Early onset of hypernatraemic dehydration and fever in exclusively breast-fed infants

Five cases of moderately severe hypernatraemic dehydration were identified within a 5-month period between two regional hospitals in Hong Kong. Unlike previous reported cases, these exclusively breast-fed infants presented with the unusual triad of fever, absence of overt signs of dehydration and within the first week of life. Three of the cases also had high serum bilirubin concentrations at presentation. The fever subsided quickly and the serum bilirubin concentration fell rapidly within a few hours of rehydration. All infants made an uneventful recovery without permanent neurological sequelae. Fever, presumably secondary to dehydration, is an useful early warning sign. These cases emphasize the importance of early and regular measurement of bodyweight in exclusively breast-fed infants so that prompt identification of affected cases may prevent potentially detrimental complications.

Chronic exposure to antibodies directed against anti-opiate peptides alter delta-opioid receptor levels

The development of addictive states in response to chronic opioid use may be regulated partially by the release of endogenous peptides. These anti-opiate peptides (AOP) are secreted or released into the CNS and produce diverse actions that counterbalance the effects of prolonged opiate exposure. Though the mechanism(s) by which these peptides exert their physiological properties remain largely unknown, there is some indication that AOP's modulate opioid receptor levels. In this study, we investigated the effects of chronically infused alpha-melanocyte stimulating hormone (alpha-MSH), dynorphin(1-8) (DYN(1-8)), dynorphin A (DYNA), and NPFF antibodies on delta-opioid receptor expression in rat brains. Quantitative autoradiographic experiments revealed that antibodies directed against alpha-MSH and DYNA produced significant increases in delta receptor levels in the caudate, claustrum, and cingulate cortex of the rat brain. Conversely, NPFF monoclonal antibodies caused significant decreases in the caudate, nucleus accumbens, olfactory tubercle, and cingulate cortex. These results suggest that the density of delta-opioid receptors is affected by changes in the levels of the anti-opioid peptides in the extracelluar fluid in the rat brain.

Amino acid sequence analysis of bitter peptides from a soybean proglycinin subunit synthesized in Escherichia coli

The cDNA encoding A1aB1b proglycinin was expressed in E. coli, for the efficient isolation of a single peptide responsible for the bitterness. The 55-kD proglycinin was highly purified, hydrolyzed, and further purified through a series of chromatographic steps to yield fractions with the major bitter peptides. The most bitter-tasting fractions contained peptides with average molecular weights lower than 1,700 Da. An analysis of the amino acid sequences indicated that many small bitter peptides (< 1,000 Da) are composed of uncharged polar amino acids as well as hydrophobic amino acids, with a charged residue often being present at either end. This suggests the involvement of a certain structural requirement in taste perception.

Varicella pneumonia complicated by acute respiratory distress syndrome in an adult

Primary varicella infection is uncommon in adults, but carries a higher rate of morbidity and mortality than in children. Pneumonia is the most common complication of primary varicella infection in adults. However, varicella pneumonia complicated with acute respiratory distress syndrome (ARDS) is very rare. We report a case of ARDS secondary to varicella pneumonia in a 26-year-old man with primary varicella. The patient was otherwise healthy and had no evidence of human immunodeficiency virus infection. The initial chest radiograph showed bilateral reticulonodular infiltrates, which quickly evolved to diffuse alveolar consolidations. Arterial blood gas analysis revealed a ratio of arterial partial pressure to fraction of inspired oxygen of 87. Abnormal liver function and thrombocytopenia were also noted. Treatment consisted of mechanical ventilatory support and intravenous administration of acyclovir. His pulmonary condition gradually improved and he was successfully weaned from the ventilator 1 week later. He was discharged on the 15th hospital day with a favorable outcome. His pulmonary function improved progressively, with normal spirometry and lung volumes, but persistent mild impairment of diffusing capacity, 6 months after discharge.

