Myeloperoxidase anti-neutrophil cytoplasmic antibody-associated vasculitis with a unique imaging presentation of organizing pneumonia: A case report.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) constitutes a group of blood vessel inflammation diseases of autoimmune origin. Myeloperoxidase (MPO) ANCA is closely related to ANCA associated AAV. The MPO-ANCA positive AAV patients have lung involvement at high rates; however, there are only a few reported cases with organizing pneumonia (OP). A 78-year-old man was presented to our hospital due to a fever of 38 °C despite a whole month of antibiotics treatment. Chest computed tomography image revealed restricted consolidations visible in the middle lobe of the right lung and the upper lobe of the left lung, which suggested an OP pattern. MPO-ANCA and urine occult blood tests were positive. Histopathological examination of the transbronchial biopsy revealed OP and mucus plug. Histological findings on renal biopsy showed necrotizing glomerulonephritis related to AAV. The patient was diagnosed with MPO-ANCA positive AAV and was treated with systemic corticosteroid therapy, from which he recovered rapidly. Thus, when diagnosing OP, the possibility of AAV should be considered by ordering patients' serum ANCA and occult hematuria tests.

Safety of bronchoscopy in patients with malignant hematologic disorders.

BACKGROUND: Factors affecting the safety of bronchoscopy in patients with malignant hematologic disorders have not been well described. We evaluated the safety of bronchoscopy and describe factors affecting its complication rate in such patients. METHODS: Between January 2009 and December 2018, 316 bronchoscopies in 282 patients with malignant hematologic disorders and pulmonary infiltrates were performed at our institution. The bronchoscopic procedure used and its complications were evaluated. RESULTS: The most common underlying disease was acute myeloid leukemia (134/282 patients, 47.5%). Platelet transfusion was performed the day before or the day of bronchoscopy in 42.4%, supplemental oxygen was administered before the procedure in 23.1%, and midazolam was used in 74.4%. Thirty-five bronchoscopies (11.1%) were complicated by hemoptysis and 7 patients developed pneumothorax, 4 of whom required thoracic drainage. Two patients (0.6%) were intubated within 48 h of the procedure and prolonged oxygen desaturation (> 48 h) occurred in 3.8%. Multivariate analysis showed that only use of midazolam significantly reduced the risk of prolonged oxygen desaturation (hazard ratio 0.28, 95% confidence interval 0.09-0.85, p = 0.03). Transbronchial lung biopsy significantly increased the risk of hemoptysis (hazard ratio 10.40, 95% confidence interval 4.18-25.90, p = 0.00), while use of midazolam significantly reduced the risk (hazard ratio 0.31, 95% confidence interval 0.14-0.73, p = 0.01). CONCLUSIONS: Bronchoscopy is relatively safe in patients with malignant hematologic disorders. Caution and judicious use of sedatives may improve the patient's procedural tolerance and lower complications.

IgG4-related disease in the differential diagnosis of lung nodules.

IgG4-related disease is an evolving entity of immune-mediated origin. We report a case of IgG4-related disease mimicking lung cancer with pleural dissemination. A 76-year-old male non-smoker was admitted to our hospital because of chest X-ray abnormality. Chest computed tomography scan showed a lung nodule measuring 26 × 14 mm with tiny nodules on the adjacent pleural surface. Wedge resection by video-assisted thoracoscopic surgery (VATS) was performed to aid diagnosis. Pathological findings of the nodule consisted of lymphoid follicular hyperplasia with lymphoplasmacytic infiltrate, fibrosis, and obstructive vasculitis. Focal and scattered thickening of the pleura with lymphoplasmacytic infiltrate was also observed. The IgG4/IgG ratio in the most prominent area exceeded 80%. Thus, we made a diagnosis of IgG4-related lung and pleural disease. To our knowledge, there has been no report of IgG4-related lung disease mimicking lung cancer with pleural dissemination.

Development of a CT image case database and content-based image retrieval system for non-cancerous respiratory diseases: Method and preliminary assessment.

