Nodular pulmonary amyloidosis diagnosed by ultrasound-guided percutaneous needle biopsy.

Pulmonary amyloidosis is characterized by extracellular deposition of fibrous protein called amyloid in the lungs and has three subtypes: nodular, diffuse, and tracheobronchial amyloidosis. Pulmonary nodular amyloidosis can mimic other lung diseases including infectious diseases, metastatic lung tumors, sarcoidosis, and pulmonary hyalinizing granuloma. A biopsy of the lesion is essential for a definitive diagnosis. Herein, we report the case of a 66-year-old man who presented for shortness of breath on exertion and was diagnosed with nodular pulmonary amyloidosis on ultrasound-guided percutaneous needle biopsy. A chest X-ray and computed tomography (CT) revealed bilateral slowly growing multiple calcified pulmonary nodules and cavities. Malignancy was suspected based on 18F-fluoro-deoxyglucose (18F-FDG) positron emission tomography/CT (PET/CT) images. An ultrasound-guided percutaneous needle biopsy was performed, and histopathologic examination of the lesion confirmed nodular pulmonary amyloidosis. This case highlights the importance of considering nodular pulmonary amyloidosis in the differential diagnosis of pulmonary nodules with increased uptake of 18F-FDG on PET/CT and the utility of ultrasound-guided needle biopsy in the definitive diagnosis.

The prevalence of obstructive sleep apnea in Japanese asthma patients.

BACKGROUND: Obstructive sleep apnea (OSA) occurs more commonly in asthma patients than in the general population because these conditions share some comorbidities. In Japan, the prevalence of OSA in the general population is reported to be approximately 20%; however, few reports have described the prevalence of OSA in asthma patients. Furthermore, the characteristics of Japanese patients with OSA and asthma are not clear. METHODS: Adult asthma patients were recruited from the outpatient departments of our institution between August 31, 2017, and March 31, 2019. In all included patients, the presence and severity of OSA were evaluated by the Epworth Sleepiness Scale (ESS) and a home sleep test (HST) using portable polysomnography (PSG). The rate of coexisting OSA in asthma patients and the characteristics of those patients according to the severity of OSA were investigated. RESULTS: Fifty-three patients were included. OSA was detected in 36 (67.9%) patients (mild, n = 15; moderate, n = 14; and severe, n = 7). Patients with OSA had significantly higher body mass index, Brinkman index, apnea-hypopnea index (AHI), and 3% oxygen desaturation index (ODI) values in comparison to those without OSA, while the percentage of the predicted value of forced vital capacity (%FVC) and lowest SpO2 levels were significantly lower. As the severity of OSA increased, age, brain natriuretic peptide level, AHI, and 3%ODI increased, and in contrast, FVC, %FVC, forced expiratory volume in one second (FEV1), percentage of the predicted value of FEV1 (%FEV1), Epworth Sleepiness Scale (ESS), 3%ODI, and lowest SpO2 levels decreased. In particular, the fact that the ESS value was inversely correlated with the severity of OSA in our patients was different from the general characteristics of OSA. Moreover, the AHI value was negatively correlated with FVC, %FVC, FEV1, and %FEV1. BMI was the only independent factor for the presence of OSA, and for asthma severity (FEV1, % of predicted), there was a weak correlation with smoking history. CONCLUSIONS: This is the first report to investigate the prevalence of OSA in Japanese asthma patients, using an HST. This study suggests that an HST should be performed in addition to the sleep interview for asthma patients with refractory disease, a low pulmonary function, advanced age, and high BMI because the more severe the OSA, the lower the ESS value may be.

Usefulness of Computed Tomography for Evaluating the Effects of Bronchial Thermoplasty in Japanese Patients with Severe Asthma.

