We studied the effects of inhaled and intravenous furosemide (40mg) on bronchial responsiveness to acetylcholine (ACh) in patients with chronic congestive heart failure. The measurement of bronchial responsiveness was performed by inhaling doses of ACh and calculating the provocative concentration of ACh needed to cause a 20% fall in FEV_1.0 (PC20-ACh). Intravenous furosemide (N=11) had a marked diuretic effect (urine output 1014ml (SEM 156) in 2 hours), but had no effect on resting pulmonary function and PC20-ACh. In contrast, inhaled furosemide (N=10) had no effect on urine output and resting pulmonary function, but caused significant increase in PC20-ACh from 2.74 (GSEM 1.28) to 8.47 (GSEM 1.22)mg/ml (p<0.05).
We conclude that inhaled furosemide, but not intravenous furosemide reduces bronchial hyperresponsiveness to ACh in patients with chronic congestive heart failure. The mechanism of this effect appears to be related to the ion transport system of airway epithelium.

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The functional residual capacity (FRC) has been measured by gas dilution technique (GA) and body plethysmographic technique (BP) using the panting maneuver (PA). However, this maneuver is difficult to perform for patients who experience discomfort in breathing, and in cases of chronic obstructive pulmonary diseases, the FRC value measured by panting maneuver overestimates the true FRC value. Thus, in order to minimize these factors, we measured FRC during non-panting breathing (NP) using a BP device (BX-82, Minato Co., Osaka) and compared the results with the usual two methods. One hundred healthy subjects (Group I), 72 patients with restrictive ventilatory disorder (Group II, %VC=62.7%) and 66 patients with pulmonary emphysema (Group III, FEV_1.0%=44.9%) were studied. All measurements were performed under 0.5Hz respiratory frequency. The non-panting FRC measurement was performed by closing the mouth shutter of the BP for about 500 msec at the end of both the expiratory and inspiratory phase. From the box volume change and mouth pressure change, lisajous curves were formed and fitted by linear regression method. From this regression line, the volume of FRC was calculated. The obtained data had no significant differences among them, and there was a significant relationship between each technique. The correlation coefficient of non-panting breathing technique in Group III was slightly poor compared with the other techniques, and we therefore tried to re-classify Group III into small groups according to the severity of obstruction. It was subsequently found that this technique did not have the tendency to give a higher FRC value with increase in obstructive disorder. We believe that this method seems to reflect true FRC value and will be useful for patients with dyspnea and patients who cannot perform the panting maneuver skillfully.

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We examined, in 32 normal adults, the effect of hypoxia on the sensation of dyspnea during hypercapnic ventilatory response (HCVR). The tests were conducted under two different levels of inspiratory O₂ content, either hyperoxia (P_ETO₂>150Torr) or hypoxia (P_ETO₂ 50-55Torr), with simultaneous assessment of dyspnea sensation by visual analogue scaling (VAS). The sensation was evaluated either in relation to V_E standardized by predicted MVV (the slope of VAS-V_E regression line or VAS at V_E 40%) or in relation to P_ETCO₂ (the slope of VAS-P_ETCO₂ line or VAS at P_ETCO₂55Torr). Concomitant hypoxia significantly enhanced both the mean value of ΔV_E/ΔP_ETCO₂ and that ofΔP0.1/ΔP_ETCO₂. The sensation of dyspnea did not differ between the two conditions when it was evaluated in relation to ventilation, whereas it was markedly greater during hypoxic HCVR when it was evaluated in relation to P_ETCO₂. The hypoxic augmentation of the sensation, compared at P_ETCO₂ 55Torr, could be explained by increase of the motor output from the respiratory center, since it was positively correlated with the relative change of V_E, V_TT_I, and ΔP_0.1/ΔP_ETCO₂ (r=0.70, p<0.0001; r=0.63, p<0.0001; r=0.40, p<0.05, respectively). From these findings, we conclude that hypoxia does not have a direct dyspnogenic effect, at least in normal subjects.

