Alveolar macrophages and T-lymphocytes in bronchoalveolar lavage fluid from patients with diffuse lung diseases have been shown to be activated. The object of this study was to investigate whether the numbers of nucleolar organizer regions (NORs) in alveolar macrophages and lymphocytes were abnormally high in these patients or not. Alveolar macrophages and lymphocytes were collected by bronchoalveolar lavage from 7 control subjects, 36 patients with pulmonary sarcoidosis, 10 patients with hypersensitivity pneumonitis, 6 patients with measles pneumonia, 6 patients with mycoplasma pneumonia, and 6 patients with progressive systemic sclerosis related to interstitial pneumonitis. These cells were cytocentrifuged and stained by one-step silver staining. Argyrophilic proteins of the nucleolar organizer regions (Ag-NORs) were counted in 300 alveolar macrophages and lymphocytes. The numbers found in control subjects were compared to those found in patients with diffuse lung diseases. In the patients with sarcoidosis, these numbers were also compared among subgroups divided according to staging, involvement of other organs, administration of steroids, and differences in deposition of ⁶⁷Ga. We also examined correlations between Ag-NORs and known markers of activation in sarcoidosis. The numbers of Ag-NORs were significantly greater in patients with diffuse lung diseases than in control subjects. There were no significant differences in the numbers of Ag-NORs among subgroups of patients with sarcoidosis. No correlations were seen between the Ag-NORs and the markers of activation of disease. The numbers of Ag-NORs in lymphocytes of patients with hypersensitivity pneumonitis correlated with the ratio of HLA-DR, CD8 double-positive lymphocytes. In patients with measles pneumonia, the number of Ag-NORs was high in the acute phase and normal in the convalescent phase. These data suggest that Ag-NORs may be a simple and sensitive marker of activation in patients with diffuse lung diseases.

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To study the effects of percutaneous transluminal mitral commissurotomy (PTMC) on bronchial responsiveness to inhaled methacholine in patients with mitral valve stenosis (MS), methacholine inhalation tests and pulmonary function tests were done in 10 patients with MS before and one week after PTMC. The mean log cumulative dose producing a 35% decrease in respiratory conductance (PD₃₅Grs) was significantly higher after PTMC in nine patients in whom PTMC was successful (p<0.05). There were no significant changes in the results of pulmonary function tests after PTMC. One patient had severe mitral regurgitation after PTMC, and a decrease in PD₃₅Grs. Six of the other nine patients in whom PTMC was successful continued to be hyperresponsive to inhaled methacholine. These data show that bronchial hyperresponsiveness in patients with MS is less severe after PTMC, concomitant with the relief of pulmonary congestion, and they suggest that the remaining bronchial hyperresponsiveness is responsible for peripheral airway narrowing with organic remodeling.

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Six cases of allergic bronchopulmonary aspergillosis (ABPA) were evaluated. In four cases, diagnosis and steroid therapy were delayed, which resulted in irreversible pulmonary dysfunction.
The important points for early diagnosis were:
(1) Differentiation from pulmonary tuberculosis, (2) the presence of bronchial asthma was not essential for diagnosis, and (3) fungi other than Aspergillus fumigatus might cause this syndrome.

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Hypoxemia after the treatment of asthmatic attack continues for a while, and can even become worse after the treatment. This hypoxemia has been attributed to inhomogeneity of ventilation-to-perfusion ratios in the lungs of asthmatic patients. We studied post-hyperventilation hypoxemia in subjects with hypoxemia after a methacholine challenge test. Nineteen subjects who were hyperresponsive and hypoxemic after a methacholine challenge were studied. The methacholine challenge with incremental doses was stopped when the respiratory resistance doubled. Thereafter, oxygen and carbon dioxide concentrations in the expired air, mouth flow (VE), and oxygen saturation (using a pulse oximeter, SpO₂) were monitored continuously. End-tidal PCO₂ (PETCO₂) as well as respiratory exchange ratio (R) were thus obtained. In 14 subjects, VE signficantly increased from 8.6±1.2 (mean±SD) to 13.4±2.6l/min and then decreased gradually, while PETCO₂ significantly decreased from 38.5±2.3 to 29.1±4.4 Torr and then increased gradually, SpO₂ decreased from 97±1.3 to 89±2.4% concomitant with a significant decrease in R from 0.86±0.04 to 0.67±0.05. In contrast, in 5 subjects VE significantly increased from 7.5±2.8 to 12.4±1.6l/min and then remained unchanged, while PETCO₂ significantly decreased from 37.9±1.3 to 31.3±3.9 Torr and then remained unchanged, SpO₂ decreased from 98±1.1 to 92±1.9% with no change in R (from 0.84±0.06 to 0.87±0.06). In the subjects whose R was low during hypoxemia, the time courses of the changes in SpO₂ VE, PETCO₂, and R were similar to those observed during hypoxemia after voluntary hyperventilation. It is possible that the body store of CO₂ was depleted during the hyperventilation that accompanied bronchoconstriction, that CO₂ gradually reaccumulated during recovery, and that this process entailed the development of hypoxemia.

