A rare case of large pyosalpinx in an elderly patient with well-controlled type 2 diabetes mellitus: a case report.

BACKGROUND: Pyosalpinx, which is one of the pelvic inflammatory diseases, is usually observed in young women; it is rarely found in older women. Possible causative agents are thought to be Chlamydia trachomatis and Neisseria gonorrhea in addition to some Enterobacteriaceae. On the other hand, type 2 diabetes is a disease with a lot of complications such as hyperglycemia, inflammation, and immune disorders. Therefore, patients with type 2 diabetes mellitus have an increased susceptibility to infection especially when glycemic control is poor. CASE PRESENTATION: We experienced a rare case of large pyosalpinx in an elderly patient with well-controlled type 2 diabetes mellitus. A 72-year-old Japanese woman with a 10-year history of type 2 diabetes mellitus had symptoms of diarrhea and persistent pain in left lower abdomen. She had mild tenderness to palpation in her abdomen. Inflammation markers were markedly elevated. Her abdominal computed tomography and magnetic resonance imaging on admission revealed a tumor in left side of intrapelvis and we diagnosed her as having pyosalpinx. Pathogenic bacteria were not detected. On admission, her glycemic control was relatively good; in addition, her glycated hemoglobin levels were around 6% for over 1 year. Although pathogenic bacteria were not detected, we started antibiotics therapy. Fourteen days after starting the antibiotics her laboratory data were improved. Three months later, the tumor was markedly smaller compared to that on admission. CONCLUSIONS: We should keep in mind that older patients with type 2 diabetes mellitus are immunocompromised hosts and thereby they could have rare pelvic inflammatory disease such as pyosalpinx even when good glycemic control is obtained for a long period of time.

Clinical course of pituitary function and image in IgG4-related hypophysitis.

A 76-year-old man had a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism. Based on various findings including the swelling of the pituitary gland, increase of serum IgG4 level and abundant IgG4-positive plasma cell infiltration in immunostaining of the pituitary gland, we diagnosed this subject as IgG4-related hypophysitis. In general, a high-dose glucocorticoid treatment is effective for IgG4-related disease. His clinical symptom, laboratory data and adrenal insufficiency were almost improved without any therapy. The serum IgG4 level was decreased and pituitary size was normalized with hydrocortisone as physiological replacement. This case report provides the possibility that IgG4 level is decreased spontaneously or with physiological dose of glucocorticoid therapy. LEARNING POINTS: We performed the pituitary gland biopsy and histochemical examination glucocorticoid therapy in a subject with IgG4-related hypophysitis.This case report provides the possibility that IgG4 level is decreased spontaneously or with a physiological dose of glucocorticoid therapy. We reported the clinical course of IgG4-related hypophysitis without a high-dose glucocorticoid treatment, although there were a few reports about the retrospective examination.Although the patient had still higher IgG4 level compared to normal range, his clinical symptom disappeared and his laboratory data were improved.We should keep in mind the possibility of IgG4-related hypophysitis when we examine one of the uncertain causes of a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism.

[USE OF QuantiFERON-TB Gold in Tube AND T-SPOT.TB FOR DIAGNOSING PATIENTS WITH SUSPECTED PULMONARY TUBERCULOSIS].

OBJECTIVE: We analyzed the use of QFT-TB Gold in Tube and T-SPOT.TB in diagnosing patients with suspected pulmonary tuberculosis. SUBJECTS AND METHODS: We evaluated 122 patients with suspected pulmonary tuberculosis (where chest X-ray showed consolidation or. tumor shadow in predilection sites of pulmonary tuberculosis and through contact investigation). QFT-TB Gold and T-SPOT.TB were performed for all the patients. The positive response rate and history of pulmonary tuberculosis in patients who showed positive results for the tests were evaluated. RESULTS: Ninteen patients showed positive results for QFT-TB Gold, and 9, for T-SPOT.TB. Four patients showed positive results for QFT-TB Gold, and 3, for T-SPOT.TB in 4 patients with active tuberculosis. The patients without active tuberculosis whose IGRAs were positive (old pulmonary tuberculosis, Mycobacterium avium cmplex, pneumonia, lung cancer, pulmonary sequestration, bronchiectasis) had a past history of pulmonary tuberculosis. CONCLUSION: The positive result rate of QFT?-TB Gold was higher than that of T-SPOT.TB in the subjects with suspected pulmonary tuberculosis. We think that QFT-TB Gold reflected the past history of pulmonary tuberculosis.

Partial remission by cyclosporine monotherapy in a patient with membranous nephropathy superimposed diabetic nephropathy.

