[Segmental Bronchoalveolar Lavage Provided a Favorable Clinical Course in a Case of Autoimmune Pulmonary Alveolar Proteinosis].

A 49-year-old man was diagnosed with autoimmune pulmonary alveolar proteinosis. Chest computed tomography (CT) showed typical CT findings of pulmonary alveolar proteinosis: thickening of septa with ground-glass opacities in both lung fields. The diagnosis of autoimmune pulmonary alveolar proteinosis (PAP) was based on findings of bronchoalveolar lavage (BAL) fluid with milky appearance and elevated serum titer of anti-granulocyte-macrophage colony-stimulating factor antibody. We decided to perform segmental BAL via bronchoscopy. The surgery was performed under a general anesthesia since the patient had severe hypoxemia and strong cough reflex. Following 3 repeated courses of therapy, his respiratory condition and the ground-glass opacity in both lung fields improved remarkably, with no recurrence in 3 years. There are only a few published case reports in the world of the usefulness of segmental BAL under general anesthesia for PAP. We consider that segmental BAL is a useful therapeutic method for PAP in cases with severe hypoxemia, such as the present patient.

Immune checkpoint inhibitors-induced eosinophilic pneumonia: A case report.

A 78-year-old male with renal cell carcinoma was treated with combined immunotherapy of nivolumab and ipilimumab. After four courses of the treatment, a chest computed tomography (CT) revealed newly formed ground-glass opacities (GGOs) in both the lower lung lobes; drug-induced pneumonia was speculated. Eosinophil counts were elevated in both peripheral blood and bronchoalveolar lavage fluid. Both the immune checkpoint inhibitors (ICIs) were discontinued, following which the chest CT findings improved. Based on these findings, a diagnosis of ICI-induced eosinophilic pneumonia was made. Hence, clinicians should be wary of the risk of eosinophilic pneumonia during ICI-anticancer therapy.

A Case of Pulmonary Infectious Bulla Caused by Mycobacterium Avium.

A 37-year-old Japanese man presented with a bulla with niveau-like opacity in the right upper lung on chest radiography. Air-fluid level gradually increased despite broad-spectrum antibiotic therapy. Right upper lobectomy was performed, and epithelioid granuloma with mycobacteria was histopathologically observed. Bacterial culture of the fluid was negative, but mycobacterial culture was positive for Mycobacterium avium; therefore, the patient was diagnosed with pulmonary infected bulla caused by Mycobacterium avium. He was further treated with antimycobacterial agents after resection of the infected bulla. To our knowledge, this is the first report of pulmonary infected bulla caused by only Mycobacterium avium in the English literature.

[A Retrospective Study of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) Performed on Tuberculous Lymphadenitis Cases].

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been reported to be useful not only for the diagnosis of lymph node metastasis of lung cancer but also for benign diseases. We retrospectively analyzed the results of patients with tuberculous lymphadenitis (TL) who had undergone EBUS-TBNA between November 2010 and January 2016. EBUS-TBNA was performed in 427 cases during that period. Six cases were finally diagnosed as TL. The punctured lymph node was 8 lesions. Pathological findings consistent with TL were obtained in all 6 cases (100%), and the tissue specimens were positive in Ziehl-Neelsen staining in 3 of the 6 cases (50%). In all 6 cases, the acid-fast bacteria (AFB) smear test of the needle rinse fluid was negative, 2 cases were positive for AFB culture (33.3%), and 2 cases were positive for Mycobacterium tuberculosis (MTB)-PCR test (33.3%). In this study, the positive rate of mycobacterial culture and the MTB-PCR test of the needle rinse fluid was low, though the concordance rate of pathological findings with TL was high (100%). The results suggest that EBUS-TBNA should be carefully evaluated in patients with TL, considering the low positive rate of mycobacterial culture and MTB-PCR test in the needle rinse fluid.

Immune-mediated thrombocytopenia and hypothyroidism in a lung cancer patient treated with nivolumab.

Patients treated with immune checkpoint inhibitors can develop various immunological complications; however, few cases of immune thrombocytopenia occurring in association with the administration of these agents have so far been reported. We herein report the case of a 62-year-old Japanese man with non-small-cell lung cancer who developed immune thrombocytopenia and hypothyroidism during nivolumab therapy. After the second administration of the drug, his peripheral blood platelet count rapidly decreased to 1.6 × 104/µl with a petechial rash and symptoms associated with a low thyroid function. Nivolumab-induced immune thrombocytopenia and hypothyroidism were suspected based on the presence of platelet-associated IgG, an increased level of autoantibodies to thyroglobulin and thyroid peroxidase and an enlarged thyroid gland. The patient eventually made a full recovery after treatment with oral prednisolone and levothyroxine. Further investigations and the accumulation of data are necessary to elucidate the precise mechanisms underlying the autoimmune responses that occur in patients treated with immune checkpoint inhibitors.