Background. Bronchial artery aneurysm is a rare disease but can be life-threatening when it ruptures. Case. A 74-year-old woman with hypertention presented with sudden back pain at dinner and visited our emergency department. Contrast-enhanced computed tomography showed an enlargement of the middle mediastinum and a high-density 6-mm nodule connected to the bronchial artery in the early phase. After the examination, her systolic blood pressure dropped to about 40 mmHg. Emergency bronchial artery angiography showed a bronchial artery aneurysm, so artery embolization with N-butyl-2-cyanoacrylate (NBCA) /lipiodol and a microcoil was performed, which succeeded. Her post-procedure course was uneventful, and she was discharged on the 16^th day of admission. There has been no recurrence in the 1 year and 5 months since the procedure. Conclusion. Ruptured bronchial artery aneurysm should be diagnosed early. Artery embolization is effective for the treatment, and NBCA is useful as an embolic material.

Background. Granulomatous polyangiitis (GPA) is a primary systemic vasculitis characterized by necrotizing granulomatous vasculitis that affects small and/or medium-sized blood vessels and is an anti-neutrophil cytoplasmic antibody (ANCA) -related vasculitis. Although histopathological evaluations are essential for the diagnosis, the diagnostic rate with a transbronchial lung biopsy (TBLB) is known to be low. Case. An 80-year-old woman was observed on computed tomography (CT) to have multiple lung infiltrates in September 20XX-3. A TBLB and 3 percutaneous lung biopsies revealed no specific pathological findings, and her blood tests were negative for ANCA. Therefore, vasculitis was not diagnosed. The pulmonary shadows improved with steroid therapy, which was subsequently gradually tapered and discontinued. In April 20XX, the patient developed anorexia and vomiting. Chest X-ray and CT showed a cavity in the right upper lung lobe. At this time, blood tests were positive for myeloperoxidase-ANCA, and necrotizing granulomatous vasculitis was detected by a cryobiopsy. She was therefore finally diagnosed with GPA. Conclusion. A cryobiopsy is considered useful for detecting vasculitis, and the accumulation of more cases in the future is expected.

Background. A fistula empyema often requires surgery, such as fenestration, but there are reports that surgery can be avoided with bronchial embolization. Case 1. A 76-year-old man was admitted to our hospital due to increasing dyspnea of several days' duration. He was diagnosed with a fistula empyema and treated with chest tube drainage and antibiotics. Because air leakage persisted, bronchial embolization using an Endobronchial Watanabe Spigot (EWS) was performed on the 8th day of hospitalization. The air leakage resolved, and on the 11th hospital day, suction with a digitalized chest drainage system (Thopaz+™) was started. The thoracic cavity with the empyema gradually contracted, and the drain was removed on the 19th hospital day. Case 2. A 47-year-old man was admitted to our hospital for the evaluation of a cough and pleural effusion. He was diagnosed with a fistula empyema and treated with chest tube drainage and antibiotics. Because air leakage persisted, as in Case 1, bronchial embolization using an EWS was performed on the 4th day of hospitalization. The air leakage resolved, and on the 5th hospital day, suction with a digitalized chest drainage system was started. The thoracic cavity with the empyema gradually contracted, and the drain was removed on the 18th hospital day. Conclusion. We successfully managed 2 patients in whom surgery was avoided by bronchial embolization using an EWS, followed by stable negative-pressure drainage using a digitalized chest drainage system.

Background. Idiopathic tracheal stenosis is a rare disease of unknown etiology with no established treatments. Previously reported endoscopic or surgical treatments have resulted in high recurrence rates and difficulty preserving the vocal cord function. Case. A 49-year-old woman experienced dyspnea for 6 months. On her first visit, inspiratory stridor was audible. Bronchoscopy revealed circumferential stenosis 2 cm below the vocal cords. Tracheotomy was performed distal to the stenosis to secure the airway. A biopsy of the stenosis site after tracheotomy revealed nonspecific fibrous tissue with infiltration of inflammatory cells. The patient was diagnosed with idiopathic tracheal stenosis by excluding other diseases that cause tracheal stenosis. Two months after undergoing tracheotomy, the patient was readmitted for radical surgery and underwent bronchoscopic observation, which indicated spontaneous improvement of the tracheal stenosis. She therefore did not undergo surgery. After 2 more months, the tracheotomy was closed, as the stenosis had disappeared circumferentially. The patient has since been followed up for 3 years with no recurrence. Conclusion. Our case showed that elective follow-up under tracheotomy with the expectation of spontaneous remission might be a viable treatment option for idiopathic tracheal stenosis.

