Background and purpose. Bronchoalveolar lavage (BAL) lymphocytosis is considered when deciding whether or not to perform corticosteroid treatment for fibrotic hypersensitivity pneumonitis (HP). However, there is scant evidence as to whether or not the BAL lymphocyte percentage can predict the posttreatment response and prognosis in fibrotic HP. Methods. We conducted a retrospective single-center study of 62 cases of fibrotic HP who had undergone corticosteroid treatment and received a BAL analysis within 1 year before the treatment. The association of the BAL lymphocyte percentage with the posttreatment mortality was evaluated using a multivariate analysis. Treatment responses were compared among the 3 stratified groups with high (≥40%, n=14), medium (10-39%, n=26), and low (<10%, n=22) lymphocyte percentages, in terms of the change in radiological scores, percent predicted forced vital capacity (%FVC), and survival rates from the date of initiating corticosteroids. Results. In the entire cohort, a multivariate Cox proportional regression analysis revealed that a low BAL lymphocyte percentage or medium (10-39%) to low (<10%) lymphocyte percentage was significantly associated with a high mortality, independent of the %FVC and presence of extensive ground-glass attenuation (GGA). There were significant or improving trends in one-year GGA scores and six-month FVCs from baseline in all three stratified groups. In contrast, the significant deterioration of the 1-year fibrosis scores from baseline was observed in the medium (10-39%) and low (<10%) lymphocyte percentage groups, showing poor survival rates compared to the high group (≥40%) (median survival time: not-reached, 69 months; P=0.089, and 37 months; P=0.049, respectively). Furthermore, a subgroup analysis of each of the three groups stratified by the presence or absence of extensive GGA revealed that its absence contributed to poor survival rates in all three groups. Conclusion. A low BAL lymphocyte percentage at the time of corticosteroid treatment in fibrotic HP may predict unfavorable outcomes, including continuous fibrotic progression and high mortality. Careful management may be required for corticosteroid therapy in fibrotic HP patients with a poor prognosis, especially those with a BAL lymphocyte percentage <40% and the absence of GGA.
Background. Percutaneous drainage may be insufficient for managing intractable infectious pulmonary cyst. However, lung resection leaves a dead space. Case. Case 1: The patient was a male patient aged 63 years. He was referred to our department for suspected empyema. He was diagnosed with an infectious pulmonary cyst by chest computed tomography (CT) and given antibiotics. Bronchoscopy determined that there was no traffic to the trachea and trans-airway drainage was not possible. Therefore, we performed surgery. We opened the bulla under thoracoscopy, flushed the drainage and intracystic abscess, and finished the operation. He was discharged post operate 13 days. Case 2: The patient was a male patient aged 47 years of age who had a history of left pneumothorax and adhesion therapy. He was referred to our department for suspected left empyema. The patient was diagnosed with infectious pulmonary cyst by chest CT, and was given antibiotics but was refractory. Therefore we performed surgery as in case 1. He was discharged post operate 5 days. In both cases, pulmonary cyst was opened and healed by drainage and intracystic abscess. Conclusion. In this procedure, the residual lung was well dilated, and the inflammatory response improved promptly. This approach may therefore be a viable alternative to surgical procedures for managing infectious pulmonary cyst. We herein report the treatment of an infectious pulmonary cyst with a review of the literature.
Background. Endoscopic ultrasound fine-needle aspiration with an Acquire needle is useful for diagnosing pancreatic cancer, gastrointestinal stromal tumor and intraperitoneal lymph node metastasis. Case. A 78-year-old man had mediastinal and hilar lymphadenopathy on positron emission tomography computed tomography (PET-CT). Gastric, prostate and renal cancers were strongly suspected based on upper gastrointestinal endoscopy and PET-CT findings. We performed an Acquire endobronchial ultrasound-transbronchial needle biopsy (EBUS-TBNB), collecting samples of lymph nodes through the bronchus. Immunohistochemical staining of the specimen, which was negative for TTF-1 and positive for CA9, lead to the diagnosis of lymph nodes metastasis from clear cell renal cell carcinoma. Furthermore, the sample obtained by an additional puncture was sufficient to carry out next-generation sequencing (amount of nucleic acid: DNA 952 ng and RNA 240 ng). Conclusion. An Acquire EBUS-TBNB was useful for obtaining an adequate sample volume.
Background. Diffuse pulmonary ossification is a rare disease characterized by diffuse microlithiasis-like nodular shadows in the lung. Although it is most common in elderly men, younger cases without underlying diseases have been reported. Case presentation. A 20-year-old man was evaluated in our hospital because of abnormal findings on chest imaging. A bronchoscopic examination was performed and a transbronchial lung biopsy showed bone tissue with fatty bone marrow. The patient was diagnosed with idiopathic diffuse pulmonary ossification. Conclusion. There are few cases of diffuse pulmonary ossification diagnosed by bronchoscopy. Bronchoscopy is a less-invasive procedure than thoracoscopic surgery and may allow for an early diagnosis of diffuse pulmonary ossification in clinical practice.
