Background. Postoperative pulmonary fistula is sometimes refractory, and endoscopic therapy is often selected for treatment. Case. A 74-year-old man with lung cancer in the right upper lobe was treated with right upper lobectomy. A prolonged pulmonary fistula occurred postoperatively. He underwent pleurodesis with an autologous blood patch and reoperation; however, the pulmonary fistula did not disappear. Bronchoscopy revealed that the responsible bronchus was the right B4 bronchus. We performed bronchial closure using fibrin glue and an Endobronchial Watanabe Spigot (EWS). The pulmonary fistula disappeared. But, the patient expectorated the EWS. We diagnosed a recurrence of the pulmonary fistula. We performed bronchoscopic bronchial closure six times using an EWS or polyglycolic acid (PGA) sheet and fibrin glue, but the pulmonary fistula did not disappear. We then performed bronchial closure using N-butyl-2-cyanoacrylate (NBCA), fibrin glue, and a PGA sheet. The pulmonary fistula disappeared. In the three years since this bronchial closure, the patient has remained free of recurrence of the pulmonary fistula. Conclusion. Bronchoscopic bronchial closure using NBCA is therefore considered to be an effective therapy for postoperative refractory pulmonary fistula.
Background. Inhalation of waterproofing spray can cause lung injury, and fluorocarbons seem to be the causative substance. We encountered a case of spontaneously recovering lung injury following inhalation of water repellant spray. Case. A 39-year-old man sprayed water repellant at a shoe factory as part of his work and subsequently developed dyspnea, headache, and chills about 2 hours later. He did not smoke after the spraying. The next day he was admitted to our hospital. A chest high-resolution CT scan on admission revealed diffuse ground glass opacities. There was a high percentage (30%) of neutrophils in his bronchoalveolar lavage fluid. The lung injury and dyspnea resolved spontaneously after about 7 days. Conclusion. We speculated that the lung injury was caused by inhalation of fluorocarbon. The fact that he did not smoke after the incident prevented the building of thermal decomposition products, which is thought to be the reason for his spontaneous recovery.
Background. Thoracic actinomycosis is a relatively rare disease that is often difficult to diagnose and requires prolonged antibiotic therapy. We report a case of bronchial actinomycosis diagnosed by bronchoscopy that showed spontaneous remission. Case. A 77-year-old Japanese man presented at our hospital with fever and cough and was given a diagnosis of pneumonia. Chest CT scans revealed a mass in the right S7 while he was receiving antibiotic therapy for pneumonia. We suspected lung cancer and performed bronchoscopy. Sputum was present at the right B7 orifice, and we found polyps with edematous mucosa after removing it. We diagnosed the patient with actinomycosis through this pathological examination. After diagnosis, his clinical symptoms and CT findings improved without antibiotic therapy, and no exacerbation has been observed for over a year. Conclusion. We experienced a case of bronchial actinomycosis with spontaneous remission. Removal of mucous plugs with bronchoscopy may have contributed to the remission.
Background. Lung carcinoid with non-tuberculous mycobacteriosis is extremely rare. Case. The patient was a 51-year-old woman in whom a nodular shadow with surrounding disseminated shadows was detected in the S8 region of the right lung by computed tomography. The shadows appeared to reflect infectious disease or inflammatory pseudotumor caused by NTM or eumycetes. Mycobacterium intracellulare was detected in a sputum culture. Bronchoscopy showed a protruding region that obstructed the entrance of B8a, and lung carcinoid was detected in a biopsy specimen. We performed lobectomy of the right lower lobe and lymph node dissection. A tumor, which was diagnosed as a typical carcinoid, and an epithelioid cell granuloma caused M. intracellulare, were detected in the peripheral region. Conclusion. In this case, we suspected that NTM had multiplied enough to form a granuloma as a result of the obstruction of the B8 bronchus by the tumor. The early diagnosis by bronchoscopy enabled curative resection. If NTM coexists with a malignant lung tumor, the diagnosis of the malignant tumor may be delayed. In such cases, we should perform bronchoscopy as early as possible or observe the patient strictly.
