Background. Lung aplasia is an uncommon condition, and most reported cases are those of infants with accompanying complicated anomalies of other organs. Adult cases of lung aplasia without other anomalies have also been reported. However, articles describing the ramification pattern of bronchial trees of the normal side contralateral to the aplasia are rare. Case. A 37-year-old woman was scheduled for emergency cesarean section under general anesthesia. Lung abnormality was originally identified during childhood; however, no detailed examination was performed because she was asymptomatic. Preoperative chest X-ray demonstrated marked deviation of the mediastinum to the left and shift of the over-inflated right lung to the left hemithorax. The left lung was not visible. Cesarean section under general anesthesia was accomplished safely, and the mother and newborn were discharged uneventfully. With her consent, we performed chest CT and bronchoscopy for precise diagnosis of her lung condition at a later date. Result. A remnant of the left main bronchus was seen, resembling a diverticulum. The right upper lobe had two bronchi, namely cephalic B¹⁺³ and caudal B² indicative of displaced anomalous bronchus. Most of the entire right pulmonary S³, middle lobe, and S⁷ were shifted to the left hemithorax through the anterior mediastinum. There was no atelectasis. Conclusion. In the present case of adult left lung aplasia, the right upper lobe had cephalic B¹⁺³ and displaced anomalous bronchus B².

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Case. A 74-year-old man was admitted to our hospital because of acute worsening of an interstitial shadow on a chest radiograph. He was diagnosed as having idiopathic pulmonary fibrosis (IPF) and had been followed up for several years. One month before admission, therapeutic N-acetylcysteine (NAC) inhalation was started because of gradual worsening of chest computed tomography (CT) findings and a tendency of a decline in vital capacity. A chest CT on admission revealed newly-developing ground glass attenuation with honeycombing, and lymphocytosis was observed in bronchoalveolar lavage fluid. He had noted worsening cough and dyspnea one week after starting NAC inhalation. At this point, the diagnosis of NAC-induced lung injury was considered. Steroid pulse therapy followed by oral prednisolone was started, and significant improvement of chest radiograph findings were observed. Conclusion. Although the frequency of NAC-induced lung injury may be rare, we have to keep in mind that it is possible that NAC inhalation could induce drug-induced lung injury.

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Background. Pulmonary aspergillosis shows a variety of clinical states, and there are cases including different types. Here, we report a resected case of pulmonary aspergilloma overlapping with a clinical state suspected to be allergic bronchopulmonary aspergillosis (ABPA), which was preoperatively controlled by steroid therapy. Case. A 73-year-old man with a history of right upper and middle bilobectomy for non-tuberculosis mycobacterium infection about three years ago in another hospital, was diagnosed with a fungal ball in the right apical thoracic cavity about one year before admission to our hospital. He showed left lung infiltration one month prior, and was admitted to our hospital for progression of hypoxia. Because his condition did not improve with antibiotics, we suspected ABPA based on the elevation of Aspergillus-specific IgE. His symptoms remarkably improved after steroid administration. Subsequently, cavernostomy and intrathoracic transplantation of latissimus dorsi myocutaneous flap were performed. After this procedure, the patient showed air leakage from a bronchial fistula, which was successfully treated with bronchoscopic embolization of fibrin glue. Conclusion. Multimodality therapy for pulmonary aspergilloma resulted in a favorable therapeutic outcome.

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Background. In patients with severe motor and intellectual disabilities (SMID), tracheostomy is often employed for the management of aspiration pneumonia and respiratory failure. Post-tracheostomy tracheal stenosis is a very rare complication, and we often encounter serious clinical problems during the treatment of this entity. The surgical management for post-tracheostomy tracheal stenosis with SMID is difficult to introduce because of general condition and social background. We encountered a patient with cerebral palsy who showed improvement of post-tracheostomy tracheal stenosis by long-term T-tube intubation. Case. A 36-year-old woman with cerebral palsy underwent tracheostomy after intracerebral hemorrhage at age 34. Granulation tissue appeared around the tracheostomy edge, with persistent bleeding arising from this granulation. Bronchoscopy revealed prominent granulation tissue at the tracheotomy entrance, causing stenosis. After cauterization of granulation by argon plasma laser coagulation, a T-tube was inserted. The T-tube was left in place for 3 years, but follow-up shows no stenosis after the T-tube insertion at present. Conclusion. For post-tracheostomy tracheal stenosis in long-term tracheotomy management of patients with cerebral palsy, T-tube stent therapy appears effective as an alternative to surgical resection.