Background: Bronchial thermoplasty (BT) improves clinical outcomes and quality of life for patients with severe asthma and has shown sustained reductions in airway narrowing and air trapping in previous CT studies. However, there is a lack of a comprehensive analysis, including CT evaluation, of clinical outcomes in Japanese patients who have undergone BT for severe asthma. This study aimed to evaluate the impact of BT in Japanese asthma patients, with a focus on the CT metric "WA at Pi10" to assess airway disease. Methods: Twelve patients with severe persistent asthma who underwent BT were assessed using ACQ6, AQLQ, pulmonary function tests, FeNO measurement, blood sampling, and chest CT before BT and one year after the third procedure for the upper lobes. Results: The median age of the patient was 62.0 years, 7/12 (58.3%) were male, 4/12 (33.3%) used regular oral corticosteroids, and 8/12 (66.7%) received biologics. Median FEV1% was 73.6%, and median peripheral eosinophil count was 163.8/µL. After one year of BT, ACQ6 scores improved from 2.4 to 0.8 points (p = 0.007), and AQLQ scores improved from 4.3 to 5.8 points (p < 0.001). Significant improvements were also observed in asthma exacerbations, unscheduled visits due to exacerbations, FeNO, and √WA at Pi10 (p < 0.05). The baseline mucus score on the CT findings was negatively correlated with FEV1 (r = -0.688, p = 0.013) and with the maximum mid-expiratory flow rate (r = -0.631, p = 0.028), and positively correlated with the peripheral blood eosinophil count (r = -0.719, p = 0.008). Changes in √WA at Pi10 after one year were positively correlated with changes in the mucus score (r = 0.742, p = 0.007). Conclusion: This study has limitations, including its single-arm observational design and the small sample size. However, BT led to a symptomatic improvement in patients with severe asthma. The validated "√WA at Pi10" metric on CT effectively evaluated the therapeutic response in Japanese asthma patients after BT.

Mortality and prognostic factors for spontaneous pneumothorax in older adults.

Spontaneous pneumothorax occurs predominantly in young males and older adults, often as a secondary condition, and can be refractory and fatal. This study aimed to investigate the mortality and prognostic factors for pneumothorax in older patients. We retrospectively cohort studied patients with pneumothorax aged ≥65 years who visited our department from October 2012 to January 2019. Data on sex, age, medical history, smoking history, underlying lung disease, treatment, and prognosis were extracted from medical records. Cox proportional hazards regression analysis was used to investigate pneumothorax mortality and prognostic factors. In total, 239 patients were included. Among them, 36 (15%) died during hospitalization. Respiratory disease was the direct cause of death in 30 patients (83.3%), and 211 (88.3%) patients had underlying lung disease. The incidence of pneumonia in our hospital was 22.6% (54 cases). On admission, the mortality rate was 33% (18/54) in patients with concomitant pneumonia; univariate analysis showed significant differences in the Charlson Comorbidity Index (CCI), activities of daily living (ADL), and concomitant pneumonia. In the Cox proportional hazards analysis of ADL (p = 0.09), CCI (p = 0.05), and concomitant pneumonia on admission (p = 0.02), concomitant pneumonia on admission was found to be an independent predictor of in-hospital mortality. This study suggests that concomitant pneumonia at admission may be a mortality risk factor for pneumothorax.

Interferential Current Stimulation for Swallowing Disorders in Chronic Obstructive Pulmonary Disease: A Preliminary Study.

Objectives: Swallowing function is affected in patients with chronic obstructive pulmonary disease (COPD), putting them at risk of exacerbation of COPD. We previously reported the effectiveness of the repetitive saliva swallowing test (RSST) in screening for patients at risk of COPD exacerbation. However, evidence on how to improve swallowing function in this population is extremely limited. Interferential current transcutaneous electrical sensory stimulation (IFC-TESS) stimulates the larynx and pharynx, thereby improving their sensory function. IFC-TESS is an emerging tool to enhance airway protection and increase swallowing frequency; however, its safety and efficacy in patients with COPD is unknown. Therefore, we performed a preliminary prospective study focusing on stable COPD patients. Methods: Patients with stable COPD who were hospitalized for yearly evaluation were recruited. Patients were included if their RSST was 5 or less. Nurses carried out IFC-TESS twice daily for 10 days. Swallow screening results were compared before and after the 10-day intervention. Results: Ten patients were included in the study. The IFC-TESS intervention was performed safely. Patients and nurses reported no discomfort or concerns regarding the intervention. The EAT-10 and RSST scores improved significantly after the intervention, and tongue pressure also tended to improve. Conclusions: IFC-TESS may be a promising intervention to improve swallowing in patients with COPD who are easily fatigued and struggle to perform swallowing exercises.

The Japanese Respiratory Society guidelines may reduce unnecessary chest computed tomography in patients with pneumonia requiring hospitalization: A retrospective study.