Background. Coronavirus disease 2019 (COVID-19) is known to cause hemoptysis and bloody sputum, and pulmonary hemorrhaging is sometimes observed at the autopsy of patients with COVID-19. However, there have been few reports of pulmonary hemorrhaging diagnosed by bronchoscopy in patients with COVID-19. Case. A 32-year-old man presented at the hospital with a chief complaint of a fever without hemoptysis or bloody sputum. The patient reported close contact with family members diagnosed with COVID-19. However, polymerase chain reaction testing was negative for COVID-19. Community-acquired pneumonia was suspected, as chest X-ray showed infiltration shadows in both lung fields. A course of levofloxacin did not improve the infection. Bronchoalveolar lavage (BAL) was performed, which revealed pulmonary hemorrhaging associated with COVID-19. The patient was then administered dexamethasone, which promptly improved his condition, and he was discharged thereafter. Conclusion. In this patient, COVID-19 caused pulmonary hemorrhaging, along with persistent shadows detected on chest X-ray; BAL was useful in its diagnosis.

Background. Exostosis (osteochondroma) is the most frequent primary benign bone tumor, and the ribs are rarely involved. Exostosis is sometimes identified as a cause of pneumothorax or hemothorax. We herein report a case of costal exostosis extending into the lung. Case. Two years ago, a 19-year-old man had been referred to a hospital because of chest pain. A tumor of the left rib was discovered, but the doctor decided to just perform observation, to avoid interference with his schoolwork. Two years later, he was referred to our hospital for surgery. Chest computed tomography revealed a bone tumor protruding from the left third rib toward the lung. The symptoms were suggestive of a rib tumor; therefore, thoracoscopic surgery was performed. Intraoperative observation revealed a tumor rising from the left third rib and extending into the upper lung lobe. The tumor base was resected, and wide wedge resection of left upper lobe, including the tip of the tumor remaining in the lung, was performed. A histopathological examination revealed bone tissue with cartilaginous cap on the surface in the left upper lung lobe. Thus, the patient was diagnosed with costal exostosis. Conclusion. Although costal exostosis is a benign tumor, it can cause chronic mechanical irritation of intrathoracic organs, potentially leading to pneumothorax or hemothorax. Therefore, surgical resection should be considered.

Background. A few reports have described postoperative bronchopleural fistulae or bronchial perforations other than bronchopleural fistula with a bronchial stump, but some reports have described such fistulae occurring from damage to the tissues of the trachea and bronchi due to the use of energy devices. Case. A 61-year-old woman received a preoperative diagnosis of right lower lobe lung adenocarcinoma. During thoracoscopic right lower lobectomy, bleeding occurred from the bronchial artery around the intermediate bronchus, and soft coagulation was performed using ball electrode coagulation. About 5 weeks after the first operation, the patient developed a fever, and bronchoscopy revealed perforation of the middle bronchial trunk, probably caused by thermal damage from soft coagulation. Since closing the fistula was difficult, open-window thoracostomy was performed. The fistula closed spontaneously with daily wound care. Conclusion. Soft coagulation is an effective technique for hemostasis and repair of air leaks, but it can cause thermal damage and should be used with a proper understanding of the characteristics of both the device and bronchial anatomy.

Background. Bronchial foreign bodies are often difficult to extract safely after a long time has passed because of granulation or incarceration. Case. A 74-year-old woman suffered from chronic cough after swallowing a fishbone. The cause of the cough was unclear, and 1 year later, she consulted a local doctor with a chief complaint of a fever and discomfort in the left thorax, at which point she was treated for pneumonia. At that time, chest computed tomography showed left upper lobe bronchus obstruction and left upper lobe atelectasis. A foreign body was found stuck in the bronchus, but it was difficult to extract by bronchoscopy, so the patient was referred to our hospital. The bronchial wall of the left main bronchus was edematous. A foreign body resembling a fishbone was observed at the bifurcation of the left upper and lower lobe bronchus, and the orifice of the left upper lobe bronchus was narrowed due to granulation. We administered prednisolone at 40 mg/day for 3 days to improve the bronchial edema before extracting the fishbone with a flexible bronchoscope under general anesthesia. We found that bronchial edema had been improved. Transient positive airway pressure was effective in expanding the bronchial lumen and extracting the fishbone stuck in the bronchus. We succeeded in extracting the fishbone using alligator biopsy forceps. Conclusion. We improved the bronchial edema with the preadministration of prednisolone and expanded the bronchial lumen under general anesthesia to control breathing and the cough reflex, thereby extracting the intrabronchial fishbone.