Background. Thoracic empyema after transbronchial biopsy (TBB) is a rare complication in lung cancer patients. Case. A 58-year-old man complained of impaired mobility of the left upper limb. Metastatic brain tumors in the right frontal lobe were diagnosed by brain MRI, and stereotactic brain radiation were performed. Chest CT showed a tumor 53 mm in diameter immediately below the pleura in the S6 segment of the left lung. TBB through the left B6 revealed squamous cell carcinoma. He developed a high fever 3 days after TBB and chest radiography showed left pleural effusion. The left pleural effusion was purulent, and the laboratory findings of pleural effusion led to a diagnosis of bacterial empyema. He began receiving an antimicrobial agent, and thoracic cavity drainage were performed. However, since the empyema cavity was multiloculated, drainage was not effective. Urokinase was administered into the thoracic cavity, which increased the drainage and alleviated the thoracic empyema. Conclusion. Thoracic empyema caused by TBB is rare, but it is necessary to pay attention to patients who have large tumors with central necrosis or cavitary lesions immediately below the pleura.
Case. A 53-year-old man, who had been diagnosed which diffuse panbronchiolitis 9 years previously and who was treated with low-dose macrolide, was referred to our hospital because of worsening cough and sputa. Chest computed tomography showed the thickening of the bronchial walls and mild bronchiectasis in the central area rather than the peripheral area of both lung fields. An electron microscopic examination of biopsy specimens from the bronchial mucosa, which had been obtained by bronchoscopy, showed defects of the inner and outer dynein arms of the cilia. Although he did not have situs inversus, he was diagnosed with primary ciliary dyskinesia (PCD). Conclusion. Situs inversus has been reported to exist in only 50% of patients with PCD. Thus, PCD should be considered in the differential diagnoses of patients with repeated lower tract infection, even in patients without situs inversus.
Background. Multiple pulmonary leiomyomatous hamartoma (MPLH) is a rare disease, usually found in the lungs of middle aged or older women. Case. The case is focused on a 50-year-old woman who received a diagnosis of Turner syndrome and received female hormone replacement therapy when she was younger. Although she had no symptoms, a chest computed tomography (CT) scan revealed multiple small nodular shadows in the bilateral lung fields. A transbronchial lung biopsy (TBLB) was performed. The histological findings revealed proliferation of the smooth muscle cells without mitosis. We diagnosed multiple pulmonary leiomyomatous hamartoma because MRI revealed uterine atrophy without uterine leiomyoma. Conclusion. TBLB was useful for the diagnosis of multiple pulmonary leiomyomatous hamartoma. Therefore, one should consider this diagnosis when patients present with multiple nodular shadows.
Background. Pulmonary hamartoma develops generally in lung parenchyma or in the bronchus but rarely in the trachea. Case. A 66-year-old woman was referred to our department due to a round nodule with a diameter of 3 mm in the trachea, which was found on a chest CT performed due to her laryngeal discomfort. Flexible fiberoptic bronchoscopy found a smooth polypoid tumor in the trachea. The polypoid tumor was totally resected using conventional biopsy forceps with little bleeding and was diagnosed as hamartoma. Conclusion. We report a rare case of endotracheal hamartoma occurred in woman, which was completely resected by a flexible fiberoptic bronchoscope.
Background. Endobronchial hamartoma predominantly consists of adipose tissue, mimicking a lipoma. Because it is difficult to diagnose, surgical resection is often performed despite the possibility of a benign nature. Case. A 69-year-old man presented with a fever and shortness of breath. Chest computed tomography (CT) showed a tumor in the intermediate stem bronchus causing obstructive pneumonia of the right middle and lower lobes. The CT values suggested that the tumor contained fatty tissue, indicating a benign nature. Therefore, we resected the tumor using a snare and Nd-YAG laser with a flexible endobronchial scope. A histopathological analysis led to the diagnosis of endobronchial lipomatous hamartoma, as some bronchial glands were found in the tumor. Conclusion. Endobronchial lipomatous hamartoma is a rare, benign endobronchial tumor and it is also difficult to diagnose. In this case, we diagnosed this patient with endobronchial lipomatous hamartoma due to the presence of bronchial glands. If an endobronchial tumor is believed to be benign, endoscopic resection should be considered as a treatment option to confirm the diagnosis.
