Background. The Japan Allergic Bronchopulmonary Mycosis (ABPM) Research Program has proposed new clinical diagnostic criteria for ABPM in 2019. These criteria have made it possible to widen the range of symptoms when making an ABPM diagnosis. Case. A 43-year-old woman with no history of bronchial asthma was referred to our hospital due to a cough lasting for a month. Chest computed tomography (CT) revealed a mucous plug with central bronchiectasis in the right B⁴ and infiltrative shadows and centrilobular nodules in the peripheral right S⁴. The serum IgE levels and peripheral blood eosinophil counts were within the normal ranges. The mucous plug obstructing the right B⁴ was bronchoscopically identified and removed. A microscopic examination of the mucous plug showed marked eosinophil infiltration with hyphae. A culture revealed the presence of Schizophyllum commune. The serum levels of both anti-S. commune IgG and IgE were elevated. Thereafter, the patient's symptoms diminished, and the abnormal shadows on chest CT improved. No recurrence has been observed for five years. The patient was therefore retroactively diagnosed with ABPM according to the new criteria. Conclusion. Even if patients have no symptoms of bronchial asthma, those presenting with mucus plugs in the central bronchi should be suspected of having ABPM and therefore should undergo bronchoscopy.

Background. The diagnosis of atypical cases of allergic bronchopulmonary mycosis (ABPM), such as cases without asthma or caused by fungi other than Aspergillus, is often difficult. In 2019, new ABPM diagnostic criteria that include solutions to these problems were proposed in Japan. Case. A 69-year-old man who had a history of 7 years of maintenance hemodialysis and a history of chemoradiotherapy for esophageal cancer completed 4 months previously, was referred to our hospital due to 1 month of antimicrobial-refractory cough, fever, and multiple lung opacities. Blood tests revealed peripheral blood eosinophilia and high total IgE levels, and chest CT showed multiple lung opacities in both lung fields; the distribution of shadows was predominantly in the irradiation field, but was also outside the irradiation field. High-attenuation mucus (HAM) was detected in the infiltrative shadow on the mediastinal side of the lower right lobe. The mucus plug that was confirmed by subsequent bronchoscopy showed marked eosinophil infiltration on histological examination and was positive for filamentous fungi. His symptoms were quickly resolved with systemic corticosteroid treatment. Finally, the isolated fungus was identified as S. commune, and a test for the specific IgE/IgG antibody against the fungus was strongly positive. Since these findings satisfied the new clinical criteria, the diagnosis was confirmed as ABPM. Conclusion. The detection of HAM by CT may increase the possibility of confirming and collecting mucus plugs when performing bronchoscopy. It may be efficacious for differentiating and confirming the diagnosis of atypical cases of ABPM.

Background. A paradoxical reaction is a phenomenon that causes a transient exacerbation of existing lesions or fever after the initiation of tuberculosis treatment, and it is often difficult to differentiate from other diseases. Case Presentation. A 35-year-old woman with Crohn's disease was referred to our hospital for the evaluation of fever and an abnormal shadow on chest radiography. She was diagnosed with pulmonary tuberculosis and miliary tuberculosis based on a positive sputum smear for acid-fast bacilli; and a positive polymerase chain reaction for Mycobacterium tuberculosis, and treatment with anti-tuberculous drugs was initiated. A negative sputum smear for acid-fast bacilli and the regression of the lesions were confirmed after the initiation of treatment. However, she developed worsening cough 15 months after the initiation of treatment. Furthermore, chest computed tomography revealed enlargement of the mediastinal lymph nodes, enlargement of the consolidation in the right lower lobe, and a bronchial polyp at the truncus intermedius. A sputum smear for acid-fast bacilli was positive. Bronchoscopic biopsy of each lesion was performed, and a histopathological examination revealed caseous necrosis and epithelioid cells; however, no acid-fast bacilli were detected in the biopsy specimens. We continued anti-tuberculosis treatment because we considered that these lesions had formed as a result of a paradoxical reaction. Treatment was discontinued when cultures of bronchoscopic specimens to detect acid-fast bacilli were confirmed to be negative. Conclusion. Physicians should be aware that paradoxical reactions can occur late in the course of treatment and may have multiple manifestations, and a histological diagnosis should be performed to exclude other diseases.

