Chronic rhinosinusitis possibly associated with decreased lung function in chronic cough patients

OBJECTIVES

The purpose of this study is to investigate the lung function in Chronic Rhinosinusitis (CRS) patients with Chronic Cough (CC).

METHODS

A total of 1413 CC patients were retrospectively screened and 109 CRS patients with CC were enrolled. Lung function, Lund-Mackay Computed Tomography (CT) score, smoking status, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples, and Sino-Nasal Outcome Test were examined. Normal control subjects are also recruited.

RESULTS

The Forced Expiratory Volume in 1 second (FEV1.0), Percent Predicted FEV1.0, and FEV1.0/Forced Vital Capacity (FVC) ratio in the patients were significantly low as compared with the control subjects. The FEV1.0/FVC ratio was negatively correlated with the Lund-Mackay CT scores of the patients with a high CT score.

CONCLUSIONS

The CRS patients with CC should be investigated with lung function. In addition, the multidisciplinary evaluation including a pulmonologist is needed to manage the CRS patients with CC.

LEVEL OF EVIDENCE

Level 4.

Lund-Mackay Computed Tomography Score Is Associated With Obstructive Pulmonary Function Changes in Chronic Cough Patients

BACKGROUND

A remarkable relationship between upper airway conditions and lung diseases has been reported. At the same time, sinonasal findings in chronic cough patients have not been fully examined.

OBJECTIVE

The purpose of this study is to show paranasal sinus findings and lung function in chronic cough patients without asthma and chest X-ray abnormalities.

METHODS

A total of 1412 patients with persistent cough were enrolled in this study. Of these patients, 376 patients were evaluated for further examination, as the patients with asthma and/or chest X-ray abnormality were excluded from the study. Normal control subjects without any chronic respiratory symptoms were also recruited. Pulmonary function was examined by spirometry. A bronchial obstruction reversibility test was applied. The Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples were examined. The Sino-Nasal Outcome Test was used to determine the severity of clinical symptoms.

RESULTS

The patients with an abnormal soft tissue shadow in the paranasal sinus had significant obstructive lung function. The percent predicted forced expiratory volume in 1 second (FEV_1.0) and the FEV_1.0/forced vital capacity ratio negatively correlated with Lund-Mackay CT scores both before and after bronchodilator inhalation. There was a statistically significant correlation between pulmonary function and eosinophil count.

CONCLUSION

The patients with chronic cough frequently had paranasal sinus abnormalities. The Lund-Mackay CT score may be useful for assessing the condition of the lower airway in chronic cough patients. Upper airway examinations should play a part in the management of chronic cough.

Household Food Security, Food Consumption Patterns, and the Quality of Children's Diet in a Rural Northern Ghana Community

Twenty households in a rural northern Ghana community were studied to ascertain evidence of seasonality and the relationship between household food-security status and the food and nutrient intakes of preschool children. All food consumed by household members was weighed for three consecutive days, and nutrient intakes were calculated from appropriate food composition tables. Diet quality was assessed by quantitative and descriptive analysis. Mean daily intakes of selected food items reflected an over-dependence on cereals and a minimal consumption of animal products. The consumption of vegetables, especially low during the pre-harvest season, increased during the post-harvest season. Nutrient intakes, which were generally lower than recommended dietary allowances, increased during the post-harvest season, although not significantly for calories, protein, and iron (p <.05), in contrast to vitamins A and C (p < .001). There was a significant association between household food-security status and the intakes of calories (p < .001) and protein (p < .01) but not of micronutrients. Diet quality was adversely influenced by a low intake of micronutrients derived primarily from plant sources as well as by poor dietary habits. Calorie and protein intakes appear to have been more influenced by household food availability and were subject to less seasonal fluctuation, while the reverse held true for the micronutrients. In addition, household food security did not necessarily ensure the quality of children's diets in an area where food consumption patterns are monotonous.

