Background. Although the finding of small pulmonary nodules and bronchiectasis in the diagnostic imaging of the thorax suggests nontuberculous mycobacterial (NTM) lung disease, isolation of the bacterium from sputum is often difficult. Objective. The usefulness of bronchial washing for diagnosing NTM lung disease in patients with small pulmonary nodules and bronchiectasis was evaluated. Methods. The study subjects included patients who visited our hospital between May 2002 and December 2009 and who were suspected of having NTM lung disease on the basis of the finding of small pulmonary nodules and bronchiectasis in diagnostic imaging. Bronchial lavage fluid from 76 patients (whose sputum could not be collected for bacterial culture, or whose sputum smears and polymerase chain reaction (PCR) samples showed no evidence of nontuberculous acid-fast bacilli) was analyzed by acid-fast staining, culture and PCR. Results. The results of NTM culture of bronchial lavage fluid indicated NTM lung disease in 44 patients (58%). In total, 96% of the patients studied were given diagnoses of NTM lung disease based on this test and sputum cultures. Diagnosis of this disease was possible in 29 (51%) of the 57 patients whose sputum culture did not reveal NTM infection. Among the 9 patients from whose sputum culture NTM had been isolated only once, a high percentage (78%, 7/9 patients) was given a diagnosis of this disease. Conclusion. Bronchial washing enabled the isolation of NTM from 58% of the patients who had presented with small pulmonary nodules and bronchiectasis, suggesting NTM lung disease on thoracic diagnostic imaging, but for NTM was not found in sputum smears or PCR. Bronchial washing may be useful in diagnosing NTM lung disease, because it often enables diagnosis even in cases in which NTM cannot be isolated from sputum culture.

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Background and Purpose. The effectiveness of video-assisted thoracoscopic surgery (VATS) for adult acute thoracic empyema has recently been reported. However, the optimal duration of postoperative antibiotic treatment remains unclear. Patients and Methods. We reviewed the records of 22 adult patients with acute thoracic empyema who underwent VATS and postoperative short-term antibiotic treatment in our institution from March 2005 to July 2010. Results. The patients were 20 men and 2 women, with a mean age of 65.5 years (range, 46-86). The mean duration from diagnosis to VATS was 19.1 days (range, 3-45), and the mean time of operation was 162.8min (range, 83-287). The mean durations of postoperative drainage and hospital stay were 9.7 days (range, 6-17) and 16.5 days (range, 8-49), respectively. The mean duration of postoperative antibiotic administration by IV infusion was 5.7 days (range, 3-10), and no oral antibiotics were administered. Only one recurrence of partial thoracic empyema due to the recurrence of a lung abscess was observed. However, that case was treated successfully with drainage and additional antibiotic administration by IV infusion for 7 days, and the patient was discharged from hospital. The remaining 21 cases had uneventful postoperative courses. No recurrence of empyema was observed in any patients after discharge. Conclusion. VATS with short-term antibiotic treatment is a safe and effective management strategy for adult patients with acute thoracic empyema.

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Background. Pulmonary complications after hematopoietic stem cell transplantation (HSCT) are common and sometimes fatal. Although they are classified as either infectious or non-infectious, they are often difficult to differentiate, and therefore bronchoscopy is considered an important tool for investigating such complications. Objective and Methods. In the present study, we compared the clinical characteristics of pulmonary complications that developed in patients with hematological diseases after HSCT with those that developed in patients who had not undergone HSCT. We retrospectively analyzed the underlying diseases, chest radiological findings, bronchoscopic findings and lung symptom outcomes after bronchoscopy in 42 patients (post-HSCT, n=13; non-HSCT, n=29) to diagnose abnormal chest shadows associated with hematological diseases over the past 10 years at our hospital. Results. Leukemia and multiple myeloma were the most frequently noted underlying diseases in the post-and non-HSCT groups, respectively. Bronchoscopic examinations provided a definitive diagnosis in 12 (92.3%) and 21 (72.4%) patients in the post-and non-HSCT groups, respectively. Among the definitively diagnosed diseases, non-infectious pulmonary complications were more frequently found than infectious diseases in the post-HSCT group (n=8, 61.5%), whereas infectious pulmonary complications were more frequently found than non-infectious diseases in the non-HSCT group (n=15, 51.7%). These findings were significantly different (p=0.02; χ^2 test). Non-infectious pulmonary complications tended to be associated with a poor prognosis in both groups. No serious complications resulted from the bronchoscopic procedure, which positively influenced the subsequent management of lung symptoms in 9 (69.2%) and 15 (51.7%) patients the post-and non-HSCT groups, respectively. Conclusion. We speculate that a history of treatment with HSCT influences the etiology of abnormal chest shadows in patients with concurrent hematological disease.

