Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for either mediastinal or hilar lymph nodes and transbronchial lung biopsy (TBLB) are useful and highly diagnostic modalities in patients suspected of having sarcoidosis. Objective. The aim of the present study was to retrospectively assess any differences in the medical history and clinical characteristics between patients presenting with sarcoidosis who could not be successfully diagnosed with EBUS-TBNA and those who were successfully diagnosed with EBUS-TBNA. Methods. We analyzed patients suspected of having sarcoidosis who underwent EBUS-TBNA between November 2010 and December 2014 at the Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan. Results. Of the 56 patients examined, EBUS-TBNA pathologically diagnosed sarcoidosis in 51 (91.1%). However, EBUS-TBNA did not result in a diagnosis in the remaining 5 patients (8.9%). These 5 undiagnosed patients showed no marked differences from the other 51 patients with respect to the location of the punctured lymph node, the number of punctures, the average size of the longest lymph node, or the staging based on chest radiography. Three of the 5 patients had insufficient sample volumes to make a diagnosis, while the remaining two showed non-specific pathological changes. Of these 5 patients, Cases 1 and 2 demonstrated non-caseating granulomas by TBLB following EBUS-TBNA, and a second EBUS-TBNA was diagnostic for Case 3. In Case 4, despite undergoing EBUS-TBNA twice, biopsies of both the mediastinal lymph nodes and the lung by video-assisted thoracic surgery were necessary to confirm the presence of non-caseating granulomas. Mediastinoscopy was necessary for a lymph node biopsy in Case 5, even though EBUS-TBNA and TBLB were performed for multiple lymph nodes and the lung. Conclusion. According to the findings of this study, we were unable to identify any differences in either the medical history or clinical characteristics of these two patient groups. However, this study was a single-center study and included only 5 subjects; further studies will therefore be necessary to clarify the factors associated with an accurate diagnosis of sarcoidosis using EBUS-TBNA.

Background. Allergic bronchopulmonary aspergillosis (ABPA) is characterized by asthmatic symptoms and sometimes causes atelectasis by mucus plugs. This disease is treated by oral corticosteroid, but its activity is often uncontrollable. Case. A 70-year-old woman treated as an asthmatic patient was hospitalized due to an asthmatic attack and right lower lobe atelectasis with eosinophilia when she was 64 years old. Both the serum total and Aspergillus fumigatus (AF)-specific immunoglobulin E levels were high, and AF precipitins were positive. Bronchoscopic findings showed a mucus plug in the right basal bronchus. Finally, ABPA was diagnosed treatment by oral corticosteroid was begun, however the atelectasis often recurred. We started omalizumab 300 mg every other week for her. Atelectasis had not recurred after 11 months from the initiation of omalizumab therapy, and 34 months later, the steroid and oxygen therapy were discontinued. Moreover the disease activity has been kept under control since then. Conclusion. We speculated that omalizumab could be useful for treatment of uncontrollable formation of mucus plug in ABPA.

Background. In general, flexible bronchoscopy is performed under a supine position. This case report describes successful placement of a tracheal stent in a sitting patient unable to keep a supine position. The invaded esophageal tumor occupied the trachea lumen causing choking in a supine position. Case. A 60-year-old man in whom as refractory bronchial asthma had been diagnosed was transferred from another hospital. The patient had various respiratory distress symptoms depend on his position (sitting/supine) in our institution. Flexible bronchoscopy was performed looking for a trachea foreign body or tumor. A tumor occupying the tracheal lumen was found and needle aspiration cytology revealed squamous cell carcinoma. After flexible bronchoscopy procedure, enhanced thoracic CT revealed wall thickening of the esophagus and invaded into trachea. The patient could not keep a supine position due to tracheal obstruction by tumor. Placement tracheal stent in a sitting position. Combined modality therapy was performed by the gastrointestinal department. Conclusion. Invasive esophageal carcinoma growth due to direct invasion to trachea is rare. In the present case, under a sitting position placement of an expandable metallic stent was one of the options for this choking status patient.