BACKGROUND: To evaluate the benefits of using a CT image case database (DB) with content-based image retrieval system for the diagnosis of typical non-cancerous respiratory diseases. METHODS: Using this DB, which comprised data on 191 cases covering 69 diseases, 933 imaging findings that contributed to differential diagnoses were annotated. Ten test cases were selected. Image similarity between each marked test case lesion and the lesions of the top 10 retrieved cases were assessed and classified as similar, somewhat similar, or dissimilar by two physicians in consensus. Additionally, the accuracy of five internal medicine residents' abilities to interpret CT findings and provide disease diagnoses with and without the proposed system was evaluated by image interpretation experiments involving five test cases. The rates of concordance between the subjects' interpretations and the correct answers prepared in advance by two specialists in consensus were converted into scores. RESULTS: The mean (± SD) of image similarity among the 10 test cases was as follows: 5.1 ± 2.7 (similar), 2.9 ± 1.0 (somewhat similar), and 2.0 ± 2.4 (dissimilar). Using the proposed system, the subjects' mean score for the correct interpretation of CT findings improved from 15.1 to 28.2 points (p = 0.131) and for the correct disease diagnoses, from 9.3 to 28.2 points (p = 0.034). CONCLUSIONS: Although this was a preliminary small-scale assessment, the results suggest that this system may contribute to an improved interpretation of CT findings and differential diagnosis of non-cancerous respiratory diseases, which are difficult to diagnose for inexperienced physicians.

Treatment outcome of patients with unresectable stage III non-small cell lung cancer and interstitial pneumonia.

BACKGROUND: The standard treatment for unresectable stage III non-small cell lung cancer (LC) is chemoradiation therapy (CRT); however, the optimal treatment for LC in patients with interstitial pneumonia (IP) (LC-IP) has not been determined. This study compared the clinical course of LC-IP patients to that of patients without IP (LC without IP) and determined the key factors of survival. METHODS: We retrieved the records of 52 consecutive LC patients treated at our institution between January 2011 and September 2016. The characteristics and outcomes of LC patients with and without IP were compared. Survival was analyzed using the Kaplan-Meier method and univariate and multivariate analyses of two-year survival were also conducted. RESULTS: Forty-two men and 10 women were evaluated. Eleven patients (21%) had IP as their underlying disease. Except for age, the backgrounds of LC patients with and without IP were almost identical. Among LC-IP patients, the median predicted forced vital capacity was 86% and the Gender-Age-Physiology (GAP) index was 3. None of the LC-IP patients received CRT but 32 (78%) of the LC without IP patients underwent CRT. Chemotherapy alone was the main treatment for LC-IP. The median survival times were 485 and 1271 days in LC patients with and without IP, respectively (p=0.419). Multivariate analysis of survival longer than two years revealed CRT as the only predictive factor. CONCLUSIONS: CRT was the only predictive factor for longer survival in LC patients; however, no LC-IP patients received CRT, possibly because of the underlying IP.

Pneumatosis intestinalis induced by osimertinib in a patient with lung adenocarcinoma harbouring epidermal growth factor receptor gene mutation with simultaneously detected exon 19 deletion and T790 M point mutation: a case report.

BACKGROUND: Pneumatosis intestinalis is a rare adverse event that occurs in patients with lung cancer, especially those undergoing treatment with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI). Osimertinib is the most recently approved EGFR-TKI, and its usage is increasing in clinical practice for lung cancer patients who have mutations in the EGFR gene. CASE PRESENTATION: A 74-year-old woman with clinical stage IV (T2aN2M1b) lung adenocarcinoma was determined to have EGFR gene mutations, namely a deletion in exon 19 and a point mutation (T790 M) in exon 20. Osimertinib was started as seventh-line therapy. Follow-up computed tomography on the 97th day after osimertinib administration incidentally demonstrated intra-mural air in the transverse colon, as well as intrahepatic portal vein gas. Pneumatosis intestinalis and portal vein gas improved by fasting and temporary interruption of osimertinib. Osimertinib was then restarted and continued without recurrence of pneumatosis intestinalis. Overall, following progression-free survival of 12.2 months, with an overall duration of administration of 19.4 months (581 days), osimertinib was continued during beyond-progressive disease status, until a few days before the patient died of lung cancer. CONCLUSIONS: Pneumatosis intestinalis should be noted as an important adverse event that can occur with administration of osimertinib; thus far, such an event has never been reported. This was a valuable case in which osimertinib was successfully restarted after complete recovery from pneumatosis intestinalis, such that further extended administration of osimertinib was achieved.

