[Three cases of surgical treatment of dumbbell neurogenic tumor of the mediastinum--evaluation of intraspinal extension in cases without clinical symptoms]

Three cases of dumbbell neurogenic tumor of the posterior mediastinum are reported. None of these cases had any clinical symptoms, and an abnormal mass shadow of the mediastinum had been detected on routine chest roentgenogram. In these three cases, however, myelogram and/or CT findings were suggestive of tumor extension to the spinal canal in various degrees. Two tumors were resected in two-stage operations with combined thoracic and neurosurgical approaches, and the other case was treated by one-stage operation with the combined two approaches. All tumors were completely resectable without serious complications such as hemorrhage, leakage of spinal fluid, or neurologic deficit. Even in asymptomatic patients with neurogenic tumor located in the paravertebral region, it should be determined whether or not the tumor extends to the spinal canal through the intervertebral foramen, prior to planning the surgical procedure.

[A case of hypersensitivity pneumonitis due to isocyanate exposure showing progression even two months after removal of the antigen]

A 68-year-old male developed dry cough and exertional dyspnea after handling paint spray containing isocyanates (TDI, MDI) for three months. Initially, the symptoms fluctuated according to whether he was at work or not. He was admitted to our hospital on February 7, 1990, because of progressive worsening of symptoms. In spite of admission to hospital and cessation of exposure to isocyanates, there was no improvement of symptoms. His chest X-ray film showed diffuse small nodular and reticular shadows. Transbronchial lung biopsy revealed thickening of the alveolar walls and formation of Masson's bodies associated with mononuclear cell infiltration in alveolar spaces. High titers of TDI-HSA and MDI-HSA specific IgG antibodies were detected by ELISA, and a high level of serum soluble IL2 receptor was also detected. From these results, we diagnosed hypersensitivity pneumonitis due to exposure to isocyanates. One week administration of prednisolone caused dramatic improvement of his symptoms, chest X-ray findings, and laboratory data. His clinical course and response to prednisolone therapy indicated that long-term steroid administration could not be avoided. The prolonged symptoms and the necessity for long-term steroid therapy are discussed.

Detection of human T-cell lymphotropic virus type I-related antibodies in patients with lymphocytic interstitial pneumonia

Lymphocytic interstitial pneumonia (LIP) is a rare form of interstitial pneumonia with infiltration of mononuclear cells in the interstitium, the pathogenesis of which is unknown. We studied six patients with LIP to investigate the immunologic characteristics of lymphocytes in the lower respiratory tract and the possible involvement of human T-cell lymphotropic virus type I (HTLV-I), which is endemic in the southwestern region of Japan. Lymphocyte surface antigen phenotyping in peripheral blood (PB) and bronchoalveolar lavage fluid (BALF) cells revealed a predominance of CD8 positive (suppressor/cytotoxic) T-lymphocytes (PB: 51.5 +/- 0.8%; BALF: 52.9 +/- 12.7%), which consisted of an increased number of CD8 positive CD11 negative (cytotoxic) T-lymphocytes (PB: 30.2 +/- 10.5%; BALF: 57.1 +/- 11.8%). The increased number of cytotoxic T-lymphocytes among patients with LIP led us to investigate the possible involvement of HTLV-I, EB virus, and HIV in patients with chronic interstitial disorders of LIP, sarcoidosis, and IPF. The seropositivity rate for HTLV-I was 83.7% (5/6) in patients with LIP, 3.1% (1/28) with IPF, 7.1% (2/28) with sarcoidosis, and 0% (0/28) in healthy volunteers. None of the patients were seropositive for either HIV or EB virus. These results suggest that HTLV-I may be involved in a direct or indirect role in the pathologic mechanisms through the host immune reaction to the antigenicity of the virus and/or the possible involvement of viral regulatory genes to disrupt the normal immune reaction of the host.