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Hospital-acquired pneumonia is one of the most important fatal respiratory diseases in the elderly. Prompt and precise empiric therapy is essential for recovery. Fourteen isolates from twelve elderly lepromatous leprosy patients (9 men, 3 women, mean age of 75.8 years) with hospital-acquired pneumonia were studied. Subsequently, empiric therapy with gentamicin and β-lactams for nosocomial pneumonia in the elderly was examined. Fourteen types of bacteria isolated from expectorated sputum specimens consisted mainly of ten strains of gram-negative bacilli (71%) six of Klebsiella pneumoniae, one each of Citrobacter freundii, Enterobacter agglomerans, Serratia liquefaciens, and Aeromonas hydrophilia and four strains of gram-positive cocci (29%) two of Staphylococcus sp., one each of Streptococcus sp. and Streptococcus pneumoniae. Methicillin-resistant Staphylococcus aureus and Pseudomonas sp. were not detected. Resistance rates of the etiologic agents to the antibiotics showed that gentamicin was 7.7%, ceftazidime 0%, and cefmetazole 23.1%. Cephalosporins were superior to penicillins. As a result of empiric therapy, six elderly leprosy patients with nosocomial pneumonia were cured and one improved temporarily. This study shows the necessity of specific empiric therapy for hospital-acquired pneumonia in a hospital with many elderly patients. The combination of gentamicin and β-lactams is of value as an initial antibiotic therapy for hospital-acquired pneumonia in the elderly.

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Morphlogical features of Swyer-James syndrome were studied in a specimen obtained during left pneumonectomy. A 67-year-old woman was admitted because her left lung was hyperlucent and contained a solitary nodule. Primary lung adenocarcinoma complicated with Swyer-James syndrome was diagnosed, and left pneumonectomy done. The left upper lobe was inflated and fixed for morphological study. The volume of the specimen was obviously lower than normal but the bronchial branching was normal. Macroscopically, the specimen had irregular bronchial walls, bronchiectatic changes, and dilation of distal air spaces, similar to panlobular emphysema. Microscopically, there was scarring in periarteriolar regions that suggested bronchiolitis obliterans, enlargement of distal airspaces, and an abnormally low number of capillaies. These findings suggest hypoplasia of the lung due to abnormal lung growth after birth.

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A 48-year-old man who had been a welder for 25 years was admitted to our hospital on February 18, 1990 for investigation of a diffuse bilateral lung shadow that had a ground-glass appearance. On the day of admission, he had been welding copper water supply pipe and used silver brazing with an oxyacetylene torch. After almost 7 hours of work, he had a chill, high fever, and dyspnea. Blood gas analysis revealed severe hypoxemia (PaO₂ 34.5Torr, PaCO₂ 29.4Torr). The level of copper in serum was slightly higher than normal (174μg/dl). A transbronchial lung biopsy specimen showed lymphocyte infiltration and fibrous changes of the alveolar walls, which seemed to be granulomatous pneumonitis. Steroid therapy was effective against the symptoms, and the radiographic findings also improved. We think this is a rare case of interstitial pneumonitis caused by inhalation of cadmium fumes contained in silver brazing.

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A 67-year-old woman was admitted to our hospital because of fever. Chest roentgenogram showed an enlargement of mediastinal lymph nodes. Despited thorough examination, no definite diagnosis could be made. The mediastinal lymph nodes got smaller over the next 3 weeks and a chest roentgenogram taken 4 months later showed no mediastinal lymphadenopathy. The mediastinal lymphadenopathy and fever recurred 5 months later. She underwent thoracotomy and the mediastinal lymph nodes were excised. Microscopic examination of pretracheal lymph node specimens showed invasion of poorly differentiated adenocarcinoma associated with abundant tumor-infiltrating lymphocytes. The other lymph nodes showed sarcoid reaction. Although she has been followed for one year and 11 months, no primary site of the cancer has been found. Metastasis of cancer of unknown origin to mediastinal lymph nodes is extremely rare. It is also interesting that the lymph node swelling diminished spontaneously. The tumor-infiltrating lymphocytes and sarcoid reactions may have been immunological responses to the cancer and may have caused the transient regression.

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A 68-year-old woman with bronchial asthma and a history of drug hypersensitivity came to our hospital because of severe pain, swelling, and ecchymoses in the lower extremity. The eosinophil count was 53.5%, therefore Churg-Staruss syndrome was diagnosed and she was given predonisolone (PSL) (30mg/day). A skin specimen taken the next day showed tissue eosinophilia, acute and subacute necrotizing vasculitis. Immunofluorescence staining showed IgG in the blood vessels. After one month of PSL, biopsy specimens of muscle fiber revealed atrophy of type IIb fibers, and myxomatous degeneration of neuronfibers. Eosinophilia decreased rapidly after administration of PSL, but the necrotizing lesions of the skin, muscle, and nerve were so severe that she needed orthopedic shoes.

