[A case of spontaneous bilateral chylothorax]

A 42-year-old woman sought medical attention because of a suddenly developed neck mass. Chest radiography disclosed bilateral pleural effusion, which turned out to be chylothorax. Although lymphatic leakage was suspected, no underlying cause was identified. Her condition resolved spontaneously in seven days. A few similar cases have been described in the literature, and are collectively referred to as "spontaneous bilateral chylothorax".

[Pulmonary tuberculosis mimicking fungus ball]

We treated a 42-year-old man with pulmonary tuberculosis presenting as a round mass in a cavitary lesion that resembled a fungus ball. These findings appeared within a short time. The diagnosis was confirmed by isolation of Mycobacterium tuberculosis from his sputum. He also had diabetes mellitus that was poorly controlled. The patient was treated with antituberculous chemotherapy and insulin therapy. With these treatments, the roentgenographic abnormalities resolved fairly rapidly.

Visualization of pulmonary arteriovenous malformation by three dimensional computed tomography: a case report

Pulmonary arteriovenous malformation (PAVM) is an anomaly condition characterized by abnormal vascular communications between arteries and veins in the lungs. Hereby we describe a 60-year-old female with PAVM. Although the patient was asymptomatic, an abnormal round opacity was found on a chest X-ray film. Computed tomography (CT) of the lung disclosed nodules connected with enlarged vessels. Because PAVM was suspected, the patient was further evaluated by spiral CT coupled with three dimensional reconstruction of the images (3D-CT). As a result, PAVM was clearly visualized and invasive procedures such as angiography was not performed. The present case illustrates that 3D-CT is a diagnostic procedure of choice when PAVM is suspected.

Pneumoconiosis in Rush Mat Workers Exposed to Clay Dye “Sendo” Dust

STUDY OBJECTIVES

The purpose of this study was to describe the clinical, chest radiographic, high-resolution CT, and histopathologic features of clay dye "sendo" dust pneumoconiosis in seven rush mat ("tatami") workers.

PATIENTS

Seven patients with a history of occupational exposure to sendo dust and radiographic changes suggestive of pneumoconiosis were retrospectively reviewed.

RESULTS

The duration of exposure ranged from 15 to 45 years (median, 30 years). Three patients had cough, and four patients had abnormal pulmonary function test results. Chest radiographs showed nodular opacities < 3 mm in diameter (types p and q) in all patients. The standard International Labor Office profusion score ranged from 0/1 to 1/1 (median, 1/0). High-resolution CT demonstrated small nodular opacities (types p and q) in all seven patients. In four patients, high-resolution CT demonstrated branching centrilobular structures, airway ectasia, airway wall thickening, and emphysematous changes. None of the patients had conglomerate nodules, large opacities, honeycombing, pleural effusion, or lymphadenopathy. Microscopic examination of the specimens obtained by open lung biopsy or transbronchial lung biopsy revealed nodular fibrosis with accumulation of dust-laden macrophages, but no silicotic nodules. Needle-like particles of 1 to 20 microm in length were evident among the dust deposits, and birefringent crystals were identified under polarizing microscopy. Four of seven patients showed intra-alveolar fibroblastic foci similar to Masson bodies, accompanied by dust deposition.

CONCLUSION

Rush mat workers' sendo dust pneumoconiosis is caused by dust containing free silica. The radiographic and high-resolution CT findings consist of small nodular opacities < 3 mm in diameter and bronchial and bronchiolar abnormalities.