Enhanced neutrophil functions in a patient with colony-stimulating activity-producing lung cancer

We studied neutrophil functions in a patient with colony-stimulating activity (CSA)-producing lung cancer. A 59-year-old man had an abnormal chest X-ray and leucocytosis, predominantly with neutrophils. Pneumonectomy was performed, and the histological diagnosis of the tumour was large-cell carcinoma of the lung. The tumour induced marked granulocytosis in tumour-transplanted nude mice, and the conditioned media of the tumour contained very strong human-active CSA. Superoxide release and membrane depolarization in neutrophils stimulated by the chemotactic peptide, N-formyl-methionyl-leucyl-phenylalanine, were markedly enhanced in the patient. These findings suggest that CSA produced by the tumour primed neutrophil functions in vivo in the patient.

Siiyama (serine 53 (TCC) to phenylalanine 53 (TTC)). A new alpha 1-antitrypsin-deficient variant with mutation on a predicted conserved residue of the serpin backbone

alpha 1-antitrypsin (alpha 1AT), a plasma serine protease inhibitor, increases the risk of precocious pulmonary emphysema in individuals when deficient. Although more than 25 years have passed since a deficiency in the serum level of alpha 1AT was reported, it is only recently that the consequence of the amino acid replacement which leads to the deficient state has been discussed in terms of the crystallographic structure of alpha 1AT and the amino acid residues conserved in the superfamily to which it belongs. Our case involved a 38-year-old Japanese male with alpha 1AT deficiency which was analyzed and identified as a new deficient variant. The serum alpha 1AT of the proband migrated to the S position of the reference serum which is more cathodal than M1, the predominant normal variant, when isoelectric focusing (pH 4.2-4.9) is performed by a combination of Western blotting and crossed immunoelectrophoresis. The new deficient variant is designated as Siiyama after his birthplace. Although liver biopsy specimen showed no apparent pathological findings, PAS-positive with diastase-resistant inclusion bodies and immunoreactive aggregates were detected in several hepatocytes. In addition, similar alpha 1AT mRNA transcript levels were observed in peripheral blood leukocytes from the proband and healthy subjects by Northern analysis. All the coding exons (exon Ic, II, III, IV, and V) of the alpha 1AT gene of the proband and his family were amplified by polymerase chain reaction and followed by direct sequencing. A single missense mutation, Ser53 (TCC) to Phe53 (TTC was identified in exon II of the proband's alpha 1AT gene. All his family examined were heterozygous at this base. Ser53 is one of the most conserved residues as predicted by Huber and Carrell (Huber, R., and Carrell, R. W. (1989) Biochemistry 28, 8951-8966) and is thought to contribute to the organization of the internal core element of the alpha 1AT molecule. The mutational matrix number of Ser to Phe substitution is -3, indicating that this change is evolutionally rare. In this regard, a possible explanation for the deficient state in alpha 1AT Siiyama is that the change from an uncharged polar to a nonpolar amino acid imposed on the conserved serpin backbone exerts severe effects on the integrity of the molecule, and hence alters the intracellular processing of alpha 1AT.

[A case of diffuse panbronchiolitis, performed an open lung biopsy after improvement with 6 years medication]

A 51-year-old male was hospitalized in June 1983, complaining of productive cough and dyspnea. Diffuse panbronchiolitis (DPB) was diagnosed on the basis of the physical examination, chest roentgenogram, chest CT and transbronchial lung biopsy (TBLB). The patient underwent surgery for chronic sinusitis and deviated nasal septum, and received Pseudomonas aeruginosa vaccine, ampicillin and erythromycin. He revealed a posterior mediastinal tumor in March 1989. The clinical findings of DPB improved but open lung biopsy was performed on the occasion of surgery for the posterior mediastinal tumor. Pathologically, fibrosis and mild infiltration of mononuclear cells localized in the walls of respiratory bronchioli and in surrounding areas was recognized in addition to slight accumulation of foamy macrophages in interstitial spaces. These morphological findings, as well as the clinical findings, might suggest repair of DPB lesions.