Background. A displaced right B²⁺³ bronchus is a rare bronchial anomaly. We experienced a case of right upper lobectomy for lung cancer with the anomaly in which preoperative three-dimensional computed tomography (3D-CT) reconstruction was utilized. Case. A 69-year-old man with a chief complaint of chest discomfort underwent chest X-ray, and an abnormal shadow in the right upper lung field was detected. Chest CT showed a mass 7.1 cm in size in his right upper lobe. A transbronchial lung biopsy through the right B¹b revealed the histologic diagnosis of non-small cell carcinoma (clinical T4N1M0-stage IIIA). The preoperative 3D-CT reconstructed image was useful for recognizing a bronchial anomaly wherein the right B²⁺³ bronchus branched from the intermediate bronchus. Each branch of the pulmonary artery at A¹, A^2a, A^2b, A^3a, and A^3b showed separate branching from the pulmonary trunk. We separately dissected the B¹ and B²⁺³ branches from the intermediate bronchus and completed right upper lobectomy. The pathological diagnosis was pT3N0M0-stage IIB. Conclusion. We reported a case of lung cancer in the right upper lobe with a right B²⁺³ bronchial anomaly, which we safely resected.

Background. Allergic bronchopulmonary mycosis is caused by type 2 immune reactions on the host side against inhaled fungus, leading to pulmonary structural changes if there is no treatment. Case. A 68-year-old man was diagnosed with hypersensitivity pneumonitis six years ago. While he recovered by antigen avoidance, bronchiectasis and pulmonary fibrosis remained, mainly located in the right lower lobe. He had also been diagnosed with bronchial asthma and eosinophilic pneumonia one year ago and underwent corticosteroid therapy, with his condition improving. Follow-up was continued, and computed tomography images revealed new consolidations on the bronchiectasis of the right lower lobe, while bronchoscopy confirmed mucus plugs in the right lower bronchus. In histological studies, Grocott staining revealed filamentous fungi, so the patient was diagnosed with allergic bronchopulmonary mycosis. He was treated with corticosteroids, and the consolidations in the right lower lobe improved, even when the corticosteroids were tapered. Conclusion. This case suggests that abnormal bronchioles might be a risk factor for allergic bronchopulmonary mycosis in patients with asthma.

Backgroud. The onset of interstitial pneumonia during treatment of rheumatoid arthritis (RA) rarely leads to the diagnosis of anti-aminoacyl tRNA synthetase (ARS) syndrome. Case. A 66-year-old man was admitted to our hospital complaining of a 1-month history of persistent cough and dyspnea on exertion with the onset of interstitial pneumonia during treatment, such as sodium aurothiomalate for RA. Chest high-resolution computed tomography (HRCT) revealed diffuse reticular lesions, interlobular septal thickening, and traction bronchiectasis, admixed with consolidation predominantly in the bilateral lower lobes. The histopathological findings of video-assisted thoracic surgery (VATS) specimens showed fibro-cellular non-specific interstitial pneumonia. Consequently, we diagnosed him with anti-ARS syndrome due to positive serum findings for anti-PL-12 antibody. Conclusion. Anti-ARS antibodies should be measured in patients with suspected connective tissue disease-interstitial lung disease showing the above findings on HRCT.

Background. Tracheal metastases of lung cancer are rare. Furthermore, developmental modes of tracheal and bronchial metastases are difficult to determine. Case. An 81-year-old woman diagnosed with small-cell lung carcinoma underwent right lower lobectomy (stage IA3). Six months after the surgery, she visited our hospital with dyspnea and wheeze. Chest computed tomography and a bronchoscopic examination revealed multiple masses in the trachea and confirmed the recurrence of small-cell lung cancer. She underwent bronchoscopic partial resection and palliative radiation therapy as no other recurrent lesions were found. Subsequently, only tracheal and bronchial lesions recurred repeatedly; therefore, local therapy was performed twice. She survived for 21 months from the first recurrence without chemotherapy (at her request). Based on the pathological findings, we considered the possibility of the tracheal metastases spreading through the submucosal lymphatics. Conclusion. We herein report a rare case of small-cell lung cancer with tracheal and bronchial metastases that might have spread via the lymphatics.

