We used a new type of endoscope developed by the authors in 10 patients with localized inflammatory pulmonary lesions in the peripheral areas which were far from the 3 branch and needed to be distinguished from lung cancer.
Endoscopic findings revealed reddening, obstruction, stenosis, hypersecretion and dilation in the peripheral airway. The endoscopic findings in this disease were different from those peripheral lung cancer. The combination of thin-section CT, endoscopy and lung biopsy was the best method for determining the morphological changes in localized pulmonary lesions.

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The effect of progesterone is most likely exacted by directly stimulating the central nervous system. However, it remains unclear whether progesterone and/or estrogen act through the peripheral chemoreceptor. The carotid body is thought to be the sole sensing organ of hypoxia. The present study was conducted to determine whether administration of female hormones, i. e., progestin and/or estrogen, augment ventilatory response to hypoxia in the awake male Wistar rat. The combined administration of a synthetic progestin (TZP 4238) and estradiol for 5 days significantly increased tidal volume and minute ventilation, reduced arterial PCO₂, and enhanced the ventilatory response to hypoxic gas inhalation. Augmentation of hypoxic ventilatory response was achieved by a increment of respiratory rate with a shortening of expiratory time. Administration of either TZP 4238 or estradiol alone or vehicle had no effects on respiratory variables. Our results suggest that female hormones may act through the peripheral chemoreceptor as well as the central nervous system.

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We have performed bronchoalveolar lavage (BAL) examination in 27 cases; 5 with Clamydial pneumonia, 7 with Mycoplasmal pneumonia and 15 in the control group (5 non-smokers, 10 smokers), and the following results were obtained.
1. In Chlamydial pneumonia and Mycoplasmal pneumonia, the cell population of alveolar macrophages in BALF decreased (p<0.01) and that of lymphocytes increased compared with control group (p<0.01).
2. In all cases of Mycoplasmal pneumonia without peripheral eosinophilia, the cell population of eosinophils in BALF increased compared with cases of Chlamydial pneumonia (p<0.05).
These results indicate that lymphocytes played the main role in the immune host defense in Chlamydial pneumonia, whereas infiltration of lymphocytes and eosinophils into the pneumonic lesion occurred in Mycoplasma pneumoniae infection.

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Fifty patients with bronchial asthma were divided into four groups according to the amount of expectoration per day: 0-24, 25-49, 50-99 and 100+ml/day. Clinical features of patients with mucus hypersecretion (more than 50ml/day of expectoration) were evaluated by age, severity of disease, cellular composition of bronchoalveolar lavage (BAL) fluid, and ventilatory function.
1. The proportion of patients with steroid-dependent intractable asthma (SDIA) in each group increased with increase in mucus hypersecretion.
2. Many of the patients with mucus hypersecretion (more than 50ml/day) were over the age of 40.
3. The proportion of BAL eosinophils was significantly higher in patients with hypersecretion (more than 50ml/day) than in those with expectoration of less than 49ml/day. There was a significant correlation between the proportion of BAL eosinophils and the amount of expectoration per day (r=0.48, p<0.05). Proportions of lymphocytes and neutrophils in the BAL fluid were not related to the amount of expectoration per day.
4. There was no significant correlation between the amount of expectoration per day and ventilatory function in patients with asthma in this study.

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To assess the effect of diffusion limitation on gas exchange in injured lungs with non-cardiogenic pulmonary edema, an experimental model of acute lung injury with alveolar flooding was produced in six mongrel dogs by intravenously injecting oleic acid at 0.06ml/kg.
The effect of diffusion limitation was quantitatively examined by measuring the excretion (E) of three indicator gases (acetylene, ethylene and freon-22) with differing solubility (λ). and tissue diffusivity (d). The indicator gases were dissolved in normal saline and infused at a constant rate through a peripheral vein. Since acetylene and ethylene have nearly identical of d but differing λ, the difference in E values of these two gases may solely reflect the effect of uneven distribution of ventilation-perfusion ratios (V_A/Q) in the lung. Thus, measured E values of acetylene and ethylene allowed us to approximately predict the E of freon-22, the value corresponding to the condition where d of freon-22 was taken to be equal to that of acetylene or ethylene. The difference between predicted and measured E values of freon-22 is indicative of the limitation of diffusion in the lung periphery. In all the lungs studied, measured E values of freon-22 were consistently smaller than those predicted from acetylene and ethylene, leading to the conclusion that gas exchange in injured lungs with widespread pulmonary edema was partly impaired by diffusion in aqueous media.