Comparison of proton therapy and conformal X-ray therapy in non-small cell lung cancer (NSCLC)

This study compares the performance of one proton and four conformal X-ray planning techniques in treating non-small cell lung cancer (NSCLC). The treatment volumes for 13 NSCLC patients undergoing radical radiotherapy were planned using the five different techniques and dose-volume histograms (DVH) were used extensively in the comparative analysis. The minimum dose to the phase 2 target volume was escalated to 90 Gy, or until the point at which pre-set tolerance limits of spinal cord or lung were exceeded. The proton plan could treat nine of the 13 patients up to a dose of 90 Gy. Among the four X-ray techniques, performance varied enormously. One of them could not treat any of the patients, even to the conventional 60 Gy level, without failing to meet one or more of the criteria, whilst another one could treat 10 out of the 13 patients, although with this technique only four were permitted to have the dose escalated to 90 Gy. It was also found that two of the 13 patients could not be treated by any of the proton or X-ray plans to the conventional level, and were therefore considered unsuitable for radical radiotherapy. Various issues in conformal NSCLC radiotherapy including organ movement, tumour control, other possible organs at risk etc., are also discussed.

Clinical usefulness of MR imaging of the breast in the evaluation of the problematic mammogram

OBJECTIVE

This study was undertaken to determine the usefulness of MR imaging of the breast as an adjunct to mammography in problematic cases in which the significance, presence, or location of an abnormality could not be determined.

MATERIALS AND METHODS

From January 1993 through February 1998, 86 lesions for which histologic or mammographic follow-up was available were evaluated by breast MR imaging because of equivocal findings on mammography. MR studies were performed with a dedicated breast multicoil on a 1.5-T scanner. Early studies were done using a T1-weighted two-dimensional spin-echo sequence before and after the administration of contrast material. Later studies were performed using a three-dimensional fast spoiled gradient sequence with fat suppression. Studies were considered to be positive for an abnormality if a focal area of enhancement was seen after contrast administration.

RESULTS

MR imaging had positive findings in 38 sites. Twenty-six of these sites corresponded in location to the mammographic abnormality that had prompted the recommendation for MR imaging. The remaining 12 sites occurred in areas not suspected mammographically. At biopsy, 10 (26%) of the 38 positive sites were malignant. MR imaging had negative findings at 60 other sites that had been suspected mammographically. Of these 60 sites, six were treated with excision, all with benign results; the remaining 54 sites showed mammographic stability on follow-up that ranged from 5 to 66 months (mean, 19 months).

CONCLUSION

MR imaging of the breast can be a valuable adjunct to mammography for selected problematic cases.

Aspects of mammalian spermatogenesis: electrophoretical analysis of protamines in mammalian species

Protamines are small, highly basic proteins that replace histones and testicular basic proteins during the development of mature spermatozoa, spermatogenesis. In mammals, extensive disulfide crosslinking of protamines result in the formation of a compact chromatin structure devoid of transcriptional activity. As determined by isolation and electrophoresis of protamines, only one protamine has been detected in the mature spermatozoa of most mammalian species. However, in the spermatozoa of the mouse and human, two different protamines called P1 and P2, have been found. In this report we demonstrated by electrophoretic analysis that these two protamines are also present in the spermatozoa of Microtus arvalis, Microtus agretis, Apodemus flavicollis, Apodemus sylvaticus, Clethrionomys glareolus, the Chinese and the golden hamster. However, only one protamine is found in the spermatozoa of the guinea pig, dog, bull, black monkey, and the rhesus monkey. The mammalian protamines are highly conserved during mammalian evolution. In general, the homologies on the amino acid sequence of the various mammalian protamines range from 52% to 96%. Furthermore, in the case of mouse and human protamines, the genes of the protamines are closely linked and located on chromosome 7 and 16, respectively. Accordingly, it can be assumed that both types of protamine genes have arisen by gene duplication during mammalian evolution. According to the results of an electrophoretical analysis of the mammalian protamines, the predicted point of gene duplication during evolution is deduced carefully.

Characterization of receptor-interacting protein 140 in retinoid receptor activities