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Pseudomonas cepacia is a gram negative rod, having no fermentative activity on glucose. This organism was detected in the sputum, throat swab, or throat washing of 22 inpatients treated between January, 1990, and December, 1990, at the First Department of Internal Medicine, Kagawa Medical School. The primary diseases for which these 22 patients were hospitalized were leukemia in 12, malignant lymphoma in 5, lung cancer in 2, myelodysplastic syndrome in 1, and embryonal cell carcinoma in 1. Twelve of the 22 patients had episodes of pneumonia which complied clinically with the diagnostic criteria provided to facilitate the National Nosocomial Infection Study. The complication of pneumonia occurred in 7 patients with leukemia, 2 with malignant lymphoma, 2 with lung cancer, and 1 with myelodysplastic syndrome. In 10 of these 12 patients, the organism was detected before the onset of pneumonia. All 22 patients in whom the organism was demonstrated had received antibiotics. The antibiotics which was most frequently used to treat these patients 1 month before detection of Pseudomonas cepacia were amikacin and cef tizoxime, which were used in 13 patients. Of the antibiotics in which the susceptibility to Pseudomonas cepacia was, evaluated, minocycline was effective in 100% (21/21), ceftazidime in 50% (11/22), and ofloxacin in 27.3% (6/22). Physicans should be especially aware of the possibility of colonization and nosocomial respiratory infection by Pseudomonas cepacia in patients with severe underlying diseases.

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This study was performed to investigate the mechanism by which ^99mTc-DTPA molecules pass through the pulmonary epithelium following inhalation of ^99mTc-DTPA aerosol. Interstitial pneumonitis was induced in 6-week-old male rats by instilling 1mg/kg of bleomycin into the trachea. Disappearance of radioactivity from the lungs was measured with a gamma camera every 2 weeks to estimate pulmonary epithelial permeability, and light- and electron-microscopic histopathologic examinations were performed at the same intervals.
There was a statistically significant increase in the pulmonary epithelial permeability at 2 weeks after the instillation of bleomycin. However, subsequent changes in pulmonary epithelial permeability were not uniform; some animals showed recovery and some showed further increase and/or partial recovery. Microscopically, increase in the capillary bed, round cell infiltration, and widening of the interstitial space were observed in addition to the presence of macrophages in the alveolar spaces at 2 weeks. Electron microscopic examination revealed vacuolization, thinning and detachment of the alveolar epithelium, and denudation of the basement membrane. Prominent fibrosis, honeycombing, thinning of the pulmonary epithelium, and increase in collagen fibers were observed after 18 weeks.
We consider that vacuolization, thinning, and detachment of the pulmonary epithelium and denudation of the basement membrane are related to the increase in pulmonary epithelial permeability in bleomycin-induced interstitial pneumonitis.

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Neutrophils which are isolated in the lung adhere to endothelial cells due to chemotactic factors, and release various proteases, superoxide anions and prostanoids in inflammatory processes. However, this host defense mechanism can cause tissue damage. Excessive adherent neutrophils are not always derived from lung injury. We have previously reported that an increase in cell density in human neutrophils attenuates superoxide anion generation by cell to cell communication (autoregulation). Autoregulation of the protein kinase c stimulator, phorbol myristate acetate, and also of the cell membrane receptor stimulator, N-formyl-methionyl-leucyl-phenyl-alanine was observed. The autoregulation was not related to the presence of extracellular Ca²⁺ not to a change of [Ca²⁺]i induced by stimulants.
These results suggest that neutrophils accumulated in the lung tissue have a built-in defense mechanism induced by membrane to membrane contact of neutrophils, which protects tissues from an excessive inflammatory response.

