Background. Diaminodiphenylsulfone (DDS) is used for pemphigus and leprosy, which rarely causes drug-induced eosinophilic pneumonia. Case. A 34-year-old woman presented with a high fever and dyspnea two weeks after the initiation of topical steroids and DDS for her pemphigus. Chest radiograph and chest computed tomography showed multiple nodules in the bilateral lungs. Pulmonary eosinophilia was confirmed by bronchoalveolar lavage, and pathological imaging showed organization in the airspace and the infiltration of inflammatory cells, mainly composed of eosinophils. She was diagnosed with eosinophilic pneumonia based on her clinical course and lung pathology, and her condition promptly improved with oral steroid treatment. A drug-induced lymphocyte stimulation test for DDS was positive, and DDS was considered the causative drug. Conclusion. We herein report an extremely rare case of DDS-induced eosinophilic pneumonia with atypical radiological findings. Bronchoscopy plays a critical role in the diagnosis.

Introduction.Aspergillus species are ubiquitous fungi that are part of the normal environmental flora and abound in the soil. They are inhaled in large numbers daily and can penetrate human lungs in the form of microscopic spores. They are common colonizers of the airways in immunocompromised individuals and the primary cause of invasive mycosis. Invasive pulmonary aspergillosis (IPA) usually occurs in severely immunocompromised patients. However, a few cases of IPA in immunocompetent hosts have been reported. Case. A 49-year-old man visited a hospital and reported a 1-week history of a fever, cough, and appetite loss. He was a habitual drinker. He was diagnosed with bacterial bronchopneumonia and alcohol-related liver disease. He was referred to our hospital after his symptoms persisted for an additional 2 weeks. He was diagnosed with IPA by bronchoscopy performed at the first admission. He had no classical risk factors for immunosuppression, such as human immunodeficiency virus infection, hematologic malignancies, or immunosuppressive therapy. Conclusion. IPA should be considered during the differential diagnosis in patients presenting with unresolved pneumonia, even for those without classical risk factors. In this case, alcohol consumption was thought to be a principal risk factor for IPA. The early diagnosis of IPA by bronchoscopy is crucial for initiating timely and effective treatment in order to achieve favorable outcomes.

Background. A right displaced B³ bronchus is a relatively rare anomaly. We report two cases of lung cancer involving the right upper lobe in which a right displaced B³ bronchus branched from the middle lobe bronchus. Case 1. A 45-year-old woman with a 1.8-cm mass in the right S¹ underwent transbronchial biopsy (TBB) and was diagnosed with adenocarcinoma (cT1bN0M0 stage IA2). Case 2. A 69-year-old woman with a 2.6-cm mass in the right S² underwent TBB and was diagnosed with adenocarcinoma (cT1bN0M0 stage IA3). In both cases, the B³ bronchus arose from the middle lobe and right upper lobectomy was performed by dividing B¹+B² and B³ separately. Conclusion. The presence of bronchial anomalies in lung cancer patients necessitates preoperative evaluation, including CT and bronchoscopy, for safe surgical management. In such cases, the range of hilar and mediastinal lymph node dissection should be determined based on the tumor location.

Background. Hereditary angioedema (HAE) is a hereditary disease, caused by a genetic abnormality of the complement component 1 inhibitor (C1-INH). Physical and mental stress and invasive procedures may cause edema near the intervention site, which can lead to fatal laryngeal edema. There have been few reports on bronchoscopy in HAE. Case. A 42-year-old woman had been diagnosed with HAE at 23 years old and was taking long-term prophylaxis. In February 2019, she developed pneumonia of unknown cause, and in February 2020, it worsened. Bronchoscopy was performed without any adverse events due to strict preparation for acute attacks and the administration of short-term prophylaxis prior to the examination. Conclusion. It is important to ask patients about any medical or family history suggesting HAE before performing bronchoscopy. Careful prophylaxis may be required to prevent a fatal attack.

Background. Tracheal adenoid cystic carcinoma (TACC) is a low-grade malignancy that metastasizes to distant sites, mainly the lungs, in the late phase. We report a case of long-term survival of a patient with surgically-resected TACC who was managed with watchful waiting, in which pleural dissemination was observed as a rare pattern of recurrence, 8 years after the initial surgery. Case. The patient was a 72-year-old man who had undergone tracheal sleeve resection for TACC 8 years previously. As the pathological airway margins were positive, he received postoperative radiotherapy (60 Gy in 30 fractions). No evidence of recurrence was found until the detection of a 0.5-cm solitary pulmonary nodule in S⁶ of the right lower lobe on follow-up computed tomography. The pulmonary nodule was suspected to be pulmonary metastasis of TACC; thus, we planned to perform thoracoscopic wedge resection for the diagnosis and treatment. During surgery, we detected diffuse whitish nodules on the parietal pleura. A biopsy of the pleural nodules showed pleural dissemination of TACC. As previous studies reported described that TACC was generally chemoresistant and because the patient was elderly, we decided to follow the patient with watchful waiting. At 8 years after the pleural biopsy, the pleural and pulmonary metastases showed slow growth and the patient had no detectable symptoms; thus, he was only followed up as an outpatient. Conclusion. We reported a case in which long-term survival was achieved with watchful waiting after a relapse with pleural dissemination in a patient who had undergone surgical treatment for TACC. The optimal therapy for TACC with distant metastasis is controversial; however, watchful waiting can be an option, considering the indolent growth characteristic of TACC.