Clinical features of acute respiratory infections associated with the Streptococcus milleri group in the elderly

The Streptococcus milleri group are becoming increasingly recognized as important pulmonary pathogens which may lead to the development of empyema or lung abscesses. Although several small series have been reported, the clinical and laboratory features of Streptococcus milleri infection have yet to be fully characterized in the elderly. We retrospectively examined the clinical features of 19 patients with Streptococcus milleri pulmonary disease who were admitted to our hospital between 2000 and 2002, based on their clinical records and laboratory data. The microbiological diagnosis was based on the results of quantitative sputum culture and other invasive procedures, including transthoracic needle aspiration or bronchoscopic examinations. There were thirteen cases of pneumonia, two of contaminant pneumonia and pleuritis, one of bronchitis, two of pulmonary abscess, and one of empyema. The patients ranged in age from 65 to 91. The most common symptoms at presentation were shortness of breath, coughing, sputum, and weight loss. An underlying disease existed in 14 of the 19 cases. We conclude that the Streptococcus milleri group is a more important cause of pulmonary infections than has been previously recognized.

[Clinical efficacy of oral clarithromycin monotherapy in patients with mild or moderate community-acquired pneumonia]

Clarithromycin (CAM) is a new macrolide antibiotic which is active against a wide range of organisms responsible for community-acquired pneumonia (CAP) and has superior pharmacokinetics and tolerance compared to erythromycin. In this study, we evaluated the clinical efficacy and antimicrobial activity of CAM in the empirical treatment of patients with CAP. CAM (200 mg given twice daily for 2 weeks) was orally administered to 26 patients with mild or moderate suspected atypical pneumonia, including 15 patients in whom treatment with beta-lactam antibiotics was largely ineffective. Causative pathogens were identified on the basis of quantitative sputum cultures, blood cultures, and routine serological testings; M. pneumoniae was most commonly observed in patients with CAP (38.5%; 10/26), followed by H. influenzae (11.5%; 3/26), C. pneumoniae (3.8%; 1/26), and S. constellatus (3.8%; 1/26). Penicillin-resistant, or penicillin-susceptible Streptococcus pneumoniae were isolated from 1 patient (3.8%) and 2 patients (7.7%), respectively out of 26 patients with CAP. There were no detectable pathogens in 8 of 26 patients. The treatment of CAM resulted in complete resolution of all signs and symptoms of pneumonia in all the patients and was not accompanied with any adverse events. The overall incidence of laboratory abnormalities was not detectable in the patients evaluated. Although it is important to make differential diagnosis of atypical from bacterial pneumonia in designing therapeutic strategy, it is often difficult to make an appropriate diagnosis in patients with CAP. Because of diagnostic difficulties, CAM with a broad antimicrobial spectrum is recommended as the first-line drug for the treatment of lower respiratory infections, particularly in patients with suspected atypical pneumonia.

Chronic eosinophilic pneumonia associated with Schizophyllum commune

We describe the first known Japanese patient with chronic eosinophilic pneumonia caused by Schizophyllum commune. The patient presented to Social Insurance Tagawa Hospital, Fukuoka, Japan with cough, wheezing, dyspnoea, and fever. Computed tomograms of the chest showed bilateral areas of consolidation with air bronchograms as well as interstitial infiltrates in the upper lobe, without ectasia of proximal bronchi. Fibreoptic bronchoscopy revealed no impacted mucus in the bronchi. BAL fluid from the right upper lobe yielded an increased total cell count with a high percentage of eosinophils. A transbronchial lung biopsy specimen showed a bronchoalveolar chronic inflammatory infiltrate composed of eosinophils, lymphocytes and plasma cells, associated with fibrosis of the alveolar walls. S. commune was identified in lavage fluid. Antibodies to this organism were present in the serum, confirming that S. commune was the cause of chronic eosinophilic pneumonia. Inhaled corticosteroids without accompanying oral corticosteroids or antifungal agents decreased the respiratory symptoms, and the infiltrates disappeared from the chest radiograph within a few days

[A case of primary nasopharyngeal tuberculosis]

BACKGROUND

Although the prevalence of nasopharyngeal tuberculosis has decreased after the wide use of anti-tuberculous agents, recently the number of reports with the disease has slightly increased in accordance with advances in the diagnostic tools. A case of nasopharyngeal tuberculosis without any tuberculous lesions in other organs (primary nasopharyngeal tuberculosis) was reported.