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We examined the activity of defensins from human neutrophils against Mycobacterium avium complex (MAC). MAC were cultured in the presence of defensins at 37°C for 4-48 hours. After incubation, colony counts were enumerated by colony-forming units(CFU). Human neutrophil peptide-1 (HNP-1) at 5μg/ml had the ability to kill MAC. We tested 8 strains of MAC. HNP-1 was successful in killing every strain, although the degree of killing varied from strain to strain. We also found that HNP-2 and HNP-3 were as effective in killing MAC as HNP-1. We suggest that defensins play an important role in the host defenses against MAC.

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The degree of lung injury in bronchiolo-alveolar lesions may be quantitated from the pulmonary epithelial permeability estimated by ^99mTc-DTPA (diethylene triamine penta acetate) aerosol inhalation scintigram. However, significant aerosol deposition sometimes occurs in the central airways and obscures the permeability change in the lung periphery. The radioaerosol deposition pattern and its effect on assessing the pulmonary epithelial permeability was studied.
^99mTc-DTPA aerosol scintigraphy was performed in 47 patients with pulmonary fibrosis (PF), 12 patients with chronic obstructive pulmonary diseases (COPD), and 27 non-smoking and 17 smoking healthy volunteers. The scintigraphic images of the lungs were classified into 4 grades, 0; homogeneous distribution, 1; patchy distribution, 2; hot spots with partial defect, and 3; hot spots with little deposition in the lung field. The rate constant was used as a parameter for the permeability.
The smokers and patients with PF showed increased kep values of 2.36±1.21%/min (mean±SD) and 2.49±1.29%/min as compared with the nonsmokers with 0.94±0.27%/min, respectively. The nonsmokers, smokers and 36 patients with PF were classified as deposition grade 0 or 1, suggesting good aerosol penetration to the lungperiphery. All patients with COPD showed either grade 2 or 3 deposition.
Aerosol deposition in the central airways can cause underestimation of the permeability because of the thicker lining layer in the bronchus than in the alveolus. In conclusion, the aerosol deposition pattern should be analyzed when the method is applied clinically to assess the permeability of the bronchiolo-alveolar epithelium.

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A 37-year-old woman was admitted to our hospital with the complaints of cough, lymph node swelling. Chest X-ray film showed diffuse small nodular shadows in the bilateral lower lung fields.
Bronchoalveolar lavage fluid revealed an increased proportion of lymphocytes (71%) with low OKT4/T8 ratio (0.26). Lung tissue biopsied by bronchofiberscopy showed the existence of interstitial pneumonia. Precipitating antibodies in this patient's serum against various antigens including Trichosporon cutaneum were positive. After admission, all symptoms resolved gradually without specific therapy. But, as soon as the patient was discharged and returned to her home, all symptoms including fever, cough, dyspnea and lymphadenopathy recurred rapidly. The diagnosis of hypersensitivity pneumonitis was made on the basis of these laboratory findings and clinical course. The patient died from respiratory failure after detection of anti-HTLV-I antibody, and autopsy revealed massive ATL cell infiltration of lung tissue, and immunoenzymatic analysis showed a high OKT4/T8 ratio (3.5). Chronic HTLV-1 infection since infancy was suspected in this case, to have modified the immune regulation of the lung, and to have led to the onset of hypersensitivity pneumonitis and the active immune response in the lungs, finally followed by the acute exacerbation of ATL.

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Intrathoracic lymphadenopathy in eosinophilic pneumonia is very rare and few cases have been confirmed histologically. This is the first case of eosinophilic pneumonia with mediastinoscopic lymph node biopsy reported in Japan. The case is a 42-year-old man who was admitted to our hospital complaining of cough, general fatigue and dyspnea of one month's duration. Chest X-ray demonstrated bilateral hilar and mediastinal lymph node enlargement with interlobar pleural thickening and infiltrative shadows in right lower lung field. Computed tomography revealed infiltrative shadows at right S⁴, S⁵, S⁸ and S⁹ and S¹⁰ segments and #2, #3, #5, #6 lymph node enlargement. Biopsy of the lymph node via mediastinoscopy demonstrated that the architecture was preserved, sinusoids were filled with histiocytes and eosinophils, and lymphoid follicles were compressed. Immunohistochemical technique using monoclonal antibody EG2 which reacts with the secreted form of Eosinophilic Cationic Protein (ECP), demonstrated that eosinophils infiltrating the mediastinal lymph nodes were activated. The pathogenesis of mediastinal lymphadenopathy in eosinophilic pneumonia remains to be determined, but our case suggests that mediastinal lymph nodes may play a role in eosinophilic pneumonia.

