Alterations in smoking habits are associated with acute eosinophilic pneumonia.

BACKGROUND: Acute eosinophilic pneumonia (AEP) is characterized by a febrile illness, diffuse pulmonary infiltrates, and pulmonary eosinophilia. The etiology of AEP remains unknown, but several studies have proposed a relationship between cigarette smoking and AEP. However, most studies showing this possibility are single-case reports, and cigarette smoke has not been fully validated as a causative agent of AEP in a large series of patients. The present study was conducted to clarify the etiologic role of cigarette smoking in AEP, with special reference to alterations in smoking habits. METHODS: We took a detailed history of smoking habits before AEP onset in 33 patients with AEP, and performed a cigarette smoke provocation test. RESULTS: Of our AEP patients, all but one (97%) were current smokers. Interestingly, 21 of these were new-onset smokers, and 2 had restarted smoking after a 1- to 2-year cessation of smoking. The duration between starting smoking and AEP onset was within 1 month (0.67 +/- 0.53 months). Additionally, six of the remaining smokers had increased the quantity of cigarettes smoked daily, fourfold to fivefold, mostly within the month before AEP onset (0.81 +/- 0.58 months). Only three smokers had not changed their smoking habits before AEP onset. Cigarette smoke provocation tests revealed positive results in all nine patients tested. CONCLUSION: These data suggest that recent alterations in smoking habits, not only beginning to smoke, but also restarting to smoke and increasing daily smoking doses, are associated with the development of AEP.

[A case of bronchial infection of Wangiella dermatitidis].

A 81-year-old woman was admitted to our hospital because of bloody sputum. Chest radiograph showed an enhanced right pulmonary hilum shadow. Computed tomography (CT) revealed localized bronchiectasis of the right lower lung and a nodule protruding into the bronchus. A parenchymal shadow was also seen distal to the nodule. Transbronchial biopsy revealed a cluster of yeast-like fungi and the bronchial lavage culture showed several olive-black colored colonies on Sabouraud agar. Before culture, we empirically administered fluconazole (400 mg/day) on the assumption of candida infection based on the yeast like microscopic findings, however that was not appropriate. Substitution by itraconazole (200 mg/day) made a slight improvement of the shadow on CT. Later polymerase chain reaction of specimens taken by TBLB identified the olive-black fungus as Wangiella dermatitidis. W. dermatitidis is a dematicious fungus sometimes causing tinea nigra or subcutaneous infection. In compromised patients, it causes phaeohyphomycosis especially in the central nerve system. In cystic fibrosis patients, this fungus is recognized to colonize the respiratory tract and rarely causes pneumonia. This case had no previous immunosuppressing disease, except for localized bronchiectasis which was found by CT on admission. We think this is a very rare W. dermatitidis infection case showing a nodular lesion in an immunocompetent patient.

Quantitative analysis of fibroblastic foci in usual interstitial pneumonia.

STUDY OBJECTIVES: Using semiquantitative scoring methods, several studies have shown that the amount of fibroblastic foci (FF), which are one of the pathologic characteristics in usual interstitial pneumonia (UIP), is a significant prognostic factor of UIP. In those studies, the degree of FF was evaluated semiquantitatively on several scales by a panel of pulmonary pathologists. However, the evaluation was somewhat subjective because interobserver variation was not small. Additionally, these methods are not entirely practical because two or more pathologists are required. In this study, we tried to develop a more quantitative scoring method of FF. PATIENTS AND METHODS: With a charge-coupled device camera, we made images of lung sections obtained from 15 patients with UIP associated with collagen vascular disease (CVD) [CVD-UIP] and 16 patients with idiopathic pulmonary fibrosis (IPF) [IPF/UIP], and calculated the proportion of FF areas in the target image areas with an image analytic software. MEASUREMENTS AND RESULTS: Our quantitative scoring method enabled us to readily and objectively evaluate the extent of FF as a quantitative percentage of FF area (%FF) score. Interobserver and intraobserver correlations were high in our method (r = 0.877 and r = 0.898, respectively). The quantitative %FF score (+/- SD) of IPF/UIP patients was 1.67 +/- 0.90%, which was significantly higher than that of CVD-UIP patients (0.39 +/- 0.24%, p < 0.0001). A Cox proportional hazards model showed that the quantitative %FF score was a significant predictor of survival in UIP patients. The quantitative %FF score had a correlation with scores assessed by the semiquantitative scoring methods previously reported, but patients with the same score assessed by the semiquantitative methods had widely varying scores assessed by our method. CONCLUSIONS: These results suggest that our quantitative scoring method for FF is more objective than the semiquantitative scoring methods previously reported, providing accurate information about the prognosis of patients with UIP.

