Background. Pulmonary cryptococcosis may present with nodules or cavities on radiographic imaging and must therefore be differentiated from lung cancer. Case. A 59-year-old man was admitted to our hospital due to a fever. Computed tomography showed symmetrical nodules in the bilateral lower lungs, and fluorodeoxyglucose positron emission tomography (FDG-PET) showed an increased uptake of FDG in the lesions. Gadolinium-enhanced head magnetic resonance imaging showed contrast enhancement of the brain surface. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the subcarinal mediastinal lymph node, which was performed based on the increased uptake on FDG-PET revealed cryptococcal fungi. We diagnosed the patient with disseminated cryptococcosis. His symptoms resolved with anti-fungal treatment, and the pulmonary and brain manifestations significantly improved. Conclusion. EBUS-TBNA of the mediastinal lymph nodes guided by FDG-PET can be useful for the diagnosis of pulmonary cryptococcosis.
Background. Pleuroscopy is useful when making a definite diagnosis of pleural effusion of unknown etiology. We encountered a patient with pleural effusion of unknown etiology who was examined by pleuroscopy under local anesthesia, and diagnosed with pancreatic pleural effusion, which was later complicated by a mediastinal pancreatic pseudocyst. Case. A 39-year-old woman was admitted to a neighborhood hospital. She had a history of alcohol pancreatitis last year. Chest X-ray showed massive pleural effusion on the right side of the lung. Thoracentesis was performed but a definitive diagnosis could not be made. Pleuroscopy revealed diffuse redness, swelling, and fibrous hypertrophy on the pulmonary apex and the dorsal posterior pulmonary wall. The amylase level in the pleural effusion was high and MRCP revealed a mediastinal pancreatic pseudocyst. We determined a mediastinal pancreatic pseudocyst accompanied by pancreatic pleural effusion. Conclusion. When pleural effusion of unknown etiology is noted in patients with repeated alcoholic pancreatitis, mediastinal pancreatic pseudocyst should be considered in the differentiation.
Case. A 78-year-old man presented with persistent cough. Computed tomography (CT) of the chest demonstrated a tumor with a fat density in the left bronchus and partial atelectasis of the left lower lobe. A bronchoscopy revealed a tumor mobilized easily without no stem. Although it was difficult to observe the peripheral bronchial lumen, forceps were insertable to the tumor. In order to confirm the pathological diagnosis, resection with a snare under a flexible bronchoscope was performed with general anesthesia. Fat tissue was seen in the stump of the tumor, and after the resection, the lumen of the left B8 could be observed well. Pathologically, mature adipose tissue growth in the bronchial submucosal layer and the tumor were diagnosed as an endobronchial lipoma. Conclusion. Bronchoscopic snare resection for endobronchial lipomas was difficult to definitively resect, but was effective in releasing atelectasis.
Background. Endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is useful for diagnosis of mediastinal lesions adjacent to the esophagus. Case. 47-year-old man was treated with cisplatin and pemetrexed for lung adenocarcinoma (cT4N3M1c, BRA, PUL, cStage IVB), and had partial response after 4 cycles of both. After 1 cycle of maintenance therapy with pemetrexed, he presented with fever and chest pain. Chest computed tomography revealed #4L mediastinal lymph node enlargement. We performed biopsy on #4L mediastinal lymph node through esophagus, because it was difficult to perform biopsy through the airway, and yellowish-white fluid was aspirated. In the fluid, no atypical cells were detected, and H. parahaemolyticus and H. parainfluenzae were detected in the bacterial culture. We diagnosed bacterial mediastinal lymphadenitis caused by the Haemophilus species which improved by antibiotics. Conclusion. Solitary bacterial lymphadenitis caused by Haemophilus species is rare and EUS-B-FNA is useful for diagnosis.
Background. Typical chest computed tomography (CT) findings in welder's lung are faint centrilobular opacities, and large nodules or mass lesions are rare. Case. A 50-year-old man who had worked as a welder since 20 years of age complained of finger joint pain and was diagnosed with rheumatoid arthritis (RA). Chest CT showed multiple irregularly shaped nodules and masses. The histological findings of a transbronchial lung biopsy (TBLB) were typical of welder's lung, but the CT findings were not typical, and the multiple nodules grew in size over time. A re-biopsy using endobronchial ultrasonography with a guide sheath (EBUS-GS) revealed the same histological findings as at the previous examination. Conclusion. We encountered a rare case of welder's lung with RA. There was no obvious association between welder's lung and RA.