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In 11 autopsy cases of acute onset interstitial pneumonia of unknown etiology, all cases had thickening of alveolar septa with various degrees of lymphocytic infiltration and fibroblast proliferation. Only a few cases had edematous alveolar septa, which were weakly positive in alcian-blue staining. Intra-alveolar, intra-alveolar duct and intra-bronchiolar organization was a characteristic finding. These findings may represent the repair phase rather than the exudative phase of diffuse alveolar damage.
Localized bacterial pneumonia was superimposed in 3 cases, and neither Pneumocystis carinii nor viral inclusion bodies were identified in any case. The severity of fibrosis was not obviously correlated with the period of artificial ventilation. From these findings, terminal infection and oxygen therapy did not seem to significantly modify the course of acute-onset interstitial pneumonia.
Further examination of autopsy cases as well as open-lung biopsy is important to elucidate the time course of acute-onset interstitial pneumonia.

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Role of inspiratory muscle function in the genesis of dyspnea in COPD patients has yet to be fully studied. The present study investigated the possible relationship between respiratory muscle function and the sensation of dyspnea (modified Borg Scale) during exercise in eight patients with severe COPD (FEV₁ 0.61L±0.15L). The electrical activity of the diaphragm (EMGdi) was recorded with esophageal electrodes, and that of sternomastoid muscle (EMGsm) was recorded from the surface electrodes. The ratio of high frequency (150 to 350Hz) to low frequency (20 to 47Hz) power (H/L) of EMGdi and EMGsm was analyzed to assess inspiratory muscle fatigue, which was determined by a 20% fall of H/L ratio from the control value. Flow, volume, esophageal (Pes) and transdiaphragmatic pressure (Pdi) were measured. Tension time index (TTdi) was calculated from Pdi and the ratio of inspiratory time to total time for one cycle (T₁/T_TOT). At rest, we measured maximal esophageal pressure (Pesmax), maximal transdiaphragmatic pressure (Pdimax), maximal EMGdi (EMGdimax) and EMGsm (EMGsmmax). Progressive treadmill exercise test was performed, stating with 3 minutes' walk at a speed of 0.75mph at 0% grade, subsequently increasing the velocity at a rate of 0.25mph and the elevation at a rate of 4% per stage. Exercise was discontinued at maximum respiratory effort sensation. Six of the eight patients showed diaphragmatic fatigue at their maximal exercise.
With diaphragmatic fatigue, these patients were extremely dyspneic (Borg scale 9 or 10), and terminated the exercise. There were high correlations between the Borg scale and VE/MVV, and Pes/Pesmax and EMGsm/EMGsmmax, however, TTdi and EMGdi/EMGdimax showed less correlation with the Borg scale. These findings suggest that during treadmill exercise in COPD patients, the activity of the extradiaphragmatic ventilatory muscles is directly related to the severity of dyspnea.

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An attempt was made to interpret the clinical significance of secondary infections associated with lung cancer. The incidence of secondary infections was 51.4% in 214 in-patients with lung cancer in our institution in 1988 and 1989, and almost all of them had respiratory infections caused by commonly encountered bacteria. The incidence of infection was high in lung cancer of cell types other than adenocarcinoma, and in those with hypoalbuminemia, impaired cellular immunity and obstruction of the airway. The prognosis in patients with infection was much poorer than that in patients without infection. Major pathogens responsible for infection were Staphylococus aureus including methicillin-resistant S. aureus (MRSA), Haemophilus influenzae, Klebsiella spp. and Pseudomonas aeruginosa. These pathogens, except for H. influenzae, were isolated in the terminal stage in cases with airway obstruction and post cancer chemotherapy. The efficacy rate of 194 therapeutic regimens against infection was 57.7%. It was thus found that the efficacy rate in 1988 and 1989 exceeded that in the 1970s. The effectiveness was very poor for infections caused by S. aureus and P. aeruginosa, and for cases with airway obstruction and marked impairment of pulmonary blood flow. The efficacy rate of single-drug regimens was 57.1% (80/140) and that of combined regimens was 59.3% (32/54). The above results indicate that a new combined therapy which includes a β-lactam antibiotic as well as measures to improve the general health of compromised hosts are required in the treatment of secondary infections in these patients.