BACKGROUND: With the abundance of CT scanners in Japan, doctors can easily order CT scans to diagnose pneumonia. The Japanese Respiratory Society (JRS) guidelines uniquely recommend conditions for which additional CT scans should be considered at the time of diagnosis of pneumonia, a feature not found in other guidelines. In this study, we aimed to evaluate the usefulness of the recommendations in a bid to reduce the number of unnecessary CT examinations. METHODS: We retrospectively reviewed the electronic medical records of consecutive patients with pneumonia hospitalized between April 2016 and March 2017 to extract patients' backgrounds and clinical courses. Conformity with the JRS guideline recommendations was also examined. In the patients who did not meet the recommendations, we investigated the proportion of them for whom an additional CT scan influenced the clinical decisions. Finally, we evaluated whether there was a difference in hospital stay depending on the additional chest CT at the time of admission. RESULTS: We included 363 hospitalized patients with pneumonia. Chest CT scan was performed in 306 patients (84.3%), of whom 186 (60.8%) did not meet the JRS guideline recommendations. Chest CT revealed findings requiring a change in treatment strategy in only 14 (7.5%) of the 186 patients. Among the 240 patients (66.1%) who did not meet the recommendations, no statistically significant difference was observed in the hospital stay or mortality between patients with and without CT scans. CONCLUSIONS: Adherence to the JRS guideline recommendations may reduce the excessive use of CT scans in the diagnosis of pneumonia.

Varicella-zoster pneumonia with endobronchial lesions.

Varicella-zoster pneumonia with endobronchial lesions is rare. When immunosuppressed patients get skin lesions with systemic symptoms, the possibility of varicella-zoster virus infection of the respiratory tract should be kept in mind. In our case, the pulmonary lesions persisted for 15 months.

Hemorrhaging from an Intramedullary Cavernous Malformation Diagnosed Due to Recurrent Pneumonia and Diffuse Aspiration Bronchiolitis.

While aspiration pneumonia constitutes the majority of pneumonia cases in the elderly, it remains highly underdiagnosed. We experienced a case of recurrent pneumonia and chronic cough that was later diagnosed as aspiration pneumonia and diffuse aspiration bronchiolitis (DAB) due to recurrent hemorrhaging from an intramedullary cavernous malformation. The patient was finally diagnosed when life-threatening respiratory depression caused emergency attention. This is the first report of hemorrhaging from an intramedullary cavernous malformation diagnosed due to aspiration pneumonia and DAB. These findings highlight the importance of considering aspiration in cases with recurrent pneumonia or chronic cough. The underlying cause may be a life-threatening condition.

A Need for a Diagnostic Management Protocol in Barium Aspiration.

We experienced a patient who presented with lung abscess one month after aspirating barium during a gastric cancer screening examination. The patient had no subjective symptoms suggesting a swallowing disorder. Rigorous history taking under suspicion of aspiration and a further assessment of the cause of aspiration revealed hypopharyngeal cancer. Lung abscess and hypopharyngeal cancer, both treatable but potentially fatal conditions, were not diagnosed until one month after the aspiration. This highlights the need for guidance for patients and physicians to follow in the event of barium aspiration, as it is the most common complication of a barium examination. A health checkup for one condition (gastric cancer) may also be an opportunity to diagnose another underlying condition.

Osimertinib for Lung Squamous Cell Carcinoma: A Case Report and Literature Review.

The efficacy of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in lung squamous cell carcinoma is said to be low. Thus far, only four cases of osimertinib in lung squamous cell carcinoma have been published. We experienced a case of EGFR mutant lung squamous cell carcinoma in which fifth-line treatment with osimertinib was effective after T790M EGFR mutation turned positive. Osimertinib was resumed after sixth-line chemotherapy was ineffective, showing efficacy again. Osimertinib may be a promising treatment option for EGFR mutant lung squamous cell carcinoma. This is the first report to show its effect in a case of rechallenge after intervening chemotherapy. It may therefore be important to evaluate EGFR in never-smoker lung squamous cell carcinoma patients.

Intractable pleural effusion associated with superior vena cava and upper extremity deep vein thrombosis in a patient with advanced lung cancer.