Receptor-interacting protein 140 (RIP140) contains multiple receptor interaction domains and interacts with retinoic acid receptors in a ligand-dependent manner. Nine LXXLL receptor-interacting motifs are organized into two clusters within this molecule, each differentially interacting with retinoic acid receptor (RAR) and retinoid X receptor (RXR). RAR interacts with the 5' cluster, whereas RXR interacts with both clusters. Additionally, a third ligand-dependent receptor-interacting domain is assigned to the very C terminus of this molecule, which contains no LXXLL motif. In mammalian cells, receptor heterodimerization is required for efficient interaction of RAR/RXR with RIP140. Furthermore, the heterodimeric, holoreceptors cooperatively interact with RIP140, which requires the activation function 2 domains of both receptors. By using different retinoic acid reporter systems, it is demonstrated that RIP140 strongly suppresses retinoic acid induction of reporter activities, but coactivator SRC-1 enhances it. Furthermore, an intrinsic repressive activity of RIP140 is demonstrated in a GAL4 fusion system. Unlike receptor corepressor, which interacts with antagonist-bound RAR/RXRs, RIP140 does not interact with antagonist-occupied RAR/RXR dimers. These data suggest that RIP140 represents a third coregulator category that is able to suppress the activation of certain agonist-bound hormone receptors.

Targeting a SWI/SNF-related chromatin remodeling complex to the beta-globin promoter in erythroid cells

Chromatin remodeling complexes such as the SWI/SNF complex make DNA accessible to transcription factors by disrupting nucleosomes. However, it is not known how such complexes are targeted to the promoter. For example, a SWI/SNF1-like chromatin remodeling complex erythroid Krüppel-like factor (EKLF) coactivator-remodeling complex 1 (E-RC1) disrupts the nucleosomes over the human beta-globin promoter in an EKLF-dependent manner. However, it is not known whether E-RC1 is targeted specifically to the beta-globin promoter or whether E-RC1 is randomly targeted, but its activity is evident only at the beta-globin promoter. Because E-RC1 cannot remodel chromatin over the beta-globin promoter without EKLF in vitro, it has been proposed that SWI/SNF1-like complexes such as E-RC1 are targeted specifically to the promoter by selectively interacting with promoter-associated transcription factors such as EKLF. In this report, we test this hypothesis in the cellular context by using the ProteIN POsition Identification with Nuclease Tail (PIN*POINT) assay. We find that the Brahma-related gene (BRG) 1 and BRG1-associated factor (BAF) 170 subunits of E-RC1 are both recruited near the transcription initiation site of the beta-globin promoter. On transiently transfected templates, both the locus control region and the EKLF-binding site are important for their recruitment to the beta-globin promoter in mouse erythroleukemia cells. When the beta-globin promoter was linked to the cytomegalovirus enhancer, the E-RC1 complex was not recruited, suggesting that recruitment of the E-RC1 complex is not a general property of enhancers.

Geldanamycin induces cell cycle arrest in K562 erythroleukemic cells

Geldanamycin (GA), a benzoquinone ansamycin, is one of the specific inhibitors of 90-kDa heat shock protein and induces growth inhibition and apoptosis in certain cancer cell lines. We have investigated the mechanism of GA-induced growth inhibition in K562 erythroleukemic cells. DNA flow-cytometric analysis indicated that GA-induced growth arrest was associated with G2/M phase arrest of the cell cycle. GA treatment down-regulated the expression of cyclin B1 and inhibited phosphorylation of Cdc2 protein, both key regulatory proteins at the G2/M boundary. GA also markedly inhibited the Cdc2 kinase activity, which may be in part a result of up-regulation of p27KIP1 by GA. The present results suggest a novel mechanism that p27KIP1 could be involved in the regulation of G2 to M phase transition.

Occupational exposures to blood among emergency medicine residents

OBJECTIVES

To investigate the epidemiologic characteristics of potentially infectious occupational exposures to blood among emergency medicine (EM) residents.

METHODS

A SAEM-sponsored multiple-choice survey was administered anonymously to all EM residents participating in the 1998 American Board of Emergency Medicine in-service examination. Survey questions included resident demographics, use of universal precautions, frequency and types of exposures to blood, and exposure reporting. Residents who experienced at least one exposure were then asked to complete an additional set of questions referring only to their latest exposure. Mean values were calculated for each variable and differences between groups were compared by chi-square analysis.

RESULTS

Three thousand one hundred sixty-two surveys were distributed to the resident participants, and 2,985 surveys (94.4%) were returned. Of the participants, 56.1% reported at least one exposure to blood during their EM training. The frequency of this self-reported exposure increased with advancing EM level of training (43% EM-1, 58% EM-2, 64% EM-3, 76% EM-4, p<0.001). Of these residents, 36.6% always followed universal precautions, 54% frequently, and 9.4% sometimes, rarely, or never. Those individuals who "always" followed universal precautions reported significantly fewer exposures than those who did not (p<0.005). The latest exposures were most commonly caused by a solid needle or sharp object (39.4%), by a hollow-bore needle (30.6%), or by eye splashes (17.2%). Of these exposures, 71.7% occurred in the ED setting, and only 46.7% of these exposures were reported to health care providers.