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In order to study the scintigraphic findings related to the pathophysiology of pulmonary aspergilloma, chest scintigraphy with Tl-201 chloride and perfusion lung scintigraphy were performed in 18 and 19 patients with pulmonary aspergilloma, respectively.
In Tl-201 scintigraphy, accumulation of Tl-201 in the diseased areas related to Aspergillus infection was observed in 18 of 19 foci. Roentgenographic findings related to the accumulation of Tl-201 in the lesion were thickness of the cavity wall and pleural thickening adjacent to the cavity, but they showed no relation to the size of the fungus ball, and 2 cases without fungus ball showed positive results. Moreover, in Tl-201 single photon emission computed tomography, accumulation of Tl-201 was demonstrated in the area surrounding fungus ball. In addition, findings of inflammation such as leukocytosis, elevated erythrocyte sedimentation rate, positive CRP and fever were observed in more than 50% of all cases. These results suggest that tissues surrounding the fungus ball, including the cavity wall and thickened pleura undergo inflammatory process secondary to infection by Aspergillus. Perfusion lung scintigrams showed decreased perfusion in all of 19 cases, which was more marked than that expected from the chest radiograph in many cases. In Tl-201 myocardial scintigraphy, visualization of the right ventricle was observed in 15 of 18 cases.
Tl-201 chest scintigraphy and perfusion lung scintigraphy are useful for evaluation of the activity of the disease process, right ventricular overloading, and regional perfusion in pulmonary aspergilloma.

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Resting energy expenditure (REE) and respiratory heat loss (RHL) were measured in 17 patients with chronic obstructive pulmonary disease (COPD), 7 patients with pulmonary fibrosis (PF), and 8 normal healthy subjects, three hours after a light breakfast.
Correlations between these values, and also predicted basal metabolic rate (PreBMR) and normalized lung functions were assessed. REE, REE/Pre BMR, RHL and RHL/REE in all patients increased significantly compared with those of control subjects. When all the studied subjects were combined, significant negative relationships were found between REE, REE/PreBMR, RHL and RHL/REE and percent predicted values of forced expiratory volume in one second (FEV_1.0), between RHL and RHL/REE and percent predicted values of vital capacity (VC), and between REE/PreBMR, RHL and RHL/REE and percent predicted values of carbon monoxide diffusing capacity (D_Lco).
These results indicate that resting energy expenditure and respiratory heat loss increase in patients with COPD and PF in association with even slight to moderate deterioration of lung function. Therefore, elevated resting energy expenditure and respiratory heat loss need to be taken into account in determining caloric and water requirements of these patients.

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The first nationwide survey of pediatric home mechanical ventilation (HMV) was conducted. From 35 out of 149 medical centers investigated, 49 cases of HVM were reported. The patients ranged in age from 1 to 20 years, and the causes of respiratory failure were neuromuscular diseases (51%), central hypoventilation (33%), respiratory disorders (10%) and cervical cord injury (6%). Since 1983 when 2 patients were discharged home on mechanical ventilation, more and more ventilator-dependent children have been sent home every year.
However, home mechanical ventilation is not yet well recognized in Japan as an option for pediatric patients with chronic respiratory failure, and there are many problems to be solved. Firstly, very few, if any, hospitals have a designated home care team composed of physicians and other specialists. Secondly, the current health insurance system scarcely covers the cost of home ventilation. Thirdly, development of home use equipment, in particular, portable ventilators and monitors is imperative.
There are 107 hospitalized patients in 56 institutions who are reportedly able to go home if a support system is established. A program for pediatric home mechanical ventilation should be urgently developed on a national basis.

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A 52-year-old man with pulmonary aspergilloma is reported. In immunoassays, type I, III and IV hypersensitivity reactions of Gell & Coombs were observed. The finding of such immunological reactions, especially type I hypersensitivity, has rarely been observed in this disease.
The present study was performed to investigate these reactions, especially to determine whether type I allergy participates in pulmonary aspergilloma. We reviewed 126 cases of pulmonary aspergilloma reported in the Japanese literature between January 1980 and April 1991. The following results were obtained: Elevation of serum IgE was observed in 49% of the subjects examined, positive IgE RAST score in 280, precipitating antibody against A. fumigatus in 79%, and positive lymphocyte stimulation test using A. fumigatus antigen in 68%.
In conculusion, type I, III and IV hypersensitivity of Gell & Coombs appears to participate in pulmonary aspergilloma. The occurrence of type I hypersensitivity is not rare in this disease.