It has been noted that cyclosporine A (CsA) is an effective drug for membranous nephropathy (MN). Diabetes is a common disease that sometimes causes nephrotic syndrome. We report the case of an 89-year-old woman with type 2 diabetes mellitus who exhibited nephrotic syndrome. Examination of a renal biopsy indicated MN and she was prescribed CsA as monotherapy. Her edema subsided and she achieved partial remission. This is the first report of a patient in diabetic condition with MN having achieved partial remission after CsA monotherapy without steroid therapy. The use of steroid in patients with diabetes may worsen their diabetic condition, especially if they are of very advanced age. CsA monotherapy may be useful for diabetic patients with MN.

Benefits and adverse events among elderly patients receiving concurrent chemoradiotherapy for locally advanced non-small cell lung cancer: analysis of the Okayama Lung Cancer Study Group trial 0007.

INTRODUCTION: Thoracic radiotherapy (RT) with concurrent chemotherapy may be offered to selected elderly patients with locally advanced non-small cell lung cancer. The Okayama Lung Cancer Study Group (OLCSG) 0007 trial with patients up to 75 years showed that with concurrent RT, docetaxel and cisplatin (DP) chemotherapy was an alternative to mitomycin C, vindesine, and cisplatin (MVP) chemotherapy. METHODS: Of the 99 patients in the DP arm, 73 were younger than 70 years and 26 were 70 years or older. Of the 101 patients in the MVP arm, 75 were younger than 70 years and 26 were 70 years or older. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method and were compared using an early period weighted log-rank test. Toxicities and treatment intensities were compared by χ(2) and t tests, respectively. RESULTS: OS and PFS tended to be longer in the DP arm versus MVP arm: median OS (months), 27.5 versus 22.9 (p = 0.109) and 25.6 versus 23.4 (p = 0.064) in the ≥70-year and <70-year groups, respectively; median PFS (months), 19.0 versus 11.5 (p = 0.175) and 12.0 versus 9.3 (p = 0.132) in the ≥70-year and less than 70-year groups, respectively. Severe toxicity (neutropenia, esophagitis, and pneumonitis) rates did not differ between age groups. Nevertheless, the absence of statistically significant differences in this retrospective analysis might be due to the small number of patients. Radiation intensity was similar between the groups, but chemotherapy intensity was lower in the ≥70-year group. CONCLUSION: Chemotherapy with concurrent RT may be effective and tolerable in elderly patients with locally advanced non-small cell lung cancer.

[A case of miliary tuberculosis difficult to distinguish from metastatic lung cancer].

We report a case of the coexistence of pulmonary tuberculosis and lung cancer maked a wrong diagnosis of lung cancer and metastatic lung carcinoma. The patient was a 80-years-old woman who had ascites and anorexia and decreased weight. Chest CT film showed a mass shadow in the right S, and infiltrative shadows on bilateral lung fields. FDG-PET revealed the tumor in the right lower lung field and many infiltrative shadows in all lung fields, and showed that FDG accumulated diffusely along the peritoneum. We made a diagnosis of lung cancer and metastatic lung carcinoma. However we obtained a diagnosis of coexisting of pulmonary tuberclosis and lung cancer autopsy. When the patient has a shadow suggestive of lung tumor shadow with many infiltrative shadows, we tend to make a diagnosis of lung cancer and metastatic lung carcinoma. We saw the importance of a postmortem examination in a new light.

[Clinical effects of intravenous ciprofloxacin on community-acquired pneumonia with positive Immunocard Mycoplasma test results].

We studied the clinical effects of intravenous ciprofloxacin (CPFX) on community-acquired pneumonia in patients with positive Immunocard Mycoplasma test results. The subjects were 35 patients (59.4 +/- 24.8 years old) with community-acquired pneumonia with positive Immunocard Mycoplasma test results. We infused CPFX 300mg copy intravenously twice daily for 3-14 days. It was effective in 33 of 35 patients, with an efficacy rate of 94.3%. Adverse reactions consisted of itching in 2 patients, malaise in 2 patients, drug eruption in 1 patient, elevation of GPT in 1 patient and elevation of BUN in 1 patient, but all were mild. We conclude that intravenous CPFX is useful for community-acquired pneumonia in case with positive Immunocard Mycoplasma test results.

[Case of multiple intrapulmonary lymph nodes].

A 45-year-old man who had hypertension, hyperthyroidism, and bronchial asthma was admitted to our hospital because of a low-grade fever and chest pain. The physical findings and laboratory data were almost all within normal limits except for evidence of mild inflammation and liver dysfunction. The chest X-ray findings seemed normal, but a computed tomography (CT) scan showed multiple nodules in both lower lung fields. We suspected the cryptococcosis or lung cancer. Biopsy by video-assisted thoracoscopic surgery (VATS) yielded a diagnosis of multiple intrapulmonary lymph nodes. In cases with the above radiologic findings, careful attention should be paid to making the differential diagnosis between intrapulmonary lymph nodes and primary lung cancer. The promotion of diagnostic imaging and advances in techniques have made it easier to identify small peripheral nodules in the lungs, and we now know of their existence. Solitary intrapulmonary lymph nodes are encountered frequently, but multiple or increasing numbers of nodes, as in our case, are very rare. Moreover, because cases with elevated CEA levels have been reported, differentiation from lung cancer appears to be important.

