Pimobendan is a positive isotropic agent that dilates blood vessels and sensitizes the myocardium to calcum. We studied the clinical usefulness of single oral doses of pimobendan (2.5mg) in 8 patients with pulmonary hypertension caused by chronic pulmonary emphysema. We measured the short-term effects of pimobendan on pulmonary hemodynamics and gas exchange.
Pimobendan significantly decreased mean pulmonary artery pressure from 23.4±3.4 to 18.5±2.5mmHg, and total pulmonary resistance from 383±111 to 281±81 dyne·sec·cm^-5, while oxygen delivery and cardiac output increased significantly (oxygen delivery: from 81.8±10.2 to 93.5±16.2ml O₂/min. cardiac output: from 4.98±0.76 to 5.77±1.49l/min, means±SD). Systemic vascular resistance was not significantly reduced. The ratio of pulmonary to systemic vascular resistance was reduced, but not significantly. Arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂) did not change significantly.
These results indicate that pimobendan may be useful in the treatment of patients with secondary pulmonary hypertension.

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To clarify the clinical features of severe community-acquired pneumonia, we retrospectively studied 121 patients treated at our hospital. We divided the patients into three groups, based on the severity, of their disease. Patients were put in the “mild” group (n=56) if they recovered after treatment with antimicrobial agents only, they were put in the “moderate” group (n=34) if the required oxygen therapy and recovered, and they were put in the “severe” group (n=31) if they required mechanical ventilation. Age and underlying disease were recorded, as well as signs, symptoms, and laboratory data obtained during the first 24 hours after admission. The data indicated that the following nine findings were associated with the severity of disease: age of at least 65 years, an underlying disease of (31) the respiratory or central nervous system, dyspnea, a pulse rate of at least 90 beats per minute, a respiratory rate of at least 25 breaths per minute, an albumin concentration no greater than 3.5g/dl, a blood urea nitrogen level of at least 20mg/dl, a PaO₂ no greater than 60mmHg or an SaO₂ no greater than 90%, and a high score on a scale of the extent of roentgenographic evidence of pulmonary infiltrates. Patients in whom these are found be managed carefully.

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To gather data about smoking habits among members of the Japan Society of Chest Diseases, a questionnaire was distributed during the 36th annual meeting. A total of 2411 out of 3725 questionnaires were returned (65%). The percentage of smokers was 23%. Smoking was prohibited in the hospitals of 281 respondents (8%). Seventy-nine percent reported that patients smoking areas were separated from patients' non-smoking areas, but only 41% reported that physicians' smoking areas were separated from physicians' non-smoking areas. Tobacco was being solid in over 50% of the hospitals represented, either via vending machines or through hospital retail stores. However, 79% of the respoondents indicated that hospitals should be smoke-free. Questions of ethics in medicine are highlighted by this questionnaire. The obvious issues involved are whether or nor both patients and physicians should be required to stop smoking in health-care facilities. The larger issue is the degree and method by which the Japan Society of Chest Diseases should involve itself actively in smoking reform for the sake of society in general.

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A 44-year-old Japanse man who had suffered from bronchial asthma since childhood was given the diagnosis of chronic eosinophilic pneumonia because of his symptoms, chest roentgenographic findings, and the results of a transbronchial lung biopsy. At the time of the onset of the disease, the pleural effusion contained 73% eosinophils. Symptoms were relieved and the laboratory findings returned forward normal after a short course of high-dose corticosteroids. The concentrations of IL-5, IL-6, and G-CSF in pleural fluid and in serum were very high; the concentrations of these cytokines were 3 times to 35 times higher in pleural fluid than in serum. In contrast, no IL-3 or GM-CSF was detected in any of these samples. The precise etiology of chronic eosinophilic pneumonia is still unclear, but this case suggests that inappropriate production of IL-5, IL-6 and G-CSF in the lung play a pivotal role in this disease. Inhibition of the production of these cytokines may be another therapeutic approach to this disease.

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A 21-year-old man was admitted to our hospital with acute progressive dyspnea and a high fever. He had started smoking 6 weeks before admission. A chest radiograph showed diffuse infiltrates with Kerley B lines and bilateral pleural effusions. There was no evidence of infection. His condition improved rapidly and without medication. On admission the concentrations of interleukin-5 in bronchoalveolar lavage fluid and in blood were high, but they were normal one week later. Acute eosinophilic pneumonia was diagnosed. A positive result of a lymphocyte stimulation test indicated that the development of symptoms was closely associated with ingestion of aspirin. We know of no previous report of acute eosinophilic pneumonia associated with aspirin.