The Efficacy of Nafamostat Mesilate on the Performance of a Hybrid-artificial Liver using a Polyurethane foam/porcine Hepatocyte Spheroid Culture System in Human Plasma

Nafamostat mesilate (FUT) is a protease inhibitor of complement activation. The present study investigates whether FUT protects porcine hepatocytes from being injured by human plasma in a multi-capillary polyurethane foam packed-bed culture system (MC-PUF) such as the hybrid-artificial liver (PUF-HAL). Human plasmas with 1 mM of added ammonia were perfused using a small-scale PUF-HAL with porcine hepatocytes. FUT was continuously infused (10 μ g/ml, 50 μ g/ml,). The ammonia detoxification was maintained in human plasma for 24 hours and for 48 hours with FUT which suppressed the rapid increase of asparaginic acid aminotransferase (AST) and alanine aminotransferase (ALT). After 60 hours of perfusion, hepatocyte spheroids completely collapsed in the human plasma, but a small amount of hepatocyte spheroid was maintained by FUT. The effect of FUT was slightly greater at 50 μ g/ml than at 10 μ g/ml. Our results suggest that FUT has protective effects against porcine hepatocytes in human plasma, and our PUF-HAL using porcine hepatocytes can function in human plasma for about 48 hours with FUT.

High Detection Rates of Urine Mycobacterium tuberculosis in Patients with Suspected Miliary Tuberculosis

Objective The utility of detecting Mycobacterium tuberculosis in urine samples from patients with pulmonary tuberculous with diffuse small nodular shadows (suspected miliary tuberculosis (MTB)) is still unclear in Japan. A retrospective cross-sectional study was conducted to investigate the detection rates of M. tuberculosis in urine of patients with suspected MTB. Methods Among 687 hospitalized patients with tuberculosis, 45 with culture-confirmed suspected MTB and the data of culture and polymerase chain reaction (PCR) for M. tuberculosis in urine and sputum samples were investigated. The detection rates of M. tuberculosis in urine using cultures and PCR were calculated. The detection rate of urine was then compared with that of bone marrow aspiration. Results Fourteen patients with suspected MTB were ultimately analyzed. A diagnosis of miliary tuberculosis was suspected in all patients before anti-tuberculosis chemotherapy. Positive results by PCR (11 [78.6%] cases) and culture (8 [57.1%]) were obtained from urine samples. In patients with suspected MTB, there was no significant difference in the detection rates between M. tuberculosis in urine using a combination of PCR and culture (85.6% [12/14 cases]) and bone marrow aspiration (66.7% [8/12 cases]) (p>0.05). Conclusion Using PCR and culture, we demonstrated high detection rates of M. tuberculosis in the urine of patients with suspected MTB. A combination of PCR and culture compared favorably with the detection rates achieved with bone marrow aspiration. We believe that detection of M. tuberculosis from urine and sputum samples may be easy and safe for patients with disseminated tuberculosis infections such as definitive MTB.

What Are the Current Situations and the Challenges of Maternal and Child Malnutrition in Asia?

Changes in lifestyle have led to better nutrition or increasing the risk of NCDs in Asia, while there are still many children and reproductive-aged women (RAW) suffering undernutrition whose lives are at risk in the same region. The MDG of reducing the prevalence of underweight <5 children to half has been achieved already or nearly achieved in many Asian countries, whereas South Asian (SA) countries and several other countries (Cambodia, Laos, East Timor and Yemen) have difficulties in achieving the goal by 2015. In particular, East Timor and Yemen are in a critical situation with undernutrition. There is a strong concern about a rapid increase in overweight and obesity rates in West Asian (WA) and some Central Asian (CA) countries. Iron deficiency is one of the most important risk factors that threaten healthy life among RAW especially in SA, followed by Southeast Asia (SEA) and CA. The same issue is observed among children (1-4 y) in the same regions. Dietary risks (based on DALYS) increase with advancing age in most Asian regions whereas high Body Mass Index is the most important risk factor in WA and some CA countries. High priority should be placed on measures to tackle undernutrition and micronutrient deficiencies including iron deficiency in SA and some countries in SEA and WA; overweight and obesity in WA and CA; and dietary risks among RAW, in most Asian regions.