Background. When the disease of a patient with non-small cell lung cancer (NSCLC) and an epidermal growth factor receptor (EGFR) mutation progresses after EGFR-tyrosine kinase inhibitor (EGFR-TKI) therapy, it is important to perform a re-biopsy for reliable tissue collection. However, there are some cases in which a re-biopsy by bronchoscopy is difficult. Case. A 47-year-old man with pulmonary adenocarcinoma (stage IVA) and an EGFR mutation (exon 19 deletion) was diagnosed with an increase in primary tumor size after EGFR-TKI therapy. We performed endobronchial ultrasonography (EBUS) using a guide sheath (GS) for a re-biopsy. When the bronchial lumen was observed with an ultra-thin bronchoscope (BF-XP260F), it was found to be obstructed by a white sub-epithelial lesion. When we used a thin bronchoscope (BF-P260F) and inserted an ultrasound probe, the lesion was occluded at the entrance, and no additional probes could be inserted. The brush could be inserted through the GS at the same site into the lesion under fluoroscopic guidance. When we re-inserted the ultrasound probe, EBUS showed that the probe was located within the lesion. The histopathological diagnosis revealed adenocarcinoma positive for EGFR mutations (exon 19 deletion and exon 20 T790M). Conclusion. We experienced a case in which the method of performing EBUS-GS with a brush was useful for collecting reliable tissue by a re-biopsy when a peripheral bronchus was obstructed at the margin of a lesion.
Background. It is very rare for inflammation to spread into the thoracic cavity from an iliopsoas abscess, and there have not been any reports of a case of bronchopleural fistula associated with iliopsoas abscess. Case. A 64-year-old man with Crohn's disease was treated for right empyema due to an iliopsoas abscess secondary to Crohn's disease by drainage and antibiotics. Although the empyema was improved by these treatments, the iliopsoas abscess developed into bronchopleural fistula and aspiration pneumonia 18 months after empyema improved. The patient received bronchial occlusion into the right B8 bronchus and right B9+10 bronchus with an Endobronchial Watanabe Spigot (EWS), and the aspiration pneumonia improved. At 52 months since bronchial occlusion, there have been no episodes of aspiration pneumonia due to the bronchopleural fistula after the bronchial occlusion. Conclusion. Bronchial occlusion with an EWS can maintain a good therapeutic outcome over the long term without serious side effects.
Background. Congenital bronchial atresia (CBA) is likely caused by ischemia of the bronchial artery during embryonic development. Cases. During a routine medical checkup, chest X-ray showed abnormal findings in Case 1 (37-year-old woman) and Case 2 (65-year-old man). Neither patient had a history of lung infection or subjective symptoms. Computed tomography suggested bronchial atresia accompanied by localized emphysema in both cases. However, mucoid impaction was seen only in Case 2. Bronchoscopy revealed a fine recess resulting in membranous occlusion at the inlet of the left B6 in Case 1 and a complete absence of the right B6 in Case 2. No abnormalities in the mucosal epithelium covering the bronchial atresia were observed in either case. Both patients were finally diagnosed with CBA. Conclusion. We encountered two cases of CBA detected during a medical checkup with different radiological findings. In cases identified as having localized emphysema on imaging studies, bronchoscopy should be considered due to possibility of CBA, regardless of mucoid impaction.
Background. Bronchoscopy using a high-flow nasal cannula (HFNC) in patients with acute respiratory failure (ARF) and underlying lung cancer has not yet been reported. Case. A 34-year-old woman visited our hospital due to worsening cough with sputum. Chest X-ray revealed an abnormal shadow in the lung fields. On the day following admission, she developed ARF. An HFNC was used during diagnostic bronchoscopy to maintain oxygenation, and diagnostic bronchoalveolar lavage (BAL: 50 ml×2 times) was successfully completed. A cytological evaluation of the BAL fluid revealed adenocarcinoma; thus, the patient was diagnosed with pulmonary lymphangitic carcinomatosis. We explained the risks, particularly lung injury, and benefits of tyrosine kinase inhibitor (TKI) treatment to the patient and then started oral epidermal growth factor receptor (EGFR)-TKI therapy with erlotinib with her written consent. We selected erlotinib because it has been indicated as being effective in EGFR mutation-negative lung cancer. Her respiratory symptoms rapidly improved. The final results of molecular testing of EGFR revealed that the cancer harbored the EGFR exon 19 deletion. Conclusions. HFNC may be an effective tool for maintaining oxygenation during diagnostic bronchoscopy in patients with ARF. For the appropriate molecular diagnosis of lung cancer in patients with ARF, the samples should be subjected to a molecular analysis.
Background. Adenoid cystic carcinoma (ACC) of the trachea is rare. ACCs are categorized into cribriform, tubular and solid types, and solid type is known to have the poorest prognosis. Case. A 57-year-old Japanese man who had suffered from diplopia for 2 months visited a hospital. Head magnetic resonance imaging (MRI) showed a right intraorbital tumor and multiple brain tumors, and chest computed tomography (CT) revealed multiple bilateral pulmonary nodules. He was introduced to our hospital for further examinations, and chest CT at the first visit showed a thickened tracheal wall in the right upper ventral trachea and multiple bilateral pulmonary nodules. Positron emission tomography (PET)-CT demonstrated a mild fluorodeoxyglucose (FDG) uptake (maximum standardized uptake value 5.4) in the tracheal lesion. Bronchoscopic findings revealed a submucosal tumor with vascular hyperplasia in the right upper ventral trachea with magenta coloring on autofluorescence imaging. Histopathologically, the biopsied specimen obtained from the lesion was diagnosed as solid-type ACC arising in the trachea. Conclusion. Our patient with solid-type ACC of the trachea had accompanying diplopia but showed no respiratory symptoms. ACC of the trachea sometimes show asymptomatic intramural progression without any respiratory symptoms, so physicians should be alert for this disease.
