Background. Primary pulmonary malignant melanoma is very rare, and only a few cases have been reported in Japan. Case. A 40-year-old female presented with wheezing, cough and bloody sputum. CT showed a mass in the left lower lobe. A bronchoscopic examination was performed and showed a polypoid black-colored tumor in the left basal bronchus. Transbronchial biopsy showed a large number of melanocytes, and the pathological diagnosis was malignant melanoma. The patient also had brain metastasis and was transferred to another institution. She received both chemotherapy and immunotherapy, and showed temporary improvement. However, she finally died of left total atelectasis and growth of the brain metastasis 30 months after the first medical examination. We performed an autopsy, but detected no other lesions except those in the lung and brain. Therefore, we diagnosed this case as primary pulmonary malignant melanoma. Conclusion. Malignant melanoma generally occurs in the skin, and lung lesions are mostly metastases from the skin. However, the present case is thought to have had primary pulmonary malignant melanoma based on the autopsy findings. We herein report this rare case and provide a review of the previous literature.

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Background. Healthy adults sometimes accidentally swallow a nail at work. Case. A 38-year-old man accidentally swallowed a U-shaped nail during electrical wiring work and was referred to our hospital. A chest X-ray revealed a foreign body in the left hilar region of the lung. After sedation by midazolam, flexible bronchoscopy was performed and revealed that the U-shaped nail was located in the left second carina with the sharp tip pointing toward the central line of the body. The risk of airway injury during the removal was considered high because the size of the nail (13 mm wide and 20 mm long) was larger than the diameter of either the intubation tube or rigid bronchoscope. In order to protect the airway, we used an overtube commonly used for digestive endoscopic procedures for the endotracheal intubation. We grasped the U-shaped nail tightly with alligator forceps and successfully removed it through the overtube. Conclusion. An overtube is useful for the protection of the airway from injury in removal of sharp and large airway foreign bodies.

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Background. Bordetella bronchiseptica, a known causative pathogen of anthroponotic infectious diseases, has only been detected in humans in a few reports and rarely colonizes in the lower respiratory tract. Case. A 57-year-old woman developed bronchiectasis from a childhood respiratory tract infection and since her youth had suffered from frequent recurrences of lower respiratory infection. Nocardia infection had been previously confirmed from specimens obtained by bronchoscopy, and treatment was provided accordingly. This time, the presence of Bordetella bronchiseptica was verified by bronchoscopic examination performed in the search for a cause of aggravated symptoms, and these symptoms improved after treatment with clarithromycin. Discussion. Bordetella bronchiseptica is a glucose non-fermentative Gram-negative bacillus, belonging to the same genus as Bordetella pertussis. According to the literature, Bordetella bronchiseptica is known to establish chronic lower respiratory infections via several mechanisms. Only one case has previously been reported in Japan: a case of chronic lower respiratory infection, as was the present case. Our experience provides valuable insight, because appropriate therapy for illness due to this organism has not been confirmed. Conclusion. We reported a case of bronchoscopy as a useful method for detecting and identifying causative bacterial species.

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Background. Intravascular large B-cell lymphoma (IVLBCL) is a disease with poor prognosis. It is important to diagnose and treat as soon as possible. Spontaneous regression can be confirmed in rare cases. Case. A 67-year-old man had spontaneous regression of fever, cytopenia, swelling of the liver and spleen, and elevated AST and ALT levels three and half and also two years ago. He presented to our hospital with the same symptoms. Because of increasing serum LDH and soluble interleukin-2 receptor (sIL-2R) levels, malignant lymphoma was suspected. However, the diagnosis was not confirmed by bone marrow and random skin biopsies. Dyspnea emerged two weeks after the patient first visited our hospital, and chest X-ray film and chest CT scan showed diffuse ground glass opacity. A transbronchial lung biopsy (TBLB) was performed, and we confirmed a diagnosis of IVLBCL. Surprisingly, the abnormalities of the chest X-ray film had spontaneously disappeared before the first treatment. Conclusion. This is a case of IVLBCL diagnosed by TBLB. Despite the clinical course and laboratory findings suggesting IVLBCL, we could not obtain the diagnoses by bone marrow biopsy and random skin biopsy. This is a rare case in which abnormalities of the chest X-ray film spontaneously disappeared after TBLB and before the treatment was started. We therefore report this case with some literature review.