Background. Empyema with fistula is complicated and difficult to treat. We report a case of bacteria-positive empyema with bronchial fistula that was successfully treated with Endobronchial Watanabe Spigot (EWS) fixation to the fistula, and omentopexy and thoracoplasty procedures. Case. The patient was a 75-year-old man who underwent a right upper lobectomy for lung cancer, then complication pneumonectomy 5 years later due to recurrence. After the operation, the patient suffered from empyema due to a bronchial fistula and underwent fenestration to open the empyema cavity. After macroscopic purification of the cavity, a surgical procedure was used to close it, while a bacterial culture of a specimen from the empyema cavity remained positive. An EWS was directly inserted into the fistula from the operative field and fixed with a non-absorbable monofilament thread, after which the omentum was layered on the EWS and thoracoplasty was employed to compress the cavity. The postoperative course was uneventful without the recurrence of fistula or empyema. Conclusion. Fixation using an EWS may be a useful option for closing a fistula when curative surgery is considered for empyema.

Background. Broncholithiasis is a rare condition defined as the presence of calcified or ossified materials within the bronchial lumen. Tuberculosis is most common cause of broncholithiasis, and there are few reports of broncholithiasis associated with nontuberculous mycobacteria (NTM). Case. A 77-year-old woman was admitted to our hospital due to an abnormal shadow detected on chest X-ray at a medical checkup. Chest computed tomography showed multiple micronodules and bronchiectasis in the left lower lobe, and a calcified lesion existed within the proximal site of the left B⁶b. Flexible bronchoscopy revealed that a hard, yellowish-brown material incarcerated in the left B⁶b, and bronchoscopic removal was attempted because it was free in the airway. The pathological findings showed a calcification and an amorphous exudate with a large amount of acid-fast bacilli confirmed to be Mycobacterium intracellulare by culture. Other pathogens were not detected. Therefore, we diagnosed this case as broncholithiasis and NTM and speculated that NTM might be the cause of broncholith. Conclusion. We reported a case of broncholithiasis associated with NTM. Bronchoscopy was useful for the diagnosis and removal of broncholith even though this was an asymptomatic case.

Background. Limited-stage pulmonary amyloidosis is a degenerative disease that causes amyloid deposition under the mucosa of trachea, bronchus, and lung. Case. A 66-year-old woman was diagnosed with intractable asthma and repeated pneumonia at another facility. She was referred to our hospital for a closer inspection. Bronchial stenosis was found on chest computed tomography, and rhonchi were prolonged on chest auscultation. We performed bronchoscopy. A yellow diffuse nodal lesion was detected from the trachea to the right and left bronchus mucosa, with constriction. A transbronchial biopsy showed non-AA amyloidosis, and a biopsy specimen was obtained from the site. The patient's other organs did not have any significant findings. The patient's diagnosis was revised to localized tracheobronchial amyloidosis. External beam radiotherapy (EBRT) was performed for the trachea-bronchial lesion, and the patient's symptoms were improved. Conclusion. We reported the effectiveness of EBRT for trachea-bronchial amyloidosis. We have now added this case and report the consideration of the philology.

Background. Heavy smoking is a risk factor for the development of double primary lung cancers and metachronous multiple cancers in various organs. Case. A 67-year-old man with a history of heavy smoking was undergoing regular follow-up examinations in our cardiology department due to angina pectoris and other diseases. In April 20XX, he was referred to our department due to an abnormal chest X-ray shadow. Chest computed tomography (CT) showed a 20-mm nodule with spicula at the peripheral segment (S³) of the left lung with no mediastinal lymphadenopathy and no distant metastasis. On bronchoscopy, besides the left segment (S³) nodule, we also detected another small nodule at the surface of the right bronchus (B⁶) entrance. Both lesions showed the same histology of moderately differentiated squamous cell carcinoma, but the nodule at the bronchus (B⁶) was found to be carcinoma in situ. The clinical diagnosis was therefore double primary lung cancers. The left segment (S³) lesion was excised by video-assisted thoracic surgery (VATS), and the right bronchus (B⁶) lesion was treated with radiation (60 Gy in 17 fractions). In September 20XX+1, recurrence in the anterior mediastinal lymph node was detected by fluorodeoxyglucose-positron emission tomography (FDG-PET) /CT and was completely resected by VATS. However, in August 20XX+2, esophageal squamous cell carcinoma and stomach adenocarcinoma were simultaneously detected by upper gastrointestinal endoscopy. Conclusion. Double primary lung cancers, especially in heavy smokers, should be followed carefully with examinations by various modalities at regular intervals, including FDG-PET/CT and digestive system endoscopy, due to the risk of metachronous multiple cancers.

