Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a highly accurate diagnostic modality that is considered to be minimally invasive. Recently, EBUS-TBNA has become increasingly adopted in many institutions in Japan. However, it is sometimes difficult to perform EBUS-TBNA under local anesthesia because of the extended examination time. Purpose. The purpose of this study was to evaluate the discomfort level during bronchoscopic examination in EBUS-TBNA. We retrospectively analyzed the differences in discomfort between conventional bronchoscopic examination (CBE) and EBUS-TBNA using a questionnaire survey. Method. The Japan Society for Respiratory Endoscopy, Guidelines Development Committee conducted a questionnaire survey about discomfort levels during bronchoscopic examination from September 2008 to March 2009. The same survey was used after bronchoscopic examination and the charts were retrospectively reviewed. A visual analogue scale (VAS) was used to evaluate the discomfort level. Local anesthesia with mild conscious sedation using midazolam was used in all cases. Results. In total, 108 patients (79 EBUS-TBNA, and 29 CBE cases) were enrolled. No significant difference in discomfort level during examination was observed between EBUS-TBNA and CBE cases (p=0.9724). The average discomfort level over 5 evaluation phases in EBUS-TBNA was 1.95. The average examination time of EBUS-TBNA was 24 minutes, which was significantly longer than CBE (p<0.0001). However, the midazolam dose was significantly higher in the EBUS-TBNA group (p<0.0001); as a result, only 19% of patients in this group clearly remembered the examination. Conclusion. It appears that EBUS-TBNA using local anesthesia and mild conscious sedation can be performed without an increase in discomfort level. Adequate local anesthesia procedures and appropriate sedatives are important to minimize discomfort.

View full abstract

Background. Amyloid deposits are found in many organs, but rarely in the pulmonary system. Case. A 50-year-old man visited our hospital in July 2004, with complaints of wheezing and dyspnea. There was a mass-like lesion protruding into the lumen of the trachea on chest X-ray films and CT. It was diagnosed as amyloidosis by bronchoscopic biopsy. Laser therapy and argon plasma coagulation (APC) were performed in July and August 2004, respectively. His symptoms and pulmonary function test scores improved. After APC was performed again in September 2004, bilateral pneumothorax and pneumomediastinum occurred, and the patient died of massive hemoptysis 9 days after the procedure. Conclusion. We encountered a case of tracheobronchial amyloidosis and performed laser therapy and APC, but the patient died of massive hemoptysis.

View full abstract

Background. There are some reports of a final diagnosis of rheumatic pleurisy obtained by thoracoscopy under general anesthesia, but reports on thoracoscopy under local anesthesia are rare, and thus we present this case report. Case. A 40-year-old man, chief complaints of cough and arthralgia was admitted in December, 2008. Radiographic findings displayed right pleural effusion. In addition to his typical rheumatic symptoms of arthralgia and morning stiffness, his laboratory data disclosed both elevated CCP antibody (1295.8U/ml) and rheumatoid factor (111.9IU/ml). Accordingly, he was given a diagnosis of rheumatoid arthritis. Thoracocentesis revealed an elevated adenosine deaminase level 86.8IU/l. However, in order to differentiate rheumatic pleurisy from tuberculous pleurisy, we performed thoracoscopy under local anesthesia. The parietal pleura was diffusely hypertrophic with granular nodules. Biopsy of the lesion revealed rheumatoid nodules, resulting in a final diagnosis of rheumatic pleurisy. Conclusion. We encountered a case in which thoracoscopy under local anesthesia was efficacious in the diagnosis of rheumatic pleurisy.

View full abstract

Background. Histopathological confirmation of allergic granulomatosis and angiitis (AGA) is based on the presence of extravascular granulomas associated with necrosis and predominant extravascular eosinophils, as well as necrotizing vasculitis. However, none of these lesions is commonly found in transbronchial lung biopsy (TBLB) specimens. Case. A 41-year-old man, who developed bronchial asthma at the age of 38, had been treated with oral corticosteroids for severe persistent asthma. He was referred to our hospital because of dyspnea on exertion, with abnormal chest X-ray images showing multiple consolidations in both lung fields. His leukocyte count was 11,300/μl with eosinophils (3,277/μl) and bronchoalveolar lavage fluid also showed an eosinophilia level of 85.0% of all cells. Tests were seronegative for myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) and no local symptoms due to vasculitis developed. A biopsy specimen obtained by TBLB revealed necrotizing granulomas with eosinophilic infiltration and angiitis, which were consistent with AGA. Conclusion. Diagnosis of AGA can be difficult when local signs due to vasculitis become less obvious because of oral corticosteroid therapy. Histopathological examination by TBLB was helpful for the early diagnosis of AGA in the present case.