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Case. A 66-year-old woman, who had been found to have asthma during a follow-up examination of rheumatoid arthritis, had received combined treatment with inhaled steroids and β_2-agonists for one year. The presence of ground-glass opacity was observed in both lungs on chest computed tomography, therefore she was referred to our department. A respiratory function test showed severe obstructive ventilatory impairment [FEV_<1.0> 1,000 ml (50.5%), FEV_<1.0>/FVC 45.7%], and these findings were unresponsive to an inhaled bronchodilator. Laboratory data showed peripheral eosinophilia (2,170/μl). Surgical lung biopsy specimens demonstrated a variety of histopathological findings, which included follicular bronchiolitis, organizing pneumonia, and airway infiltration of eosinophils. The patient's respiratory function improved [FEV_<1.0> 1,670 ml (84.3%), FEV_<1.0>/FVC 62.6%] in response to systemic treatment with corticosteroids. We herein report a case of rheumatoid arthritis presenting with diverse findings in her lung pathology, although drug-induced lung injury could not be ruled out. Conclusion. Pulmonary involvement in patients with rheumatoid arthritis could be detected by not only lung images but also various examinations, such as pulmonary function tests.

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Background. Herpes esophagitis is a relatively rare disease, which occurs in patients with cancer or immunodeficiency. To the best of our knowledge, there have been no case reports of patients with herpes esophagitis and the formation of an esophagotracheal fistula. In this report, we demonstrate the usefulness of a custom-made silicon airway stent for closure of esophagotracheal fistulas caused by herpes esophagitis. Case. A 79-year-old woman developed dysphagia, severe coughing during swallowing, and hoarseness, and visited a hospital for thorough examination. Left recurrent laryngeal nerve paralysis was detected by laryngeal fiberscopic examination, and a left hilar tumorous shadow and an esophageal tracheal fistula were observed on computed tomography. Biopsy of the esophageal wall around the fistula was performed by upper gastrointestinal endoscopy, and herpes esophagitis with an esophagotracheal fistula was diagnosed. After treatment with acyclovir, the patient was referred to our hospital for closure of the fistula. The fistula was successfully closed by airway stent placement using a custom-made Dumon Y stent under rigid bronchoscopy. The patient became capable of ingesting orally after undergoing swallowing rehabilitation. Conclusion. There are no reports to our knowledge of patients in Japan with herpes esophagitis who had an esophagotracheal fistula. Custom-made silicon airway stent placement may be an effective and useful treatment as an option for fistula closure.

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Objectives. ACC is a rare malignancy that may also originate in the trachea. Surgical resection is the mainstay of treatment for tracheal ACC but the size and location of the tumor, and the coexistence of underlying diseases can make the surgical procedure very difficult. We performed tracheoplasty using a pedicled autologous bronchial flap in a case of ACC that originated from the lower trachea with malignant invasion to the right main bronchus. The surgical procedure was safe and resulted in an effective closure of the tracheal defects. Case. A 59-year-old woman who had abnormality recognized on a medical checkup was admitted to our hospital. Bronchoscopic examination showed a tumor was growing from the right upper lobe bronchus and extended downward to the right lateral wall of the trachea. The tumor was diagnosed as ACC. The invaded lateral wall of the trachea and the right main bronchus were resected. The reconstruction was done by suturing the remaining portion of the bronchus to the tracheal defect using interrupted 3-0 Maxon absorbable sutures on the tracheal cartilages, and the membranous portion of the trachea was interrupted with a 3-0 Maxon running suture. A bronchoscopy study performed on the 24th day after operation disclosed a well vascularized anastomotic region. Conclusions. Multiple surgical complications (e.g., infection, dehiscence, migration, stenosis) can occur when the carina or tracheobronchial angle is invaded by cancer of the upper lobe and main bronchus. This surgical procedure is safe and effective to close tracheal defects after non-circumferential resections, in particular, when end-to-end reconstruction is risky.