CONCLUSION

Emergency medicine residents are frequently exposed to blood, most commonly due to puncture injuries by sharp objects. The rate of exposure reporting is low, which may compromise appropriate postexposure counseling and prophylaxis.

Tuberculosis exposure risk in emergency medicine residents

OBJECTIVES

To assess purified protein derivative (PPD) test surveillance and respiratory protection practices of emergency medicine (EM) residents, along with the prevalence of PPD test conversion and the development of active tuberculosis (TB) in EM residents.

METHODS

The study instrument was an anonymous, self-reporting, multiple-choice survey administered to U.S. and Canadian EM residents. It was distributed for voluntary completion in conjunction with the American Board of Emergency Medicine's annual in-service examination, which was administered February 25, 1998.

RESULTS

A total of 89.3% (n = 2,985) of residents eligible to complete the survey completed at least part of it. The majority of residents are PPD-tested once a year. The prevalence of PPD test conversions in EM residents was between 1.4% (36/2,575) and 2.0% (52/2,575). Of the residents who PPD test-converted, the ED was most often the perceived area of TB source exposure (n = 15). Two residents (0.08%) reported having developed active TB, including chest radiographic findings or clinical infection, which equals a 0.14% (95% CI = 0.005 to 0.31) risk of developing active TB over a three-year residency. Half of all the residents do not routinely wear National Institute for Occupational Safety and Health (NIOSH)-approved particulate filtration respirator (PFR) masks in patient encounters at risk for TB exposure. While more than a third of EM residents have not undergone fit testing for a NIOSH-approved PFR mask, the lack of routine easy availability of such masks is the most common reason they are not routinely worn by EM residents during at-risk encounters for TB transmission.

CONCLUSIONS

Most surveillance PPD testing of EM residents is performed at intervals recommended by the CDC. TB control programs at institutions sponsoring EM residencies need to improve both compliance with PFR mask fit testing by EM residents and availability of approved PFR masks in appropriate areas of the ED. Despite poor compliance with personal respiratory protection in ED patient encounters at risk for TB transmission, the risk of an EM resident's developing active TB over a three-year residency is low.

Effects of low oxygen condition on the generation of reactive oxygen species and the development in mouse embryos cultured in vitro

OBJECTIVE(S)

To elucidate the relationship between intracellular H2O2 production and embryo development in different oxygen culture conditions.

METHODS

Pronuclear stage embryos were obtained from C57BL/CBA F1 and ICR mice. Measurement of H2O2 level was performed with 2',7'-dichlorodihydroflourescein diacetate and the number of blastomeres was counted after staining with 4',6'-diamidino-2-phenylindole.

RESULTS

Regardless of strains, H2O2 level reached a peak at the 2-cell stage in 20% O2. But in embryos cultured in 5% O2 it was significantly lower at the 2-cell and 4-cell stages compared to those from 20% O2. The embryos cultured in 20% O2 showed developmental delay or block, but in 5% O2 these phenomena were overcome and the development was significantly increased with an infrequent fragmentation.

CONCLUSIONS

Our data suggest that the 5% O2 decreases the relative concentration of H2O2 and results in improved embryo development in terms of quantity and quality without regard to type of strains.

General weakness as an indication for parathyroid surgery in patients with secondary hyperparathyroidism

HYPOTHESES

There are factors that affect patients with general weakness owing to secondary hyperparathyroidism and as reported by results noted after parathyroidectomy and autotransplantation.

DESIGN

Case series and consecutive samples.

SETTING

Tertiary care center.

PATIENTS

From July 1996 to June 1998, 56 patients with secondary hyperparathyroidism underwent total parathyroidectomy and autotransplantation. Their ages were 45 +/- 13 years (mean +/- SD) and preoperative duration of dialysis was 75 +/- 37 months. Prior to surgery the patients were divided into 2 groups: group A comprised 2 men and 19 women who had some general weakness; and group B, 15 men and 20 women who reported no general weakness. The etiologies of renal failure, such as diabetic nephropathy (n = 3) or hypertensive nephropathy (n = 3), were found only in group A patients.