Evaluation of short-term clinical efficacy of 3-day therapy with azithromycin in comparison with 5-day cefcapene-pivoxyl for acute streptococcal tonsillopharyngitis in primary care

Group A streptococcal (GAS) tonsillopharyngitis is one of the few conditions for which antibiotics are advocated among common upper respiratory infections. Although a 3-day course of azithromycin is attracting attention as a treatment of choice for the condition, it is not clear if the efficacy of the treatment is comparable with that of treatment with cephalosporins. A prospective, randomized, comparative multicenter study was conducted to compare the efficacy of azithromycin (AZM) given once daily for 3 days with that of cefcapene-pivoxyl (CFPN-PI) divided into three daily doses for 5 days. 88 patients (male: 38, mean age: 16.5) were treated with AZM and 69 (male: 34, mean age: 16.9) with CFPN-PI. The symptoms of all but 5 (2 for AZM and 3 for CFPN-PI) of the patients were resolved by the 8th day of the treatment. By the 4th day of the treatment, criteria for clinical efficacy were fulfilled in 71 (80.7%) subjects who were treated with AZM and in 48 (67.6%) of those treated with CFPN-PI (p = 0.07). The same figures on the 8th day of the treatment were 86 (97.7%) and 68 (95.8%), respectively (p = 0.66), confirming there was no significant difference in clinical efficacy between the two treatments. Mild adverse reactions were reported by two patients treated with AZM and by none treated with CFPN-PI. The clinical efficacy of a 3-day course with AZM was comparable with that of a 5-day course of CFPN-PI for GAS tonsillopharyngitis.

Insufficient level of iodine content in household powder salt in Nepal

Universal salt iodization (USI) is long term strategy for the control of iodine deficiency disorder (IDD) in Nepal. Standardized periodic testing of the iodine content in salt is a critical part of a salt iodisation programme. To achieve programmatic objective, this study was carried out to estimate the iodine content of household salt in Kavre, Lalitpur and Parsa districts of Nepal. Iodometric titration of 1803 salt samples collected from the households through the students of different schools revealed that 289 (16.0%) had less than 15 ppm iodine. Two hundred forty-one powder salt samples without two children logo (14.3% among total powder salt samples) had iodine below 15 ppm. It includes 25.8% of total salt samples from Parsa district of Terai ecological region. Among total, the largest proportion of the population accounting for almost 93.0% used powder salt. In total 1803 salt samples, mean and median iodine concentration were 31.8 ppm (95.0% CI=31.0-32.6) and 29.5 ppm respectively. The mean and median iodine concentration of phoda (dhike) salt were 22.1 ppm (95.0% CI= 19.2-25.1) and 18.9 ppm; powder salt were 32.6 ppm (95.0% CI= 31.7- 33.4) and 30.6 ppm respectively. In the community level, people are still using the non-iodized salt. To eliminate the IDD more efforts are required at program implementation and monitoring level.

[Comparison of ciprofloxacin with biapenem in patients with moderate or severe pneumonia]

We conducted the comparative study to clarify the clinical efficacy and features of ciprofloxacin (CPFX) and biapenem (BIPM) in the treatment of moderate or severe pneumonia. Among 209 patients enrolled, 173 patients (CPFX; 87, BIPM; 86) complying with the protocol were evaluated for safety and 171 (CPFX; 85, BIPM; 86) for efficacy. No significant difference was noted between groups in patient profiles. Both groups were similar in efficacy, as evaluated by the following variables: fever, WBC, CRP, and chest X ray score. The incidence of adverse drug reactions was 16.1% (14/87 patients) in the CPFX group and 16.3% (14/86 patients) in the BIPM group. Phlebitis occasionally occurred in the CPFX group and drug eruption and liver function disorder occasionally in the BIPM group. In conclusion, both CPFX and BIPM were useful in treating moderate or severe pneumonia and no difference was seen between groups in efficacy. Some differences were noted in adverse reactions, however.