Respiratory nicotine absorption in non-smoking females during passive smoking

The aim of this study was to measure nicotine concentrations in inspired and expired air so as to learn more about respiratory (nasopharyngeal cavity and lung) nicotine absorption from inspired air and to estimate the nicotine intake during passive smoking. A total of 17 young non-smoking women were exposed to experimental passive smoking. Inspired and expired air was sucked at a constant rate into samplers filled with acid-treated diatomite (Uniport-S) to absorb nicotine in the air. Absorbed nicotine was assayed by gas chromatography. The range of nicotine concentration in the inspired air was 40-200 micrograms/m3. In this setting, 47 samples obtained from the 17 subjects were assayed. Nicotine absorption, which was calculated as [(nicotine concentration in inspired air-nicotine concentration in expired air)/nicotine concentration in inspired air] x 100, remained at 60%-80% (mean +/- SD, 71.3% +/- 10.2%) without being affected by the nicotine concentration in the inspired air. From this result, it was estimated that the average intake of nicotine was 0.026 mg/h in a group of non-smokers exposed in a room containing a nicotine concentration of 100 micrograms/m3, which is equivalent to fairly severe involuntary tobacco smoking. This is the first report on the estimation of respiratory nicotine absorption and nicotine intake during passive smoking based on the direct measurement of nicotine concentrations in both inspired and expired air.

Soluble interleukin-2 receptor in sera of patients with pulmonary tuberculosis

Interleukin-2 receptor, the complex of IL-2R-alpha and/or IL-2R-beta, is expressed mainly on T-lymphocytes, and the soluble form of IL-2R-alpha (sIL-2R-alpha) has been reported to be detected in the serum of patients with lymphoproliferative disorders or disease characterized by the cellular immune reaction. We measured serum sIL-2R-alpha levels among patients with pulmonary diseases and found that sIL-2R-alpha levels were significantly elevated in patients with active pulmonary tuberculosis (1,327 +/- 209 U/ml) and sarcoidosis (1,037 +/- 115 U/ml) when compared with healthy volunteers (468 +/- 49 U/ml, p less than 0.01). Among patients with pulmonary tuberculosis, the sIL-2R-alpha levels were high in sera from patients with extensive parenchymal lesions on the roentgenogram (2,745 +/- 705 U/ml) and patients with tuberculous pleurisy (2,111 +/- 679 U/ml). In contrast, the sIL-2R-alpha levels in tuberculous patients with minimal lesion (455 +/- 92 U/ml) or moderate lesion (1,082 +/- 189 U/ml) were not significantly elevated when compared with healthy volunteers. After the treatment with antituberculosis agents, serum sIL-2R-alpha levels decreased in accordance with improvement of roentgenographic findings and laboratory data. These results suggest that serum sIL-2R-alpha level may be useful as a monitor for the disease activity in patients with pulmonary tuberculosis.

Sequential changes of perivascular edema cuffs in models of permeability and hemodynamic pulmonary edema

The areas of perivascular edema cuffs surrounding pulmonary arteries and veins were sequentially measured as an index of the fluid transport unit in lung interstitium (FTULI) in epinephrine-induced and oleic acid-induced pulmonary edema in rats. The former edema represents a model of hemodynamic edema and the latter, permeability pulmonary edema, respectively. In epinephrine-induced pulmonary edema, both the ratio of edema cuff area to cross-sectional area of the pulmonary artery (Rr) and the ratio of lung weight to body weight (L/B) were increased in parallel, reached maximum levels at 0.5 h after the treatment, and returned to the control levels after 3 h. In oleic acid-induced pulmonary edema, the changes in Rr and L/B were not parallel, and the maximum levels were reached at different times, Rr at 3 h and L/B at 1.5 h. Rr returned close to the control level in 24 h but L/B remained elevated so that rate of recovery was delayed. The cuffs around the veins appeared similar to those around the arteries, but were very slight in both models. The difference in the time course of Rr and L/B in the two models may suggest that the recruitment of FTULI is insufficient in oleic acid-induced pulmonary edema; this limitation seems to be an important factor which makes the permeability edema refractory to treatment, together with the damage to the blood gas barrier.

[Two cases of mediastinal goiter with progressive deviation of the trachea by its growth and their thyroid hormone values in the fluid of the cystic lesions]

We reported two operated cases (a 35-year-old male and 52-year-old male) of mediastinal goiter accompanied by marked tracheal deviation. The two patients did not have any clinical symptoms. CT, MRI, ultrasonography and angiography finding of the two cases are presented. Fluid was obtained from the cystic lesions by ultrasonically guided needle aspiration. The levels of thyroid hormones (T3, T4) in the fluid were not high in comparison with serum levels. Surgical resection was performed on the 35-year-old male case by collar incision and on the 52-year-old male case by median sternotomy.