Background. Mizoribine (MZR) is a purine analog, and is administered as a disease modifying anti-rheumatic drug (DMARD). MZR-induced acute lung injury is rare as an adverse effect. Case. A 68-year-old woman complaining of high fever and dyspnea was admitted to our hospital. She was a patient with rheumatoid arthritis, and had been given prednisolone, methotrexate (MTX) and tacrolimus orally by her primary care doctor who specializes in rheumatology. Six days before admission, she changed her prescription from MTX to MZR. SpO₂ was 71%, and chest radiograph and computed tomography on admission showed diffuse ground-glass opacities in both lung fields. Laboratory data showed high serum LDH and KL-6 levels. The bronchoalveolar lavage fluid (BALF) showed an increase in the proportion of lymphocytes (50%). A drug lymphocyte stimulation test (DLST) using peripheral blood was positive for MZR. Based on these findings, the present case was diagnosed as acute lung injury caused by MZR. The patient's symptoms immediately improved by withdrawing MZR and administration of corticosteroid. Conclusion. MZR-induced acute lung injury is rare and its mechanism and frequency are unknown. This case is important to provide awareness of using MZR.

Background. Pulmonary giant cell carcinoma is rare, and it is considered to be very difficult to definitively diagnose by bronchofiberscopy. Case. We herein report the case of a 77-year-old man with granulocyte colony stimulating factor (G-CSF)-producing giant cell carcinoma of the lung who had initially been diagnosed with a lung abscess. He was admitted to our hospital due to the presence of a mass shadow on the left lower lobe of the lung that increased in size on a chest X-ray, despite the administration of broad-spectrum antibiotics. A presumptive diagnosis of a lung abscess was made, and his antibiotic therapy was continued. However, the symptoms and inflammatory reaction persisted. Thus, flexible fiberoptic bronchoscopy was performed. Bronchoscopy revealed a polypoid tumor in the left B¹⁰b bronchus. Lung biopsy showed giant cell carcinoma that was positive for G-CSF and the patient's serum G-CSF level was elevated. As a result, this patient was diagnosed with G-CSF-producing giant cell carcinoma of the lung. Conclusion. This is a rare case of pulmonary giant cell carcinoma that was diagnosed by bronchofiberscopy.

Background. Endobronchial metastasis (EM) of extrathoracic malignancy is rare. Case. We herein report a case of EM of clear cell renal cell carcinoma (RCC) in a 68-year-old man. The patient has a history of left nephrectomy due to clear cell RCC 22 years prior. He presented with bloody sputa, dysbasia, anesthesia of the limbs, and pain in the left shoulder joint. A computed tomography (CT) scan revealed a tumor mass in the lower lobe of the right lung, as well as osteolytic signs of the cervical vertebrae, thoracic vertebrae, and bilateral ribs. The patient was referred to our hospital for a closer examination and treatment of disseminated tumors and spinal cord compression due to the vertebral lesions. Bronchoscopy showed a tumor in the right B¹⁰. A transbronchial biopsy revealed EM of clear cell RCC. Conclusion. The case presented here illustrates that relapse of renal cancer can occur after a long-term disease-free period of over 20 years and suggests that patients with RCC should be carefully monitored for relapse.

Background. Endobronchial aspergilloma is a rare variety of pulmonary aspergillosis. We herein report a case of calcified endobronchial aspergilloma mimicking broncholithiasis. Case. A 66-year-old woman with a history of pulmonary tuberculosis had been followed up because of an abnormal chest shadow for 26 years. Computed tomography (CT) of the chest taken seven years prior revealed a calcified nodule in the left B³a bronchus with consolidation around it. Calcification was also observed in the mediastinal and hilar lymph nodes. She was referred to our hospital for further evaluation of the increased consolidation in 2014. She had no specific respiratory symptoms. Flexible bronchoscopy showed a yellowish-brown mass lesion obstructing the orifice of the left B³a bronchus. A histologic examination of the biopsy specimen revealed a mass of Aspergillus hyphae with calcification on the surface. Chest CT taken three weeks after the bronchoscopic examination revealed the disappearance of the calcified nodule and a decrease in the consolidation adjacent to the bronchus. Conclusion. Endobronchial aspergilloma with calcification has been rarely reported and should be included in the differential diagnosis of intrabronchial calcification. Flexible bronchoscopy with biopsy is therefore considered to be useful for obtaining a definitive diagnosis.

