We encountered 4 patients (8.3%) with late bronchopleural fistula (BPF) out of 48 cases of pneumonectomy for lung cancer. They were all men with an average age of 66.8 years and there were two cases each of left and right completion pneumonectomy. Their early postoperative courses were uneventful. The mean period from pneumonectomy to occurrence of BPF was 91.0 days (48∿179 days), and it took 7.3 days (3∿11 days) from the appearance of symptoms to admission for the 3 symptomatic cases. All bronchial stumps had been closed by manual folding sutures (by infolding and suturing the membranous portion inside after Sweet's procedure). This method showed a significantly high frequency of late BPF (19.0%) compared to other methods. In three patients, the BPF were confirmed to be at the angles of their infolded bronchial stumps. Three patients with symptoms died due to pyothorax or pneumonia and one case was healed following omentopexy and modified Clagett's operation. On the other hand, no late BPF occurred in 7 cases in which the bronchial stump was covered with the thymus, omentum, pericardium or parietal pleura, including 2 patients with manual folding sutures. In late BPF it is important to start treatment as soon as possible and to decide upon the surgical operation without missing the opportunity.

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This study was designed to clarify role of H_2O_2 released by neutrophils and macrophages in the pathogenesis of interstitial pneumonia in terms of idiopathic interstitial pneumonia (IIP) and rheumatoid arthritis interstitial pneumonia (RA-IP). To accomplish this, H_2O_2 production by neutrophils and macrophages in bronchoalveolar lavage fluid (BALF) were measured in 8 patients with IIP or RA-IP and compared to 6 normal controls and 7 patients with sarcoidosis. Both spontaneous and PMA-induced H_2O_2 production by neutrophils from patients with IIP and RA-IP was higher than that from normal controls and sarcoidosis. However, H_2O_2 production by macrophages was not significantly different between IIP, RA-IP, normal controls and sarcoidosis. These results surggested that in IP, macrophages and neutrophils produced H_2O_2, the most important source of H_2O_2, in the development of fibrosis, was neutrophils.

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Occasionally, mycobacterium is detected from bronchial lavage fluid (BLF) even in patients without any sign of pulmonary tuberculosis. In contrast, we sometimes experience BLF smear-positive culture-negative (SPCN) cases in these patients. To determine the significance of mycobacterium detection in BLF, we studied 75 smear or culture positive samples in the past four years at our hospital. We compared results between sputum and BLF examination in these cases. Atypical Mycobacterium (AM) was detected in 33% of BLF and in 7% of the sputum respectively. These results lead us to consider that AM caused BLF SPCN because its growth was limited in the culture medium. Therefore, we examined five BLF SPCN cases using three different media, common 3% Ogawa medium, 2% Ogawa medium and Ogawa K medium. No colony was found in any of the cases. We then cultured smear positive BLF using Ogawa medium without NaOH, which is toxic to particular AM strains. Mycobacterium was found in 63% of the cases compared to 36% when common Ogawa medium was used. More AM was confirmed from BLF when Ogawa medium without NaOH was used. From these results, we conclude that AM is more frequent than mycobacterium tuberculosis in SPCN BLF, and Ogawa medium without NaOH is useful for the detection of the atypical mycobacterium.

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A 28-year-old woman suffering from Japanese cedar pollinosis was admitted in October 1992 because of severe intractable cough which was resistant to bronchodilators and antibiotics. The patient had had similar episodes of coughing in autumn but not in other seasons in the previous 2 years, and had never had wheezing. Chest X-ray films and pulmonary function tests were normal. Methacholine challenge test results were negative. Serum IgE antibodies against house dust, mites and Japanese cedar pollen were positive. Since no obvious causes of coughing were found and allergy was suspected, specific immunotherapy for house dust and Japanese cedar pollen was initiated. The patient has been free of coughing for the past 4 years. This case provides suggestions as to the relationship between persistent cough and allergy.

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A 57-year-old man in whom acute adult T-cell leukemia (ATL) had been diagnosed and in whom partial response had been maintained for one year was admitted with high fever, inguinal lymphadenopathy and exertional dyspnea. His chest X-ray film showed bilateral infiltration shadows, but no organism was detected in his sputum. Bronchoalveolar lavage (BAL) was performed for diagnosis of the pulmonary lesion. There were abundunt ATL tumor cells and a few cysts of pneumocystis carinii in the BAL fluid. He received chemotherapy for ATL and pneumocystis carinii pneumonia, and his pulmonary lesion disappeared immediately.