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A case of Mycoplasma pneumoniae bronchiolitis with hypoxemia is presented. A 41-year-old man was admitted to hospital because of fever, productive cough and dyspnea with wheezing of one month duration. On admission, bronchial asthma was suspected on the basis of reversible airflow obstruction and sputum eosinophilia. However, despite treatment with bronchodilators, his condition did not improve. Chest film and computed tomogram revealed small nodular shadows and tramlines in the bilateral lower lung fields, and pulmonary function tests indicated peripheral airway obstruction. Serologic titer for Mycoplasma pneumoniae was 1:160. A diagnosis of bronchiolitis due to Mycoplasma pneumoniae was made. Improvement of lung function and roentgenographic findings was observed following administration of erythromycin and doxycycline. The concentrations of prostanoids in sputum were markedly higher than in cases of bronchial asthma, and decreased as he improved. These observations suggest that Mycoplasma bronchiolitis should be considered in the differential diagnosis of wheezing, and that measurement of prostanoids in sputum may be useful in the differentiation of infective bronchiolitis and bronchial asthma.

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Marked obstructive ventilatory impairment and diffusion disturbance were noted in two intravenous methylphenidate (Ritalin) abusers. In one patient, chest radiogram demonstrated pulmonary emphysema accompanied by bullae and atelectasis, and spontaneous pneumothorax was also present. The primary finding in the other patient was interstitial shadows. Both patients began to note dyspnea during exertion after about 10 years of use. Since radiography also disclosed pulmonary emphysema in an ex-companion of Ritalin abuse, and since the onset was at relatively young ages, these pulmonary disorders are considered to have been a result of intravenous Ritalin abuse.
Intravenous drug abuse should be considered in patients with precocious emphysema or obstructive ventilatory impairment accompanied by diffusion disturbance.

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A 44-year-old male was hospitalized due to dyspnea and persistent cough with copious sputum (about 100ml/day). Chest radiograph on admission showed hyperinflation and fine nodular shadows throughout both lungs, as well as a tram line appearance in the right lower lung field which suggested thickening of bronchial walls. Pulmonary function tests demonstrated moderate to severe reduction of %VC, FEV_1.0 and PaO₂. Fiberoptic bronchoscopy revealed inflammatory change in the walls of proximal bronchi. Although his dyspnea resolved rapidly, productive cough and impaired lung function were persistent and improved very slowly over the one-month-period following admission. After resolution, similar symptoms were provoked again 5 to 6 hours after returning to his home, suggesting the recurrence of hypersensitivity pneumonitis.
Open lung biopsy was performed for the differential diagnosis of hypersensitivity, diffuse panbronchiolitis, and bronchial asthma, because neither transbronchial lung biopsy nor broncho-alveolar lavage was diagnostic. Histopathology of the open lung biopsy specimens revealed marked desquamation of bronchiolar epithelium in addition to bronchiolo-alveolitis with epitheloid granulomas, consistent with hypersesitivity pneumonitis.
Copious sputum is a very uncommon clinical feature in hypersesitivity pneumonitis. We consider that the large volume of airway fluid was caused by epithelial ulceration of bronchioles and catarrhal bronchitis associated with hypresesitivity pneumonitis.

