promising diagnostic tool for the assessment of the size of the spleen and is useful to detect disease activity and extent of disease in sarcoidosis. Patients with sarcoidosis who had splenomegaly had more disseminated disease, especially pulmonary parenchymal disease, than did those without splenomegaly.

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We report 2 patients with Bird breeder's lung associated with keeping budgerigars. Patient 1 kept a budgerigar indoors for 13 years. Histological examination revealed fibrosis and granulomatous changes in the alveolar septa. Among T lymphocyte subsets in BALF, helper T cell were increased. In the serum, precipitating antibodies to budgerigar dropping extract were observed. Patient 2 had kept Budgerigar for 7 months. Histologically, alveolitis was the primary finding, and suppressor T cell in the BALF were increased. Precipitating antibodies to budgerigar dropping extract was observed only in the BALF but not in serum. In patient 1 who showed a chronic course and granuloma formation, helper T cell in the BALF were increased while in patient 2 who showed an acute course and alveolitis, suppressor T cell in the BALF were increased, and precipitating antibody was observed only in the BALF. These findings suggest that T lymphocyte subsets in the BALF differ depending on the stage of hypersensitivity pneumonitis, and specific local antibody production precedes systemic antibody production.

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A 54-year-old woman, who had received left radical mastectomy 12 years previously, was admitted with persistent cough and hemoptysis.
Plain chest X-ray film showed no abnormality but fiberoptic bronchoscopy revealed that a polypoid lesion occluded the right truncus intermeding and the surrounding bronchial mucosa was firm and edematous. Biopsy specimen demonstrated adenocarcinoma. Right middle and lower sleeve bilobectomy was performed. The tumor occupied mainly the outer and submucosal layer of the bronchial wall. Histologically, this tumor showed scirrhous adenocarcinoma with the same pathologic appearance as the primary breast lesion.
It is considered that endobronchial metastasis from breast carcinoma is not particularly uncommon, therefore any patient with a past history of breast cancer and respiratory symptoms should undergo fiberoptic bronchoscopy, particularly when the chest X-ray is normal or shows non-specific changes.

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A 23-year-man with morbid obesity and obstructive sleep apnea syndrome (OSAS) was admitted. he was 170cm in height and 170kg in weight. He underwent dietary treatment several times, but his weight returned to its original level, or even higher, within a short period. A diagnosis of OSAS was made by nocturnal polysomnography.
In this morbidly obese patient with OSAS a nocturnal sleep apnea study was performed before and after weight reduction surgery (gastric restriction). The postoperative findings revealed a dramatic body weight reduction. At the same time, the results of apnea and oxygen desaturation were remarkably improved too.
These results indicate that weight reduction surgery is a definitely effective treatment for morbid obesity associated with OSAS.

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A case of peripheral adenoid cystic carcinoma in a 70-year-old woman is presented. She had a coin lesion in the left upper lung field on chest X-ray film. Before one month on admission to our hospital, she noticed a tumor in the left thigh and underwent simple resection. Histological diagnosis was liposarcoma. Lung metastasis of the liposarcoma or primary lung cancer were suspected. Lung wedge resection was performed and adenoid cystic carcinoma was diagnosed. Generally adenoid cystic carcinoma originates from bronchial gland, arising in the trachea or main bronchus. In this case, the tumor originated from the peripheral lung field.

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A 18-year-old female complained of a dyspneic sensation and involuntary movements in the epigastrium. On physical examination, fine rhythmic movements in the epigastrium were observed on each inspiration with a rate of 5-10per breath. Arterial blood gas analysis was normal. Recording of the respiratory parameters and the EMG of respiratory muscles were performed. Analysis of the respiratory flow revealed that her spontaneous inspirations consisted of short inspirations (i. e., flutter wave) (150-170 beats per minute). EMG of respiratory muscles demonstrated that these flutter waves were driven by intercostal muscles and diaphragm. The flutter waves were not suppressed by breath holding at the maximal inspiration. With intravenous injection of 200mg of diphenylhydantoin, flutter waves disappeared within 10 minutes. There were no abnormal findings on chest roentgenogram, electrocardiogram, head CT scan and MRI of the cervical spine. During one year's follow up no attack developed again. We have encountered 3 cases of the syndrome since 1981. In two of them, the spontaneous respiration was superimposed on a high-frequency wave throughout the whole respiratory cycle while in one case the high-frequency wave developed only in the inspiratory phase of spontaneous respiration. In the present case the respiratory flow pattern was similar to the last mentioned and the EMG-analysis of respiratory muscles confirmed that the flutter waves were driven by intercostal muscles and diaphragm. Furthermore, synchronization of activities of the two respiratory muscles suggests that the syndrome is of central origin.

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Two cases of human chorionic gonadotropin (HCG)-producing lung carcinoma are reported. Both were male, aged 66 and 65, respectively histological examination of percutaneous lung biopsy revealed large cell carcinoma. The patients both developed bilateral gynecomastia during their clinical course. Endocrine function tests demonstrated high levels of HCG, HCG-β, luteinizing hormone, estrone, estrdiol, progesterone in the blood. They were given only anticancer chemotherapy with no effect and died. Autopsy revealed extensive metastases of lung cancer and the presence of HCG in tumor cells was demonstrated by immunohistochemical technique in both cases.

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A 43-year-old woman was admitted to our hospital because of fever and dyspnea. She had facial rash, hair-loss, arthralgia, urinary casts, thrombocytopenia, lymphocytopenia, and deposits of IgG, IgM, C3 in the epidermis. SLE was diagnosed. She also had severe dyspnea, which gradually progressed. In spite of steroid pulse therapy and cyclophosphamide, she eventually died about two months after admission.
Chest X-ray film showed bilateral ground-glass shadow and volume-loss. High-resolution CT of the lung showed marked high density area with airbronchogram in the posterior part and a gradually enlarging slight high density area in the anterior area. Pathological findings of the posterior area were atelectasis and dense fibrosis. The findings of the anterior area were collapsed alveoli and dilated alveolar ducts. These findings might suggest that alveolar collapse play a major role in the course of pulmonary fibrosis of this patient.

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