Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been recognized as a useful and relatively safe procedure. We encountered a rare case of cardiac tamponade due to acute purulent pericarditis after EBUS-TBNA. Case. An 81-year-old man, who suffered from convulsive seizures induced by metastatic brain tumors, underwent EBUS-TBNA of the enlarged #10L mediastinal lymph node without complications and we diagnosed with non-small cell lung cancer. The patient was readmitted on the 14th day after receiving EBUS-TBNA for dyspnea from cardiac tamponade and underwent a pericardial drainage procedure in the treatment of purulent pericardial effusion. Purulent pericarditis was ameliorated by pericardial drainage for 12 days and antibiotic treatment for 26 days. Conclusion. We should be aware that EBUS-TBNA may induce serious complications such as acute pericarditis.
Background. Treatment of bronchial stenosis due to tuberculosis is difficult. Case. A woman in her 30s was admitted because of stenosis of the left main bronchus caused by bronchial tuberculosis. We diagnosed tuberculosis 3 years previously and treated her. After treatment, we observed and treated her wheezing. Although stenosis of the left main bronchus was found by chance 2 years later, she chose conservative treatment. She has since recently suffered from recurrent pneumonia and decided to undergo bronchoscopic intervention to dilate the bronchial stenosis. Chest computed tomography (CT) showed segmental stenosis of the left main bronchus. A thin bronchoscope could not be introduced through the stenosis. We considered that the cause of recurrent pneumonia was due to bronchial stenosis. Bronchoscopic dilation of the left main bronchus was performed with argon plasma coagulation and a balloon dilator. A conventional bronchoscope could then be introduced through the left main bronchus. No complications occurred during the clinical course. She has had no symptoms for restenosis for longer than 6 months. Conclusion. Bronchoscopic balloon dilation and argon plasma coagulation for bronchial stenosis due to tuberculosis is an effective and safe technique.
Background. A 19-gauge needle has recently become available for use in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). It is expected to be possible to obtain a larger size of specimens using this needle compared to those available previously. Case. A 69-year-old man underwent right ophthalmectomy under a diagnosis of right choroid malignant melanoma 4 years previously. Three years ago, a nodule measuring 23 mm in longest dimension developed in the superior segment of the lower lobe of the right lung, but it was negative on positron emission tomography-computed tomography (PET-CT), and so he was followed up with chest CT. One-and-a-half years ago, we performed EBUS-TBNA using a 22-gauge needle for diagnosis, but there were no specific findings. Subsequently, the lesion showed slight enlargement, and we again performed EBUS-TBNA with a 19-gauge needle to obtain a larger specimen. A total of four passes were made, and we obtained histological specimens with cartilage suggesting pulmonary hamartoma. Conclusions. In the present case, EBUS-TBNA using a new 19-gauge needle provided larger and better quality specimens compared to the conventional 22-gauge needle, and was effective for diagnosing pulmonary hamartoma.
Background. Gastric tube-bronchial fistula is rare disease, which results in the inflow of gastric fluid to the airway. Therefore, we need to decrease this inflow using an airway stent. Case. A 57-year-old man underwent esophagectomy for squamous cell carcinoma after irradiation therapy. On follow-up CT, a liver tumor and swelling of the mediastinal lymph nodes were noted, and we diagnosed e recurrence of esophageal cancer. He was treated with chemoradiotherapy. However, he developed pneumonia and we observed his trachea and bronchus by bronchoscopy, and identified a gastric tube-bronchial fistula. We inserted a straight Dumon stent into the left bronchus to cover the fistula and prevent gastric fluid reflux. After the improvement of pneumonia, he was discharged with continuation of intravenous hyperalimentation. Conclusion. The placement of the Dumon stent enabled the discharge of the patient.