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Background. We encountered a case of paradoxical reaction (PR)-like bronchial tuberculosis after discontinuation of infliximab (IFX), an anti-TNF-α drug, at the onset of tuberculosis. Case. A 28-year-old man began to cough during treatment of Crohn's disease by IFX. Miliary tuberculosis was diagnosed by bronchoscopy. His doctor stopped IFX and initiated standard anti-tuberculosis therapy. Four months after initiation of tuberculosis treatment, his symptom and chest X-ray worsened, and acid-fast bacilli were positive in sputum smear although the culture of the sputum turned out to be negative. In bronchoscopy, the left main bronchus was edematous and narrowed. Lymphadenopathy was observed around the left 2nd carina, and the B^6 bronchus was constricted. Acid-fast bacilli smear in bronchial washing fluid from B^6 bronchus was negative. Therefore, we diagnosed the exacerbation as PR. After continuation of the same treatment of tuberculosis for half a year, bronchoscopic examination showed improved bronchial constriction. Conclusion. PR, caused by augmented immunity after cessation of IFX therapy, worsened lymphadenopathy. The content of lymph nodes were disseminated to the surface of bronchi, causing bronchial and smaller airway inflammation like bronchial tuberculosis.

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Background. A huge hematoma progressed and was remarkably enhanced by hemorrhage in chronic expanding hematoma. Case. A 68-year-old man was referred to our hospital for dyspnea. The patient had undergone right pneumonectomy for lung cancer and open window thoracotomy for empyema 15 years previously. The right thoracic cavity became filled with hematoma during two years. The hematoma pressed on the mediastinum remarkable, resulting in tracheal stenosis. The patient developed severe dyspnea and superior vena cava syndrome. Chronic expanding hematoma was diagnosed. The embolization of the hemorrhagic artery was performed for hemostasis. Hematoma dissection was performed. Pathological diagnosis revealed that the pleura which was also removed had squamous cell carcinoma. Surgery can improve symptoms, but hematoma began to increase again. The general condition worsened, and the patient died. Conclusion. Chronic expanding hematoma was the main cause of the hematoma. However, the carcinoma which recurred in the pleura affected the clinical course. Because the hematoma pressed the mediastinum and resulted in severe tracheal stenosis, the surgical treatment for this disease was difficult.

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Background. Pulmonary metastasis of renal cell carcinoma is often accompanied by hypervascularity. It is known that we should note bleeding at the time of bronchoscopic biopsy. Case. A 62-year-old man underwent nephrectomy to treat renal cell carcinoma 10 years previously. Chest CT disclosed a well-enhanced nodular shadow in the right upper lobe of the lung. Bronchoscopic findings showed stenosis, enlarged vessels and pulsatile protuberance, so we avoided biopsy for fear of bleeding. Because pulmonary metastasis was considered, right upper lobe resection was performed. Histological examination of the resected lung revealed metastasis of renal cell carcinoma. Section specimen of the pulsatile lesion showed a large muscular artery and vein between the tumor and bronchial mucosa, and an arteriovenous fistula was formed in the adjacent area. The pulsatile lesion revealed by bronchoscopy was diagnosed as dilated artery and arteriovenous fistula. Conclusion. Abnormal blood vessels were confirmed around pulmonary metastasis from renal cell carcinoma pathologically.

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Background. Aspiration of foreign bodies into the bronchus frequently occur in children as well as in elderly people. It is rare that spontaneous expectoration of the foreign body from the bronchus improves atelectasis after a few months. Case. A 71-year-old Japanese woman suffered from nonproductive cough, fever, and dyspnea for 3 months. Chest computed tomography (CT) showed right lower lobe atelectasis. Bronchoscopy revealed that a foreign body was embedded in the right basal bronchus which had reddish and edematous bronchial walls. She did not remember the causative accidental inspiration of the foreign body. Endoscopic removal of the foreign body or a surgical approach was proposed, but she did not want to undergo such further treatments. Therefore, treatment with a total of clarithromycin for 2 weeks and levofloxacin for 2 weeks was applied to treat obstructive pneumonia, and then she was followed up. Four months after the first symptom (1.5 months after starting antimicrobial treatment), she suddenly expectorated a citrus fruit seed of 1 cm in size on coughing. After then, right lower atelectasis improved on chest CT, and symptoms of cough also improved. Conclusion. We encountered a case of right lower atelectasis caused by bronchial foreign body that was improved by spontaneous expectoration of a citrus fruit seed 4 months after the first symptom.

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