Background. Renal cell carcinoma is rarely identified as a cause of pleural tumor and malignant pleural effusion. We report a case of renal cell carcinoma with only pleural metastasis that was diagnosed by thoracoscopy under local anesthesia. Case. An 85-year-old man visited our hospital, complaining of dyspnea on exertion and left pleural effusion, which was diagnosed by his previous doctor. Chest computed tomography showed left pleural effusion and multiple nodular shadows along the left pleura, but no obvious nodular or mass shadows in the lungs. No significant findings were noted during pleural fluid examination. Thoracoscopy under local anesthesia revealed irregular, easily hemorrhagic lesions on the parietal pleura, and the histological examination of a biopsy led to a diagnosis of clear cell renal cell carcinoma. Additional imaging examination findings were consistent with renal cell carcinoma in the right kidney, leading to the diagnosis of pleural metastasis of renal cell carcinoma. Conclusion. When a pleural tumor and malignant pleural effusion are suspected, but the disease cannot be identified by imaging or pleural fluid examination, thoracoscopy under local anesthesia should be actively considered.
Background. Patients with prostate cancer are rarely diagnosed with respiratory symptoms at the same time as pulmonary metastasis. In addition, few cases of pneumonia-like metastasis of prostate cancer have been reported. Case. A 78-year-old man was referred to our hospital because of cough, which had persisted for two months and an abnormal chest X-ray shadow. Chest CT revealed pneumonia-like multiple consolidations and hilar-mediastinal lymphadenopathy. Enhanced abdominal CT showed an enlarged prostate with invasion of the seminal vesicle and multiple sclerotic bone lesions. He was diagnosed with prostate cancer following needle biopsy of the prostate. His pulmonary lesion was also diagnosed as metastasis of prostate cancer by transbronchial lung biopsy. Thereafter, his pulmonary lesion improved after hormonal therapy for prostate cancer. Conclusions. We experienced a case of pneumonia-like metastasis of prostate cancer. Clinicians should be careful to recognize that metastatic cancer sometimes has atypical radiological imaging features, and that transbronchial lung biopsy is considered a useful strategy for making an accurate diagnosis and determining treatment if a patient has respiratory symptoms.
Background. Characteristic imaging findings and the appearance of bronchoalveolar lavage fluid are useful in the diagnosis of pulmonary alveolar proteinosis. Case. A 37-year-old male was referred to our hospital because of chest and back pain. Although hypoxemia was not evident, chest computed tomography showed ground-glass opacities predominantly in the upper and middle lung lobes and centrilobular ground-glass opacities in the upper lobes, suggesting hypersensitivity pneumonitis. Bronchoscopy showed that the bronchoalveolar lavage fluid had a normal appearance, but the cytology of the fluid and the results of a transbronchial lung biopsy led to the diagnosis of pulmonary alveolar proteinosis. Serum anti-granulocyte-macrophage colony-stimulating factor antibody was positive, and a diagnosis of autoimmune pulmonary alveolar proteinosis was made. In the present patient, symptoms, chest imaging findings, and bronchoalveolar lavage fluid were atypical for alveolar proteinosis. Conclusion. Clinicians should be aware that early-stage or mild pulmonary alveolar proteinosis may present with atypical clinical features.
Background. Although the efficacy of bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) for fistulous pyothorax has been noted, there are few case reports that describe the procedure and identify the bronchus causing fistulous pyothorax in detail in Japan. We identified the causative bronchus by indigocarmine solution injection and balloon occlusion test and performed bronchial occlusion with two EWSs to successfully treat fistulous pyothorax. Case Presentation. A 40-year-old man was treated with thoracic drainage with chest tube and antibiotics. However, he did not show improvement of air leak, and follow-up chest computed tomography revealed a fistulous pyothorax. The patient was referred to the Department of Respiratory Medicine for bronchoscopic treatment. He underwent bronchoscopy three times to identify the responsible bronchi and received bronchial occlusion with an EWS using a combination of techniques. Gradual reduction and termination of the air leak was obtained. The chest tube was removed 14 days after the first bronchoscopy, and we confirmed the successful treatment of fistulous pyothorax. Conclusion. Bronchial occlusion with an EWS in combination with several techniques was useful for treating fistulous pyothorax.
Background. Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD) are caused by immunosuppressive agents such as methotrexate (MTX). We report a rare case of MTX-induced OIIA-LPD with extensive tracheal and bronchial lesions diagnosed based on endobronchial biopsy (EBB). Case. The patient was a 75-year-old woman who was diagnosed with rheumatoid arthritis 15 years previously, and MTX treatment was initiated at the time of the diagnosis. One year prior to her current presentation, computed tomography (CT) revealed a mass shadow in the left lower lobe of the chest, which gradually increased in size; thus, bronchoscopy was performed. Endoscopic findings revealed multiple elevated lesions in the trachea and bronchi, which could not be detected using CT. Pathological EBB findings indicated lymphoproliferative disorders (LPD). Two months after the discontinuation of MTX, endoscopic findings revealed shrinkage of the tracheal mass and a mass shadow in the left lower lobe, which led to the diagnosis of MTX-induced OIIA-LPD. Conclusion. When a mass shadow appears in the lung field during long-term MTX treatment and MTX-induced OIIA-LPD is suspected, bronchoscopy is essential for determining the presence of extensive airway lesions. EBB of airway lesions is considered important for the diagnosis of MTX-induced OIIA-LPD.