[Positive phase periods of ImmunoCard Mycoplasma tests].

We evaluated the positive phase period of ImmunoCard Mycoplasma tests. The subjects were 74 penumonia patients (male : 38, female : 36, 17-94 years old) with positive ImmunoCard Mycoplasma tests. ImmunoCard Mycoplasma tests were performed every week for 8 weeks later, then every 4 weeks until negative conversion. The positive phase period was within a week in 30 of 74 patients (40.5%) and within 4 weeks in 52 patients (70.3%). In each generation the positive phase period of the most patients was within a week. The positive phase period of the elderly had no tendency to be longer than that of the young patients. These results indicated that about half of the patients with positive ImmunoCard Mycoplasma tests showed Mycoplasma infection which occurred within the past 1 week.

Coxiella burnetii and acute exacerbations/infections in patients with chronic lung disease.

The aim of the present study was to determine the incidence of Q fever in patients with an acute exacerbation of a chronic lower respiratory tract infection. Eighty patients treated for acute exacerbation of chronic lower respiratory tract infections during a 30-month period were studied. Q fever was diagnosed by ELISA. Two elderly woman with pre-existing bronchiectasis (2.5%) were diagnosed as having an acute infection by Coxiella burnetii. The acute illness was considered to be a result of mixed infection with Pseudomonas aeruginosa and Haemophilus influenzae with C. burnetii. Co-infection with C. burnetii can occur during a bacterial exacerbation of a chronic lower respiratory tract infection.

A phase II trial of cisplatin and irinotecan alternating with doxorubicin, cyclophosphamide and etoposide in previously untreated patients with extensive-disease small-cell lung cancer.

PURPOSE: The aim of this trial was to investigate the efficacy and safety of cisplatin (P) and irinotecan (I) (PI) alternating with doxorubicin (A), cyclophosphamide (C) and etoposide (E) (ACE) in patients with extensive-disease small-cell lung cancer (ED-SCLC). PATIENTS AND METHODS: Patients with previously untreated ED-SCLC were enrolled in this trial. In the first, third and fifth cycles, PI (P: 60 mg/m(2) on day 1; I: 60 mg/m(2)/day on days 1, 8 and 15) was administered, whereas ACE (A: 50 mg/m(2) on day 1; C: 750 mg/m(2) on day 1; E 80 mg/m(2)/day on days 1-3) was given in the second, fourth and sixth cycles. Each cycle was repeated every 4 weeks. At the end of six cycles, patients who had obtained a complete response were given prophylactic cranial irradiation. RESULTS: In total, 28 patients were enrolled, of whom 27 were assessable for efficacy and safety. Objective responses, including 4 (15%) complete responses, were observed in 25 patients (93%). Median survival time was 12.9 months. The principal toxicity was myelosuppression; grade 4 neutropenia and thrombocytopenia were observed in 89 and 4%, respectively. Febrile neutropenia occurred in 30% of patients. Diarrhea was mild (grade 3-4; 4%). All toxicities were reversible and there were no treatment-related deaths. The mean percentage of the delivered doses, relative to the projected doses, of PI and ACE were 84.6 and 91.1%, respectively. CONCLUSIONS: These results indicate the PI-ACE regimen to have promising activity against ED-SCLC with moderate toxicities.

Influence of altering administration sequence of docetaxel, gemcitabine and cisplatin in patients with advanced non-small cell lung cancer.

BACKGROUND: A phase II study of a triplet chemotherapy with the administration sequence of gemcitabine (GEM), docetaxel (DCT) and cisplatin (CDDP) (OLCSG9908) was previously conducted in patients with advanced non-small cell lung cancer (NSCLC). The objective response rate was 34% and the median survival time (MST) and 1-year survival rate were 11.7 months and 49%, respectively. In an in vitro study of different sequence exposures to GEM and DCT, it was reported that the synergistic effect was more prominent using the administration sequence of DCT followed by GEM compared with the reverse sequence. In order to estimate the effects of the administration sequence, a phase II study of the same triplet chemotherapy was conducted with the administration sequence of DCT, CDDP and GEM. PATIENTS AND METHODS: Patients with unresectable stage IIIB/IV NSCLC were eligible. All drugs were given intravenously on days 1 and 8, and repeated every 4 weeks for up to 4 cycles. DCT (30 mg/m2) was given first, followed by CDDP (40 mg/m2) and GEM (800 mg/m2). RESULTS: Thirty-four patients were enrolled on this study (OLCSG0101). The objective response rate was 38% (95% CI: 22-56%). As grade 3/4 hematological toxicities, neutropenia, thrombocytopenia and anemia were observed in 70%, 41% and 21%, respectively, and febrile neutropenia was observed in 12%. As grade 3/4 non-hematological toxicities, vomiting and liver dysfunction were observed in 15% and 18%, respectively. These toxicities were manageable by conventional therapy. The MST and 1-year survival rate were 13.3 months (95% CI: 7.8-18.7 months) and 55% (95% CI: 38-73%), respectively. These results were similar to those of OLCSG9908. CONCLUSION: This triplet chemotherapy is well tolerated and effective in patients with advanced NSCLC, however, the treatment outcome was not significantly influenced by the administration sequence of DCT and GEM.