Background. Thoracic empyema with bronchopleural fistula is a troublesome condition that is sometimes difficult to treat with antibiotics and chest drainage. Thus, many cases require surgical treatment, such as open window thoracotomy. We report two cases of bronchopleural fistula that were successfully treated with occlusion by Endobronchial Watanabe Spigot (EWS). Case 1. A woman in her 40s underwent transbronchial lung biopsy (TBLB) after the detection of an abnormal shadow on her left lower lobe. She had fever and left chest pain after TBLB, and was diagnosed with thoracic empyema with bronchopleural fistula. The placement of an EWS at the left B⁹ successfully reduced the air leakage and the chest tube was removed. Case 2. A man in his 70s underwent right lower lobectomy. At five months after surgery, the patient complained of fever and cough. He was diagnosed with thoracic empyema and was hospitalized. Air leakage from the chest tube continued. He was treated with bronchial occlusion by EWS at the right B¹ and B². After the procedures, the air leakage from the chest tube disappeared and he was discharged to home. Conclusion. Bronchial occlusion by EWS was useful in the treatment of bronchopleural fistula and allowed surgery to be avoided.

Background. Primary racemose hemangioma of the bronchial artery is a rare disease caused by congenital malformation of the bronchial arteries, which is one of the causes of massive hemoptysis due to vascular rupture. Case. A 77-year-old man was admitted to our hospital because of massive hemoptysis upon waking. Bronchoscopy revealed bleeding from the right B². Right bronchial arteriography revealed a convoluted bronchial artery with hypervascularity; hence, bronchial artery embolization (BAE) was performed. However, bloody sputum appeared again after BAE, another bronchoscopic examination revealed a partially red and papillary protrusion with bleeding at the orifice of the right B². After thoracoscopic right upper lobectomy, there was no recurrence of hemorrhage. Based on the bronchoscopic, bronchial arteriographic, and pathological findings, the patient was diagnosed with primary racemose hemangioma of the bronchial artery. Conclusion. We experienced a case of primary racemose hemangioma of the bronchial artery with apparent bleeding lesion by bronchoscopy. An understanding of the characteristic bronchoscopic findings of this disease is important for its diagnosis. Additionally, surgical treatment such as pulmonary resection should also be considered if re-bleeding occurs after BAE.

Background. Pulmonary hamartomas, usually located in the lung parenchyma, are more common than endobronchial hamartomas. We report a case of an endobronchial hamartoma that occluded the intermedius bronchus over an extended period, which was subsequently treated with bronchoscopic resection and surgery. Case. The patient was a 59-year-old man who presented with atelectasis of the right middle lobe, who was diagnosed with a benign tumor in the middle lobe bronchus nine years previously. The patient chose to undergo conservative treatment because he did not experience any symptoms. However, the tumor grew and caused atelectasis of the middle and lower lobe six years after the initial consultation. Despite this, the patient indicated that he did not wish to receive any treatment for the same reasons as before. He was admitted to our hospital with a chief complaint of tussis as the tumor grew bigger. Bronchoscopy revealed a tumor in the intermedius bronchus that projected to the main bronchus. The tumor was resected using a high-frequency electrosurgical snare and was diagnosed as an endobronchial hamartoma. The inferior lobar bronchus and B⁵ were opened, and computed tomography revealed recovery of the lower lobe from atelectasis; however, good expansion of the middle lobe could not be achieved. Considering the remaining tumor in B⁴ as well as the end-stage lung damage in the middle lobe, middle lobectomy via video-assisted thoracic surgery was scheduled. Conclusion. We could preserve the respiratory function and achieve a radical cure using bronchoscopic resection and surgery, even in a patient with long-term endobronchial hamartoma with atelectasis.

Background. Duodenal mucinous adenocarcinoma (DMA) is a very rare disease. There have been no previous reports of pulmonary metastases in patients with DMA who have had a long-term postoperative survival. In addition, few studies have assessed the utility of cell blocks (CBs) from liquid samples in bronchoscopy. Case. A 73-year-old man with a history of pancreaticoduodenectomy for DMA 11 years ago was referred to our hospital because of abnormal findings on chest X-ray. The patient had been recurrence-free for more than 5 years postoperatively. Chest computed tomography (CT) showed a 13.5-cm tumor in the left upper lobe and an approximately 2-cm part-solid nodular opacity in the right middle lobe. CT-guided biopsy samples of the left lung tumor were determined to be pulmonary metastasis of the DMA. Regarding the right lung lesion, we suspected primary lung cancer and thus performed a bronchoscopic examination. Because tissue samples from the forceps biopsy were insufficient to identify the tumor origin, we examined CBs prepared from the device (brush and forceps) washing fluid. Immunohistochemical analyses of the CB samples showed the same staining pattern as DMA, confirming the diagnosis of DMA metastasis. Conclusion. We herein report a rare case of DMA metastasizing to the lungs 11 years after pancreaticoduodenectomy. In this case, CB samples from the device washing fluid following bronchoscopy were useful for the diagnosis.