Background. Few cases of bronchial foreign body due to damage by a suction catheter have been reported. Case. An 82-year-old man with a history of amyotrophic lateral sclerosis on long-term ventilation was admitted to our hospital for a persistent fever since five days before admission despite antibiotic treatment. A chest computed tomography scan revealed a tubular foreign body exceeding 3 cm in length in the truncus intermedius. Emergency flexible bronchoscopy showed a large amount of purulent sputum and the foreign body, which was removed using biopsy forceps. The object was found to be a broken endotracheal suction catheter made of silicone. The same suction catheter had been used for a long time before being inhaled. Conclusion. The number of patients on long-term ventilation has been increasing, and some home-care patients use the same suction catheter continuously for economical reasons. Physicians must be alert for complications such as damage due to suction catheters in patients on long-term ventilation.

Background. Congenital bronchial atresia is a rare disease. Since advances in diagnostic imaging technologies have allowed this disease to be diagnosed without surgery, the numbers of reported cases of congenital bronchial atresia have been increasing. However, these patients are often asymptomatic, and whether or not surgical resection should be performed in asymptomatic patients with congenital bronchial atresia is unclear. Case. A 32-year-old Japanese man was found to have abnormal findings on chest X-ray at a regular medical checkup. Chest computed tomography showed cystic bronchiectasis and localized emphysematous change in the right S². He was referred to our hospital for further examination and was diagnosed with congenital bronchial atresia after several imaging examinations and bronchoscopy. Intrabronchial infection was suspected, so right upper lobe resection was performed. Purulent discharge was obtained in the cystic lesion of the resected lung, and microbial tests were conducted. The smear preparation showed Gram-negative rods, but the aerobic culture was negative. A bacterial floral analysis using the 16S ribosomal RNA gene showed numerous oral anaerobes, including Prevotella spp., and a subclinical infection in the cystic lesion of the congenital bronchial atresia was suspected. Conclusion. Surgical resection for congenital bronchial atresia may therefore occasionally be necessary when repetitive subclinical infection in the affected lesion is suspected, even if the patient is clinically asymptomatic.

Background. We herein report a patient with acute cerebral infarction after EBUS-TBNA who was successfully treated with recombinant tissue plasminogen activator (rt-PA). Case. A 77-year-old man was admitted due to shortness of breath. The patient had undergone left upper lobectomy for lung cancer one year prior. Chest computed tomography showed pericardial effusion and adenopathy of the subcarinal lymph node. Drainage of the pericardium was performed, and the cytology of the pericardial effusion was negative for malignancy. EBUS-TBNA was performed for the evaluation of the lymphadenopathy. Eight hours after EBUS-TBNA, the patient developed left hemiplegia and was diagnosed with acute cerebral infarction. Under the careful evaluation of stroke specialists, rt-PA was intravenously administrated within four hours of the emergence of symptoms under close observation in the intensive-care unit. Fortunately, the patient did not suffer any bleeding complications. His neurological symptoms gradually improved, and the left hemiplegia eventually disappeared. Conclusion. rt-PA treatment with acute cerebral infarction may be carefully administered after biopsy, but there have been no reports of its administration after EBUS-TBNA. We herein report the first case of intravenous administration of rt-PA for acute cerebral infarction after EBUS-TBNA.

Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful tool for diagnosing mediastinal lymphadenopathies, such as metastatic lung cancer or sarcoidosis, and the utility of EBUS-TBNA in diagnosing infectious disease has recently been reported. We encountered a case in which cryptococcosis was diagnosed using EBUS-TBNA. Case. The patient was a 75-year-old man. In X-4 year, he developed cryptococcal meningitis during steroid therapy for immunoglobulin G4-related kidney disease. Liposomal amphotericin B and itraconazole were administered for cryptococcal meningitis until November, X-1 year. In May X year, he was referred to our department due to an enlarged subcarinal lymph node and a nodule in the left S⁶ on computed tomography. ¹⁸F-fluorodeoxy glucose-positron emission tomography showed high uptake by both lesions. We first performed a transbronchial lung biopsy for the left S⁶ nodule, but no diagnosis could be reached. We then performed EBUS-TBNA for the subcarinal lymph node, and cryptococcosis was diagnosed pathologically. After restarting itraconazole, both the subcarinal lymph node and the left S⁶ nodule decreased in size, and pulmonary cryptococcosis with mediastinal lymphadenitis was diagnosed. Results. EBUS-TBNA was useful in diagnosing mediastinal cryptococcosis. Conclusion. EBUS-TBNA may prove useful in diagnosing mediastinal lymphadenopathy from cryptococcosis.