[Comparison of nursing home-acquired pneumonia with community-acquired elderly pneumonia]

To clarify whether the environment of a nursing home affects the clinical features of patients with pneumonia, we compared the characteristics of 103 patients (nursing home group) who suffered from pneumonia at a nursing home with 153 elderly patients with the same background (community group) who lived in their own home. Although there were no significant differences in CRP, WBC, and body temperature at admission and duration of hospitalization, the degree of independency of the nursing home group was significantly lower than the community group. As the degree of independency became worse, the length of hospitalization extended and mortality increased. Bacteriological findings of sputum culture showed that methicillin-resistant Staphylococcus aureus (MRSA) was cultured in 20 cases (19%) of the nursing home group and 18 cases (13%) of the community group. In isolated analysis of total care cases, MRSA positive rates were similar in the nursing home group (17/58; 29%) and the community group (8/30; 27%). Only 1 case with penicillin-susceptible Streptococcus pneumoniae (PSSP) was found in the nursing home group, however 7 species of PSSP were cultured in the community group, including 5 self-help cases. Pseudomonas aeruginosa was cultured in 8 patients of each group, and most of them were total care cases. We concluded that the difference in frequency and species of bacteria depended on the condition of patients, rather than the environment, and differences in conditions might lead to differences in clinical features.

Prevalence of previously undiagnosed airflow limitation in patients who underwent preoperative pulmonary function test

Although being a rapidly expanding socioeconomical burden worldwide, chronic obstructive pulmonary disease (COPD) is often overlooked because of its insidious progression. Since spirometry is the primary tool for the diagnosis of COPD, physicians should be aware of the disease in any situation where interpreting spirometry. This study was to estimate the prevalence of undiagnosed COPD among patients who underwent spirometry as a preoperative evaluation for elective surgeries. Patients aged 40 years or older who completed routine spirometry as a preoperative evaluation for elective surgeries between January to December, 2000. Medical records were reviewed for medical history, clinical findings, smoking status, and discharge diagnoses for patients who demonstrated airflow limitation (AL), defined as FEV(1)/FVC<70% on spirometry. Of the 1031 patients who qualified for the study, 263 (26%) presented AL. Sixty-nine of these patients with AL (26%) had underlying conditions that could account for AL, such as asthma and previously diagnosed COPD. The remaining 194 patients with AL (74%) were suspected to have undiagnosed COPD, 90% of which was mild in severity. Only 30 (15%) of these patients appeared to be diagnosed have received a diagnosed as COPD by physician on this occasion. This study testifies that COPD is often unnoticed, and demonstrates that every spirometry, such as in preoperative evaluation, gives a clue to identify affected individuals, for which awareness of the disease is essential.

Assessment of IDD problem by estimation of urinary iodine among school children

Iodine deficiency disorder (IDD) is a major micronutrient deficiency problem in Nepal. Urinary iodine estimation has been the gold standard employed for the assessment of iodine status and of IDD. This study was conducted with objective to assess the urinary iodine among the school children of Kavre, Lalitpur and Parsa districts. Attempts were made to relate urinary iodine with salt use and other sociodemographic variables. Altogether 190 urine samples (74 samples from Kavre, 89 from Parsa and 27 from Lalitpur district) were collected from school children aged 5-13 years. The urinary iodine was analyzed by using urinary iodine assay kit (Bioclone Australia Pvt Limited). It was found that 3.2% children had urine iodine concentration below 20 microg/l. Similarly, the percentage of children with urine iodine concentration 21-50 microg/l, 51-99 microg/l, 100-299 microg/l and above 300 microg/l were 14.2%, 10.5%, 43.7% and 28.4% respectively. Iodine deficient population of school children was 39.2% of Kavre, 19.1% of Parsa and 25.9% of Lalitpur. Overall, it was found that 27.9% children had urine iodine level less than the normal WHO levels. The median urine iodine level was 139.0 microg/l of Kavre, 266.7 microg/l of Parsa and 244.4 microg/l of Lalitpur school children. Urinary iodine excretion (UIE) median value among male students was 211.9 microg/l, among female students was 190.2 microg/l and the difference was statistically insignificant (P > 0.05). There was no significant correlation between consumed salt iodine level and urine iodine excretion level (P > 0.05). Short-term iodine supplementation programs should be arranged for iodine deficient children in the study districts. This study shows that IDD continues to be prevalent in the country as a major public health problem, which requires strengthening effective intervention program and other preventive measures.