Background. Bronchial foreign bodies that had been staying for a long time, were sometimes difficult to remove because granulation was formed its around. Case. 78-year-old man visited local hospital for hemoptysis which developed 3 months after he started to take the anticoagulant for stroke. He was followed-up because no significant findings were detected by the chest computed tomography (CT) and the examination of sputum. Two months later, he developed hemoptysis again, and then, complete atelectasis of his middle lobe was recognized on CT. In spite of the treatment by antibacterial agent, atelectasis was not improved. So, he was referred to our institution. Because we could recognize a liner shadow with high absorption range at the inlet of middle lobar bronchus by a review of the chest CT scans, bronchoscopy was performed for suspicious of bronchial foreign body. Bronchoscopy demonstrated the white flat foreign body at the intermediate bronchus in the area of the bifurcation of middle lobar bronchus, and granulation was formed around with obstruction of middle lobar bronchus. The foreign body could be removed easily by biopsy forceps, and was proved to be a fish bone. We decided to follow him with taking tranilast, without procedures for the granulation caused by obstruction of middle lobar bronchus. Chest radiography 1 month after the foreign body was removed, showed the atelectasis was a tendency to improve. And chest CT 3 months later showed that the complete atelectasis of middle lobe was completely improved. Conclusion. We removed the foreign body only using biopsy forceps because its invagination to the bronchial wall was thought to be slight. We did not procedure to the granulation, to expect natural regression by removal. The complete atelectasis of middle lobe was improved with medication of tranilast.

Background. Under the current situation of the coronavirus disease 2019 (COVID-19) outbreak, we should thoroughly implement prophylaxis when we perform bronchoscopy in patients suspected of having COVID-19, as this procedure produces aerosol. However, it is very difficult to differentiate pneumocystis pneumonia (PCP) from COVID-19 by diagnostic imaging, as the images of these diseases are quite similar. Therefore, bronchoscopy is required for the differential diagnosis. We herein report 2 cases in which bronchoscopy was very useful for making diagnosis. Case 1. A man in his 40s visited our hospital with a chief complaint of a fever. He was diagnosed with pneumonia and treated by antibiotics; however, his condition did not improve. Since blood tests showed positive findings for HIV, β-D-glucan, and C7-HRP, we suspected his clinical symptoms to be due to infection with PCP or cytomegalovirus (CMV) under an immunocompromised state. Therefore, bronchoalveolar lavage (BAL) was performed. The bronchoalveolar lavage fluid (BALF) was positive for pneumocystis and CMV on polymerase chain reaction (PCR); therefore, we finally diagnosed him with PCP and CMV pneumonia. Case 2. A woman in her 70s who had been treated with immunosuppressants for rheumatoid arthritis and polymyalgia visited our hospital with a chief complaint of a fever and chills. She was diagnosed with pneumonia and treated by antibiotics; however, her condition did not improve. Blood tests were negative for HIV but positive for β-D-glucan. Therefore, we suspected her symptom to be due to PCP caused by immune deficiency. BAL was subsequently performed, and the BALF was positive for pneumocystis on PCR. Based on these findings, we ultimately diagnosed her with PCP. Conclusion. Even during the COVID-19 outbreak, bronchoscopy should be performed with thorough prophylaxis if considered necessary for a differential diagnosis.

Background. A bronchial foreign body, such as a pickled plum stone, is rare; thus, the selection of an appropriate removal technique is important. Case. An 82-year-old woman with a drop in activities of daily living and decline in her cognitive function due to Parkinson's disease and depression was admitted to a mental hospital. After having a pickled plum for dinner, she developed dyspnea. Although the symptoms improved spontaneously, she developed dyspnea again three days later. Chest X-ray and computed tomography showed a bronchial foreign body (pickled plum stone) in the truncus intermedius; therefore, she was transferred to our hospital for bronchial foreign body removal. A bronchoscopic examination also detected the bronchial foreign body in the truncus intermedius. We removed it using five-pronged grasping forceps and alligator grasping forceps. Antibiotics were effective for treating her obstructive pneumonia; therefore, she was transferred back to the previous hospital. Conclusion. We encountered a case of successful removal of a bronchial foreign body (pickled plum stone) using five-pronged grasping forceps and alligator grasping forceps.