INTERVENTIONS

Serum levels of calcium, phosphorus, alkaline phosphatase, and parathyroid hormone (intact) were checked preoperatively and 1 day, 1 week, and 3 months after surgery. Extension force of the quadriceps femoris muscle was measured at 60 degrees of right knee flexion preoperatively and 3 months after surgery. The extension force was expressed as newtons (N) in 2 different quantities: peak force and average force. The degree of general weakness was classified into 4 groups: 0, no weakness; 1, some subjective weakness and/or walking with assistance; 2, the patient was wheelchair bound; and 3, the patient was bedridden.

MAIN OUTCOME MEASURES

The t test was used for paired and unpaired data; Wilcoxon signed rank and Fisher exact tests were incorporated for nonparametric data. Any values of P<.05 were considered significant.

RESULTS

Prior to surgery, 2 patients in group A reported degree 3 weakness; 5, degree 2 weakness; and 14, degree 1 weakness. Three months after surgery, the peak force was noticed to have increased from 185 +/- 56 N to 249 +/- 82 N (mean +/- SD) (n = 11, P = .003), and the average force showed an increase from 136 +/- 45 N to 202 +/- 69 N (n = 11, P = .003). Postoperatively, only 5 patients had degree 1 weakness, 1 had degree 2 weakness, and none had degree 3 weakness. The patient with degree 2 weakness after surgery had diabetes mellitus and a femoral neck fracture prior to parathyroidectomy. Improvement in condition of general weakness was found (P<.001) between preoperative and postoperative periods. Serum levels of calcium were higher in group A (2.82 +/- 0.23 mmol/L [11.3 +/- 0.9 mg/dL]) than in group B (2.64 +/- 0.27 mmol/L [10.6 +/- 1.1 mg/dL]) (P = .013), and serum levels of parathyroid hormone (intact) were lower in group A (108.9 +/- 39.2 pmol/L) than in group B (139.8 +/- 39.6 pmol/L) (P = .006). Except for sex, other data such as phosphorus and alkaline phosphatase levels, age, and duration of dialysis were not significantly different between the 2 groups.

CONCLUSIONS

General weakness that is commonly observed in patients with secondary hyperparathyroidism is found more frequently in women and only in patients with diabetic nephropathy or hypertensive nephropathy. Patients with general weakness had relatively higher levels of calcium and lower levels of parathyroid hormone (intact). We found that improvement of muscle power and general weakness can be achieved by parathyroidectomy and autotransplantation. In addition to itchy skin, bone pain, and soft tissue calcification, general weakness that may cause disability is also an indication for surgery in secondary hyperparathyrodism.

Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage. The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.

Glucagonoma syndrome: a case report

Glucagonoma is a very rare islet cell tumor of the pancreas. We present a case of pancreatic tail tumor with the typical glucagonoma syndrome of necrolytic migratory erythema (NME), diabetes mellitus (DM), anemia, weight loss and glossitis. After complete resection of the pancreatic tumor, the glucagonoma syndrome subsided. In reviewing 120 cases of glucagonoma in the literature, the average tumor diameter was 3.6 cm. Most (68.1%) of the tumors occurred in the pancreatic tail. Two-thirds of the reported glucagonomas were malignant and 53.5% metastasized to other organs. The curative resection rate was 45.8%. A triad of pancreatic tumor, NME and DM should lead to the diagnosis of glucagonoma.

Roles of RhoA and phospholipase A2 in the elevation of intracellular H2O2 by transforming growth factor-beta in Swiss 3T3 fibroblasts

We have investigated the mechanisms by which transforming growth factor-beta (TGF-beta) increased intracellular H2O2 in Swiss 3T3 fibroblasts. Increase of intracellular H2O2 by TGF-beta was maximal at 30 min and blocked by catalase from Aspergillus niger. Scrape-loading of C3 transferase, which down-regulated RhoA, inhibited the production of H2O2 in response to TGF-beta. TGF-beta stimulated release of arachidonic acid, which was completely inhibited by mepacrine, a phospholipase A2 inhibitor. Mepacrine also blocked the increase of H2O2 by TGF-beta. In addition, arachidonic acid increased intracellular H2O2. Furthermore, TGF-beta stimulated stress fibre formation, which was blocked by catalase, without membrane ruffling. Catalase also inhibited stimulation of thymidine incorporation by TGF-beta. These results suggested that TGF-beta increased intracellular H2O2 through RhoA and phospholipase A2, and also suggested that intracellular H2O2 was required for the stimulation of stress fibre formation and DNA synthesis in response to TGF-beta.