Background. Ectopic calcification is characterized by diffuse calcium deposition in various organs. Its main cause is chronic kidney disease. The pathogenesis and clinical course have not yet been fully elucidated. Case. A 59-year-old man was referred to our hospital due to the appearance of bilateral ground-glass opacities (GGOs) on chest CT findings. He had been on hemodialysis for chronic kidney disease since 1992 but had stopped it following deceased donor renal transplantation in 2006. We performed bronchoscopy and a transbronchial lung biopsy (TBLB) for the bilateral GGOs. A histopathological analysis of the TBLB specimens revealed calcification of lung tissue. Given the pathological analysis findings and his clinical background, he was diagnosed with ectopic pulmonary calcification. Computed tomography (CT) findings revealed gradual enlargement and densification of the GGOs, suggesting the progression of calcification. He is scheduled for parathyroidectomy to prevent calcification. Conclusion. Bronchoscopy is useful for the diagnosis of ectopic pulmonary calcification by helping to rule out other diseases and is also a less-invasive method of performing a histopathological evaluation. The present case is unique with respect to the long-term follow-up of chest CT findings due to ectopic pulmonary calcification.

Background. Nodules, cavitations and consolidations are common radiological findings of pulmonary cryptococcosis, but ground-glass opacities (GGOs) are not. To our knowledge, Cryptococcus sp. has never been detected from GGOs in the literature. Case. A 63-year-old man, who underwent renal transplant 16 months previously, was admitted to our hospital because of nodules in the right lower lung lobe on chest computed tomography (CT). One month later, chest CT showed not only nodules but also multiple GGOs. Bronchoscopy was performed, and the bronchoalveolar lavage fluid from the right B⁵, the segment where there was only a GGO and were not any nodular lesions, revealed Cryptococcus neoformans, leading to a diagnosis of pulmonary cryptococcosis. He was treated with fosfluconazole and fluconazole, and the GGOs improved within a few weeks. Conclusion. This is the first report of pulmonary cryptococcosis in which Cryptococcus sp. was detected from a GGO. We should suspect this disease when we see a GGO on CT.

Background. Recent advances in cancer therapy and diagnostic technology have improved the chances of successfully treating multiple primary cancers. Case. A 64-year-old man had undergone treatment for sigmoid colon cancer and an abdominal tumor 1 year previously. Histopathologically, the cancer was diagnosed as being moderately differentiated adenocarcinoma, whereas the abdominal tumor was diagnosed as to be metastatic neuroendocrine carcinoma of unknown origin. Six months after treatment, chest computed tomography revealed the presence of a small nodule in the right upper lobe of the lung. Another 5 months later, the nodule had increased in size and the patient presented with a swollen lower paratracheal lymph node. A high accumulation of fluorodeoxyglucose was observed in the nodule and lymph node on positron emission tomography. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) from the lower paratracheal lymph node confirmed metastatic lung adenocarcinoma. We performed a right upper lobectomy along with the dissection of the systematic lymph node, following which a histopathological diagnosis of lung adenocarcinoma, pT2aN2M0 stage IIIA was reached. Conclusion. The findings of this study demonstrate the importance of histopathologically diagnosing a newly arising tumor after previous cancer treatment, particularly in cancers of unknown origin. EBUS-TBNA is a safe and useful diagnostic procedure for multiple primary cancers.

Background. Actinomycosis associated broncholithiasis is uncommon. Case. A 73-year-old man with a history of pulmonary tuberculosis was admitted to our hospital because of persistent bloody sputum following chemoradiotherapy for laryngeal cancer. Bronchoscopy revealed a yellow-white mass in the right B² orifice, and endobronchial actinomycosis was diagnosed by biopsy. Despite the administration of ampicillin for 1 month and amoxicillin for 5 months, the size of the mass remained unchanged. A definitive diagnosis of endobronchial actinomycosis associated with broncholithiasis was subsequently confirmed by repeat biopsy. Conclusion. Although endobronchial actinomycosis associated with broncholithiasis is a rare condition, we should consider it as a differential diagnosis for bloody sputum and thus perform bronchoscopy to investigate.