We herein report a case with intractable pleural effusion attributed to superior vena cava (SVC) and upper extremity deep vein thrombosis in a patient with lung cancer. A 62-year-old woman presented to our hospital with shortness of breath and bilateral upper extremity edema. One year ago, she was diagnosed with stage IVB lung adenocarcinoma with bilateral malignant pleural effusions. A genetic analysis of the cells from pleural effusion revealed an epidermal growth factor receptor (EGFR) point mutation at exon 21 (L858R); since then, she was treated with gefitinib. Although her lung cancer and metastatic lesions had markedly reduced and the tumor cells in the pleural effusion had disappeared, pleural effusion remained. Contrast-enhanced whole-body computed tomography (CT) revealed intravenous thrombosis extending from the SVC to the left brachiocephalic and subclavian veins, and her pleural effusion was attributed to this thrombosis. Anticoagulant therapy with intravenous heparin and oral warfarin was started, nevertheless, the thrombus remained and pleural effusion did not decrease. After the placement of a pleuroperitoneal shunt, her pleural effusion resolved and her symptoms improved. This case highlights the importance of awareness of SVC or upper extremity deep vein thrombosis as a differential diagnosis of intractable pleural effusion in lung cancer patients.

Repetitive Saliva Swallowing Test Predicts COPD Exacerbation.

Introduction: Predicting phenotypes at risk of chronic obstructive pulmonary disease (COPD) exacerbation is extremely important. Dysphagia is becoming recognized as one of these phenotypes. A convenient method of screening for dysphagia and COPD exacerbation risk is desired. The repetitive saliva swallowing test (RSST) is one of the least invasive dysphagia screening methods. We previously reported the possible relation between the RSST result and COPD exacerbation in a retrospective study. Based on this, we performed a prospective study to evaluate the efficacy of RSST as a predictor of COPD exacerbation and to determine its optimal cut-off value for COPD. Methods: Seventy patients with COPD were recruited. Patients underwent the following dysphagia screening tests: the 10-item Eating Assessment Tool, Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease, RSST, water swallowing test, and simple swallow provocation test. After one year, they were classified into two groups according to the presence of COPD exacerbation during the follow-up period. Results: Twenty-seven patients had one or more exacerbations in the past year. During the follow-up period, 28 patients had one or more exacerbations (E group), and 42 had none (non-E group). There were no significant differences between the groups except for the presence of past exacerbations and the results of the RSST, when the cut-off value was set at 2, 3, 4, or 5 swallows. The number of swallows in the RSST was significantly lower in the E group than in the Non-E group. A cut-off value of 5 was the most effective. The time to first exacerbation was significantly longer in those with an RSST value of >5. The RSST was more reliable for differentiating the E group and non-E group than the presence of exacerbation in the past year (hazard ratios: 13.78 and 2.70, respectively). Conclusion: An RSST cut-off value of 5 may be a strong predictor of COPD exacerbation.

Repetitive saliva swallowing test and water swallowing test may identify a COPD phenotype at high risk of exacerbation.

INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) are known to present with dysphagia from an early stage. Dysphagia leads to swallowing-related complications, in turn leading to COPD exacerbation. Dysphagia screening is recommended; however little is known of its utility in detecting a COPD phenotype at risk for exacerbation. The simple swallowing provocation test (SSPT), considered to be a standard screening test, requires specific equipment, physician skill and patient discomfort. OBJECTIVES: The aim of this study was to find an easier and less invasive measure to screen for dysphagia in patients with COPD. METHODS: We retrospectively reviewed patients with COPD who were screened for dysphagia [Repetitive saliva swallowing test (RSST), water swallowing test (WST), SSPT and a questionnaire] from June to November 2016. The patients were classified into two groups according to the presence of COPD exacerbation in the past 3 years (ie, exacerbation and non-exacerbation group), and the dysphagia screening results were compared between the groups. RESULTS: Of the 80 cases included, 42 had 1 or more exacerbations in the past 3 years (exacerbation group), and 38 had none (non-exacerbation group). Statistically significant differences between the groups were observed in the RSST, and vocal change in the WST (P < 0.05). There were no significant differences between the groups in the results of SSPT, COPD stage and other clinical status. CONCLUSIONS: Compared to the SSPT, RSST and WST may be more appropriate screening methods in patients with COPD. A prospective study is necessary for further assessment.

A case of huge lymphatic and venous malformations of the mediastinum.