View full abstract

Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful and safe procedure, but recently there have been some reports of infectious complications after EBUS-TBNA. Case. A 62-year-old man presented with a small nodule of the right upper lobe, and mediastinal lymphadenopathy. EBUS-TBNA was performed on the #4R lymph node and a pathological diagnosis of squamous cell carcinoma was obtained. Eighteen days after EBUS-TBNA, the patient was admitted to our hospital with chest pain. A therapeutic antibiotics regimen was commenced for the treatment of the mediastinal abscess and pericarditis; however, a cardiac tamponade developed on the second hospital day. Pericardiocentesis and drainage of the mediastinal abscess were subsequently performed. A pericardial effusion culture revealed Streptococcus milleri. The antibiotic regimen continued. He recovered and was discharged on day 32. Conclusion. Rare but severe infections such as mediastinitis may occur after EBUS-TBNA. Prophylactic antibiotic use should be considered in EBUS-TBNA procedures.

View full abstract

Background. The formation of a broncho-bronchial artery fistula is a rare late complication of bronchial artery embolization. We report the case of a patient who coughed up embolization coils because of the presence of a broncho-bronchial artery fistula. Case. A 59-year-old woman was given a diagnosis of racemose hemangioma, and was treated by bronchial artery embolization in October 2006. She visited our hospital in February 2009 because she had coughed-up embolization coils twice. Chest computed tomography (CT) revealed coils protruding into the right main bronchus. She was immediately admitted to the emergency department. After bronchial artery embolization, she underwent a S^2 segmentectomy of the right lung for complete resection of a racemose hemangioma of the bronchial artery. Conclusion. We encountered a patient with racemose hemangioma who coughed up the coils after bronchial artery embolization. It is necessary to consider the correct placement, possible effects, and potential complications of bronchial artery embolization.

View full abstract

Background. It has been previously considered that type 1 congenital pulmonary airway malformation (CPAM) has fewer coexisting malformations; however, in this study we encountered 2 resection cases of type 1 CPAM complicated with abnormal blood vessels. Case. Case 1 was a baby who was born at 30 weeks and 6 days of gestation. From the 29th week of gestation, fetal anomaly was observed on ultrasonography. CPAM was suspected according to the imaging and clinical findings, and a right lower lobectomy was performed at 6 days of age. From the intraoperative findings, an abnormal blood vessel was observed that flowed from the aorta into the right lower lobe. Case 2 was a 4-year-old girl with prolonged pneumonia and a cystic shadow on chest radiograpy. When performing angiography during preoperative scanning, partial anomalous pulmonary venous return and an abnormal bronchial artery were observed, and a left upper lobectomy was performed. In both cases type 1 CPAM was pathologically diagnosed postoperatively. Conclusion. Because CPAM is a disorder requiring resection, we need to carefully consider the possibility of the complication of abnormal blood vessels.

View full abstract

Background. Pulmonary cryptococcosis developing in otherwise healthy people is difficult to distinguish from lung cancer clinically, and is often diagnosed by thoracoscopic lung biopsy. Case. A 51-year-old man had an abnormal chest shadow in a health check, and he visited another hospital. Two nodules in the right pulmonary apex were found, and he was referred to our hospital. Tests for serum cryptococcal antigen, antibody, and tumor markers were all negative. Two independent nodules under the right pulmonary apex were found on chest computed tomography. Bronchoscopy was performed and we obtained bronchoalveolar lavage fluid and smear material from the right B^1a. Exfoliative cytodiagnosis showed class III cells, but we suspected adenocarcinoma. Histology and fungal culture of material obtained by thoracoscopic lung biopsy demonstrated pulmonary cryptococcosis. The patient received chemotherapy with fluconazole (FLCZ) 200mg/day for 3 months, with a successful outcome. Conclusion. We report a case of pulmonary cryptococcosis mimicking lung cancer. In cases in which it is difficult to exclude lung cancer on imaging and bronchoscopic findings, thoracoscopic lung biopsy can be effective for diagnosis.

View full abstract