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A 46-year-old man was admitted to the hospital for evaluation of a dense infiltrative shadow in the right middle lung field. Bronchoscopic examination revealed a polypoid lesion in the right middle-lobe bronchus (B⁵_bii). Examination of a biopsy specimen showed a lump with many Nocardia asteroides bacteria. The response to chemotherapy, which included sulfomethoxazole, was poor, and therefore a right middle lobectomy was done. Three mycetomas were found inside the ectatic bronchi in the S⁵ area. Pulmonary Nocardia mycetoma is rare.

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We encountered a patient with bronchial asthma and mucoid impaction who presented with a high concentration of carcinoembryonic antigen (CEA) in serum. The patient was a 46-year-old woman. One year after resection of a uterine myoma and an ovarian cyst, examination of serum revealed a high concentration of CEA (24.1ng/ml). Further examintion revealed no evidence of malignant disease, but an abnormal shadow was seen on a chest X-ray film, and was thought to be compatible with mucoid impaction. Fiberoptic bronchoscopy revealed mucoid impaction in the right lower-lobe bronchus. The concentration of CEA in bronchoalveolar lavage fluid was also high (6100ng/ml). Lavage was done five times and the impaction was removed completely. The concentrations of CEA in serum and in bronchoalveolar lavage fluid decreased to 3.4ng/ml and 621.9ng/ml, respectively.

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A 25-year-old, previously healthy man was referred to us because of fever, left-sided chest pain, and an abnormal mass shadow at the left pulmonary hilum on chest X-ray films. Laboratory tests and fiberoptic bronchoscopy revealed no abnormality. Thoracotomy was done because a mediastinal tumor was suspected. Surgery revealed that the left lingula was atelectatic and that the mass was in the left S⁴, not in the mediastinum. Pathological examination of tissue from the partially resected lung showed sulfur granules, and a diagnosis of pulmonary actinomycosis was made. At least 80 cases of pulmonary actinomycosis were reported in Japan between 1963 and 1995. Pulmonary actinomycosis is most common among men in the fifth and sixth decades of life, and almost all patients have oral disease. Pulmonary actinomycosis is often difficult to distinguish from lung cancer, because both appear as mass shadows on X-ray films, and almost all cases of pulmonary actinomycosis are diagnosed by thoracotomy.

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In a 65-year-old man with chronic obstructive pulmonary disease and acute respiratory failure, bi-level positive airway pressure device (BiPAP^®) was used as part of weaning from mechanical ventilation. As an outpatient, he had had dyspnea of grade V (Hugh-Jones) and was hypercapnic (PaCO₂ of 70torr) and hypoxemic (PaO₂ of 60torr), while he was receiving oxygen at 2L/min via nasal cannula. Acute respiratory failure developed due to pneumonia, and mechanical ventilation was begun. However, he could not be weaned with a standard weaning technique (T-piece). On the fifth day of mechanical ventilation, he was extubated and treatment with BiPAP^® was begun. He did not complain of dyspnea even though PaCO₂ did not decrease, which indicates that BiPAP^® reduced the work of breathing. Use of BiPAP^® might make reintubation unnecessary when acute ventilatory failure develops soon after extubation in patinets with COPD.

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We encountered three cases of thymic hyperplasia associated with hyperthyroidism. Case 1 was in a 35-year-old woman; a chest CT scan showed an anterior mediastinal mass and right-sided pleural effusion, which suggested the presence of a thymoma. Case 2 was in a 21-year-old man who complained of palpebral ptosis and also had myasthenia gravis (Osserman type I). Case 3 was in a 47-year-old woman; a chest CT scan showed thymic hyperplasia and mediastinal lymphadenopathy.
In all cases, anti-thyroid medication was given first, because of the associations with hyperthyroidism. Moreover, in cases 1 and 2 no tumor was found, and only hyperplasia was detected in the thymus, although both patients underwent extended thymectomy. Furthermore, surgery was not effective against the hyperthyroidism (anti-thyroid medication could not be withdrawn or reduced).
In cases 2 and 3, thymic hyperplasia, as seen on chest CT scans, resolved as thyroid function was normalized by anti-thyroid medication. The pretracheal lymphadenopathy seen in case 3 also resolved.
Thymic hyperplasia may have been a result, not a cause, of hyperthyroidism. When we encounter patients with thymic masses and hyperthyroidism, we should give anti-thyroid medication and observe the thymus for some time before resorting to surgery.