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Background. A central type bronchial squamous cell carcinoma sometimes spreads along the bronchial wall to the tracheal carina, which requires complicated treatment-strategies for radical cure and preservation of pulmonary function. Case. A 58-year-old man had a medical checkup and abnormal of sputum cytology was detected. Bronchoscopy revealed nodular lesions on a membranous portion of the peripheral right main bronchus, and right B³a. Autofluorescence imaging showed an abnormal area on the tracheal carina, right main bronchus and truncus intermedius. Bronchial biopsies resulted in a pathological diagnosis of squamous cell carcinoma, and showed tumor invasion to the tracheal carina, orifice of the left main bronchus and truncus intermedius. Photodynamic therapy (PDT) of the tracheal carina, and the orifice of the left main bronchus and truncus intermedius was undergone. One month after PDT, right sleeve upper lobectomy was performed. Because cancer cells remained at both bronchial resected margins, proton irradiation was added one month after surgery instead of additional bronchial resection. Then, he had a careful checkup and was alive for seven years without cancer recurrence. Conclusion. Multimodality therapy with PDT, sleeve lobectomy and proton irradiation was performed for bronchial squamous cell carcinoma spreading to the tracheal carina, which could lead to radical cure of tumor, preservation of the right middle and lower lobe. A good clinical course without severe complications was obtained.

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Background. Tracheal intubation may rarely cause serious complications, such as tracheobronchial rupture. Case. An 82-year-old woman was scheduled to undergo partial resection of pulmonary metastasis from colon cancer. The patient was intubated with a left-sided double-lumen tube to establish separate ventilation. The anesthesia assistant mistakenly overinflated the cuff for the bronchus. As a result, the left main bronchus membrane ruptured. Results. The patient was reintubated with a right-sided double-lumen tube. Under separate ventilation for the left lung while maintaining the least possible airway pressure, a repair operation was performed through right thoracotomy. Separate ventilation for the left lung was not adequate after the mediastinum pleura was incised, thus the right lung was ventilated intermittently during the operation. The ruptured bronchus membrane, which measured approximately 2 cm longitudinally, was sutured, covered with an intercostal muscle flap, and then sprayed with fibrin glue. The pulmonary metastasis was resected using a stapler. After the operation, the patient suffered a wound infection, but it was successfully treated without any major problems, and she was thereafter discharged from the hospital. Conclusions. It is necessary for surgeons to be aware of how to prevent and effectively manage the occurrence of a tracheobronchial rupture.

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Background. Many types of health foods are sold all over the world. A considerable number of patients take them together with their medication. In Japan, garlic and egg yolk supplements are frequently advertised, and are purchased by numerous customers. Case. A male patient aged 69 years had been taking garlic and egg yolk supplements for 4 years. He complained of shortness of breath and dry cough that lasted for a couple of weeks. Subsequently, he went to a hospital and was diagnosed with treatment-resistant pneumonia. The patient was treated with antibiotics and corticosteroids, but his symptoms did not improve. Consequently, he was transferred to our hospital. A chest plain computed tomography scan showed ground glass opacity in the bilateral middle to lower field. Bronchoalveolar lavage showed lymphocyte predominant infiltration. A specimen of transbronchial lung biopsy showed mild lymphocytic inflammation and mild organizing pneumonia. After the patient stopped taking garlic and egg yolk supplements, his symptoms improved quickly. A lymphocyte stimulating test using the same merchandise showed a positive result. Therefore, we considered garlic and egg yolk supplements might be a cause of the lung disorder in this case. Conclusion. Asking patients their histories of taking health foods and dietary supplements can lead to a diagnosis of lung injury.

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Background. Stenting for hemoptysis without bronchial stenosis is rare. Case. A 70-year-old man was diagnosed with same-lobe metastasis and lymph node metastasis 6 years after right S² lung segmentectomy in 2007 for primary lung cancer. Hemoptysis developed due to radiotherapy for brain metastasis. Computed tomography showed a large tumor in the right upper lobe without exposure in the upper bronchus. Because hemoptysis did not improve after bronchial artery embolization, the right main bronchus became totally obstructed with blood coagulation 4 days later. For control of hemoptysis, a Dumon straight stent was placed from the right main bronchus to the truncus intermedius with a rigid bronchoscope. However, the straight stent migrated medially side 4 days after placement, and so we added a Y-stent in the same location with the right limb inserted into the straight stent to prevent migration. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Conclusion. Dumon stents are useful for hemoptysis without bronchial stenosis.