Various Bronchiolar Lesions Accompanied by Idiopathic Pleuroparenchymal Fibroelastosis with a Usual Interstitial Pneumonia Pattern Demonstrating Acute Exacerbation.

A 63-year-old man presented with persistent cough and progressive dyspnea. Computed tomography showed irregular pleural thickening and fibrotic changes with volume loss in the upper lobes, and subtle reticulation in the lower lobes. Pleuroparenchymal fibroelastosis (PPFE) was diagnosed based on the findings of a surgical lung biopsy. Bronchiolar lesions, including proliferative bronchiolitis, constrictive bronchiolitis obliterans, and peribronchiolar metaplasia were evident on pathology. A usual interstitial pneumonia (UIP) pattern was also observed in the lower lobes. Three weeks after the biopsy, an acute exacerbation occurred. We herein describe a rare case of idiopathic PPFE with various bronchiolar lesions and a UIP pattern in which an acute exacerbation developed.

Reduced area of the normal lung on high-resolution computed tomography predicts poor survival in patients with lung cancer and combined pulmonary fibrosis and emphysema.

BACKGROUND: This study aimed to determine the radiologic predictors and clarify the clinical features related to survival in patients with combined pulmonary fibrosis and emphysema (CPFE) and lung cancer. METHODS: We retrospectively reviewed the medical chart data and high-resolution computed tomography (HRCT) findings for 81 consecutive patients with CPFE and 92 primary lung cancers (70 men, 11 women; mean age, 70.9 years). We selected 8 axial HRCT images per patient, and visually determined the normal lung, modified Goddard, and fibrosis scores. Multivariate analysis was performed using the Cox proportional hazards regression model. RESULTS: The major clinical features were a high smoking index of 54.8 pack-years and idiopathic pulmonary fibrosis (n = 44). The major lung cancer profile was a peripherally located squamous cell carcinoma (n = 40) or adenocarcinoma (n = 31) adjacent to emphysema in the upper/middle lobe (n = 27) or fibrosis in the lower lobe (n = 26). The median total normal lung, modified Goddard, and fibrosis scores were 10, 8, and 8, respectively. TNM Classification of malignant tumors (TNM) stage I, II, III, and IV was noted in 37, 7, 26, and 22 patients, respectively. Acute exacerbation occurred in 20 patients. Multivariate analysis showed that a higher normal lung score and TNM stage were independent radiologic and clinical predictors of poor survival at the time of diagnosis of lung cancer. CONCLUSIONS: A markedly reduced area of normal lung on HRCT was a relevant radiologic predictor of survival.

Gefitinib successfully administered in a lung cancer patient with leptomeningeal carcinomatosis after erlotinib-induced pneumatosis intestinalis.

BACKGROUND: Pneumatosis intestinalis (PI) is a rare complication of chemotherapy, characterized by multiple gas accumulations within the bowel wall. CASE PRESENTATION: A 71-year-old woman with epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma was admitted to our hospital because of reduced consciousness. She was diagnosed as having leptomeningeal carcinomatosis (LM) using lumbar puncture. Because she could not swallow a tablet, erlotinib was administered via a feeding tube. Her state of consciousness gradually improved, but she experienced diarrhea several times a day. After 3 weeks of erlotinib therapy, PI occurred. Erlotinib was discontinued and PI was resolved after treatment with conservative therapies. Erlotinib was re-administrated and PI occurred again. After improvement of erlotinib-induced PI, gefitinib was administered by a feeding tube and the patient did not experience PI or diarrhea. The patient survived 8 months from the diagnosis of LM. CONCLUSION: PI is one of the side effects of erlotinib, and consecutive therapies are useful for the treatment of PI. In this patient, gefitinib was successfully administered after erlotinib-induced PI.

The Efficacy and Safety of Long-term Pirfenidone Therapy in Patients with Idiopathic Pulmonary Fibrosis.

