Background and Objective. Lung abscess after transbronchial biopsy is a serious complication for lung cancer patients. Prophylactic antibiotics have been administered after transbronchial biopsy since 2007 at Showa University Northern Yokohama Hospital to prevent lung abscess accompanying lung cancer. This study attempted to examine the incidence and risk factors of the complications and estimate the efficacy of these prophylactic antibiotics. Methods. From April 2001 to March 2013, 783 patients with peripheral lung cancer underwent bronchoscopic biopsy under X-ray fluoroscopy. We classified patients into the lung abscess complicated group and the non-complicated group and estimated the risk factors for complication using univariate and multivariate analyses. We further classified patients into the early period (April 2001 to March 2007, n=255) or later period group (April 2007 to March 2013, n=528), and retrospectively examined the incidence of lung abscess complicating transbronchial biopsy in each group. Results. During this period, 9 patients (1.1%) developed lung abscesses as a complication. The multivariate analysis identified central necrosis and cavitary lesions as significant risk factors for lung abscess after transbronchial biopsy. The incidence in the later period group was significantly lower than in the early period group (2.4% vs. 0.6%; p=0.028). The incidence of central necrosis or cavitary lesions was significantly higher than for other radiological findings (3.3% vs. 0.6%; p=0.018). With regard to central necrosis or cavitary lesions, although not statistically significant, the incidence in the prophylactic antibiotics group (1.8%) was lower than in the no prophylactic treatment group (7.9%). Conclusion. The risk factors for development of a lung abscess after transbronchial biopsy were having a mass with central necrosis or cavitary lesions. The prophylactic administration in patients with these risk factors is reasonable.

Background. Although the detection of Pseudomonas aeruginosa (P. aeruginosa) is one of the risk factors for a poor prognosis in airway diseases, the detection rate, characteristics of patients, and risk factors in patients with rheumatoid arthritis (RA) who present with airway diseases still remain unclear. Methods. We retrospectively analyzed the bacteriological findings of bronchial lavage fluid collected by flexible bronchoscopy in 56 patients with RA who demonstrated airway diseases on chest computed tomography (CT). We also assessed the characteristics and risk factors associated with the detection of P. aeruginosa. Results. P. aeruginosa was the most frequently detected bacterial species in RA patients with airway diseases (12 cases, 21.4%). The Steinbrocker Class was higher and the history of receiving antibiotics within the previous 3 months more frequent in with P. aeruginosa patients than in without P. aeruginosa. In addition, both bronchiectasis and centrilobular nodules on chest CT were seen in all patients with P. aeruginosa. Conclusion. These findings suggest that P. aeruginosa is frequently detected in RA patients with airway diseases. Since the detection of P. aeruginosa is a risk factor for either pneumonia or poor prognosis in other airway diseases, careful attention to the presence of P. aeruginosa is therefore required in RA patients with airway diseases, especially in those with a higher Steinbrocker Class, a more frequent history of receiving antibiotics, and both bronchiectasis and centrilobular nodules on chest CT.

Background. Although the clinical benefit of rapid on-site cytologic evaluation (ROSE) during flexible bronchoscopy has been reported, its quality management has not been fully investigated. Here, we report a one-year experience of quality control with ROSE in our institution. Objective and Methods. Between October 24, 2013 and October 31, 2014, ROSE was done in 183 of 269 patients who underwent bronchoscopy in our division. ROSE was compared with pathological diagnosis in terms of its sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. During the study period, diagnostic results were reviewed among pulmonologists, cytological screeners, and pathologists. Results. Malignant tumor was the most common diagnosis (110 patients). Discordant cases were reviewed every four months and diagnostic assessments were partially modified. As a result, positive predictive value increased while accuracy was maintained. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ROSE compared with pathological diagnosis were 83%, 85%, 89%, 77% and 84%, respectively. Conclusion. Introducing ROSE in our department, quality control was properly done with periodical review.

Background. Mediastinal mature teratoma is less symptomatic, and is most generally found in medical examination. It sometimes causes pneumonia and pleurisy. In this report, we describe a case of mature mediastinal teratoma perforating into the lung and segmental bronchus. Case. A 53-year-old man was admitted to our hospital because of abnormal chest radiograph findings. A computed tomography of the chest revealed a mass in the anterior mediastinum and consolidation adjacent to the mass in the right upper lobe of the lung. We found skimmed tofu-like milky substance in the right anterior segmental bronchus (B³) with flexible fiberoptic bronchoscopy, and the material specimens were obtained for pathological and bacterial examinations. However we could not make a diagnosis. Enbloc resection of the tumor and the right upper lobectomy combined with partial resection of the pericardium was performed through a median sternotomy and right anterior thoracotomy. The tumor was mature teratoma with cartilage, skin tissue, bronchial tissue, fat tissue. The resected lung showed chemical pneumonitis caused by tumor perforation histologically. Conclusion. A mature teratoma with lung perforation could be suspected when we find the skimmed tofu-like milky substance by endoscopy.