Background. Primary bronchial schwannoma is a rare benign tumor. Recently, bronchoscopic resection using a high-frequency electrosurgical snare has reported. Case. A 47-year-old woman was referred with a chief complaint of cough and fever, and we diagnosed obstructive pneumonia. Chest computed tomography revealed a large tumor in the right main bronchus. The pedunculated tumor had a smooth surface and arose from the carina from the right main bronchus on bronchoscopy. As the tumor was benign, we performed bronchoscopic intervention. Bronchoscopic tumor resection was performed with a high-frequency electrosurgical snare and argon plasma coagulation. A diagnosis of schwannoma was made. There has been no evidence of tumor regrowth during the ten months of follow-up. Conclusion. Bronchoscopic tumor resection using a high-frequency electrosurgical snare for primary bronchial benign tumor is safe and minimally invasive. In the future, application of bronchoscopic resection will likely increase.
Background. Bronchial occlusion using Endobronchial Watanabe Spigot (EWS®) is a treatment option for bronchopleural fistula (BPF). Case. A 75-year-old man underwent bronchial occlusion using EWS® for treatment of BPF after right upper lobectomy because omentopexy was ineffective. Since the initial occlusion failed due to EWS® migration, we repeated the procedure. When we adjusted the suction pressure of thoracic drainage to -50 cm H2O, the EWS® fitted the orifice of the fistula and the air leakage disappeared. We continued the high negative pressure suction drainage, and the infection in the empyema reduced with temporal adhesion of the EWS® to the fistula. When the suction drainage pressure was subsequently reduced, the re-inserted EWS® migrated again and the BPF was found to be still present. However, since the surface of the empyema space was uniformly covered with regenerating epithelium after omentopexy, there were no signs of infection even after formation of the internal fistula between the cavity and the right main bronchus. Conclusion. Bronchial occlusion using EWS® with high negative pressure suction drainage is a useful option for the treatment of BPF and relieves the infection in empyema.
Background. Diffuse alveolar hemorrhage (DAH) is a rare complication with new anticoagulant therapy such as direct Xa inhibitor and direct thrombin inhibitor. Case. An 80-year-old woman had received rivaroxaban 15 mg a day for atrial fibrillation 2 years before the first visit. She presented with a 2-day history of cough, sore throat, and headache, and with a 1-day history of hematuria. Her creatinine clearance was 60 ml/min. Five days after the first visit, she presented again with worsening hemoptysis and dyspnea. Her creatinine clearance decreased to 37 ml/min. She underwent a bronchoalveolar lavage, and showed progressively more hemorrhage aliquots. We diagnosed DAH associated with rivaroxaban therapy, and successfully treated after withdrawal of rivaroxaban and administration of corticosteroids and hemostatic agents. Conclusion. Rivaroxaban can cause DAH. One possible reason for DAH in this case may be the excessive blood concentration level of rivaroxaban due to the decreased renal function.
Background. Mucosa-associated lymphatic tissue (MALT) lymphoma of pulmonary origin is a relatively rare disease. In particular, reports of MALT lymphoma occurring from and localized in the trachea or bronchus have been limited. Case. The patient was a 75-year-old woman with colorectal cancer who had undergone postoperative chemotherapy and had been followed up in the department of digestive surgery of our hospital. Chest computed tomography performed during the follow-up revealed elevated lesions in the region from the trachea to the bronchus, and the patient was referred to our department. As 18F-fluorodeoxyglucose-positron emission tomography performed in our department showed no accumulation of the radiotracer in the tracheobronchial region, bronchoscopy was conducted to obtain a definitive diagnosis. Bronchoscopy revealed multiple whitish elevated lesions with a tendency to easily bleed in the tracheobronchial region. Autofluorescent endoscopy showed color changes in these lesions, and biopsy specimens were obtained from the lesions. In the specimens, diffuse infiltration of small lymphocyte-like cells was observed beneath the mucosa, and immunostaining yielded CD20-positive results. Detailed whole body examination revealed no primary foci in other organs such as the esophagus, leading to a diagnosis of MALT lymphoma of tracheobronchial origin. Conclusion. MALT lymphoma of tracheobronchial origin is often diagnosed by the presence of airway stenosis. The present case is very rare because the disease was detected in an asymptomatic patient.