[Measurement of oil mists by a portable sampler and subjective symptoms among machine workers: a field investigation of machine workshops]

Machine oils are widely used in metal processing and many workers are exposed to oil mists in the work environment. Some investigators have pointed out such health hazards due to prolonged exposure to oil mist as respiratory disorders, dermatitis, and possible carcinogenesis. In Japan, a permissible limit of oil mists of 3 mg/m3 was recommended in 1977 by the Japan Association of Industrial Health (JAIH) mainly based on the hazardous effects on the respiratory system. After this recommendation was made, only a few studies have been made on the measurement of oil mists and on the health effects in machine workers to determine whether the permissible limit is justifiable or not. In the present study, the levels of oil mists in the air of machine workshops were measured together with personal exposure levels by personal samplers. Oil mists were collected by a sampler head with 2 stages which enabled differentiation of distribution of particulates between larger than 10 microns and 2-10 microns in size. Oil components collected on the stainless steel stages were washed out by sonication in CCl4 solution and measured by an oil meter with infra-red spectrometry against a standard solution of heavy oil class B according to procedures reported elsewhere by the authors. Questionnaire surveys were also conducted on 308 male machine workers composed of 221 workers exposed to oil mists and 87 nonexposed controls. The questions were composed of five items about air quality in the work environment and 18 subjective symptoms during work and daily lives. The symptoms included nasopharyngeal, muco-dermal, gastrointestinal and neuro-muscular symptoms. Statistical analysis was made by the Manthel-Haenszel method for a comparison of "yes" rates of complaints between the exposed and the non-exposed by adjusting the underlying confounding factor of age distribution. 1. The levels of oil mists measured here ranged from 94 to 813 micrograms/m3 in the ambient air and from 107 to 483 micrograms/m3 of personal exposure. There was no obvious difference between the level in the ambient air and that of personal exposure. All these measured levels were under the permissible limit (3 mg/m3) recommended by JAIH in 1977. 2. The observed distribution of particulate size of oil mists from 2 to 10 microns referred to as respirable size was 32.8 +/- 16.1% generated from the grinding machines using water-soluble type of machine oils and 50.0 +/- 12.4% from those using insoluble type.(ABSTRACT TRUNCATED AT 400 WORDS)

Influence of hypoxia on 5-lipoxygenase pathway in rat alveolar macrophages

The effect of hypoxia was studied on the ionophore A23187-induced leukotriene production by rat alveolar macrophages. The production of LTB4 and LTC4 decreased with reducing oxygenation without change of cell viability. The synthesis of 5-HETE increased during hypoxia and the total production of LTB4, LTC4 and 5-HETE, the major metabolites of the 5-lipoxygenase pathway in rat alveolar macrophages, was equal during normoxia and hypoxia. Arachidonate release and LTA4-converting into LTB4 and LTC4 was unaffected by hypoxia. LTB4- and LTC4-degradating activities were not affected by hypoxia. These results suggest that LTA4 synthase reaction of leukotrienes biosynthesis might be suppressed by hypoxia.

[A case of neurogenic pulmonary edema with repeated deterioration due to subarachnoid hemorrhage]

A 55-year-old male was admitted to our hospital for subarachnoid hemorrhage complicated with liver cirrhosis on Jan. 8th, 1988. Chest X-ray film on admission showed bilateral infiltrative shadows, which disappeared on Jan. 10th. However the same type of shadow reappeared on Jan. 12th. Although he received surgical treatment for subarachnoid hemorrhage, pulmonary deterioration occurred five times until the 21st post-operative day. These changes responded to diuretics and control of water balance. Cardiac function evaluated by ultrasonocardiography and right cardiac catheterization, and the composition and amount of plasma protein concentration were within normal limits. Although the mechanism of repeated appearance of the shadow was not clear, the edema was thought to be neurogenic. As this case showed, the control of water balance and the use of diuretics are essential for treatment of this neurogenic pulmonary edema.