Chronic pulmonary scedosporiosis simulating aspergillosis

Scedosporium apiospermum, a ubiquitously distributed saprophyte, is emerging as an important pathogen in immunocompromised patients. We describe a 72-year-old patient with chronic S. apiospermum infection of the lung simulating aspergilloma. His medical history was unremarkable except that he had undergone partial lung resection as a treatment for pulmonary tuberculosis several decades previously. He had no underlying immunosuppressive conditions. This patient illustrates that pulmonary scedosporiosis is not confined to immunocompromised patients and that the clinical presentation may be indistinguishable from that of aspergilloma.

Tuberculosis associated with gastrectomy

We describe the incidence and clinical features of patients with tuberculosis who had undergone gastric resection in our hospital. A total of 26 patients with tuberculosis who had undergone gastric resection were studied. The prevalence of gastrectomy among patients with tuberculosis was 8.0% (7/87) in 2000, 5.1% (4/78) in 2001, and 13.2% (10/76) in 2002. The average 3-year incidence was 9.1%. The patients' body mass indexes (BMIs) were below 18 kg/m2 in 9 of the 21 patients in whom it was possible to determine BMI and above 22 kg/m2 in only 2 of these 21 patients. Analysis of impaired glucose tolerance revealed oxyhyperglycemia or diabetes mellitus as one risk factor for the development of tuberculosis. Furthermore, poor nutrition among patients who have undergone gastrectomy may provide prognostic information for the development or reactivation of tuberculosis. In Japan, a fairly large percentage of elderly people have undergone gastrectomy for gastric cancer or gastric ulcer, and many have a past history of tuberculosis. Gastrectomy may be a risk factor for the reactivation of tuberculosis.

Helicobacter pylori infection rate in patients with nontuberculous mycobacteriosis who are on longterm combination chemotherapy of clarithromycin and rifampicin

Clarithromycin resistance in Helicobacter pylori has increased the incidence of eradication failure. Clarithromycin is a key drug in the current treatment regimens for H. pylori infection, and it is also used for nontuberculous mycobacteriosis (NTM). The rate of H. pylori infection in 15 patients with NTM who were on longterm clarithromycin, rifampicin, and other drug therapy was examined, using the [(13)C] urea breath test. H. pylori was detected in 5 of the 15 patients (33.3%), which was significantly lower than the prevalence of H. pyloriin subjects who had routine upper gastrointestinal endoscopy in Japan (P = 0.0006). Thus, H. pylori resistance to clarithromycin is suggested to be low in patients with longterm administration, and the possibility exists of a combination of clarithromycin and rifampicin as a second-line therapy for the eradiation of H. pylori.

[Successful treatment with micafungin in a case of candidemia associated with pneumonia]

A 63-year-old woman was admitted to our hospital with fever and cough. Candidemia was diagnosed by blood culture and culture of IVH catheter. Although, the patient was treated with fluconazole, clinical symptoms and chest radiographic findings worsened. After micafungin was replaced with fluconazole, her symptoms, chest radiographic findings improved and stabilized. It is suggested that micafungin is useful for the treatment of candidemia associated with Candida parapsilosis.