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Two cases of re-expansion pulmonary edema following decortication of a tuberculous empyema are presented. The period of compression of the whole lung by empyema was relatively short in both cases. One case showed incomplete expansion of the whole right lung after preoperative drainage, and re-expansion pulmonary edema of the whole right lung after decortication, which was treated by mechanical ventilation and steroid therapy. The other case showed incomplete expansion of the right middle and lower lobes after preoperative drainage, and re-expansion pulmonary edema of the right middle and lower lobe after decortication, which was treated by steroid therapy. In cases of tuberculous empyema with a relatively short course, re-expansion pulmonary edema may occur in a lung incompletely expanded by preoperative drainage.

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A 64-year-old man was admitted to our hospital with complaints of chest pain on Sep. 26, 1991. ECG revealed myocardial infarction-like ST-elevation in II, III, aVF, V₄, V₅, and V₆ but coronary angiography revealed no abnormal findings in the right and left coronary arteries, and no elevation of SGOT, LDH or CPK was found.
Chest CT scan, UCG and chest MRI revealed a tumor invading into myocardium in the left cardiophrenic angle. Myocardial scintigraphy revealed a cold area in the inferior wall. Histologically, the tumor was squamous cell cancer.
In spite of treatment, the patient died due to heart failure on Feb. 8, 1992.
Myocardiial metastasis showing a myocardial infarction-like ECG has been rarely reported.

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A 76-year-old man was admitted to our hospital because of productive cough and dyspnea. Chest X-ray revealed cardiomegaly, bilateral pleural effusion, mediastinal lymphadenopathy, and marked bilateral hilar lymphadenopathy (BHL). His symptoms improved after therapy including diuretic for heart failure, but BHL was unchanged. M-protein in both serum and pleural effusion, and B -J protein in urine were detected. Protein immunoelectrophoresis demonstrated a heterogeneous increase in IgA with λ light chain predominance. Bronchoscopy disclosed some prominent mucosal lesions of the bilateral bronchi, of which biopsies demonstrated amyloid deposition. Gastric mucosal biopsy also demonstrated amyloid deposition. Therefore this case was diagnosed as systemic primary amyloidosis due to AL-protein. In systemic amloidosis, there are only a few reports of lymph node enlargement due to amyloid deposition, and it is particulary rare with BHL. From the presence of M-protein in pleural effusion, it is suggested that not only congestive heart failure due to cardiac amyloidosis but also amyloid deposition in the pleura would be related to the fluid production.

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A 60-year-old woman was admitted to our hospital with a two month history of dry cough and dyspnea on exertion. A chest roentgenogram revealed diffuse interstitial shadows with a reduction of lower lung volume. Laboratory examinations revealed an increase in CPK and aldolase. There was decreased proximal muscle power, and the findings of a biopsy of the right deltoid were compatible with polymyositis. Myositic symptoms were stable, but the respiratory symptoms worsened, and an open lung biopsy was performed for diagnosis and to determine the best treatment. The histological findings of biopsy materials demonstrated active interstitial pneumonia complicated by cellular interstitial pneumonia, bronchiolitis obliterans organizing pneumonia, usual interstitial pneumonia and lymphoid hyperplasia. The patient responded well to adrenocorticosteroid and immunosuppressive therapy, and is now attending as an out patient.
It is well known that PM-DM can be associated with interstitial pneumonia, and this complication is an important prognostic factor clinically. The pathological patterns of interstitial pneumonia in PM-DM may be divided into usual interstitial pneumonia and bronchiolitis obliterans organizing pneumonia. Furthermore, it is well documented that these patterns are concurrent with the response to adrenocorticosteroid and prognostic factors. However, our case of PM-DM, in which various patterns such as rheumatoid arithritis (RA) were pathologically revealed, cannot be considered as having uniform pathological pattern. We consider that pulmonary pathological patterns of PM-DM are very varied, as with RA. It is a very important to evaluate the nature of these patterns and the subsequent clinical course in PM-DM with interstitial pneumonia.

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A case in which P. carinii was observed in bronchoalveolar lavage fluid during steroid therapy for interstitial pneumonia in a 63-year-old man is reported. he had received steroid therapy for interstitial pneumonia of unknown origin. Three weeks later, he developed acute pneumonia with Streptococcus pneumoniae, and simultaneously P. carinii was detected in the bronchoalveolar lavage fluid. Both the pneumonic shadows and P. carinii disappeared following intravenous infusion of penicillin and rapid reduction of steroid. Electron microscopic analysis of P. carinii demonstrated numerous tubular expansions and endogenies of P. carinii, suggesting that P. carinii was growing in the intra-alveolar spaces. Phospholipid analysis demonstrated a transient increase in total phospholipid content during P. carinii pneumonia, suggesting that P. carnii can affect surfactant metabolism.