Objective Pirfenidone (PFD) is often used for years, but the efficacy and safety of long-term PFD therapy in patients with idiopathic pulmonary fibrosis (IPF) are not fully understood. Methods and Patients We retrospectively evaluated 46 patients with IPF who received PFD between February 2009 and August 2014. The efficacy and safety of PFD therapy were compared between 2 groups: long-term therapy patients who received PFD for over 1 year (group L, n=30, 65%) and short-term therapy patients who could not receive PFD for more than 1 year due to worsening of their condition or side effects (group S, n=16, 35%). Results The median age of the 46 patients was 70.5 years, and the median baseline % predicted forced vital capacity (%FVC) was 70.0%. The changes in the FVC in group L were -120 mL and -170 mL at 12 and 24 months after receiving PFD, respectively. The respective median survival times after PFD therapy in groups L and S were 1,612 days and 285 days (p<0.001). The patients in group L experienced a longer time free of acute exacerbation of IPF than those in group S (947 days vs. 145 days, p=0.001). A multivariate analysis revealed that %FVC <60% was a predictor of the inability to receive PFD for over 1 year (odds ratio 0.240, 95% confidence interval 0.060-0.958; p=0.043). With regard to grade 3-5 adverse events, only one patient exhibited grade 3 hyponatremia. Conclusion Long-term PFD therapy is effective, with few severe adverse events.

[CLINICAL ANALYSIS OF 115 PULMONARY TUBERCULOSIS PATIENTS WITH SPUTUM SMEAR-NEGATIVE].

[Methods] We retrospectively studied 115 con- secutive pulmonary tuberculosis patients whose sputum smear was .negative, diagnosed by positive culture and/or PCR of various samples, or positive QFT. [Results] The culture positive rate of tuberculosis by spu- tum, gastric aspirate, bronchoscopy, and computed tomogra- phy (CT)-guided needle biopsy samples was 55.7%, 45.6%, 73.2%, and 71.4%, respectively. In multivariate analysis, negative or unknown sputum PCR, negative or unknown gastric aspirate, and minimal spread of tuberculosis were risk factors for negative culture from both sputum and gas- tric aspirate. Sputum culture was positive in only one of the four patients with multi-drug resistant Mycobacterium tuberculosis. [Conclusion] Invasive diagnostic procedures such as fiber- optic bronchoscopy should be considered in patients with negative sputum PCR and minimal spread of tuberculosis.

Antemortem diagnosis of pulmonary tumor thrombotic microangiopathy in a patient with recurrent breast cancer: a case report.

BACKGROUND: Pulmonary tumor thrombotic microangiopathy (PTTM), a rare complication of advanced cancer, is histologically characterized by tumor embolisms and fibrocellular intimal proliferation of small pulmonary arteries and arterioles. PTTM usually has an extremely poor prognosis, and antemortem diagnosis is very difficult. CASE PRESENTATION: A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. She had previously received neoadjuvant chemotherapy and left mastectomy. Because the cancer cells were positive for human epidermal growth factor receptor 2 (HER2), four cycles of trastuzumab had been administered as adjuvant chemotherapy. On admission, chest computed tomography (CT) showed peripheral consolidations in both the lower lobes and a mediastinal mass. Specimens obtained on video-assisted thoracoscopic surgical biopsy revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura. Immunohistochemical staining of the tumor cells revealed positivity for HER2, and a diagnosis of recurrent breast cancer with PTTM was made. Four cycles of trastuzumab resulted in rapid improvement of her symptoms and CT findings of peripheral consolidations and the mediastinal mass. CONCLUSION: An antemortem diagnosis of PTTM was made in a patient with HER2-positive recurrent breast cancer. Trastuzumab was effective for not only breast cancer but also PTTM.

Continuous Intravenous Morphine Infusion for Severe Dyspnea in Terminally Ill Interstitial Pneumonia Patients.

OBJECTIVE: The aims of this study were to evaluate the efficacy and safety of continuous morphine infusion for dyspnea in patients with acute exacerbation (AE) of end-stage interstitial pneumonia (IP). METHODS: We conducted a retrospective study. Based on the subjective clinical effectiveness ratings of "good," "moderate," "poor," or "unknown," the efficacy of continuous morphine infusion treatment was evaluated as defined as symptom relief that was "good" or "moderate." PATIENTS: This study included 22 consecutive opioid-naïve patients who received continuous morphine infusion in the palliative treatment of dyspnea resulting from AE-IP. RESULTS: Of 22 patients, nine achieved good dyspnea relief, eight had moderate relief, four had a poor response and one response was "unknown" within 24 hours of starting morphine infusion. Using an operational definition of dyspnea relief that was rated "good" or "moderate," the efficacy rate of morphine was 77% (n=17). There was a significant change in the respiratory rate (25 respirations per minute at baseline vs. 17 respirations per minute after 12 hours, p=0.02), however, none of the patients studied had fewer than eight respirations per minute. CONCLUSION: We conclude that continuous morphine infusion is an effective and safe therapy for severe dyspnea in terminal AE-IP patients without any serious adverse events.