CASE REPORT

A 74-year-old female complained of vertigo and cervical masses, and naso-pharygo-laryngoscopy disclosed a polypoid lesion on her nasopharynx. The biopsy from the mass revealed epithelioid cell granulomas with caseous necrosis and multinucleated giant cells consistent with tuberculosis. Since there were no tuberculous lesions in other organs except cervical lymph nodes in clinical examinations, we diagnosed the case as primary nasopharyngeal tuberculosis with tuberculous cervical lymphadenitis. The nasopharyngeal manifestation disappeared after four months chemotherapy with INH, RFP and EB.

DISCUSSION

Most reported case of nasopharyngeal tuberculosis were in the young age group. A rare case of old woman complicated with cervical tuberculous lymphadenitis was reported.

Macrolide antibiotics directly reduce active oxygen generation by neutrophils in human peripheral blood

Since a "low-dose and long-term" administration of erythromycin (EM) was reported to be effective in patients with chronic respiratory diseases, including diffuse panbronchiolitis (DPB), the modulation of host defense responses by EM has attracted much attention. Despite considerable controversy, it was recently demonstrated that macrolides reduced neutrophil function. In this study, we investigated the effects of EM, a 14-membered ring macrolide, azithromycin (AZM), a 15-membered ring macrolide, and rokitamycin (RKM), a 16-membered ring macrolide, on neutrophil function in terms of active oxygen generation of neutrophils in the absence and presence of mononuclear cells in vitro. EM and AZM significantly suppressed active oxygen generation by neutrophils in the absence of mononuclear cells at low concentration (0.5 microgram/ml. p < 0.05). At the next step, to confirm that EM and AZM directly reduced active oxygen generation by neutrophils, we investigated whether mononuclear cells affected this effect of EM and AZM. In the presence of mononuclear cells pretreated with EM or AZM, both antibiotics suppressed active oxygen generation at concentrations ranging from 0.5 to 20 micrograms/ml. However, the inhibition rates induced by EM and AZM at low concentrations were not so different between the absence and the presence of mononuclear cells. These results indicated that EM and AZM have direct effects on the active oxygen generation by neutrophils and those effects that were not influenced by mononuclear cells. This inhibitory effect may be responsible for the therapeutic efficacy of these 14-membered and 15-membered ring macrolides in patients with DPB.

Increased circulating 92 kDa matrix metalloproteinase (MMP-9) activity in exacerbations of asthma

BACKGROUND

The 72 kDa matrix metalloproteinase 2 (MMP-2) and the 92 kDa matrix metalloproteinase 9 (MMP-9) are type IV collagenases implicated in various aspects of inflammation including accumulation of inflammatory cells, tissue injury, and development of remodelling. The role of these enzymes in the pathogenesis of asthma exacerbations is unknown.

METHODS

Circulating levels of MMP-2 and MMP-9 proteins and the expression of their inhibitor, tissue inhibitor of metalloproteinase 1 (TIMP-1), were measured in 21 patients experiencing an asthma exacerbation and 21 age matched patients with stable asthma. Circulating gelatinolytic activity was compared during the asthma exacerbation and during subsequent convalescence by gelatin zymography in the same individuals. In addition, MMP-9 specific activity was quantified with a colorimetric assay which uses an artificial proenzyme containing a specific domain recognised by MMP-9 in the same paired samples.

RESULTS

A significant increase in the circulating level of MMP-9 was seen in patients with an asthma exacerbation compared with patients with stable asthma (202.9 (22.0) v 107.7 (9.9) ng/ml, p=0.0003). There were no significant differences in the circulating levels of MMP-2 or TIMP-1. Gelatin zymography identified two major circulating gelatinolytic activities corresponding to MMP-2 and MMP-9, and showed that asthma exacerbations are characterised by markedly increased MMP-9 activity with no significant change in MMP-2 activity compared with the activities during convalescence in the same individuals. Direct measurement showed that MMP-9 specific activity is significantly increased during asthma exacerbations compared with subsequent convalescence (269.6 (31.7) v 170.4 (12.6) ng/ml, p=0.0099).