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Background. Simultaneous bilateral pneumothorax is a rare condition. Very rarely, it may develop through a communication between the two sides of the thoracic cavity. Case. A 69-year-old man who had undergone resection of an esophageal carcinoma had difficulty in breathing and underwent a medical examination. He experienced a simultaneous bilateral pneumothorax, underwent bilateral chest drainages, and was hospitalized. Because of the simultaneous bilateral pneumothorax and continued air leak, an operation was performed. Results. First, thoracoscopic bullectomy was performed from the right side. At the time of changing the position, the water poured in the right thoracic cavity to test for air leaks flowed out to the left drain in large quantities; thus, a communication between the two sides of the thoracic cavity became clear. On the left side, thoracoscopic bullectomy and coverage with a polyglycolic acid sheet and fibrin glue of the mediastinal pleura, which seemed to be defective and caused suspicion of a hole between the thoracic cavities without clearly revealing any mediastinal window, were performed. Conclusion. Prevention of recurrence is important in cases of simultaneous bilateral pneumothorax; thus, it is necessary to search for a mediastinal window and close it if it exists. In addition, a preoperative strategy is also necessary when no mediastinal window is found.

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Background. Cryptogenic organizing pneumonia (COP) usually responds well to corticosteroid treatment and typically has a good prognosis. However, a few cases are refractory to corticosteroid treatment. Immunosuppressant drugs are associated with an increased risk of malignant lymphoproliferative disorders. Case. A 63-year-old man presented with a history of cough for a month. High resolution computed tomography (HRCT) of the chest showed air-space consolidation predominantly in both lungs. We diagnosed COP by transbronchial lung biopsy (TBLB) specimens. Clinical data and HRCT findings were improved by prednisolone therapy, but recurrent exacerbation occurred during steroid tapering. Although, we re-examined the abnormal lesions in the left lower lobe by video-assisted thoracoscopy and those in the right lower lobe by TBLB, histopathological examinations of all lesions revealed organizing pneumonia. We continued immunosuppressive therapy with a combination of prednisolone and immunosuppressive agents. However, lung lesions gradually deteriorated. In order to obtain a histopathological diagnosis again, we performed TBLB from the right lower lobe. Histopathological examination revealed lung invasion of diffuse large B cell type lymphoma. Conclusion. We experienced a rare case of recurrent COP complicated by primary pulmonary malignant lymphoma. It is necessary to pay attention to the possibility that malignant lymphoma may be involved in recurrent COP during immunosuppressive therapy.

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Background. Chinese herbal medicine often causes drug-induced pneumonitis. Kakkonto is one of the most famous herbal medications. Case. A 65-year-old woman with no history of medication was administered Kakkonto for prevention of common cold for a month, and subsequently, she presented at the emergency room in our hospital with acute respiratory failure. Based on her clinical history and the results of a bronchoalveolar lavage and transbronchial lung biopsy, we diagnosed drug-induced pneumonia due to Kakkonto. Conclusion. Therefore, both medical as well as non-medical staff should be aware of the adverse events caused by herbal medicines and the risk of preventive medications.

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Background. We report a case of bronchial inflammatory polyp caused by a airway foreign body which was discovered in the pneumonia and removed by microwave coagulation therapy (MCT). Case. A 65-year-old woman who was hospitalized with a diagnosis of pneumonia was found to have a bronchial polyp which was diagnosed with inflammation by biopsy in the right lower lobe inlet portion in the chest CT examination and occluding right basal bronchus in bronchoscopic finding at a local hospital in January 2014. She was referred to our hospital for MCT because the risk of future obstructive pneumonia. During bronchoscopic examination, it was discovered the airway foreign body in peripheral site from bronchial inflammatory polyp and removed. The component analysis of the foreign body was triglyceride which was more than 98%. Conclusion. The airway foreign body which was included more than 98% triglyceride was food residue. She was not notice despite the aspiration, and left. Endoscopic MCT can be useful in treating bronchial inflammatory polyp safely.

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