Two cases of hamartoangiomyomatosis with characteristic scintigraphic findings

Hamartoangiomyomatosis is a rather rare pulmonary disease which occurs in young to middle-aged women. The chief complaint of this disease is dyspnea. The chest X-ray findings of this disease are such complicated features as reticular, reticulogranular, miliary and honeycomb-like shadow. A pulmonary perfusion scintigram was prepared with a scinticamera after intravenous injection of 10 mCi of Tc-99m MAA. The anterior image showed a remarkably reduced bilateral pulmonary blood flow, especially in the middle and lower areas of the lungs. In the upper portions, the blood flow remained relatively sufficient. The posterior and lateral images also gave similar findings. In two cases of hamartoangiomyomatosis, pulmonary perfusion scintigraphy was successful in identifying the characteristic findings of the disease.

[Regional distribution of perfusion and ventilation in hamartoangiomyomatosis of the lung]

We investigated regional distribution of perfusion and ventilation in three cases of hamartoangiomyomatosis (HAM) by 133Xe gas and 99mTc-MAA. In two cases, 133Xe washout were dominantly delayed in middle lung field and in the third case, it was delayed in upper lung field. This distribution was different from the result in the other chronic obstructive pulmonary disease (COPD). In most cases of COPD, 133Xe washout was prominently delayed in the lower lung field. Distribution of pulmonary perfusion in HAM were consistent with that of ventilation as in COPD.

[Analysis of mediastinal lymphadenopathy in sarcoidosis with transesophageal ultrasonic endoscopy; influences on cardiovascular system]

We studied influences of mediastinal lymphadenopathy on cardiovascular system in nine cases of sarcoidosis with transesophageal ultrasonic endoscopy. Chest x-ray films revealed bilateral hilar lymphadenopathy in all cases, whose diagnoses were made histologically with biopsies of peripheral lung through flexible fiber optic bronchoscope and/or of lymph nodes. These findings were typical in this disease. Many compartments of cardiovascular system in mediastinal and hilar regions were visible with this technique in all subjects. And enlarged lymph nodes changed dimensions in these compartments, especially in main pulmonary arteries, left atria, pulmonary veins and aorta. Furthermore, these phenomena were seen in azygos vein and superior caval vein in some cases. It is suggested that these lymph nodes may influence hemodynamics in above-mentioned compartments of cardiovascular system, if this phenomenon deteriorates more progressively.

The role of lymphatics in removing pleural liquid in discrete hydrothorax

The thoracic duct and right lymphatic duct of the dogs in the experimental group were ligated at the neck. Saline labelled with Evans blue was injected (10 ml.kg-1) into the pleural cavity. The colloid osmotic pressure of the saline was adjusted to be exactly equal to that of normal pleural liquid. The change in the volume of the liquid and the decrease of the marker were studied for 3 h. The dynamics of the pleural liquid were investigated. In the control group, the volume of the pleural liquid decreased at the rate of 1.31 ml.h-1.kg-1 body weight and 87% of it left via the lymphatics. With the ligation of the bilateral lymphatic ducts, the lymphatic removal rate decreased to about one tenth. This result shows that the hydrothorax leaves the pleural cavity mainly via the lymphatics.

The role of lymphatics in removing pleural liquid in discrete hydrothorax

The thoracic duct and right lymphatic duct of the dogs in the experimental group were ligated at the neck. Saline labelled with Evans blue was injected (10 ml.kg-1) into the pleural cavity. The colloid osmotic pressure of the saline was adjusted to be exactly equal to that of normal pleural liquid. The change in the volume of the liquid and the decrease of the marker were studied for 3 h. The dynamics of the pleural liquid were investigated. In the control group, the volume of the pleural liquid decreased at the rate of 1.31 ml.h-1.kg-1 body weight and 87% of it left via the lymphatics. With the ligation of the bilateral lymphatic ducts, the lymphatic removal rate decreased to about one tenth. This result shows that the hydrothorax leaves the pleural cavity mainly via the lymphatics.