CONCLUSIONS

Asthma exacerbations are characterised by increased circulating MMP-9 activity. This increased activity may be related to exaggerated airway inflammation and airway remodelling.

Phase I and pharmacokinetic study of carboplatin and paclitaxel with a biweekly schedule in patients with advanced non-small-cell lung cancer

PURPOSE

A phase I study was conducted to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of carboplatin in combination with paclitaxel using a biweekly schedule in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

The pharmacokinetics of paclitaxel were determined preliminarily in some patients. The criteria for eligibility for study entry included histologically and/or cytologically confirmed NSCLC (stage IIIb or IV), no prior treatment, and measurable disease. Paclitaxel was given in combination with a fixed dose of carboplatin at an area under the concentration-time curve (AUC) of 3 mg/ml x min, every 2 weeks. The starting dose of paclitaxel was 100 mg/m(2), and the dose was increased in increments of 20 mg/m(2). Three to six patients were allocated to each dose level.

RESULTS

A total of 19 patients (11 male and 8 female) with a median age of 61 years (range 43-74 years) and a median ECOG performance status of 0 (range 0-1) were enrolled. The MTD of paclitaxel proved to be 160 mg/m(2), and the DLT was neutropenia, which improved well following treatment with G-CSF. Gastrointestinal toxicity was well tolerated. Of 17 patients who received four cycles or more, 7 (41%; 95% confidence interval 18.4-67.1%) responded to this combination therapy. The pharmacokinetics of paclitaxel did not differ from published data.

CONCLUSIONS

The recommended dose for phase II study is paclitaxel 140 mg/m(2) with a carboplatin AUC of 3 mg/ml.min. This biweekly regimen is highly effective and acceptable, and the present data indicate that the regimen may be suitable for use on an outpatient basis.

Combination chemotherapy with irinotecan and ifosfamide as second-line treatment of refractory or sensitive relapsed small cell lung cancer: a phase II study

This phase II study was conducted to investigate the efficacy and safety of irinotecan (CPT-11) and ifosfamide as second-line chemotherapy for relapsed small cell lung cancer (SCLC). Eligibility criteria included histologically or cytologically confirmed SCLC, prior chemotherapy including platinum + etoposide, and measurable or evaluable disease. CPT-11 (80 mg/m(2)) was administered intravenously on days 1, 8 and 15, while ifosfamide (1.5 g/m(2)) was given on days 1 through 3 every 4 weeks. Thirty-four patients (29 men) with a median age of 69 years (range 42-77) and a median Eastern Cooperative Oncology Group (ECOG) performance status of 1 (range 0-2) were enrolled. The response rate was 52.9% (95% confidence interval: 29.8-64.9%) with 2 complete responses and 16 partial responses. Our analyses of prognostic factors showed risk factors assessed before receiving second-line chemotherapy, which were the number of metastatic sites, performance status and the type of relapse. WHO grade 3-4 neutropenia was recorded in 52.9% of the patients, grade 3 diarrhea in 5.9%. The combination of CPT-11 and ifosfamide demonstrated clinical efficacy in relapsed SCLC with a favorable toxicity profile, particularly for performance status 0-1 and sensitive cases with only one metastatic site.

[Tuberculosis in elderly]

We compared patients with active tuberculosis treated at Kurume University Hospital between cases 65 years and above and below 65. The comparison included immunologic and clinical features. Anergy to tuberculin skin tests with purified protein derivative (PPD) was evident in 7% of patients under 65 and in 14% of those over 65. Older patients had fewer lymphocytes in peripheral blood and lower serum concentrations of interferon (IFN)-gamma than younger patients. Complications were more frequently seen in patients above 65, but the time required for negative conversion of sputum cultures did not differ by age. Adequacy of the regimen of chemotherapy and the sensitivity to anti-mycobacterial drugs were the most important determinants of the time for negative conversion of sputum culture. Major clinical problems of old tuberculosis patients were concurrent diseases, bed ridden states, necessity of nursing care, and poor performance status of patients.