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A 28-year-old woman was admitted to our hospital because of chest pain. A chest roentgenogram and a chest computed tomogram revealed many nodular shadows on both sides. Examinations of specimens obtained by and by transbronchial lung biopsy during fiberoptic bronchoscopy were not diagnostic, and therefore video thoracoscopic lung biopsy was done. The lung lesion was characterized by aggregates of epithelioid cell granulomas, along with granulomatous and necrotizing angitis. We therefore diagnosed necrotizing sarcoid granulomatosis, and began to administer prednisolone. The nodular shadows disappered within four weeks. In this case video thoracoscopic lung biopsy was useful in the diagnosis of necrotizing sarcoid granulomatosis in the lung.

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A 58-year-old woman because of coughing and an abnormality on a chest renggenogram was referred to our hospital. A chest X-ray film and a computed tomogram revealed atelectasis of the right lower lobe and a round tumor inthe left lower lobe. Fiberoptic bronchoscopy revealed an endobronchial Polypoid tumor in the intermediate bronchus, which completely obstructed the orifice of the right lower-lobe bronchus. Microscopical examination revealed B-cell diffuse, large, non-Hodgkin's lymphoma. No extrapulnonary lesion was found, and therefore primary pulmonary non-Hodgkin's lymphoma was diagnosed. Chemotherapy resulted in rapid and complete regression of the tumor, which was confirmed endoscopically and histologically. The patient was still in complete remission 8 months after the end of chemotherapy. There have been no additional interventions.

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A 74-year-old man was admitted to our hospital because of edema of the lower legs, fever, and increasing fatigue. Laboratory evaluation revealed proteinuria, microhematuria, leukocytosis, thrombocytosis, anemia, a high level of C-reactive protein. A test for myeloperoxidase-antineutrophil cytoplasmic antibodies was highly positive. Microscopic polyarteritis nodosa was diagnosed and therapy with prednisolone was begun. Examination of a renal biopsy sample showed necrotizing crescentic glomerulonephritis. A chest roentgenogram and CT scan disclosed bilateral basilar interstitial changes. Six months later, the patient was admitted again because of disturbance of consciousness, malnutrition, and hyponatremia. After admission, alveolar infiltrates developed in the right lung and the patient died on the 5th hospital day as a result of respiratory failure. An autopsy revealed Candida pneumonia of the right lung and massive intra-alveolar hemorrhage, which was believed to have caused the respiratory failure. Other findings were usual interstitial pneumonia, cellular small-vessel angiitis in the lungs, and healed angiitis in the kidneys and liver. In this case of microscopic polyangiitis and chronic interstitial pneumonia, steroid therapy was effective against the angiitis, but the patient died of an opportunistic infection and alveolar hemorrhage.

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We encountered two patients with summer-type hypersensitivity pneumonitis that developed in Nagano Prefecture. Patient 1 was a 61-year-old man who had worked in warm and humid environments as painter. He was referred to our hospital because of fever, coughing and exertional dyspnea. Respiratory symptoms developed during work but were gone within in few weeks. Patient 2 was a 50-year-old housewife who was admitted to our hospital because of persistent coughing and a low-grade fever. In both patients, chest roentgenograms and computed tomograms showed bilateral, small, nodular and reticular shadows. Examination of a specimen obtained from patient 2 by transbronchial lung biopsy revealed alveolitis. In both patients, bronchoalveolar lavage fluid had low CD4/8 ratios, but in patient 1 the lymphocyte fraction was high and in patient 2 the neutrophil fraction was high. A steroid drug was given to patient 1 because of the patients symptoms and prologed abnormal roentgenographic findings. Patient 2 reacted positively on a provocation test when returned to her house. Serum from both patients contained antibodies to Trichosporon mucoides and T. asahii. We know of no previous reports of summer-type hypersensitivity pneumonitis that developed in Nagano prefecture.

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