Background. Primary tracheobronchial amyloidosis is a rare disease. Because its symptoms are not specific, this disease is rarely suspected and difficult to diagnose in clinical practice. Case. An 85-year-old Japanese woman had complained of hoarseness 2 years prior to her presentation with pneumonia, at which time bronchial wall thickening was observed on chest computed tomography. Bronchoscopy showed circumferential wall thickening extending from her larynx to the trachea. Tracheal biopsies revealed amyloid light chain deposits under the tracheal epithelium. She had no signs of systemic amyloidosis and no cause of secondary amyloidosis. We therefore diagnosed her illness as primary tracheobronchial amyloidosis. Discussion. In a recent study, 34-35% of patients with tracheobronchial amyloidosis had complained of hoarseness. This accounted for the accompanying laryngeal amyloidosis in our patient. Hoarseness is a relatively rare symptom in respiratory diseases; therefore we must differentiate tracheobronchial amyloidosis when we see a patient with respiratory symptoms and hoarseness of unknown origin.

Background. Pneumothorax can occur as a complication of late-stage nontuberculous mycobacterial infection and is often difficult to cure. We herein report a case in which intractable pneumothorax occurring as a complication of nontuberculous mycobacterial infection was successfully treated by occluding the affected bronchus using an endobronchial Watanabe spigot (EWS) with the guide-sheath curette method. Case. The patient was an 88-year-old woman with a chief complaint of dyspnea. A chest radiograph obtained six years earlier had shown an abnormal shadow. A subsequent detailed examination led to a diagnosis of pulmonary Mycobacterium avium complex infection. Since then, the patient had been followed up by a local doctor. She had recently visited the local doctor because of dyspnea, and a chest radiograph showed right-sided pneumothorax. Therefore, she was referred to our hospital. Continuous air drainage failed to improve the condition, and on the 17th day of admission, an EWS was placed in the middle lobe bronchus using the guide-sheath curette method. The pneumothorax improved, and the drain was removed on the 22nd day of admission. Bronchial occlusion using an EWS with the guide-sheath curette method, in which an EWS is mounted on the tip of the probe and inserted through a guide-sheath to be placed at a target site, is minimally invasive and less time-consuming than other methods and allows complete occlusion of the culprit bronchus. Conclusion. Bronchial occlusion using an EWS with the guide-sheath curette method appears to be effective in the treatment of intractable pneumothorax caused by nontuberculous mycobacterial infection.

Background. Racemose hemangioma of the bronchial artery is a rare disease that is associated with congenital malformations of the bronchial artery and is characterized by enlarged and convoluted bronchial arteries. Case. A 66-year-old woman, without any specific symptoms, consulted our hospital because of an abnormal shadow on gastrointestinal radiography at an annual health examination. Chest computed tomography showed an enlarged and convoluted right bronchial artery. Bronchial arteriography revealed a tortuous and dilated right bronchial artery, with shunt formation to the right pulmonary artery at the level of the lower lobe bronchus and an aneurysm in the periphery. A bronchoscopic examination showed dusky-red elevated lesions in the right main bronchus, and the superior, middle, and inferior lobar branches. Additionally, narrow band imaging bronchoscopy revealed green pulsatile lesions. Based on these findings, she was diagnosed with primary racemose hemangioma of the bronchial artery, and the right bronchial artery was surgically ligated and excised, while carefully considering the risk of hemoptysis. Conclusion. In the present report, we described a case of primary racemose hemangioma of the bronchial artery detected on gastrointestinal radiography.

Background. Bronchoaspiration of a foreign body is rare in adults. Adult bronchoaspiration patients often develop minor symptoms. Therefore, it takes time to diagnose them as having bronchoaspiration. We herein report an adult patient who aspirated a peanut in his bronchus with ABPA-like chest shadows. Case. A 69-year-old man presented to our hospital in June with persistent cough and sputum from April, 201X. Chest plain CT showed central bronchiectasis with mucoid impaction and infiltrates in the peripheral lung. From the characteristic CT findings, we initially suspected ABPA as his diagnosis. However, further examinations denied this possibility. Reassessment of the chest HRCT revealed a foreign body in his bronchus and led us to perform bronchoscopy. A bronchoscopic examination revealed a foreign body covered with pus in the lower right lobe ports, which was later revealed to be a peanut. After extraction of the foreign body, his symptoms improved, and the chest CT findings disappeared. Conclusion. We encountered a unique case presenting with ABPA-like shadows due to long-term peanut aspiration.

Background. The diagnosis of pulmonary strongyloidiasis is difficult in areas of low prevalence. Case. A 50-year-old man visited our department due to abnormal chest shadow that had been incidentally found during a health check. Chest computed tomography revealed infiltration in the right upper lobe. Bronchoscopic biopsies were repeatedly performed but failed to provide a diagnosis. During the observational period, the size of the infiltration increased and migrated, with increased peripheral eosinophils and serum total IgE. Screening for serum anti-parasite antibodies revealed antibodies against Strongyloides. The ELISA findings for Strongyloides was also positive. Based on these results, he was diagnosed with pulmonary strongyloidiasis and was successfully treated with oral ivermectin. Conclusion. Even for cases without residential or travel histories in high prevalence areas, pulmonary parasitic disease should be considered in patients with wandering infiltrates, eosinophilia, and elevated serum IgE levels.