Marked Improvement with Pirfenidone in a Patient with Idiopathic Pulmonary Fibrosis.

A man in his mid-60's with idiopathic pulmonary fibrosis and hepatitis B-related liver cirrhosis developed exertional dyspnea and a dry cough lasting for three months. High-resolution computed tomography (HRCT) showed increasing bilateral ground-glass opacity superimposed on the usual interstitial pneumonia pattern. Six months after starting pirfenidone therapy, the partial pressure of arterial oxygen at rest increased from 81 to 101 torr, the predicted forced vital capacity (FVC) value increased from 75% to 94% and the ground-glass opacity on HRCT improved. The FVC value was subsequently maintained near or above baseline for 43 months. We concluded that our patient was a super-responder to pirfenidone therapy.

[Evaluation of mycobacterial infections using 18F-fluorodeoxyglucose-positron emission tomography: results of nine cases].

18F-fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) is a useful technique for distinguishing malignant and benign lesions, although the occurrence of false-positive results in cases involving benign lesions is possible. We evaluated nine patients with mycobacterial infections who underwent FDG-PET/CT from April 2008 to July 2010. FDG-PET/CT was performed 1-2h (during the early and late phases) after administration of FDG at a dose of 185 MBq/individual after fasting for at least 5h. Out of the nine patients, four were diagnosed with pulmonary nonmycobacterium tuberculosis, two with pulmonary tuberculosis, two with tuberculous lymphadenopathy, and one with pleural tuberculoma. All patients had a maximum standardized uptake value (SUV(max)) of > 2.5, and the SUV(max) increased from the early to the late phase. One lesion that occurred due to tuberculous pleurisy after treatment demonstrated high FDG uptake, similar to the other cases. It is difficult to distinguish mycobacterial infections from malignant diseases using FGD-PET alone; hence, the use of high-resolution CT and bacteriological tests is required for diagnosis and distinction.

Pulmonary tumor thrombotic microangiopathy: a clinical analysis of 30 autopsy cases.

OBJECTIVE: Pulmonary tumor thrombotic microangiopathy (PTTM) is a unique, rare and fatal form of pulmonary arterial tumor embolism. The aim of this study was to evaluate the clinical characteristics and pathological and immunohistochemical findings of PTTM. METHODS: Autopsy records dated between January 1983 and May 2008 in our hospital were reviewed, and those of patients who died from pulmonary tumor embolism resulting from malignant neoplasm were retrieved. The relevant tissue slides were reevaluated and examined immunohistochemically to confirm the diagnosis. RESULTS: Among 2,215 consecutive autopsy cases of carcinoma, 30 patients (1.4%) were diagnosed with definitive PTTM. The common symptom was progressive dyspnea. A hypercoagulative state was observed in all measured cases (n = 21). The chest computed tomography findings (n = 6) included consolidation, ground-glass opacity, small nodules and a tree-in-bud appearance. Perfusion scans were performed in seven patients, six of whom demonstrated multiple small defects. The median survival time after the initiation of oxygen supplementation was nine days. The most frequent primary site was the stomach (n = 18 ; 60%) , and the most frequent histological type was adenocarcinoma (28/30 ; 93.3%) . The immunohistochemical findings for tumor cells located within the tumor emboli were positive for vascular endothelial growth factor (28/29 ; 96.6%) and tissue factor (29/29 ; 100%). CONCLUSION: Clinicians should suspect PTTM in cancer patients who exhibit acute worsening respiratory insufficiency accompanied by a hypercoagulative state without embolism in major pulmonary arteries. The PTTM patients evaluated in our study had very poor prognoses. Vascular endothelial growth factor and tissue factor may play important roles in PTTM.