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A 21-year-old man presented to our hospital on June 7, 1990, asymptomatic but with an abnormal shadow in his chest roentgenogram. A well-demarcated tumorous shadow was seen in the left hilum of the lung in the frontal view of the chest X-ray, and adjacent to the posterior chest wall in the lateral view. A percutaneous needle biopsy was performed, and since there were no malignant findings, the tumor was left untreated for future examinations. However, since the tumor was observed to be enlarging gradually in subsequent chest X-rays, it was resected surgically on June 18, 1991. The tumor was fist-sized and its surface smooth, and was protruding into the thoracic cavity. At surgery, the tumor was separated from the chest wall. The tumor, weighing 170 grams, was diagnosed pathologically as a liposarcoma (myxoid type). It was confirmed that there was no infiltration into the surrounding tissue and that total resection had been performed. There are few reports of liposarcomas within the thoracic cavity developing in the extra-mediastinal chest wall. As our case is the second in Japan occurring in a young patient, we present it here together with a review of the literature.

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A 68-year-old woman presented to our hospital on January 7, 1992 with swelling of a right cervical lymph node as the chief complaint. After biopsy of the cervical lymph node, non-Hodgkin's lymphoma was diagnosed (diffuse medium cell type, B cell) and she was hospitalized on January 10. Except for the enlargement of the right cervical lymph node noted at the time of hospitalization, no abnormal findings on examination or in chest X-ray and CT scan were noted. However, at bronchoscopy rubor and swelling of the mucosa of the right second carina and the bifurcation between the left upper division and the lingular bronchus were noted, and biopsy was therefore performed. The histologic appearance of the biopsy tissue was similar to the that of the lymph node, showing infiltration by malignant lymphoma. The tumor was diagnosed to be stage IIA of the Ann Arbor classification, and COP-BLAM therapy was commenced on January 15. On January 21, the cervical lymph node was no langer present. At bronchoscopy performed on January 25, the abnormal portion of the bronchi had disappearanced, and no infiltratration was observed in the biopsied specimen.
There have been some reports describing lesions within the bronchi in cases of malignant lymphoma. However, there have been few cases in which no abnormalities were found in the chest X-ray and diagnosis was made by bronchoscopy. Thus, it seems to be useful and important to perform bronchoscopy in order to determine the stage of malignant lymphoma.

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An adult case of chickenpox with a chest roentgenogram revealing multiple nodular shadows of 5 to 20mm in diameter is reported. These shadows were different from those in previously reported varicella pneumonia cases especially with respect to size. Pulmonary function test showed disturbance in diffusion capacity, and bronchoalveolar lavage fluid analysis revealed a decreased CD4/CD8 ratio. Transbronchial lung biopsy showed mild alveolotis and focal exudation and hemorrhage into the alveolar space, which were thought to correspond to the relatively large nodules on the chest roentgenogram.
These findings suggest that multiple nodular shadows on the chest roentgenogram may been seen in some patients with chickenpox.

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A rare case of squamous cell carcinoma of the trachea in a female cigarette smoker is reported. The patient was a 72-year-old female with smoking index of 440 who developed wheezing and dyspnea on December 18, 1991. She was diagnosed as having bronchial asthma and hospitalized, but the symptoms were not improved. Bronchofiberscopic examination was performed and revealed a tracheal tumor on April 24, 1992. She was then referred to this cancer center. CT scan of the neck on admission showed a solid tumor which was 19×18mm in diameter and protruded from the membranous portion and the right side of the tracheal wall into the lumen. Bronchofiberscopic findings revealed a soft polypoid tumor with a whitish coat on the surface and a tendency to bleed, at the second tracheal ring from the vocal cord. Histological findings of the biopsied specimen were compatible with poorly differentiated squamous cell carcinoma. A segmental resection of the trachea with end-to-end anastomosis was performed on May 6th, 1992. Postoperative radiation therapy (50.4Gy) was added because of the residual microscopic cancer in the distal membranous portion of the tracheal wall. Female cases of squamous cell carcinoma of the trachea have been rarely reported in Japan. The relationship between squamous cell carcinoma of the trachea and smoking is considered.

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A 58-year-old healthy woman was admitted to our hospital on 8th October, 1991 for detailed investigation of an abnormal shadow on chest roentgenogram, which was detected by mass survey. The chest roentgenogram showed a cloudy shadow of the right upper lobe, and retrospectively, this abnormal shadow had been present since 1986. Flexible fiberoptic bronchoscopy showed complete obstruction of right B¹b bronchus by regenerated bronchial mucosa. Aseptic pus was detected in the obstructed bronchus by means of transbronchial aspiration cytology (TBAC) and chronic lung abscess was diagnosed. The chest roentgenograms of this case is very unusual, and we were unable to find a similar case of chronic lung abscess diagnosed by means of TBAC.

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