Background. Eosinophilic granulomatosis with polyangiitis (EGPA) is a type of eosinophil-rich systemic necrotizing granulomatous inflammation preceded by bronchial asthma and allergic rhinitis. The mortality rate in the acute phase of onset is several percent; thus, an early diagnosis and early treatment are important. Case. An 83-year-old man visited our hospital due to fever and repeated asthma attacks. Chest computed tomography showed consolidation and ground glass opacity in both lungs, predominantly in the left upper lobe. Because no other evidence of vasculitis was obtained, transbronchial lung biopsy (TBLB) was performed. The histological findings of the specimen showed characteristic findings, and a diagnosis of EGPA was established. Treatment was performed with steroid pulse therapy and cyclophosphamide pulse therapy. Conclusion. EGPA with only lung lesions diagnosed by TBLB is rare. In addition, it is necessary to carefully consider the content of treatment for the elderly individuals of ≥80 years of age.

Background. Pulmonary cryptococcosis is often seen in immunocompetent patients. Cryptococcus neoformans is a very common pathogen and can mimic lung cancer, bacterial pneumonia, pulmonary tuberculosis, and other pulmonary mycoses on imaging. To the best of our knowledge, there are no reports on the ultrasonographic findings of pulmonary cryptococcosis in patients who undergo endobronchial ultrasonography using a guide sheath (EBUS-GS). Case. A 55-year-old man without a history of immunocompromising diseases presented increasing multiple right lower lobe nodules, which were asymptomatic. Transbronchial biopsy was performed using EBUS-GS, and endobronchial ultrasonography showed a heterogenous patten with hyperechoic dots and short lines (type IIIa). A pathological examination revealed pulmonary infection (mycosis type); furthermore, C. neoformans antigen was detected in the serum. Therefore, he was diagnosed with pulmonary cryptococcosis, and treatment with fluconazole was initiated. Conclusion. EBUS B-mode showed type IIIa ultrasound findings in a patient with pulmonary cryptococcosis.

Background. Most long-standing foreign bodies (FBs) in the airway are asymptomatic, but some can become symptomatic. Case. We encountered a 75-year-old man. Nine years earlier, chest X-ray at a medical examination had revealed a FB suspected of being metallic in the right lower zone. However, he wished the FB to be observed, as it was asymptomatic. Two years ago, chest CT revealed that the FB was surrounded by a shadow, and a small amount of right pleural effusion was noted. Because he was still asymptomatic, we continued to observe it, until it ultimately began to induce cough as a symptom. He was therefore referred to our hospital. Bronchoscopy revealed granulomatous and friable tissue in the right B¹⁰, but the FB could not be identified. Right lower lobectomy was performed to remove the FB as well as the surrounding shadow. A pathological examination revealed that lung tissue peripheral from the FB had a high degree of fibrosis and accumulation of plasmacytes and lymphocytes, which indicated obstructive pneumonia accompanied by fibrosis. Conclusion. If a long-standing FB in the airway with surrounding shadow and atelectasis is not differentiated from malignant disease or is difficult to remove and causes obstructive pneumonia, surgical resection needs to be considered.