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A 45-year-old man with diffuse infiltrates on the chest X-ray film was admitted to the hospital. At first, sarcoidosis was suspected due to the elevated serum angiotensin-converting enzyme (ACE) activity. Transbronchial lung biopsy and bronchoalveolar lavage, however, did not lead to that diagnosis. Pulmonary alveolar proteinosis (PAP) was diagnosed after an open lung biopsy. The diffuse infiltrates on his chest X-ray film diminished spontaneously. Two years later, diffuse infiltrates increased again with an elevated serum ACE activity. In this case, it seemed that the severity of PAP was associated with serum ACE activity. We review the literature on the relationship between serum ACE activity and dysfunction of alveolar macrophages in PAP.

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A 54-year-old woman was admitted to our hospital because of an asthmatic attack. Her first asthma attack occurred when she was 53 years old. It was followed by a flu-like infection, and was preceded for one year perennial rhinitis and loss of the sense of smell. Symptoms were perennial, and unrelated to the seasons. Because these clinical findings resembled those of aspirin-induced asthma (AIA), an aspirin-DL-lysine i. v. challenge test was done. Cough, perspiration, and flushing was provoked within 15min after aspirin-DL-lysine injection, but FEV₁ did not change. Respiratory sounds were normal and no wheezing was audible. Other cyclooxygenase inhibitors (ketoprofen, sulpyrine and acetaminophen) provoked the same symptoms. Successively incresing doses of injected aspirin-DL-lysine resulted in complete tolerance to this stimulus. We propose that aspirin-induced cough without bronchoconstriction is a new type of aspirin hypersensitivity.

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The prognosis for Wegener's granulomatosis (W-G) is good if it is diagnosed early and a combination of corticosteroids and cytotoxic drugs is given.
During the past fourteen years, we were encountered four cases of W-G, three were systemic and one was limited. Of the three patients, with systemic disease, two died of myocardial infarction caused by a delay in diagnosis and one died of fluminant renal and respiratory failure. Only the one patient with a limited form of the disease survived for more than 5 years.
We emphasize the importance of early diagnosis with consideration of the systemic features of W-G.

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A 48-year-old man was admitted to our hospital because of upper abdominal pain, and a cervical tumor, on Oct. 23, 1992.
Chest X-ray, CT scan and MRI revealed a tumor (left-S10) and enlarged mediastinal lymph nodes.
A pathological diagnosis of small cell lung cancer was made by transbronchial biopsy. Ultrasonography showed liver metastases.
He received four courses of chemotherapy (Carboplatin, Ifosfamide, Etoposide). Three days after the completion of chemotherapy, his serum transaminase level was markedly increased, and he was disorientated on March 4, 1993.
In spite of plasma exchange, the patient died due to hepatic failure on March 6, 1993.
Fulminant hepatitis in a patient with lung cancer receiving chemotherapy is rarely reported.

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A 60-year-old man with cough and fever was admitted to our hospital. Chest radiography revealed multiple bullae and fungus balls in both lungs. He was treated with MCZ and FCZ for about 2 months, but the chest radiograph shadows did not improve and the fever continued. A two-stage operation was performed. The bullae were incised and the fungus balls were removed, then a muscle flap plombage was made with a pectralis major muscle, a latissimus dorsi muscle and an intercostal muscle. The postoperative course was uneventful and respiratory function was preserved.

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We present a case of chronic type farmer's lung which showed progressive pulmonary fibrosis and spontaneous pneumothorax 12 years after the first admission. A 56-year-old woman was diagnosed as having farmer's lung in 1981. After the first hospitalization, her chest roentgenogram showed regression with steroid therapy. After that, she sometimes worked at a dairy farm and required rehospitalization three time for recurrence. In April 1993, she was readmitted complaining of sudden chest pain and dyspnea after cough. Her chest roentgenogram on admission showed spontaneous pneumothorax. After treatment, her chest roentgenogram revealed severe pulmonary fibrosis and loss of lung volume.

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A 31-year-old man, asymptomatic but with an abnormal shadow adjacent to the right tracheobronchial angle on chest rentogenogram, presented to our hospital. CT and MRI of the chest revealed this shadow to be a dilated azygos arch. The inferior vena cava was interrupted, at the intrahepatic portion, by the azygos continuation.
There was also an abnormality of tracheobronchial branching. The right middle lobe bronchus gave rise to the upper lobe bronchus. The right B⁷ was absent though the left BX⁷ was present. The pulmonary arteries passed over the main bronchi bilaterally.
Interruption of the inferior vena cava is often associated with significant cardiovascular and abdominal anomalies but only rarely with anomalies of tracheobronchial branching.

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A 23-year-old man was admitted to our hospital because of non-productive cough. Chest X-ray demonstrated bilateral hilar lymphadenopathy, bilateral infiltration shadows and right pleural effusion. ECG showed complete A-V block and sinus arrest. Transbronchial lung biopsy and pleural biopsy specimens showed non-necrotizing epithelioid cell granulomas. The patient was diagnosed as having sarcoidosis, and was treated with steroid and pacemaker. After steroid therapy, myocardial imaging with thallium-201 showed increase of uptake and the pleural effusion disappeared.

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