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A 70-year-old woman with diabetes mellitus who was following a therapeutic diet showed an infiltrative shadow in the right upper lung field on chest roentgenogram in April, 1986.
She was diagnosed as having pneumonia and was treated for five months with several antibiotics, but the abnormal shadow on chest roentgenograms increased in size. Therefore, she was admitted to our hospital in October 1986.
Although tubercle bacilli were not isolated from her sputum or from materials obtained by bronchoscopic examination, we made an initial diagnosis of pulmonary tuberculosis based on the findings of chest roentgenograms, tomographs and CT scanning.
In spite of treatment with antituberculous drugs, the infiltrative shadow with cavity on chest roentgenograms continued to increase in size, and the patient developed occasional hemoptysis.
Percutaneous needle biopsy was performed in February 1987 to establish a definite diagnosis, and the presence of Aspergillus fumigatus was confirmed by microscopic examination and culture.
After treatment with miconazole and 5-FC for 3 to 4 months, the abnormal shadow on the chest roentgenogram gradually disappeared and was almost undetectable one year later. The clinical course of this patient was considered to be strongly indicative of chronic necrotizing pulmonary aspergillosis, which was described by Binder et al. in 1982.

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A 78-year-old man was admitted to the Nishinomiya Municipal Central Hospital with main symptoms of chest pain and dyspnea. Chest CT revealed a large mediastinal mass shadow, and echocardiography revealed pericardial effusion. Serum LDH was elevated. Therefore, malignant lymphoma was suspected to be the cause of cardiac tamponade. VEPA chemotherapy was commenced. Half way through the course of chemotherapy, serum LDH was decreased, the pericardial effusion had disappeared, and the mediastinal mass was reduced in size. A biopsy specimen of the mediastinal tumor revealed malignant lymphoma of diffuse large cell type, and immunoperoxidase staining of frozen sections demonstrated B cell origin. The pericardial effusion had not increased in size after four months, when the patient developed pneumonia and died. Autopsy revealed pericardial and atrial involvement by tumor. In conclusion, this case is very unusual in that (1) pericardial involvement was suspected on admission; (2) the pericardial effusion disappeared with systemic chemotherapy; and (3) cardiac metastasis was demonstrated at autopsy.

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We report an autopsy case (27-year-old male) with Marfan syndrome, who died of chronic respiratory failure due to bronchiectasis and multiple bullae in both lungs. He had suffered from expectoration of massive amounts of sputum since the age of 15 years. At this time, chest roentgenogram had revealed bronchiectatic changes in the bilateral lower lung fields. Seven years later at the age of 22 years, the formation multiple bullae in both lungs were added to the bronchiectatic changes on chest roentgenogram. Administration of erythromycin (400mg/day) was started in February, 1987, and the massive sputum volume markedly decreased according to appearence of bullous formation. He was admitted to our department because of deterioration with chronic respiratory failure and right heart failure at 26 years in December, 1989. Although various therapy was performed, he died of chronic respiratory failure in February, 1990.
Autopsy findings were as follows: (1) cyclindrical bronchiectatic changes in bilateral lower lobes and (2) extensive multiple bullae in the subpleural areas with bronchiectatic changes in the middle and bilateral lower lobes, with no bronchiectatic changes in the bilateral upper lobes.
Several pulmonary disorders accompanying Marfan syndrome have been reported, especially in children. However, the present case demonstrated that fetal pulmonary involvement by Marfan syndrome may not present until adulthood, and affect both airways and lung parenchyma.

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A 20-year-old woman took 1.2g of acetaminophen for toothache. She subsequently developed a dry cough, pyrexia, and dyspnea. Chest X-ray revealed diffuse reticulo-nodular shadows in both lung fields. Broncho-alveolar lavage examination showed a marked increase in the total cell number and an increase in the percentage of eosinophils, neutrophils, and lymphocytes. Because drug-induced pneumonitis was suspected, all drugs were stopped and she was administered methylprednisolone. Consequently her symptoms resolved, and pulumonary function and chest X-ray findings improved remarkably. The lymphocyte stimulation test was positive for Norshin^® and its acetaminophen element. Based on these findings, the diagnosis of acetaminophen-induced pneumonitis was made. Acetaminophen intoxication is well-known, but to our knowledge this is the first reported case of acetaminophen-induced allergic pneumonitis in Japan.