Background. Broncho-pleural fistula after lung resection is often difficult to manage. Case. A 77-year-old man was diagnosed with synchronous triple lung cancer. He underwent left lower lobectomy, right S² wedge resection and right S⁹⁺¹⁰ segmentectomy. He was diagnosed with broncho-pleural fistula at 2 months after right S⁹⁺¹⁰ segmentectomy and underwent fenestration. Nine months after the first fenestration procedure, he underwent thoracoplasty and muscle plombage with an Endobronchial Watanabe Spigot; however, the obstruction of B⁹⁺¹⁰ was insufficient, and the abscess cavity was increased. He underwent fenestration again, and at the second fenestration procedure, the fistula was around 9 mm in diameter. He gradually suffered from dyspnea. We expected the fistula to be able to be closed with a modified Dumon stent, one side of which is closed. After the modified Dumon stent was successfully pushed into the relevant bronchus from the empyema cavity, he required respiratory support, tracheostomy and closure of the vocal cord; however, he eventually recovered from respiratory failure and was discharged from the hospital 4 months after treatment with the modified Dumon stent. Conclusion. A one-side-closed Dumon stent contributed to the recovery of respiratory failure due to broncho-pleural fistula.

Background. Secondary pulmonary alveolar proteinosis (SPAP) is defined as pulmonary alveolar proteinosis (PAP) associated with underlying diseases showing negative findings of serum anti-granulocyte macrophage-colony stimulating factor (GM-CSF) antibody. Case. A 48-year-old man with interstitial pneumonia associated with anti-melanoma differentiation associated gene 5 (MDA5) antibody-positive dermatomyositis was treated with glucocorticoid and immunosuppressant. During the course of treatment, he was diagnosed with progression of interstitial pneumonia. Despite the intensification of immunosuppressive treatment, his chest CT findings worsened. We performed bronchoalveolar lavage and transbronchial lung biopsy. Pathological and cytological examinations showed PAP, and his serum anti- GM-CSF antibody was negative. Therefore, the diagnosis of SPAP was made. Conclusion. In case of interstitial pneumonia with progression despite immunosuppressive treatment, we need to consider the possibility of PAP and perform bronchoscopy.

Background. There have been several reports of bronchial ulcer caused by aspiration of foreign objects, but most of them involved aspiration of food or teeth, and none have reported ulceration caused by plum extract in a nutrition supplement. Case report. A 92-year-old woman, after eating 5 pieces of a commercial nutritional supplement containing plum extract, experienced wheezing and dyspnea, and she visited her physician. Computed tomography of the chest revealed a highly resorbed foreign body in the right basilar canal that could not be removed by endoscopy therefore she was referred to us. Steroids were administered for local anti-inflammatory effect, and bronchoscopy was performed 2 days after aspiration, which revealed an olive-colored foreign body in the right B⁹ that was removed using grasping forceps. After removal, the lumen was edematous all around, with white moss, hemorrhaging, and necrotic material, and ulcers were present. The foreign body was confirmed to be a health food the patient had consumed before the appearance of symptoms. Nine days after removal, bronchoscopy was performed again, and the bronchial ulcers were confirmed to have improved. The patient was subsequently discharged. Conclusion. We experienced a case of bronchial ulcers caused by a nutritional supplement that was successfully treated through bronchoscopic removal of the foreign body.

Background. The incidence of malignant lymphoma in patients with myeloproliferative neoplasms, including primary myelofibrosis (PMF), was reported to be higher than that in the general population. However, there are few reports of malignant lymphoma associated with PMF in Japan. Case. A 78-year-old woman who had been diagnosed with PMF 20 years earlier and been on the JAK inhibitor ruxolitinib for 6 years developed fatigue and dry cough. Multiple masses were observed in both lungs on chest computed tomography (CT). On the 6th day of admission, a transbronchial biopsy (TBB) was performed, and EBV-positive diffuse large B-cell lymphoma was diagnosed. On the 8th day, a fever and respiratory failure developed along with the exacerbation of multiple masses and ground-glass opacity. Respiratory failure progressed rapidly, and the patient died on the 14th day. Conclusion. We diagnosed this patient with primary pulmonary lymphoma associated with PMF by TBB. Malignant lymphoma should be considered as a differential diagnosis of lung lesions in patients with PMF.