A phase I study of 3-day topotecan and cisplatin in elderly patients with small-cell lung cancer.

PURPOSE: The aim of this phase I study was to determine the maximum-tolerated dose (MTD) in elderly patients with small-cell lung cancer (SCLC). PATIENTS AND METHODS: Patients aged over 75 years with previously untreated SCLC were enrolled in this study. Both topotecan and cisplatin were administered on days 1-3 and repeated every 3 weeks. The starting dose of topotecan was 0.5 mg/m2/day, while cisplatin was fixed at the dose of 20 mg/m2/day. Patients with limited disease (LD) SCLC received thoracic irradiation after the completion of chemotherapy. RESULTS: Twenty-one elderly patients were enrolled in this study and received a total of 59 cycles. The major hematological toxicity was neutropenia and non-hematological toxicities including diarrhea were generally mild and reversible. The MTD of topotecan was determined as 1.2 mg/m2/day. The recommended phase II study dose of topotecan was determined as 1.0 mg/m2/day with cisplatin 20 mg/m2/day daily for 3 days. An objective response was observed in 6 of 10 patients (60%) with LD-SCLC and 6 of 11 (55%) with extensive disease (ED) SCLC. The median survival time in patients with LD-SCLC and those with ED-SCLC were 16.0 and 11.0 months, respectively. CONCLUSION: The combination chemotherapy of 3-day topotecan and cisplatin appears to be tolerable and effective in elderly patients with SCLC.

Phase I study of irinotecan and amrubicin in patients with advanced non-small-cell lung cancer.

BACKGROUND: Combination chemotherapy of irinotecan and amrubicin for advanced non-small cell lung cancer (NSCLC) has not been fully evaluated. To determine the maximum-tolerated dose (MTD), a phase I study in patients with advanced NSCLC was conducted. MATERIALS AND METHODS: Patients with stage IIIB/IV NSCLC were enrolled in this study. Both patients with and without prior chemotherapy were also eligible. The drugs were administered on days 1 and 8, every 3 weeks. The starting doses of irinotecan and amrubicin were 60 and 35 mg/m2, respectively. RESULTS: Nineteen patients received a total of 53 courses. Grade 4 neutropenia was observed in 23% of courses. Anaemia and thrombocytopenia were generally mild. Grade 3 febrile neutropenia occurred in 5 courses. Other grade 3 or greater non-haematological toxicities were observed in only 4 out of 52 courses (grade 3 infection and hyponatremia). The maximum-tolerated doses (MTDs) of irinotecan and amrubicin were 100 and 45 mg/m2, respectively. Objective response was obtained in 2 patients (10.5%), who had received prior chemotherapy. CONCLUSION: This combination was well tolerated, but produced only a modest anti-tumour effect for advanced NSCLC. Further investigation into the role of this regimen as a salvage chemotherapy may be warranted in relapsed patients.

[A case of allergic granulomatosis and angiitis (Churg-Strauss syndrome) in a 15-year-old girl].

A 15-year-old girl with a 6-month history of bronchial asthma was admitted to our hospital because of fever, dyspnea, weight loss, dysesthesia, muscle weakness, gait disturbance and purpuric rash. In addition, leukocytosis, hypereosinophilia and elevation of CRP were observed. Chest radiograph and computed tomography on admission showed non-segmental patchy air-space consolidation in both lung fields. Skin biopsy was performed and the pathologic diagnosis was necrotizing arteritis with eosinophilic infiltration. Transbronchial lung biopsy revealed eosinophilic pneumonia. From the clinical course, laboratory data and pathologic findings, the diagnosis of allergic granulomatosis and angiitis (Churg-Strauss syndrome) was made. Following the skin and lung biopsies, intravenous pulse corticosteroid and oral prednisolone treatment was started and her clinical findings improved. Angiitis with allergic granulomatosis is a vasculitis that is found in adults. This is an extremely rare and interesting case of angiitis with allergic granulomatosis in childhood.