[Placement of an ultraflex nitinol stent for severe tracheobronchial obstruction in a case of relapsing polychondritis].

A 59-year-old man, who had been treated for bronchial asthma since 2000, was hospitalized with high fever and productive cough in November 2003. Chest radiography on admission showed consolidations in both lower lung fields, and computed tomography demonstrated anteroposterior narrowing of both main bronchi. A physical examination revealed deformity of auricular cartilage and saddle nose, and we diagnosed him relapsing polychondritis (RP). When he was readmitted 4 months later because of severe tracheobronchial stenosis and respiratory failure he required mechanical ventilation, but it was difficult to wean him from the ventilator. Self-expandable metallic stents were placed in the left main bronchus and the trachea. After the procedure, he was successfully weared from mechanical ventilation. Since airway complications of RP can be fatal, stent implantation should be considered in the management of RP with airway manifestations.

Nonspecific interstitial pneumonia in collagen vascular diseases: comparison of the clinical characteristics and prognostic significance with usual interstitial pneumonia.

BACKGROUND: Nonspecific interstitial pneumonia (NSIP) has recently been described as a distinct clinicopathological entity among idiopathic interstitial pneumonias (IIP), having more favorable prognosis than usual interstitial pneumonia (UIP). Although NSIP was initially reported to also occur in patients with interstitial pneumonia associated with collagen vascular diseases (IP-CVD), the prevalence of NSIP and its prognostic significance in IP-CVD remains to be determined. Thus, we attempted to clarify clinical characteristics and prognostic significance of NSIP in IP-CVD. METHODS: We histologically examined surgical lung biopsies from 43 patients with IP-CVD based on a current classification of interstitial pneumonias, and compared the clinical characteristics and prognostic significance of NSIP with UIP in IP-CVD. We also studied 98 patients with biopsy-proven NSIP and UIP in IIP, and compared the prognostic significance of histopathologic subclassification in IIP with that in IP-CVD. RESULTS: In IP-CVD, twenty-six patients (60%) were classified as NSIP, 17 (40%) as UIP. In contrast, 76 (77%) were categorized into UIP and 22 (23%) into NSIP of the patients with IIP. No significant difference in survival rates was observed between UIP and NSIP in IP-CVD (p = 0.3863), while, in IIP, NSIP has a significant better survival than UIP (p = 0.022). CONCLUSIONS: These results suggest that NSIP is more common histologic pattern than UIP in IP-CVD and, unlike in IIP, the prognosis of NSIP patients may not be different from that of UIP patients in IP-CVD.

[Bronchioloalveolar carcinoma complicated by a lesion resembling bronchiolitis obliterans organizing pneumonia in the opposite lung].

A 50-year-old woman with abnormal shadows in her chest radiograph was admitted for a more detailed examination in April 2000. A chest CT scan showed infiltrates surrounded by ground-glass opacities in the right upper lobe, and ground-glass opacities with partial infiltrative changes in the left lower lobe. A diagnosis of adenocarcinoma like bronchioloalveolar carcinoma (BAC) was made for the lesion in the right upper lobe by means of a transbronchial biopsy. However, the specimen from the left lower lobe showed nonspecific changes, and bronchiolitis obliterans organizing pneumonia (BOOP) or a metastatic lesion from the BAC was suspected. We prescribed steroids for the short term. Since the lesion in the left lobe disappeared, we performed a right upper lobectomy. In cases of primary lung carcinoma, BOOP in the opposite lung is rare and it was difficult to decide on the operability. We concluded that steroid therapy is useful for distinguishing between inflammatory and tumorous lesions in cases in which a detailed examination is difficult.

