Pulmonary nocardiosis during immunosuppressive therapy for idiopathic pulmonary fibrosis

Nocardiosis is a subacute or chronic suppurative infection caused by Nocardia species. Although it is more common in immunocompromised hosts, idiopathic pulmonary fibrosis (IPF) has not been recognized as a predisposing factor for nocardial infection. We report a case of IPF, in which pulmonary nocardiosis developed during treatment with prednisolone and cyclophosphamide. The risk of pulmonary nocardiosis may be increased in cases of IPF on immunosuppressive therapy. Since IPF often accompanies lung carcinoma, it is important to correctly differentiate nocardiosis from carcinoma.

Differential innervation of the goldfish tonic red muscles and twitch white muscles by neuropeptide-immunoreactive motoneurons

Neuropeptides in the motor nerves innervating the red and white muscles of the goldfish Carassius auratus were examined. In the tonic red muscles, varicose nerve endings immunoreactive for both calcitonin gene-related peptide and substance P were found spread over the surface of the muscle fibers, but in the twitch white muscles only scattered nerve endings immunoreactive for calcitonin gene-related peptide were found. At the electron microscopic observation, dense electron products immunoreactive for calcitonin gene-related peptide and for substance P (SP) were detected in the motor nerve endings making synapses on the muscle fibers of the red muscles. In the spinal cord, all of the motor neurons showed immunoreactivity to calcitonin gene-related peptide, but the motor neurons immunoreactive for substance P were restricted to the ventrolateral group that has been shown to project predominantly to the red muscles. These results suggest that the motor neurons innervating the red and white muscles of the goldfish are distinct in their neuropeptide content. The present study also raises the possibility that SP might be related to the unique physiological properties of the tonic type red muscles, probably by direct binding to the acetylcholine receptors.

Aneurysm in the pulmonary trunk associated with atrial septal defect, a left coronary artery fistula to the pulmonary trunk, and valvular pulmonary stenosis

A 78-year-old woman with an aneurysm in the pulmonary trunk associated with an atrial septal defect, left anterior descending coronary artery fistula to the pulmonary trunk and valvular pulmonary stenosis is reported. The aneurysm showed gradual dilatation over 16 years and was successfully treated using aneurysmorrhaphy. Although there has been some controversy regarding the optimum management for a pulmonary artery aneurysm, surgical correction is thought to be essential for aneurysms associated with congenital cardiac anomalies because of the high incidence of rupture.

Pleural amyloidosis in a patient with intractable pleural effusion and multiple myeloma

Pleural involvement of systemic amyloidosis has been rarely reported. We report a case with multiple myeloma presenting an intractable right pleural effusion, in which pleural amyloidosis was diagnosed through pleural biopsy using a Cope needle. The diagnosis of pleural amyloidosis is important, because its refractory pleural effusion should be treated with pleurodesis. Since closed pleural biopsy using a Cope needle is much less invasive than thoracoscopy, the former should be attempted first whenever pleural amyloidosis is suspected.

Nuclear hypersegmentation precedes the increase in blood eosinophils in acute eosinophilic pneumonia

In this case of acute eosinophilic pneumonia (AEP), eosinophils with hypersegmented nuclei emerged in the blood before the increase of eosinophil count. An 18-year-old woman complaining of fever, cough and dyspnea was admitted because of diffuse ground-glass opacities in her chest roentgenogram. On admission, her blood cell count revealed a marked increase of neutrophils. Although the number of eosinophils was normal, some of them contained three- or four-lobed nuclei. She was diagnosed to have AEP through bronchoalveolar lavage and transbronchial lung biopsy. The combination with acute clinical course, pulmonary infiltration and the presence of hypersegmented eosinophils in blood may imply the diagnosis of AEP.

Bacterial colonization of the upper respiratory tract of patients with primary lung cancer and nonmalignant lung disease

We examined the bacterial colonization of the upper respiratory tract of 110 patients with primary lung cancer (PLC), 75 patients with nonmalignant lung diseases (NMLD) and 45 healthy volunteers (HV), comparing the sensitivity of expectorated sputum, and throat and nasal swabs. The frequency of bacterial colonization of the upper respiratory tract was significantly higher in the PLC patients (59.1%) than in NMLD patients (37.3%, p < 0.01) and HV (37.8%, p < 0.01). The frequency of gram-negative colonization was significantly higher in PLC patients than in the other subjects (p < 0.01). Expectorated sputum and nasal swab were the most sensitive for detection of whole bacteria and methicillin-resistant Staphylococcus aureus in the patients with PLC. Our results showed that PLC patients are significantly more frequently colonized by bacteria in their upper respiratory tracts and that a combination culture of expectorated sputum and nasal swab is suitable to estimate the bacterial colonization of the upper respiratory tract in the patients.

[A case of chronic pigeon breeder's lung]

The patient, a 59-year-old woman, was admitted for further evaluation after a routine checkup in 1990 revealed an interstitial shadow chronic hypersensitivity pneumonia caused by her pigeons, was diagnosed. The patient later disposed of the pigeons and henhouse, where upon, she experienced dyspnea on exertion. In January 1995, the patient was admitted to our hospital with a progressive pulmonary interstitial shadow. Lung biopsy after thoracoscopic surgery revealed centrilobular fibrotic lesions, as well as, small honeycomb-like and granulomatous lesions. An antibody to the pigeon serum was detected in the patient's serum by the ouchterlony method. Chronic hypersensitivity pneumonia caused by pigeons is rare, and previously documented histological findings are few.

[Hypersensitivity pneumonitis monitored with serum KL-6, a marker of interstitial pneumonia]

A 44-year-old man was hospitalized because of exertional dyspnea that had progressed for one month. A chest X-ray film showed bilateral small nodular and reticular shadows. The patient presented with a positive inflammatory reaction and hypoxemia. Bronchoalveolar davage fluid had a high lymphocyte fraction and a low CD4/CD8 ratio. Trichosporon cutaneum antibodies were detected, and a specimen obtained by transbronchial lung biopsy showed alveolitis with granuloma formation. The patient reacted positively on a provocation test that was done by having him stay home for 5 days. Summer-type hypersensitivity pneumonitis was diagnosed, and a steroid was administered because of the prolonged abnormal chest roentgenographic findings. KL-6, a mucinous high-molecular-weight glycoprotein that is expressed on Type II pneumonocytes, was retrospectively used as a marker of pneumonitis. A new kit for enzyme-linked immunoassay (ED046) was used to measure the serum KL-6 level. The serum KL-6 level peaked approximately 10 days after the patient was admitted to the hospital and was thus kept away from antigens, and also after the provocation test. The steroid treatment was started, the KL-6 level decreased gradually. Within 2 months after steroid treatment began, the dose of the steroid was reduced and the KL-6 level decreased below the upper limit of normal. The KL-6 level remained low thereafter; it was not influenced by liver dysfunction or other inflammatory processes. However, the C-reactive protein level decreased rapidly after provocation and thereafter immediately returned to almost zero. The lactate dehydrogenose level peaked 8 days after provocation and decreased rapidly after steroid treatment. These results suggest that the serum KL-6 level provides new information regarding the clinical course and treatment of interstitial pneumonia. In addition KL-6 may be useful form monitoring disease activity, especially while tapering the dose of steroids in patients with interstitial pneumonia.