[Antifungal susceptibility of Candida species causing candidemia in Kurume University Hospital and Shaiseikai Hutukaichi Hospital]

Prevention of candidemia has been difficult and empirical therapy may eventually reduce morbidity and mortality. Successful empirical therapies depend on understanding of fungal features and antifungal agents. Susceptibility to amphotericin B (AMPH-B), flucytosine (5-FC), fluconazole (FLCZ), itraconazole (ITCZ), miconazole (MCZ), and micafungin (MCFG) of 41 Candida species isolated from blood were determined. Candida albicans was the most common species (23 species), followed by C. parapsilosis (5 species), C. tropicalis (4 species), C. glabrata (3 species), C. guilliermondii (2 species), C. krusei (1 specie), and Candida spp (3 species). The isolation rates of the drug-resistant (DR) fungi were 5% for 5-FC. The rates of DR and susceptible dose dependent (S-DD) fungi were 0% and 2% for FLCZ, respectively. The rates of DR and S-DD fungi were 0% and 17% for ITCZ, respectively. No shift to resistant species in C. albicans occurred in our hospitals. All C. albicans were susceptible for the antifungal agents examined.

Clinical utility of lipoarabinomannan antibody in pleural fluid for the diagnosis of tuberculous pleurisy

We studied the clinical utility of the detection of lipoarabinomannan antibody, using MycoDot, in pleural fluid for the diagnosis of tuberculous pleurisy. Nine patients with active tuberculous pleurisy, 1 patient with chronic tuberculous empyema, and 16 patients with nontuberculous pleural effusions were studied. The results were positive in 5 patients with tuberculous pleural disease. Sensitivity was 50% (5 of 10; including the 1 patient with chronic tuberculous empyema) and specificity was 93.8% (15 of 16). Detection of lipoarabinomannan antibody using MycoDot in pleural fluid is a specific diagnostic tool for tuberculous pleurisy; furthermore, this diagnostic method is simple, rapid, and cost-effective.

Effects of Economic Status and Education Level on the Height and Weight of Community Adolescents in Nepal

There is scarce information on the relative importance of socio-economic factors in determining the adolescent anthropometric measurements. The objective of this study was to examine the effects of economic status, education level, and food consumption on the height and weight of community adolescents in Nepal. The study was done in the communities of the Kathmandu Valley area in Nepal. All together 426 unmarried adolescent girls aged 14-19 y were selected. The adolescents were interviewed regarding socioeconomic background (education, occupation and property possessions) and frequency of foods consumption. Height and weight were determined and BMI was calculated. Z-scores of height-for-age and weight-for-age were calculated based on the WHO/NCHS standard to avoid bias by age. The adolescents participating in the survey were categorized into three groups using the various indicators of economic status: Low Economic Status (LES) group, Middle Economic Status (MES) group and High Economic Status (HES) group. The Z-scores of height and weight were significantly lower in the LES group than in the MES and HES groups (p<0.05). The Z-score of height was significantly increased with education level even under the condition of controlling economic level (p<0.05). Since the frequency of milk consumption was significantly related not only with height (p<0.05), but also with economic (chi2=31.6, df=4, p<0.001) and education levels (chi2=22.4, df=6, p<0.01), the increased height in the groups of the better economic status or the better education level was interpreted to be due to the outcome of the higher frequency of milk consumption. This study indicated that education was a more important factor affecting the height of the adolescents via improved food habits even under adverse economic conditions.

Endobronchial tuberculosis

Endobronchial tuberculosis is defined as tuberculous infection of the tracheobronchial tree. Although clinical features differ between various types and stages of endobronchial tuberculosis, common symptoms are cough, hemoptysis, sputum production, wheezing, chest pain, fever and dyspnea. Endobronchial tuberculosis is difficult to diagnose, because the lesion is not evident in the chest radiograph. Computerized tomography is very useful in evaluating bronchial lesions such as stenosis or obstruction. The most important goal of treatment in active endobronchial tuberculosis is the eradication of tubercle bacilli. The second most important goal is prevention of bronchial stenosis. Corticosteroid therapy for prevention of bronchial stenosis in endobronchial tuberculosis remains controversial, but the best results are associated with minimal delay in the initiation of steroid treatment. In inactive disease, treatment to restore full patency is appropriate. As steroids or other medication are unable to reverse stenosis from fibrous disease, airway patency must be restored mechanically by surgery or endobronchial intervention. Aerosol therapy with streptomycin and corticosteroids is useful in treatment against active endobronchial tuberculosis. Time to healing of ulcerous lesions is shorter, and bronchial stenosis is less severe in patients on aerosol therapy. Progression to bronchial stenosis may be prevented if the therapy is initiated as soon as possible.