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A 41-year-old male complaining of fever and left shoulder pain was admitted to our hospital for further examination of an abnormal shadow on chest X-ray film. His laboratory data on admission showed marked leukocytosis and elevation of serum alkaline phosphatase.
The diagnosis of large cell carcinoma of the lung was made by percutaneous biopsy and he was staged clinically as T3N0M0. Chemotherapy including CDDP and VDS resulted in resolution of symptoms and normal laboratory data. After three courses of chemotherapy, he underwent left upper lobectomy with chest wall resection. Pathological diagnosis of the resected tumor was large cell carcinoma with giant cells, and he was staged postoperatively as T3N0M0.
Since colony stimulating activity was demonstrated in both homogenate of tumor cells and tumor conditioned medium, and preoperative serum granulocyte colony-stimulating factor (G-CSF) was 105pg/ml, we concluded that leukocytosis in this patient was caused by G-CSF produced by tumor cells.
The patient was in good health two years after surgery with no signs of recurrence.

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A 68-year-old female who had undergone total hysterectomy for carcinosarcoma five months previously was noted to have a solitary nodular shadow in the right lung on chest X-ray. Percutaneous needle biopsy of the lung was performed via the right anterior chest wall, and the histologic findings showed metastasis from carcinosarcoma of uterus. Two months after needle biopsy, a chest wall mass appeared of the site of puncture of the lung needle biopsy. The mass was resected to relieve the chest wall pain and the specimen showed carcinosarcoma of uterus histologically. We consider that tumor cells were implanted to the chest wall along the needle tract after percutaneous needle biopsy of the lung. The postoperative chest computed tomogram showed the route of tumor implantation from the metastasis of right lung into the right chest wall. Dissemination and chest wall implantation of malignant cells after percutaneous lung needle biopsy have been rarely reported. However there are no reports of tumor implantation of sarcoma. The possibility of implantation of tumor cells along the needle tract after percutaneous lung needle biopsy should be carefully considered in cases of carcinosarcoma.

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A 49-year-old man with high alcohol consumption was admitted with fever, cough and progressive dyspnea after a one week history of influenza-like symptons. Chest X-ray film on admission showed diffuse peribronchial shadows and patchy infiltration in the right lower lung field. Chest X-ray film the following day and chest CT film on the 4th day of admission showed multiple nodular shadows and cavity formation. At bronchoscopy the bronchial surface was covered by white plaque, and Asp. fumigatus was subsequently cultured from BAL fluid. On the basis of suspected invasive pulmonary aspergillosis, anti-fungal agents were commenced. However, the shadows on chest X-ray increased, and the patient died on the 10th day of admission of respiratory failure and septic shock. Histological examination revealed bronchial wall invasion by hyphae of aspergillus and abscess formation in the pulmonary parenchyma. The precipitin antibody against aspergillus antigen was positive in reserved serum. Anti-Influenza A virus antibody (CF) was positive (×256), and hemagglutination inhibition test of Influenza A (H₃N₂) was positive (×2048) in serum on admission.
The suppression of cellular immunity and destruction of the mucociliary system of airways induced by Influenza A infection was suspected to have predisposed to aspergillus superinfection.

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A few weeks after treatment with INH, RFP and SM, severe aplastic anemia developed in a 49-year-old man with pulmonary atypical mycobacteriosis due to M. kansasii. All drugs were discontinued immediately after bone marrow examination revealed severely hypoplastic marrow, but pancytopenia continued for several months. Although M. kansasii was sensitive to other drugs including CS and TH, these two drugs were also discontinued because of their respective psychiatric and hepatic adverse effects. Ofloxacin (OFLX), to which M. kansasii was sensitive, was administered without clinical improvement and complete resistance to OFLX developed after several months treatment. Right upper and middle lobectomy and S₆ partial lobectomy was performed, and postoperative sparfloxacin (SPFX) administration resulted in cure of the disease. Drug sensitivity testing revealed that the organism had acquired resistance to OFLX, but was still sensitive to SPFX.
Thus, SPFX appears to be an useful drug for the treatment of atypical mycobacteriosis.

