Background. Primary tracheobronchial leiomyoma is generally characterized as an endobronchial growth that can be completely resected by bronchoscopic intervention in some cases. We herein report a case involving a man with a bronchial leiomyoma that exhibited marked extraluminal development (so-called "iceberg tumor growth pattern" ) over the bronchial wall. Case. A 39-year-old man presented to our hospital with a chief complaint of recurrent pneumonia. Chest computed tomography images showed a 15-mm-diameter tumor located at the orifice of the right middle bronchus and extending extraluminally. Bronchoscopy revealed a white and gently sloping tumor protruding into the middle right bronchus. Transbronchial biopsy of the tumor revealed a leiomyoma. Bronchotomy followed by right middle lobectomy was successfully performed to identify the tumor location and provide curative treatment. Conclusion. Both bronchoscopy and chest computed tomography can be recommended not as a bronchoscopic intervention but as a surgical intervention for endobronchial leiomyoma with an iceberg tumor growth pattern.

Background. Tracheal diverticulum is a rare disease and accidentally found during routine image examination. Here we report 4 cases of tracheal diverticulum diagnosed by taking history. Case Reports. Case 1, a 63-year-old woman, visited our hospital because of throat discomfort. Chest CT showed a cystic lesion to the left behind the trachea and bronchoscopy found a hole and inflamed mucosa in the trachea. Similarly, case 2, a 68-year-old woman, complained of sputum and throat discomfort, case 3, a 73-year-old woman, complained of chronic cough and sputum and case 4, a 62-year-old man, complained of hoarseness. Chest CT demonstrated cystic lesion at right behind the trachea and bronchoscopy showed normal in cases 2, 3 and 4. Conclusions. Patients with tracheal diverticulum are often asymptomatic. However, since there are several reports complaining of respiratory symptoms including throat discomfort, chronic cough and hoarseness, physicians should consider it when causes of these symptoms are uncertain.

Background.Pasteurella species are a known zoonotic pathogen. Recently, the number of the reports of human infection has been increasing as the number of households keeping pets has increased. Case. A 66-year-old man with a family history of tuberculosis was referred to our hospital to undergo an investigation for abnormal shadows that were observed on a chest radiograph. Chest computed tomography showed centrilobular nodules in the right upper lobe. The patient was suspected of having pulmonary tuberculosis based on the shadows on the chest radiograph and his family history of tuberculosis. Sputum smears for acid-fast bacterium were negative, and an enzyme-linked immunospot assay was positive for tuberculosis. Pasteurella multocida was identified in his bronchial lavage fluid. We diagnosed the patient as having P. multocida lung infection. His lung infection improved following the administration of antibiotics. Conclusion. We herein reported a case of P. multocida lung infection that mimicked pulmonary tuberculosis.

Background. Silicone stent placement for airway obstruction has become widespread as an effective therapy which relieves dyspnea immediately. In addition, alectinib is considered to be a promising drug for an anaplastic lymphoma kinase (ALK) positive lung cancer. We report a patient with severe airway stenosis in ALK-positive lung cancer, successfully treated by temporary stent placement and alectinib. Case. A 45-year-old man had been aware of exertional dyspnea than a week previously. He was referred by ambulance because of the loss of consciousness, and underwent pericardial drainage on cardiac tamponade. Cancerous pericarditis and airway stenosis due to the mediastinal lymph node metastasis from lung cancer were strongly suspected by computed tomography, and transfer to our hospital. We performed balloon dilatation and temporary placement of a silicone Y-stent on the patient. ALK-positive lung cancer was diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration, and successfully treated with alectinib. Airway stenosis improved and the silicone Y-stent removed five months later. Conclusion. The removable silicone stent was useful for airway stenosis due to ALK-positive lung cancer. Alectinib was an effective and useful drug.

Background. Broncholithiasis is a rare disease, but it can cause massive hemoptysis requiring emergency treatment. Case. A 70-year-old man was being followed in a nearby hospital for broncholithiasis. He took antiplatelet medicine after suffering a cerebral infarction. On admission he reported that he had been coughing badly and continually for seven days, due to a common cold. One day before admission, he expectorated a stone and suffered hemoptysis. As the hemoptysis had not stopped, he was transferred to our hospital as an emergency patient. Chest CT revealed the loss of the broncholith and consolidation in the surrounding area, and CT-angiography revealed an enlarged and tortuous right bronchial artery toward the right lower lobe. The cause of the hemoptysis was considered to be bleeding due to the separation of the broncholith. The administration of antiplatelet medicine was stopped and a hemostatic agent was administered; however, the hemoptysis did not stop. On the 5th day of hospitalization, bronchial artery embolization was performed under mechanical to stabilize his breathing. After embolization, the patient's hemoptysis immediately disappeared. On the 7th day of hospitalization, he was extubated. He started to take antiplatelet medicine on the 19th day of hospitalization; however, there was no recurrence of hemoptysis. He was discharged on the 26th day of hospitalization. Conclusion. Bronchial artery embolization is useful for treating massive hemoptysis due to broncholithiasis.