[A case of sarcoidosis manifesting as annular opacities after multiple nodular shadows].

A 40-year old man was admitted to our hospital because nodular shadows in the right upper lung field had shown deterioration on chest radiographs during a regular check-up (Sep. 28, 2000). Transbronchial lung biopsy specimens showed findings compatible with sarcoidosis. During follow-up, the nodular shadows became bigger, spread in both lung fields and turned into multiple annular opacities. In December, lung biopsy specimens obtained by VATS showed central areas of ground-glass attenuation corresponding to areas of alveolar septal inflammation, in contrast to the denser periphery, where polypoid organized granulation tissue in peripheral air spaces predominated. After 2 months, the opacities disappeared without treatment. In our case, the annular opacities on CT corresponded histologically to BOOP. It is interesting to note the relationship between sarcoidosis and BOOP.

[A case of subacute idiopathic interstitial pneumonia resistant to steroids, successfully treated with cyclophosphamide].

A 47-year-old woman was admitted to our hospital because of dry cough, fever, and subacute, progressive dyspnea. Chest radiography and computed tomography showed ground glass opacities in the lower lung fields. We suspected pneumonia caused by atypical pathogens and administered antibiotics, but they had no effect at all. Histopathologic findings from a transbronchial lung biopsy (TBLB) included intensive infiltration of mononuclear cells and edema on the alveolar wall with no evidence of fibrosis, fibroblasts, hyaline membrane, or granuloma. On the basis of these findings, we suspected interstitial pneumonia, but a surgical lung biopsy was not possible because the patient would not give her consent. After TBLB, corticosteroid was administered repetitively, but dyspnea was deteriorating as the ground glass opacities became more widespread, and tractional bronchiectasis appeared throughout the lung fields. Therefore, we decided to administer cyclophosphamide (CPA). This was very effective: all of her symptoms improved and the ground glass opacities and tractional bronchiectasis disappeared. Though we tapered and then discontinued corticosteroids a few months after CPA, there was no recurrence whatever. No signs suggesting the association of collagen vascular diseases were detected. The effectiveness of CPA in interstitial pneumonia associated with collagen vascular disease is occasionally reported, but the effect on idiopathic interstitial pneumonia, especially in acute and subacute progressive cases, is rarely reported. We think this is an interesting case to consider the availability of CPA in idiopathic interstitial pneumonia with subacute progression.

Differences in clinical features and prognosis of interstitial lung diseases between polymyositis and dermatomyositis.

OBJECTIVE: To assess the difference in clinical features and prognosis of patients with interstitial lung disease (ILD) comparing polymyositis (PM) and dermatomyositis (DM). METHODS: Medical records of 28 ILD patients with PM/DM (16 PM-ILD, 12 DM-ILD) were reviewed retrospectively. RESULTS: Serum CPK concentrations were significantly higher in PM-ILD than in DM-ILD. Bronchoalveolar lavage analysis showed that the percentages of lymphocytes and eosinophils were significantly higher in DM-ILD than in PM-ILD. Ten patients (5 PM-ILD, 5 DM-ILD) underwent surgical lung biopsy, and 3 (3 DM-ILD) had an autopsy. Nonspecific interstitial pneumonia (NSIP) was found in 7 (4 PM-ILD, 3 DM-ILD) and usual interstitial pneumonia (UIP) in 3 (1 PM-ILD, 2 DM-ILD). Interestingly, diffuse alveolar damage (DAD) was found in 3 patients with DM-ILD, who all died of deterioration of ILD; but no one with PM-ILD had DAD. Corticosteroid treatment alone achieved a favorable response in 6 patients (37.5%) with PM-ILD, but in only one (8.3%) with DM-ILD. Administration of cyclosporine in the early phase of onset benefited 4 corticosteroid-resistant patients with DM-ILD. Conclusively, survival in DM-ILD was significantly worse than that in PM-ILD. CONCLUSION: DM-ILD is more refractory to corticosteroid therapy, resulting in poorer prognosis compared with PM-ILD. These data indicate that intensive therapy, including cyclosporine, should be considered for DM-ILD.