Enhanced Expression of Interleukin-18 and its Receptor in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP) is a major interstitial lung disease (ILD). Recently, we established a new mouse model for ILD in which daily administration of interleukin (IL)-18 with IL-2 induces lethal lung injury, suggesting that IL-18 is involved in the pathogenesis of ILD. Here, utilizing immunohistochemistry, we have analyzed IL-18 and IL-18 receptor (IL-18R) alpha expression in the lungs of 18 patients with IPF/UIP and 13 control subjects by using monoclonal anti-IL-18 antibodies and a new monoclonal antibody for IL-18Ralpha (H44). IL-18 was expressed in bronchoalveolar epithelium, alveolar macrophages, and the endothelium of small vessels in control subjects, and was abundantly expressed in the majority of pulmonary cells in patients with IPF. IL-18Ralpha was expressed in bronchoalveolar epithelium and alveolar macrophages in control subjects, and was strongly expressed in interstitial cells in patients with IPF, especially in the fibroblastic foci (FF). Interestingly, IL-18Ralpha expression was only weakly observed in areas showing established fibrosis. Semiquantitative analysis revealed that the histologic FF score was significantly correlated with the IL-18Ralpha expression level in FF lesions. Moreover, IL-18 levels in the serum and bronchoalveolar lavage fluid of patients with IPF were significantly higher than those in control subjects. Our findings suggest IL-18 and IL-18R are involved in the pathogenesis of IPF/UIP.

Therapeutic management of endobronchial tuberculosis

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. Common symptoms are cough, haemoptysis, sputum production, wheezing, chest pain and fever in active disease and dyspnoea and wheezing in the fibrous stage. This form of tuberculosis is difficult to diagnose because the lesion is not evident in the chest radiograph, frequently delaying treatment. Computed tomography is very useful in evaluating bronchial lesions such as stenosis or obstruction. The most important goal of treatment in active EBTB is eradication of tubercle bacilli. The second most important goal is prevention of bronchial stenosis. Corticosteroid therapy for the prevention of bronchial stenosis in EBTB remains controversial. However, the healing time of ulcerous lesions was shorter and bronchial stenosis was less severe, in patients treated with aerosol therapy, consisting of streptomycin 100 mg, a corticosteroid (dexamethasone 0.5 mg) and naphazoline 0.1 mg administered twice-daily along with conventional oral therapy. In inactive disease, treatment to restore full patency is appropriate. As steroids or other medications are unable to reverse stenosis from fibrous disease, airway patency must be restored mechanically by surgery or endobronchial intervention. Effectiveness and complications remain important issues with the mechanical techniques as use and evaluation continue. Corticosteroid therapy for prevention of bronchial stenosis in EBTB remains controversial. Our observations suggest that progression of bronchial stenosis can be prevented in patients who are treated with aerosol therapy with corticosteroids.

Identification of epidermal growth factor receptor-derived peptides recognised by both cellular and humoral immune responses in HLA-A24+ non-small cell lung cancer patients

The epidermal growth factor receptor (EGFR) is one of the most appropriate target molecules for cancer therapy because of its high expression in epithelial cancers. A novel EGFR-tyrosine-kinase inhibitor, ZD1839, has been approved as a drug for non-small cell lung cancer (NSCLC), and many other agents are now being tested in clinical trials. Cytotoxic T lymphocyte (CTL)-directed epitope peptides could be another class of useful compounds in EGFR-targeted therapies. However, at present, there are no data on CTL-directed peptides of EGFR. Therefore, this study aimed to identify immunogenic EGFR-derived peptides in HLA-A24(+) NSCLC patients. We report in this study three such EGFR-derived peptides at positions 54-62, 124-132 and 800-809. These peptides were recognised by both cellular and humoral immune responses in most of the peripheral blood mononuclear cells (PBMCs) and sera from NSCLC patients that we tested. These results may provide a scientific basis for the development of EGFR-based immunotherapy.

[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.