Background. Sarcoidosis exhibiting the reversed halo sign (RHS) is rarely encountered. We herein report a case of sarcoidosis exhibiting the RHS that was diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Case. A 77-year-old male patient was monitored following a complete atrioventricular block (complete AVB) performed by another physician and was admitted to the internal cardiology department with a secondary complaint of heart failure. Abnormal shadows were noted on chest X-ray photographs and invasive shadows exhibiting RHS were observed on chest computed tomography (CT), which prompted his admission to the department. Cardiac sarcoidosis was suspected, as the patient had a history of a complete AVB and there was a decline in his advanced cardiac function. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and a myocardial biopsy were performed but resulted in no definitive diagnosis. Multiple diffuse shadows, nodular shadows and RHS with mural nodules, and enlargement of the mediastinal and bilateral hilar lymph nodes were observed on chest CT. While a transbronchial lung biopsy (TBLB) did not result in a diagnosis, EBUS-TBNA of the enlarged mediastinal lymph nodes revealed non-caseating epithelioid cell granuloma, leading to the diagnosis of biopsy-proven sarcoidosis. Although the RHS resolved naturally without treatment, the multiple diffuse shadows and nodular shadows and enlargement of the mediastinal and bilateral hilar lymph nodes persisted. The multiple shadows and nodular shadows disappeared following the initiation of steroid treatment, and simultaneously, the enlargement of the mediastinal and bilateral hilar lymph nodes was also ameliorated. Conclusion. In cases with enlargement of mediastinal lymph nodes and RHS with mural nodules, EBUS-TBNA should be actively used as a diagnostic method, in consideration of the possible presence of sarcoidosis.
Background. Amyloidosis is an unusual cause of mediastinal lymphadenopathy. Recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be effective for the assessment of intrathoracic lymphadenopathy. However, there have been few reports regarding the usefulness of EBUS-TBNA for diagnosis of amyloidosis. Case. A 71-year-old man was referred to us for evaluation of hilar and mediastinal lymphadenopathy with calcification. There were no diffuse interstitial changes in the lungs. A histological analysis of the mediastinal lymph node (#7) using EBUS-TBNA demonstrated amyloid deposits. A systemic workup revealed cardiac and gastrointestinal amyloidosis. A diagnosis of primary systemic amyloidosis was made. Conclusion. Amyloidosis should be considered in the differential diagnosis of hilar and mediastinal lymphadenopathy, especially if calcification is present. EBUS-TBNA can be a useful tool for the diagnosis of amyloidosis with mediastinal lymphadenopathy.
Background. It is difficult to choose an appropriate treatment for patients with high-risk pneumothorax for whom general anesthesia is considered intolerable. Case. An 82-year-old man, who recovered from a shock state due to ruptured hepatocellular carcinoma (HCC) without interventional radiology (IVR) or surgery, was transferred to our hospital with a complaint of dyspnea, three weeks after recovery from rupture. Chest X-ray showed moderate left-sided pneumothorax. A chest tube was inserted into the left pleural cavity. Air leakage continued for two weeks. We performed video-assisted thoracoscopic surgery (VATS) under local anesthesia because of his general condition. At surgery with two thoracic ports, the site of air leakage was found at the left basal segment and was covered with a polyglycolic acid (PGA) sheet after loop-ligation. The postoperative course was uneventful. The patient was discharged and died of HCC 6 weeks later. Conclusion. A patient with high-risk pneumothorax and end stage of HCC was successfully treated by VATS under local anesthesia.
Background. Sleeve resection is generally indicated for oncologically radical treatment for lung cancer with preservation of the pulmonary function but can cause anastomotic complications. We herein report a successful case of bronchoscopic intervention for anastomotic stricture after sleeve right lower lobectomy. Case. The patient was a 62-year-old man with squamous cell carcinoma of the right lower lobe extending from B6 to the truncus intermedius. We performed sleeve right lower lobectomy with telescoping anastomosis between the truncus intermedius and the right middle lobe bronchus using interrupted absorbable monofilament sutures. Anastomotic stenosis due to granulation tissue caused atelectasis of the middle lobe three months after the operation. Endoscopic resection of suture granulomas with high-frequency-wave snare and balloon dilation resolved the severe stricture and maintained the patency of the bronchial lumen without recurrence of stenosis. Conclusion. Bronchoscopic intervention can be effective for managing anastomotic stricture complicating sleeve resection.