Hereditary hemorrhagic telangiectasia with pulmonary arteriovenous malformations and embolic strokes treated successfully with video-assisted thoracoscopic resection.

A 67-year-old hypoxic woman was admitted following two episodes of cerebral infarction. Based on the clinical presentation and radiological findings, a diagnosis of hereditary hemorrhagic telangiectasia was made and the cerebral ischemic complications were considered to have been caused by paradoxical embolizations related to pulmonary arteriovenous malformations (PAVMs). We performed video-assisted thoracoscopic surgery (VATS) and identified turbulent thrombi in one of the PAVMs that were capable of circulating systemically and inducing embolic strokes. The condition of the patient improved immediately following VATS. This case suggests that VATS may be a preferred therapeutic option in the treatment of patients with PAVM accompanying recurrent episodes of life-threatening complications such as strokes.

Cavitary pulmonary infection with Mycobacterium avium observed by bronchoscopy.

A 58-year-old man was admitted to our hospital because of fever and loss of appetite. He had undergone surgery for esophageal cancer. A chest radiography 12 years after the surgery revealed cavitary lesions in the right upper lobe of the lung. The patient was then diagnosed as having Mycobacterium avium infection. The cavitary lesions worsened 2 years after clarithromycin monotherapy. Bronchoscopy was performed to observe the interior of the cavity. Gray debris adhering to the cavitary wall decreased after intensive treatment with Streptomycin, rifabutin, levofloxacin, and ethambutol. This is a rare case in which treatment efficacy of M. avium infection was directly observed by serial bronchoscopy.

Diagnostic efficacy of CT-guided transthoracic needle biopsy and fine needle aspiration in cases of pulmonary infectious disease.

PURPOSE: The purpose of our study was to evaluate the efficacy of computed-tomography (CT)-guided transthoracic needle biopsy (TNB) and fine needle aspiration (FNA) in diagnosing pulmonary infectious diseases. PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients treated at our institution between October 2006 and September 2009 and identified 161 patients who had undergone CT-guided TNB or FNA. We conducted CT-guided TNB or FNA for the patients if bronchoscopy failed to provide proper diagnosis or if their thoracic lesions were not appropriate targets for bronchoscopy. RESULTS: Twenty-three patients were diagnosed with pulmonary infectious diseases, of whom 17 were diagnosed by CT-guided TNB or FNA; sensitivity was therefore 73.9 % (17/23). The diagnostic rate for Aspergillus infection was especially high (75 %). CONCLUSION: CT-guided TNB and FNA proved to be effective as alternative methods if bronchoscopy failed to diagnose pulmonary infectious diseases, with acceptable complication rates.

[A case of allergic bronchopulmonary mycosis caused by Schizophyllum commune presenting with hyperattenuated mucoid impaction].

A 64-year-old woman was admitted to our hospital because of cough, bloody sputum and chest pain in January 2007. Chest computed tomography (CT) on admission revealed hyperattenuated mucoid impaction and consolidation in the right S3b. She was given a diagnosis of allergic bronchopulmonary mycosis caused by Schizophyllum commune. Treatment with 200 mg/day itraconazole and 15 mg/day oral prednisolone was begun, and her symptoms and consolidation resolved. In December 2007, consolidation in the left lower lobe appeared after itraconazole was stopped and replaced with oral prednisolone with inhaled fluticasone propionate. She again received 200 mg/day itraconazole and 15 mg/day oral prednisolone, resulting in a reduction in her consolidation. In May 2008, itraconazole was stopped and oral prednisolone was changed to inhaled salmeterol fluticasone propionate. In November 2008, her symptoms appeared again, and chest CT demonstrated hyperattenuated mucoid impaction and consolidation in the right S8. A transbronchial biopsy revealed granulomatosis, Charcot-Leyden crystals, and mucus infiltrated by eosinophils and fungi. Schizophyllum commune was isolated from her bronchial lavage fluid. A recurrence of allergic bronchopulmonary mycosis was diagnosed. Retreatment with itraconazole and oral prednisolone resulted in improvement of her symptoms and chest radiographic findings. To the best of our knowledge this is the first reported case of allergic bronchopulmonary mycosis caused by Schizophyllum commune presenting with hyperattenuated mucoid impaction.