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A 58-year-old fisherman was admitted because of an abnormal chest X-ray shadow on the right side. Bronchoscopic examination revealed tumor of right B⁷. Transbronchial biopsy showed squamous cell carcinoma. He was treated with four courses of CDDP and PEP. Two years later, he developed nephrotic syndrome and relapse of lung cancer. Proteinuria and pedal edema continued. Renal biopsy revealed the characteristic light and immunofluorescent microsopic features of membranous nephropathy. Oral administration of low dose etoposide resulted in reduction of the carcinomatous lung lesion and a decrease in proteinuria as well as pedal edema.

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A 63-year-old man was admitted to our hospital because of fever, skin eruption, leukocytopenia and liver dysfunction. He was receiving H2-blocker for gastric ulcer of the time he developed his symptoms. The H2-blocker was discontinued because of its possible association with leukocytopenia, and steroids were administered. On the 4th day of hospitalization, he suddenly developed expiratory wheeze and dyspnea, resembling an asthmatic attack. WBC was 400/mm³ with 65% neutrophils. Chest X-ray showed hyper inflation and increased thickness of bronchiolar walls. Bronchodilators had no effect and the patient died of respiratory failure on the 8th day. At autopsy, most bronchioles were filled with candida pseudohyphae. The large airways and lung parenchyma were not involved, except for focal bacterial pneumonia. Histological findings suggestive of bronchial asthma such as constriction of bronchial smooth muscle or infiltlation of eosinophils were not observed Candida infection was also found in the pharynx, stomach, bowel, and kidneys.
Candidiasis is becoming a more important contributory cause of death in compromized hosts. Although rare, this case suggests that patients with bronchopulmonary candidiasis present with expiratory wheeze resembling asthmatic attack.

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Teratoma of the lung in a 32-year-old female is reported. Abnormal shadow on chest X-ray film was noted at the age of 15 years. Her symptoms were subclinical fever, couch, hemosputum and frequent respiratory infections. Chest X-ray film and CT scan revealed a cyst with an intracystic solid mass in the left upper lung. Bronchogram demonstrated communication of the cyst with B⁵a and B⁵b bronchi. The left upper lobe was resected. Microscopic examination of the resected specimen revealed a mature teratoma of the lung. Teratoma of the lung is very rare. This case was diagnosed at surgery and was confirmed by microscopic examination.

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A 37-year-old man was admitted to our hospital because of abnormal shadows on chest X-ray film at routine medical examination.
The chest X-ray showed diffuse granular shadows in the bilateral upper and middle lung fields. Chest CT showed multiple cystic lesions and nodular lesions.
Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were performed. Electron microscopic examination of BAL fluid revealed Langerhans' cells, and lung tissue specimen obtained by TBLB showed granuloma with infiltration of histiocytes and eosinophils.
During the clinical course, the patient complained of cough and decrease of right visual acuity in association with an increase of abnormal shadows on chest X-ray. The lung disease gradually resolved after the cessation of smoking in spite of no therapy.
In the right eye, an exudative lesion with retinal elevation was noted in the ocular fundus. Corticosteroid administration was effective for the treatment of this lesion.
There was no pathological evidence of the right ocular lesion. However, the correlation of its clinical course with the lung disease suggests a relationship between the ocular lesion and pulmonary eosinophilic granuloma.

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Clinical criteria for definition of IIP proposed in 1991 by the Project Team for Diffuse Lung Diseases Organized by Japanese Ministry of Health and Welfare are reviewed. After the clinical, roentgenological, and pathological researches of 92 IIP patients, we concluded that IIP patients were grouped into two clinical types, acute and chronic, by their clinical courses and characteristic pathological findings. The latter is, moreover, grouped into two types, typical and atypical, by their morphological characteristics. The acute type are represented by alveolitis with marked edema and cell infiltration of alveolar wall, and by hyaline membrane formation. “Typical” of chronic types only have typical pathologic changes of interstitial pneumonia and/or fibrosis represented by honeycombing. “Atypical” have both those interstitial changes and intra-alveolar scar formation and fibrosis due to organized pneumonia and secondarily occurred emphysema such as bulla as well. The contiunity in clinical courses between acute and chronic types are still obscure.

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