A novel function of IL-12p40 as a chemotactic molecule for macrophages

IL-12p70 plays a pivotal role in regulating the Th1/Th2 balance in the initial stage of immune responses. In contrast, IL-12p40, which is produced excess over IL-12p70, has been known to down-regulate IL-12p70-mediated responses by acting as an antagonist. To investigate in vivo function of IL-12p40, RH7777 rat hepatoma cells were engineered to inducibly express mouse IL-12p40 under the tight control of doxycycline (dox). In the absence of dox, s.c. injection of these cells into syngeneic rat was shown to generate tumors. However, the induction of IL-12p40 by dox was sufficient for inhibiting tumor formation, as well as for tumor regression. Immunohistochemical analysis showed that macrophages, but not CD4+ T, CD8+ T, and NK cells, were predominantly recruited into tumor sites as early as 3 days after IL-12p40 induction. These results were further supported by the observation that IL-12p40, but not C-terminal deletion mutants by more than 5 amino acids, was able to chemoattract peritoneal macrophages in vitro, suggesting that IL-12p40, when produced in a large excess over IL-12p70 in vivo, can initially amplify the immune responses against tumors by directly recruiting macrophages. Our findings indicate that IL-12p40 may function as an effector molecule as well as an antagonist of IL-12p70.

Increased expression of IL-4, IL-5, IFN-gamma, IL-6, IL-8, and TGF-beta mRNAs in maxillary mucosa of patients with chronic sinusitis

This study aimed to investigate expression of various cytokine mRNAs, including IL-6, IL-8, TGF-beta, IL-4, IL-5, and IFN-gamma in maxillary sinus mucosa of patients with chronic sinusitis. Maxillary sinus mucosae of six patients with chronic sinusitis and turbinate mucosae of six healthy subjects were obtained. We performed RT-PCR and Southern blot to examine gene expression of the cytokines IL-6, IL-8, TGF-beta, IL-4, IL-5, and IFN-gamma in maxillary sinus mucosa and compared the results with cytokine gene expressions in normal turbinate mucosa. IL-6, IL-8, TGF-beta, IL-4, IL-5, and IFN-gamma mRNAs were expressed more frequently in maxillary sinus mucosa from patients with chronic sinusitis than in normal turbinate mucosa. All the maxillary sinus mucosa specimens revealed relatively higher mean density ratio for each cytokine investigated than did normal turbinate mucosa. IL-6, IL-8, TGF-beta, IL-4, IL-5, and IFN-gamma mRNAs were expressed simultaneously in maxillary sinus mucosa of chronic sinusitis. These cytokines may be responsible for recruitment of inflammatory cells and for mucosal thickening in chronic sinusitis, and thus chronicity of the disease.

Tracheal neurilemmoma mimicking bronchial asthma--a dilemma of difficult diagnosis: case report

Tracheal tumors are often overlooked as a cause of pulmonary symptoms until they reach an advanced state. They are often presented with a prolonged cough and shortness of breath. Most tracheal tumors in adults are cancerous (80% to 90%). Benign tracheal tumors are rare in adult patients. A case history is presented of a 19-year-old patient with a rare tracheal neurilemmoma. He was treated as having bronchial asthma initially, but his signs and symptoms did not improve with traditional therapy. The possibility of the presence of an upper airway obstruction was not raised until the typical "inspiratory tubular sound" was heard. Flow-volume loop testing, bronchoscopy, and three-dimensional computed tomography (3-D CT) confirmed the diagnosis of upper airway obstruction caused by a tracheal tumor. Therefore, surgical intervention rather than bronchoscopic removal was performed without difficulty. The patient was leading a stable life 8 months after a surgical resection. The presence of an upper airway obstruction can be proven by flow-volume loop testing and 3-D CT. Further pathologic confirmation can be accomplished by bronchoscopy. High suspicion of an upper airway obstruction such as a tracheal lesion should be raised when bronchial asthma patients fail to respond to conventional treatment.