[A case of acute chronic respiratory failure due to fat embolism syndrome after the left femoral neck fracture].

A 78 year old Japanese woman was transferred to our hospital for the treatment of a fracture of the left femoral neck in April, 2010. She had been taking oral corticosteroid (prednisolone 5 mg/day) for the treatment of idiopathic interstitial pneumonia since 2003, and had been treated by home oxygen therapy since 2007. She fell in the restroom at home and hurt herself, and was transferred to our hospital for treatment of a left femoral neck fracture in April, 2010. Her respiratory status was stable just after the transfer; however, she was transferred to the intensive care unit and started to receive mechanical ventilation due to rapidly progressive respiratory failure on the fourth day after admission. Chest X-ray and computed tomography revealed rapid progression of bilateral ground-glass attenuations, and acute exacerbation of interstitial pneumonia was clinically suspected. However, the elevation of D-dimer over time and characteristic findings of petechial hemorrhagic lesions on her palpebral conjunctivae and neck with microscopic findings of phagocytized lipid in alveolar macrophages in her endobronchial secretion led to the diagnosis of fat embolism syndrome. She was successfully treated with high-dose corticosteroid and sivelestat sodium, and she was discharged on the 21st day after admission. Although a differential diagnosis of acute exacerbation of interstitial pneumonia and fat embolism syndrome was necessary and difficult in the present case, characteristic findings of petechial hemorrhagic lesions of skin, palpebral conjunctiva and lipid-laden alveolar macrophages in endotracheal aspirate were useful for the accurate and prompt diagnosis of fat embolism syndrome.

[Retrospective analysis of the safety of four hours administration of liposomal amphotericin B in patients with chronic necrotizing pulmonary aspergillosis].

We have retrospectively analyzed the safety of 4 hours administration of liposomal amphotericin B (L-AMB) compared to less than or equal to 3 hours administration in patients with chronic necrotizing pulmonary aspergillosis (CNPA). The elevation of serum creatinine in the group with 4 hours administration of L-AMB in patients with CNPA was equal to the group with shorter administration time (less than or equal to three hours). During the administration of L-AMB, the group with 4 hours administration of LAMB had significantly a safer profile in relation to hypokalemia during L-AMB treatment than the group with shorter administration time. Additionally, white cell counts, platelet counts, serum creatinine, AST, ALT were not significantly different between L-AMB 4 hours administration group and less than or equal to 3 hours administration group. As the group with 4 hours administration of L-AMB had significantly a safer profile in relation to hypokalemia during L-AMB treatment, this modality can be one of the safer ways in the treatment of CNPA. As L-AMB is one of the fungicidal agents, 4 hours administration of L-AMB can be an optimal way of treating CNPA.

[A case of localized malignant pleural mesothelioma].

A 74-year-old man was referred to our hospital for examination of an abnormal chest shadow. A chest computed tomography (CT) scan revealed a 5-cm mass attached to the pleura involving the right upper lobe, and a nodule in the right middle lobe. Transbronchial lung biopsy was performed twice, but no definitive diagnosis was achieved. 18-fluorodeoxyglucose positron emission tomography showed abnormal uptake in the chest lesion. Chemotherapy was initiated for advanced-stage lung cancer, but was not effective. Histopathologic and immunohistochemical examinations after CT-guided needle biopsy revealed malignant mesothelioma. The tumor cells were positive for calretinin and thrombomodulin, and negative for CEA, TTF-1, and SP-A. There was local tumor invasion and metastasis in the lung and brain, without diffuse pleural spread. This is a rare and important case of localized malignant mesothelioma pathologically confirmed by biopsy.

Detection of MALT1 gene rearrangements in BAL fluid cells for the diagnosis of pulmonary mucosa-associated lymphoid tissue lymphoma.

BACKGROUND: Mucosa-associated lymphoid tissue (MALT) lymphoma constitutes approximately 90% of primary pulmonary lymphoma, and the diagnosis of pulmonary MALT lymphoma often requires invasive methods such as surgical lung biopsy. Chromosomal rearrangements involving MALT lymphoma translocation gene 1 (MALT1) have been reported to be specific for MALT lymphoma. The combination of BAL and cytologic approaches with molecular methods is useful for the diagnosis of lymphoproliferative disorders. Therefore, we examined the detection of MALT1 gene rearrangements in BAL fluid (BALF) cells for the diagnosis of MALT lymphoma. METHODS: We determined the percentage of BALF cells with MALT1 gene rearrangements by using the fluorescence in situ hybridization (FISH) method in 10 patients suspected to have pulmonary MALT lymphoma. RESULTS: MALT1 gene rearrangements in BALF cells were found in four of five cases with pulmonary MALT lymphoma (percentage of BALF cells with MALT1 gene rearrangements: 21.8% ± 6.8%). On the other hand, MALT1 gene rearrangements in BALF cells were negative in the five cases without pulmonary MALT lymphoma and one case with pulmonary MALT lymphoma. CONCLUSION: These results suggest that the detection of MALT1 gene rearrangements in BALF cells is useful for the diagnosis of pulmonary MALT lymphoma, as it is a specific method that is less invasive than surgical biopsy. Because of the small number of patients in this study, further investigations are necessary to evaluate the detection rate of MALT1 gene rearrangements in BALF cells from patients with pulmonary MALT lymphoma.

Two cases of everolimus-associated interstitial pneumonia in patients with renal cell carcinoma.

We herein report two cases of everolimus-associated interstitial pneumonia in patients with renal cell carcinoma. A 68-year-old Japanese man (case 1) was admitted to our hospital because of progressive dyspnea, left infiltration and consolidation on chest radiographs. He had started receiving everolimus (10 mg daily) three months before the admission for the treatment of recurrent renal cell carcinoma. Bronchoalveolar lavage fluid taken from his left B(4) showed a marked increase of lymphocytes (42.9%). An organizing pneumonia pattern of everolimus-associated interstitial pneumonia was strongly suspected radiologically, and treatment with high-dose corticosteroids, discontinuation of everolimus and oxygen support was started. The treatment was successful, and the patient recovered with only minor pulmonary fibrotic changes in the left lower lobe. A 57-year-old Japanese man (case 2) was referred to our department for the evaluation of interstitial pneumonia. He had started to receive everolimus (10 mg daily) four months previously. Chest CT demonstrated interstitial pneumonia predominantly in bilateral lower lobes, with small pulmonary metastatic nodules. His pulmonary complications were spontaneously resolved eight days after the discontinuation of everolimus. To the best of our knowledge, Case 1 is the first reported case of successfully treated organizing pneumonia pattern of interstitial pneumonia with acute respiratory failure induced by everolimus in Japan.