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Background. Thoracoscopy under local anesthesia is useful in patients with retention of pleural fluid. Case. A 75-year-old woman had undergone a standard radical mastectomy followed by adjuvant chemotherapy for right breast cancer at the age of 60 in January 1995. Her subsequent progress was monitored by endocrine therapy with tamoxifen and fluorouracil for 2 years. She was referred to our hospital 15 years later for medical evaluation and treatment after right pleural effusion was detected on chest X-ray films taken during a regular medical checkup in October 2009. ^<18>F-fluorodeoxyglucose positron-emission tomography (^<18>FDG-PET) showed abnormal accumulation in the lower lobe of the patient's right lung, cervical vertebrae and thoracic vertebrae. Her serum CA15-3 level was elevated (30.9U/ml) and breast cancer with pulmonary metastasis and multiple bone metastasis were suspected. Examination of her pleural effusion obtained by thoracocentesis did not yield a definitive diagnosis, so thoracoscopy under local anesthesia and bronchoscopy were performed. Recurrent breast cancer with carcinomatous pleuritis, pulmonary metastasis, and multiple bone metastasis were diagnosed. Conclusion. Respiratory endoscopy was very useful in the diagnosis of recurrent breast cancer with carcinomatous pleuritis, pulmonary metastasis and also for the differentiation of the lung cancer lesion.

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Background. The usefulness of bronchial artery embolization (BAE) has been established as a treatment of hemoptysis. However, it can be time-consuming to identify the source of bleeding by conventional bronchial angiography. Although some authors have reported the usefulness of multidetector-row computed tomography angiography (MDCTA) to locate the bleeding site, it is not commonly performed before BAE. Case. A 56-year-old woman, who was previously given a diagnosis of diffuse panbronchiolitis at age 23 was admitted to our hospital complaining of hemoptysis in June, 2007. Subsequently, she required frequent hospitalization to treat repeated hemoptysis. Bronchoscopy revealed that the orifice of the left lingular bronchus was occluded by coagulation, and suggested that the source of the bleeding was in the left superior segment. MDCTA showed an abnormally dilated bronchial artery arising from the descending aorta and distributing to the left main bronchus. Conventional bronchial angiography, which was performed before BAE, demonstrated images similar to those seen by MDCTA. BAE was successfully accomplished using 6 microcoils. She has not experienced hemoptysis nor been admitted to hospital since she underwent BAE. Conclusion. MDCTA for patients with hemoptysis is useful to determine whether BAE is indicated, and to conduct the procedure effectively.

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Background. We report a patient who underwent tracheoplasty for tracheal stenosis which was suspected to have been caused by endotracheal intubation on surgery performed 34 years previously. Case Report. A 67-year-old woman underwent uterine myomectomy under general anesthesia at age 33. Respiratory symptoms immediately developed, but she left them untreated. Recently, an upper respiratory infection triggered an acute exacerbation of her dyspnea, and a detailed examination revealed tracheal stenosis. She underwent endoscopic balloon dilatation, which was complicated by a tracheal tear. In addition, she suffered airway edema with respiratory failure, for which tracheal intubation was performed. Because of the need for invasive treatment, we performed tracheal sleeve resection and reconstruction by tracheoplasty. Currently, about 2 years after surgery, the patient is doing well. Conclusion. We speculate that the tracheal stenosis progressed slowly over a 34-year period, resulting in the gradual development of symptoms. This case suggests that, if patients with a history of endotracheal intubation develop respiratory symptoms, we should consider the possibility of tracheal stenosis, provide appropriate medical care, and perform tracheoplasty for severe tracheal stenosis, if indicated.

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Background. We encountered a very rare case of multiple aspergillomas in a patient treated with steroid and immunosuppressive drugs for rheumatoid arthritis. Case. An 89-year-old man presented with pyrexia and dyspnea. We suspected interstitial pneumonia, pulmonary aspergillosis and bacterial pneumonia based on the findings of chest X-ray films, computed tomography (CT), and blood data. Therefore, we gave him antibiotic intravenous agent (meropenem) and antifungal oral agent (voriconazole). We also continued steroid and immunosuppressive drug administration. Subsequently, his inflammation and general condition fluctuated between repeated improvement and exacerbation for about 5 months, and finally, he died of pneumonia. We performed an autopsy and found many bullae in bilateral lower lobes, fungus balls of aspergillus in the bullae, and lung abscesses caused by cocci. Conclusion. The imaging findings of this case were atypical, so it was difficult to clinically diagnose aspergillosis. Autopsy and pathological diagnosis were extremely useful in diagnosing this case.

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Background. Pleural involvement in sarcoidosis is relatively rare. We report a case of pleural sarcoidosis diagnosed by thoracoscopy in combination with narrow band imaging (NBI) under local anesthesia. Case. A 65-year-old woman was admitted, and was histological diagnosis of having sarcoidosis based on small nodules in the lungs, with mediastinal and bilateral hilar lymph node swelling and skin involvement, in July, 2001. Lung involvement gradually developed and right pleural effusion appeared in July, 2006. She was readmitted for further examinations. Thoracoscopy revealed multiple white nodules in the visceral and parietal pleura. NBI yielded clear images of white nodules with distinct margins. The pathological findings of the nodules showed non-caseous epithelioid cell granulomas, and a diagnosis of pleural sarcoidosis was made. Conclusion. Medical thoracoscopy was effective for the diagnosis of pleural sarcoidosis. In addition, thoracoscopy in combination with NBI was effective for imaging pleural nodular lesions.

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