Background. Understanding the positional relationship between a tumor and the bronchi is essential for sparing the peripheral bronchi and lungs during surgical resection of a benign tracheobronchial tumor. Case. A 51-year-old woman presented with dyspnea, and a bronchial tumor was detected. The tumor was located near the orifice of the left B6 bronchus. Before performing surgical resection, the incision line for the left main bronchus was planned based on the positional relationship between the tumor and the bronchi, which was determined from the computed tomography findings. Since no findings indicating malignancy were detected in the intraoperative rapid diagnosis, spiral bronchoplasty was used to perform the excision, while sparing the B6, considering the positional relationship determined preoperatively. The histopathological diagnosis was very difficult, and we ultimately diagnosed the patient with bronchial mucous gland adenoma, a very rare benign tumor. The patient has not shown bronchial stenosis or recurrence during a four-year follow-up. Conclusion. In conclusion, we herein reported a case of bronchial mucous gland adenoma that was successfully excised via spiral bronchoplasty.
Background. Inflammatory myofibroblastic tumor (IMT) is a rare pulmonary tumor that accounts for only 0.04% of all lung tumors. These tumors exhibit characteristics of myofibroblastic proliferation with infiltration of inflammatory cells. Tracheal or bronchial IMT is an even rarer pulmonary tumor. Case. A 36-year-old man presented to a hospital with hemoptysis, and bronchoscopy revealed a tumor obstructing the right truncus intermedius. He was diagnosed with IMT and admitted to our hospital to receive surgery. Computed tomography showed a mass shadow at 5 mm from the second carina on the distal side, measuring 15×10 mm. It completely obstructed the right truncus intermedius. We performed right middle sleeve lobectomy with preservation of the lower lobe. A histopathological examination revealed spindle cell hyperplasia with lymphocyte and plasma cell infiltration. Immunostaining was positive for SMA, vimentin, and ALK and negative for AE1/AE3, S-100, and desmin. A confirmed diagnosis of IMT was made. Since his surgery, the patient has survived without relapse for seven months. Conclusion. Tracheal or bronchial IMT is a very rare disease. Complete tumor resection is necessary.
Background. Bronchial occlusion with endobronchial Watanabe spigots (EWSs) has been known to be useful for intractable pneumothorax, empyema with bronchopleural fistula, or hemoptysis. In general, it has been recommended that EWSs should be removed within several months after insertion. There have been only a few reports of a long-term placement of EWSs. Case. A 46-year-old woman underwent thymothymectomy and left pulmonary lingula segmentectomy for invasive thymoma at the age of 24. Since intrathoracic recurrence was found 16 years later, she underwent resection of the recurrent tumors with preoperative induction chemotherapy. Postoperative air leakage continued and we failed to surgically close the fistula. Therefore, we used three EWSs to occlude the left superior bronchus and the air leakage was successfully eliminated. Thereafter, those EWSs have been placed for over six years without significant complications. Conclusion. EWSs can be placed for a long-term with careful follow-up.
Background. Immunocompromised patients with cryptococcosis present a variety of image findings, rarely mediastinal and hilar lymphadenopathy, while immunocompetent patients present mostly pulmonary nodules. Case. A 20-year-old man receiving chemotherapy for acute lymphoid leukemia developed persistent fever with mediastinal and left hilar lymphadenopathy. He underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the mediastinal lymph node which revealed the presence of yeast-like funguses, while serum cryptococcal antigen was positive. In addition to these, meningitis was confirmed by central spinal fluid examination. These findings led to a diagnosis of disseminated cryptococcosis with lymphadenitis. He responded to induction therapy with liposomal amphotericin B plus flucytosine and had an uneventful course after changing to maintenance therapy with fluconazole. Conclusion. We suggest that EBUS-TBNA and serum cryptococcal antigen aid in diagnosing cryptococcosis in immunocompromised patients with mediastinal and hilar lymphadenopathy.