Background. Paradoxical reaction in tuberculosis is defined by a clinical or radiological worsening of pre-existing tuberculosis lesions or the development of new lesions, in patients receiving anti-tuberculosis medication. We report a case of a paradoxical reaction in a patient with tracheal tuberculosis, which presented as airway stenosis caused by lymphadenopathy 12 months after treatment initiation. Case. A 54-year-old woman with tracheal, laryngeal, and esophageal tuberculosis had received anti-tuberculosis treatment as an outpatient. Twelve months after treatment initiation, the patient developed dyspnea. Bronchoscopy revealed tracheal perforation caused by an enlarged mediastinal lymph node. No growth of Mycobacterium tuberculosis was observed in culture, and we diagnosed a paradoxical reaction to her anti-tuberculosis treatment. The patient's symptoms were relieved after continuing anti-tuberculosis treatment for a total of 18 months. Conclusion. Paradoxical reactions to anti-tuberculosis treatment should always be considered during and after tuberculosis treatment.
Background. In recent years, the usefulness of bronchial occlusion with Endobronchial Watanabe Spigots (EWSs) in the treatment of intractable pneumothorax or pulmonary fistula has been reported; however, there are few reports about the removal of EWSs. Case. The patient was a 49-year-old man who had previously undergone surgical treatment for right pneumothorax. Bronchial occlusion with EWSs had been performed to treat postoperative pulmonary fistula of a left emphysematous giant bulla. Although EWSs had been placed for the long-term, the patient experienced chest discomfort and we tried to remove them at one year after occlusion. Due to the influence of postoperative change and long-term placement, it was difficult to approach the left superior division, which was target objective bronchus. In addition to multiple bronchoscopes, a single-use video bronchoscope facilitated manipulation at the sub-area branch level with forceps. Finally, we successfully removed all of the EWSs without complication. Conclusion. The removal of EWSs may be difficult depending on the state of the bronchus and patient factors. The combined use of a single-use bronchoscope can be useful in cases in which EWSs are difficult to move.
Background. Some cases of migration of Kirschner wire were seen in the region of orthopediatric surgery. However, migration to the thoracic cavity is relatively rare. Case. An 82-year-old woman underwent surgical fixation using of 3 Kirschner wires for right humerus fracture in another hospital. After 3 weeks, migration of 1 Kirschner wire was pointed out at the time of wire removal under radiographic guidance. Then she was referred to our hospital. Chest CT showed migration of one wire to the right thoracic cavity and slight pneumothorax. Video-assisted thoracic surgery (VATS) was performed immediately. Thoracoscopy showed a 7.0 cm Kirschner wire piercing the margin between S6 and S8. After removal, bleeding and bronchial fistula were not seen at the injured site. She was discharged 4 days after surgery. Conclusion. VATS was useful for examination and removal of the Kirschner wire which had migrated into the thoracic space.
Background. The case of allergic bronchopulmonary aspergillosis (ABPA) with aspergilloma is very rare, and it is difficult to control the disease. Case. A 57-year-old woman, had previously undergone a partial resection of the left upper lobe due to lung abscess at age 9, and was diagnosed with ABPA at 45-year-old. She suffered from high fever and cough, with large cystic bronchiectasis, wall thickening and cavitary effusion in the left upper lobe and consolidation in the right lower lobe in the chest CT scan, and underwent bronchoscopy. The bronchoscopy revealed a fragile fungus ball-like lesion in the left superior lobar bronchus and a marked mucus plug in the right lower lobe bronchus. We considered this fungus ball-like lesion caused by Aspergillus and started treatment with an antifungal agent. We also started steroid therapy for ABPA, and her condition improved. Aspergillus species was recognized by bronchial washing cytology from the fungus ball-like lesion. Conclusion. We should be aware of the complication of aspergilloma in the case of ABPA with severe bronchiectasis.