Introduction. Flexible bronchoscopy is a safe, widely applied procedure for the diagnosis of airway diseases or lung abnormalities. In cases of the elderly, however, we should take account of uncommon adverse events such as Takotsubo cardiomyopathy. Takotsubo cardiomyopathy is recognized as stress-induced cardiomyopathy preceded by emotional or physical stress, which is typically associated with transient dyskinesia or akinesia of the left ventricular apical wall with normal findings or hyperkinesis of the basal wall. Flexible bronchoscopy can give elderly patients so much stress that it is at risk for developing Takotsubo cardiomyopathy. Case Reports. We report a series of cases diagnosed as Takotsubo cardiomyopathy during or after flexible bronchoscopy as follows. Case 1: A woman aged 85 developed Takotsubo cardiomyopathy one day after flexible bronchoscopy. She was associated with arrhythmias, and died partly because of heart failure and progression of lung cancer. Case 2: A woman aged 85 developed Takotsubo cardiomyopathy 6 days after the procedure. Her case was associated with intraventricular thrombus and was treated with anticoagulant. Case 3: A man aged 85 developed Takotsubo cardiomyopathy 6 days after the procedure. His condition was associated with acute heart failure and was treated with non-invasive positive-pressure ventilation. He was also treated with anticoagulant, but developed cerebral embolism and led to right hemiplegia. Case 4: A man aged 78 developed Takotsubo cardiomyopathy during the procedure. He had no complications and was treated for lung cancer with irradiation. Conclusion. Takotsubo cardiomyopathy is an uncommon, but an important adverse event of flexible bronchoscopy on the elderly, partly because it can lead to severe events such as pump failure, arrhythmia, or thromboembolism. Once Takotsubo cardiomyopathy develops, activities of daily living and cognitive functions may decline before recovering from it and it can be attributed to their poor prognosis, especially in the frail elderly. To prevent Takotsubo cardiomyopathy during bronchoscopy, we should prevent emotional and physical stress with administration of the appropriate sedative or anti-anxiety medicine.

Background. To diagnose the leukemic pulmonary infiltration (LPI) of adult T cell leukemia (ATL), a transbronchial lung biopsy (TBLB) is usually recommended, but the usefulness of a flow cytometric analysis of the bronchoalveolar lavage fluid (BALF) cells is unclear. Case. A 63-year-old woman complaining of chronic cough visited our clinic. Chest computed tomography showed abnormal infiltrative shadows of the bilateral lungs. Seven-day antibiotic therapy was ineffective. After two months, abnormal lymphoid cells appeared in the peripheral blood, and anti-human T cell leukemia virus antibody was significantly positive. A BALF cell count analysis showed marked atypical lymphocytosis. A flow cytometric analysis of the BALF cells showed that atypical lymphoid cells were positive for CD4 and CD25 and negative for CD7. Conclusion. A flow cytometric analysis of the BALF cells proved useful for the diagnosis of LPI of ATL cells.

Background. Bronchial artery embolization (BAE) and surgery are the standard therapy for cases of massive hemoptysis. In recent years, some cases of hemoptysis treated with endobronchial occlusion using the endobronchial Watanabe spigot (EWS) have been reported. Case. An 82-year-old man undergoing treatment for idiopathic pulmonary fibrosis and pulmonary aspergilloma was referred to our hospital because of hemoptysis and hospitalized. He was treated with hemostatic agents, and the hemoptysis was initially controlled. However, on the night of hospital day 3, massive hemoptysis occurred. Due to difficulty in performing BAE, we attempted bronchial occlusion using an EWS. Bronchoscopy revealed bleeding from the right B² and B³, and an M-sized EWS was inserted into each bronchus. After bronchial occlusion, hemoptysis was completely controlled, and he was discharged on day 23 following therapy. At one year after therapy, hemoptysis has not recurred. Conclusion. Bronchial occlusion using an EWS can be effective as emergency therapy in cases of hemoptysis.