[Tuberculosis in patients undergoing hemodialysis]

We studied patients who were diagnosed as active tuberculosis while undergoing hemodialysis at Kurume University Hospital. The observation included immunologic and clinical features. Cellular immunity was depressed in our patients undergoing hemodialysis, as evident from the decreased numbers of lymphocytes and anergy to tuberculin skin tests with purified protein derivative (PPD). Further, in a few patients, hemodialysis was shown to eliminate IFN-gamma from the blood. Various antituberculous chemotherapy regimens have been studied in hemodialysis patients. Although the incidence and mortality of tuberculosis have been reported to be higher in hemodialysis patients than in the general population, the clinical outcome of our cases was favorable in this study. One important notice is to recognize promptly peripheral neuropathy while treating tuberculosis associated with hemodialysis, and this could be prevented by the adequate use of pyridoxine.

Phase II study of irinotecan and ifosfamide in patients with advanced non-small cell lung cancer

OBJECTIVES

This phase II study was conducted to investigate the efficacy and safety of irinotecan (CPT-11) and ifosfamide as first-line chemotherapy for advanced non-small cell lung cancer (NSCLC).

METHODS

Eligibility criteria included histologically or cytologically confirmed NSCLC (stage IIIb or IV), no prior treatment, and measurable or evaluable disease. CPT-11 (80 mg/m(2)) was administered intravenously on days 1, 8, and 15, while ifosfamide (1.5 g/m(2)) was given on days 1 through 3 every 4 weeks.

RESULTS

Forty-four patients (31 men) with a median age of 65 years (range 43-75) and a median ECOG performance status of 1 (range 0-2) were enrolled. The response rate was 29.5% [95% CI: 16.7-45.2%], with 13 partial responses. The median survival was 12.5 months, the median time to progression was 5.3 months, and the 1 and 2-year survival rates were 52.3 and 11.3%, respectively. Toxicity was generally mild; WHO grade 3-4 neutropenia was recorded in 38.6% of the patients, grade 3 diarrhea in 6.8%, and grade 3-4 nausea/vomiting in 0%.

CONCLUSIONS

CPT-11 combined with ifosfamide demonstrated anti-tumor activity in advanced NSCLC, with response and survival rates similar to those of cisplatin-based chemotherapy but with a more favorable toxicity profile.

Small peripheral pulmonary carcinomas evaluated with dynamic MR imaging: correlation with tumor vascularity and prognosis

PURPOSE

To correlate the findings at contrast material-enhanced dynamic magnetic resonance (MR) imaging of small peripheral pulmonary carcinomas with tumor vascularity and prognosis.

MATERIALS AND METHODS

Ninety-four patients with small peripheral pulmonary carcinomas who underwent surgical resection were examined retrospectively. Pathologic specimens were stained with hematoxylin-eosin and elastin-van Gieson. CD34 and vascular endothelial growth factor (VEGF) were assessed immunohistochemically. Delineated CD34-positive cells were counted as microvessels. Dynamic MR imaging was performed prior to and at 1, 2, 3, 4, 5, 6, and 8 minutes after injection of a bolus of gadopentetate dimeglumine. The two observers reviewed all images, and two pathologists performed all histologic analyses; a decision was determined with consensus. The maximum enhancement ratio (MER), the time lapse between the completion of the injection and the point of maximum signal intensity (Tmax), the washout ratio, and the slope value of the time-signal intensity curve were correlated with the microvessel density. VEGF-positive and VEGF-negative tumors were compared. All statistical analyses were performed by using nonparametric methods.

RESULTS

The MER and the slope value were positively correlated, and the Tmax was negatively correlated (Spearman rank test, P <.0001, all comparisons) with the microvessel counts. The distribution of elastic and collagen fibers correlated with the washout ratio (Kruskal-Wallis test, P <.001). There was a statistically significant difference between the slope value of VEGF-positive tumors and that of VEGF-negative tumors (Mann-Whitney U test, P <.0001). Patients with VEGF-positive tumors had a significantly shorter overall survival than did those with VEGF-negative tumors (log-rank test, P <.0001).