Background. Secondary pneumothorax caused by chemotherapy for lung carcinoma is intractable, and treatment requires various devices depending on the case. Case. A man in his 70s was diagnosed with progressive lung adenocarcinoma and underwent chemotherapy (carboplatin+pemetrexed+bevacizumab). We treated him with pemetrexed as maintenance therapy, but the lung carcinoma grew larger. We changed the regimen of the chemotherapy to nivolumab. Ten days after the start of the chemotherapy, he came to our hospital with hemosputum, and we diagnosed right pneumothorax. We started drainage and talc pleurodesis therapy, but it was not effective. We performed bronchial occlusion with Endobronchial Watanabe Spigot (EWS) using two devices. (i) We sewed a polyglycolic acid nonwoven fabric on a large spigot, and (ii) we detained EWS in the intermediate bronchus using a guidewire. The air leak stopped, and we performed pleurodesis therapy with OK-432. Subsequently, his pneumothorax healed. Conclusion. The two devices that we used were beneficial for intractable secondary pneumothorax.
Background. Bronchoesophageal fistula is often associated with pneumonia or thoracic empyema, and may sometimes follow a lethal course. This is a rare report of a relapsed bronchoesophageal fistula that was successfully treated using radical therapy. Case. The patient was a 63-year-old man who underwent endoscopic treatment for pulmonary esophageal fistula, caused by esophageal ulcer, four years earlier at another hospital. He presented to our hospital complaining of vomiting after meals for the past one month. Imaging demonstrated a relapsed bronchoesophageal fistula and subsequent pneumonia caused by esophageal obstruction due to lower thoracic esophageal cancer. After antibiotic therapy and total parenteral nutrition (TPN) management, we performed a right lower lobectomy and subtotal esophagectomy. The patient was discharged on the 15th day post-surgery and is currently undergoing outpatient chemotherapy. Conclusion. Based on the clinical course, the provisional diagnosis was relapsed bronchoesophageal fistula due to esophageal obstruction. Surgical treatment was successful after adequate improvement of the patient's general condition.
Background. Not only does the onset of thoracic empyema with bronchopleural fistula during chemotherapy for cancer make treatment with anticancer drugs difficult, the empyema with bronchopleural fistula itself also leads to the deterioration of the patient's general condition, thereby affecting the prognosis if protracted. Case. A 54-year-old man started to receive chemotherapy (carboplatin/paclitaxel/bevacizumab) for lung adenocarcinoma originating in the right upper-middle lobe; in the middle of the second treatment cycle, he suffered a sigmoid colon perforation and pneumothorax in the right lung. While the perforation was successfully managed surgically, the right pneumothorax subsequently resulted in thoracic empyema with bronchopleural fistula. The empyema cavity and air leakage decreased in response to thoracic drainage and bronchial occlusion with Endobronchial Watanabe Spigot (EWS). However, due to continuous air leakage, the patient underwent open-window thoracostomy followed by thoracoplasty and pectoralis major myocutaneous flap reconstruction, which had a curative effect. Conclusion. The combination of bronchial occlusion with EWS and surgery is a useful treatment option for refractory thoracic empyema with bronchopleural fistula associated with lung cancer.
Background. In recent years, several studies have reported IgG4-related diseases accompanied by bronchial wall thickening. Case. While the dose of oral steroids for autoimmune pancreatitis was being tapered in a 78-year-old male patient, nonproductive cough and exertional dyspnea developed, and the patient was diagnosed with asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO). The symptoms were temporarily improved by administering inhaled corticosteroids and bronchodilator; however, the exertional dyspnea was gradually aggravated after terminating the oral steroids. The serum IgG4 level was high. Bronchial wall thickening was observed by computed tomography (CT), and multiple nodules on the bronchial lumen were observed by bronchoscopy. A definitive diagnosis of Mikulicz disease was made. After the administration of systemic steroids, improvements in the bronchial wall thickening and respiratory function were confirmed, so the pulmonary lesions were suspected to be IgG4-related disease. Conclusion. IgG4-related respiratory disease can manifest as obstructive ventilatory disorder due to central airway lesions. It may be difficult to diagnose this condition in patients complicated by COPD or bronchial asthma. Hence, it was considered necessary to make an integrative diagnosis based on the physical and hematological findings as well as the detection of extra-thoracic lesions.