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We report two cases of atypical mycobacterial infection inside cavitated lesions which were directly observed by fiberoptic bronchoscopy. The first case was a 66-year-old man who was admitted with low grade fever and increase of abnormal shadow on the chest X-ray film. Mycobacterium fortuitum infection was diagnosed. A cavity was revealed in the left upper lung field on the chest X-ray film. The cavity was visualized from the peripheral site of B^<1+2> by fiberoptic bronchoscope. The inner surface of the cavity was edematous and dark red. The second case was a 60-year-old woman. She was admitted to this hospital because of hemoptysis. The chest X-ray film showed an irregular inner wall of the left cavity which communicated with the upper division of the left bronchus. The cavity was visualized from the peripheral site of upper division bronchus by fiberoptic bronchoscope. The inner surface of the cavity was edematous and partly dark red and partly pale. Mycobacterium avium complex was cultured from the washing fluid of the inner side of the cavity. The bronchoscopic findings of the inner surface of cavities in these cases resembled that of aspergillosis. One marked difference however, was the quantity of white coating material. In the case of aspergillosis, large amounts of white coating material were found on the surface of cavity. But only a small amount of white coating material was seen on the surface of the cavity in the case of atypical mycobacterial infection. This may be one of the characteristics of atypical mycobacterial infection.

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A 52-year-old man admitted with right pneumothorax. A chest tube drain was inserted and 1 hour later productive cough with protein-rich sputum developed. Chest roentogenogram showed bilateral infiltrating shadows. Re-expansion pulmonary edema was diagnosed. Bronchoalveolar lavage fluid obtained from the right middle lobe bronchus was protein-rich contained and abnormally high levels of CA19-9. The serum CA19-9 level was normal. These BALF findings were interest in analyzing the etiology of re-expansion pulmonary edema.

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A 20-year-old man underwent tracheal intubation and mechanical ventilation because of airway burn due to a fire. Bronchoscopy revealed bronchial mucosa to be diffusely covered with soot so repeated bronchial lavage was performed using saline. His condition gradually improved and he was extubated on the 12th day. Multiple mucosal protrusions were seen on the surface of the tracheobronchial mucosa on the 37th day, following which hoarseness and exertional dyspnea appeared. The protrusions were diagnosed as inflammatory polyps by biopsy. Because of increasing dyspnea due to subglottic stenosis recognized on CT carried out on the 121st day of illness, he underwent tracheostomy and was followed up in the outpatient clinic. Fourteen months after injury the tracheal stenosis had improved.

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We encountered two patients with relapsing polychondritis (RP), who initially presented only with respiratory symptoms. Steroid was not effective for one patient whose outcome was dismal. The other patient was maintained on steroid therapy (PSL 10mg) for one year, after which polychondritis relapsed. In the first patient, the stenosis of bronchus was detected by computed tomography. In the second patient, high-resolution computed tomography detected the thickened third and fourth bronchi which markedly improved after treatment. We consider that CT and HRCT are very helpful detecting early tracheobronchial manifestations of RP and also in assessing the effect of treatment.

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A 66-year-old man presented with a history of hoarseness for one year and cough for one month. The chest X-ray film showed an abnormal shadow in the right upper lung field, and the CT scan showed a tumor shadow on the right side of the 6th thoracic vertebra. Bronchoscopic findings showed peculiar protrusions, redness and edema as far as the segmental bronchus of both bronchial tree. Biopsy of the protrusions showed non-specific chronic inflammatory change. Exploratory thoracotomy yielded a diagnosis of Castleman's disease. After steroid treatment, the mediastinal tumor decreased in size and the bronchial protrusions disappeared. The peculiar protrusions seem to have been caused by Castleman's disease.

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A 71-year-old man was admitted to our hospital for treatment of lung cancer. The cancer was located in the left main bronchus and protruded into the carina. In order to determine whether left pneumonectomy was possible or not, endoscopic electrosurgery was performed using a new bronchofiberscope and a snare developed for electrosurgery. A new device to protect against electric shock was attached to the bronchofiberscope. The new snare was able to open widely in narrow spaces. Theatment was done safely and quickly with this equipment. The new equipment was useful because of decreased risk of electric shock and increased handling ability.

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A 58-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray film. Chest CT scans revealed a markedly enhanced round lesion adjacent to the pulmonary artery in left S^6. A pulmonary aneurysm was suspected, but pulmonary arteriography showed no abnormality. As bronchial arteriography revealed a vascular network like the peel of a mask melon, sclerosing hemangioma was suspected. Intraoperative diagnosis of the frozen section revealed a malignant tumor and left lower lobectomy was performed. Pathologically, the tumor was a typical carcinoid. Both sclerosing hemangioma and carcinoid appear as round tumors with distinct borders and have similar findings on bronchial arteriography. Differential diagnosis by imaging of these two diseases can be very difficult.

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Few cases of surgical treatment of malignant pulmonary disease complicated by pleural empyema have been reported. A 66-year-old man underwent resection for acute pleural empyema following preoperative fiberoptic bronchoscopic examination for primary lung cancer. Two days after fiberoptic bronchoscopic lung biopsy and bronchoalveolar lavage, the patient had a high fever and left-side chest pain due to pleural empyema. After chest drainage and adminstration of antibiotics, left pneumonectomy and resection of the empyemal cavity were performed. The patient received intrathoracic irrigation and reinforcement of the bronchial stump using pedicled intercostal muscle. The postoperative course was uneventful. It should be remembered that lung cancer might be complicated by pleural empyema resulting from fiberoptic bronchoscopic examinations.

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