CONCLUSION

Dynamic MR imaging findings correlate with tumor vascularity and may be helpful in the prediction of prognosis.

[A case of hemophagocytic syndrome associated with miliary tuberculosis]

We reported a case of a 76-year-female with hemophagocytic syndrome caused by military tuberculosis. The patients had complained high fever over 38.0 degrees C and anorexia. Her chest X-ray and computed tomography revealed disseminated miliary shadows in both lung fields. Laboratory examinations revealed anemia, thrombocytopenia and liver dysfunction. Bonemarrow aspirate revealed tuberculous granulomas and tubercle bacilli by acid-fast stains, and hemophagocytosis by macrophages. We diagnosed as miliary tuberculosis and tuberculosis-associated hemophagocytic syndrome, and started antituberculous and steroid therapy. After these therapy, fever, laboratory examinations dramatically improved. In this case, serum IL-18, sICAM-1, sVCAM-1 were elevated. These cytokines and adhesion molecules were reported to elevate in both hemophagocytic syndrome and tuberculosis correlating with disease activity. We conclude that IL-18, sICAM-1, sVCAM-1 may play important roles in pathogenesis of tuberculosis associated hemophagocytic syndrome.

High concentration of (1-->3)-beta-D-glucan in BAL fluid in patients with acute eosinophilic pneumonia

Our aim in the study was to investigate the pathogenesis of eosinophilic inflammation in patients with acute eosinophilic pneumonia (AEP), and to determine the levels of (1-->3)-beta-D-glucan, which is one of the major components of the cell wall of most fungi, in the BAL fluid (BALF) of those patients with AEP. Six patients with AEP and five patients with chronic eosinophilic pneumonia (CEP) that was in the acute stage and had been newly diagnosed, and nine healthy subjects from the Kurume University School of Medicine and the Social Institute Tagawa Hospital between 1995 and 2001 were entered into the study. In AEP patients, (1-->3)-beta-D-glucan was detected in BALF, and these findings were compared with BALF findings in patients with CEP as well as with those in healthy subjects. In the BALF of AEP patients, the mean concentration of (1-->3)-beta-D-glucan was significantly higher (p < 0.05) than that of CEP patients as well as healthy subjects. In patients with AEP, the mean concentration of (1-->3)-beta-D-glucan in BALF was significantly higher (p < 0.05) than that in the blood. In four of six patients with AEP, we measured serial changes in (1-->3)-beta-D-glucan levels, and the level of (1-->3)-beta-D-glucan in the BALF decreased with clinical improvement at follow-up. We concluded that inhaled (1-->3)-beta-D-glucan may be involved in the mechanisms of pulmonary inflammation in patients with AEP.

Chronic cystic lung disease: diagnostic accuracy of high-resolution CT in 92 patients

OBJECTIVE

The objective of this study was to determine whether the various chronic cystic lung diseases can be differentiated on the basis of the pattern and distribution of abnormalities on high-resolution CT.

MATERIALS AND METHODS

High-resolution CT scans in 92 patients with chronic cystic lung diseases (18 with pulmonary Langerhans cell histiocytosis, 18 with pulmonary lymphangioleiomyomatosis, 17 with usual interstitial pneumonia, 16 with lymphocytic interstitial pneumonia, 15 with emphysema, and eight with desquamative interstitial pneumonia or respiratory bronchiolitis interstitial lung disease) were retrospectively assessed by two independent observers without knowledge of the clinical or pathologic data. The observers recorded the abnormalities, the most likely diagnosis, and the degree of confidence in that diagnosis.

RESULTS

The two observers made a correct first-choice diagnosis in 148 (80%) of 184 interpretations. The correct diagnosis was made in 100% of interpretations of usual interstitial pneumonia, 81% of desquamative interstitial pneumonia or respiratory bronchiolitis interstitial lung disease, 81% of lymphocytic interstitial pneumonia, 77% of emphysema, 72% of lymphangioleiomyomatosis, and 72% of Langerhans cell histiocytosis. The two observers made a diagnosis with a high degree of confidence in 105 (57%) of 184 interpretations. The confident diagnosis was correct in 98 (93%) of 105 interpretations.

CONCLUSION

Although various chronic cystic lung diseases often have a characteristic appearance that allows their distinction on high-resolution CT, considerable overlap exists among the CT findings. Therefore, lung biopsy is often required for a definitive diagnosis.

Usefulness of bronchial lavage for the diagnosis of pulmonary disease caused by Mycobacterium avium-intracellulare complex (MAC) infection

To evaluate the usefulness of bronchial lavage for the diagnosis of pulmonary disease due to Mycobacterium avium-intracellulare complex (MAC) infection, we examined the clinical records and bacteriologic findings of patients admitted to our hospital between 1999 and 2002 who fulfilled the 1997 American Thoracic Society (ATS) criteria for MAC pulmonary infection. Bronchoscopic examinations were performed in those patients with MAC pulmonary disease who showed negative sputum smears for mycobacteria on 3 consecutive days ( n = 14) or who could not expectorate sputum ( n = 2). The bronchial lavage sample was smear-positive for acid-fast bacilli in 8 of the 16 patients (50.0%), polymerase chain reaction (PCR)-positive for MAC in 10 of 15 (66.7%), and culture-positive for MAC in 15 of 16 (93.7%). The brushing sample was positive for MAC in 5 of 14 patients (35.7%), and transbronchial lung biopsy (TBLB)-positive for MAC in 2 of 5 (40.0%). MAC was isolated by culture of bronchial lavage samples in a higher percentage of patients than that in whom MAC was isolated by sputum culture, and we could make an early diagnosis of MAC pulmonary disease based on the smear and PCR results for bronchial lavage samples. Bronchial lavage is useful to screen sputum smear-negative patients suspected of having MAC pulmonary disease.

Fatal idiopathic acute eosinophilic pneumonia with acute lung injury

A fatal case of idiopathic eosinophilic pneumonia with acute lung injury is described. The patient required treatment with mechanical ventilation and intravenous corticosteroids, however, she died on the third hospital day. At autopsy, both exudative and proliferative phases of diffuse alveolar damage were observed bilaterally. Marked eosinophilic infiltrate was noted in the alveolar wall and within the alveolar cavities with occasional abscess-like features. To our knowledge, this is the first report of fatal acute eosinophilic pneumonia, and provides important information for the management of this condition.

Laparoscopic hepatectomy and dissection of lymph nodes for intrahepatic cholangiocarcinoma. Case report

Usually intrahepatic cholangiocarcinoma has a poor prognosis, especially when it occurs with lymph node metastasis. As a treatment for intrahepatic cholangiocarcinoma, dissection of lymph nodes alone does not seem to offer any significant advantages. The laparoscopic hepatectomy procedure, however, is a minimally invasive liver surgery. We recently had the case of a patient who underwent successful laparoscopic hepatectomy and dissection of lymph nodes for intrahepatic cholangiocarcinoma in the left lateral segment of the liver. The patient had intrahepatic cholangiocarcinoma with distant lymph node metastasis around the common hepatic artery determined to stage IVb according to TNM classification. The operation time was 335 min, and the total blood loss was only 225 ml. A left lateral hepatectomy and complete lymph node dissection around the hepatoduodenal ligament and celiac trunk was performed. In this case, a laparoscopic procedure enabled the patient to have an early discharge, and there was no recurrence for 14 months. Another advantage for this patient was that the hospital stay lasted only 10 days. As compared with conventional surgery, laparoscopic surgery reduces blood loss and shortens the hospital stay. In conclusion, laparoscopic surgery for intrahepatic cholangiocarcinoma is a good treatment for advanced intrahepatic cholangiocarcinoma because it allows a positive early postoperative outcome and possibly a better result over the long term.