We herein report a case of huge lymphatic and venous malformations of the mediastinum (LVM). A 19-year-old man presented for evaluation of a mediastinal mass. On chest computed tomography, the mass demonstrated contrast enhancement and showed dilated veins draining into the superior and inferior vena cava, with multiple scattered calcifications. The lesion was enhanced heterogeneously on T1-weighted magnetic resonance imaging (MRI) and hyperintense on T2-weighted MRI. Contrast-enhanced MRI revealed that the mass was enhanced, with the multilocular part marginally enhanced. From these images, we diagnosed him with LVM. Given that an operation presented a high risk, we decided to follow him up without any treatment.

Pneumocystis jirovecii Pneumonia in an Immunocompetent Japanese Man: A Case Report and Literature Review.

We herein report the case of a 37-year-old immunocompetent man who died from Pneumocystis jirovecii pneumonia (PCP). He was initially treated for an acute exacerbation of interstitial pneumonia; however, the elevation of the patient's serum (1-3) ß-D glucan (BG) level suggested the possibility of PCP and sulfamethoxazole trimethoprim was added. A postmortem pathological examination and retrospective Grocott's methenamine silver (GMS) staining of the bronchoalveolar lavage fluid (BALF), which was obtained on the day of admission, revealed PCP. The present case suggests that it is essential to perform a BG assay and GMS staining of BALF specimens when patients show diffuse ground-glass opacity on chest computed tomography, regardless of their immune status.

"Pulmonary Actinomycosis attributable to Actinomyces meyeri presenting as cardiac tamponade: a case report".

BACKGROUND: Recently, it is reported that Actinomyces meyeri is the most common species causing actinomycosis. However, to our knowledge, there was no report about pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. CASE PRESENTATION: Hereby we describe a case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. At first, the patient was diagnosed with bacterial pericarditis with lung abscess in the left lower lung lobe and underwent pericardial drainage. Three days after the removal of the drainage tube, atrial fibrillation followed by cardiac arrest with asystole occurred and immediate cardiopulmonary resuscitation restored his circulation. Thereafter, he underwent pneumocentesis of the lung abscess and the culture grew A. meyeri. He was successfully treated with penicillin G. CONCLUSION: This is the first case of pulmonary actinomycosis attributable to A. meyeri presenting as cardiac tamponade. We believe that an increased awareness of the disease is necessary to expedite diagnosis therefore minimizing morbidity and mortality.

Peripheral T cell lymphoma not otherwise specified (PTCL-NOS) presenting as an endobronchial lesion: Case report and literature review.

Peripheral T cell lymphoma not otherwise specified (PTCL-NOS) is a rare entity of lymphoma. We herein report an even rarer case of a 68-year-old male with PTCL-NOS presenting as an endobronchial lesion, and review previously published cases in the literature. Initially, he was referred to our hospital for further investigation of the right upper lobe consolidation on chest radiograph. Computed tomography and 18F-fludeoxyglucose positron emission tomography revealed a right hilar mass with obstruction of the main bronchus and submandibular, right axillary and mediastinal lymphadenopathy. Pathological examination of the biopsy specimens from of the endobronchial lesion and subcutaneous nodule revealed PTCL-NOS. Chemotherapy was started but he finally died due to septic shock after the second-line chemotherapy.

Miliary Tuberculosis in a Young Woman with Hemophagocytic Syndrome: A Case Report and Literature Review.

We herein report a rare case of miliary tuberculosis-associated hemophagocytic syndrome (HPS) complicated with respiratory failure. A 19-year-old Japanese woman with a fever, general malaise, and chest radiograph abnormalities was referred to our hospital. After admission, she developed respiratory failure with pancytopenia. A histological examination of lung and bone marrow biopsy samples revealed noncaseating granulomas without evidence of acid-fast bacilli or lymphoma. In addition, a bone marrow biopsy showed marked histiocyte hyperplasia with hemophagocytosis, and a bronchoalveolar lavage fluid culture grew Mycobacterium tuberculosis. Therefore, a diagnosis of miliary tuberculosis-associated HPS was made. The patient was successfully treated with antituberculous therapy.

A Community-acquired Lung Abscess Attributable to Streptococcus pneumoniae which Extended Directly into the Chest Wall.

We herein report the case of 75-year-old Japanese female with a community-acquired lung abscess attributable to Streptococcus pneumoniae (S. penumoniae) which extended into the chest wall. The patient was admitted to our hospital with a painful mass on the left anterior chest wall. A contrast-enhanced chest computed tomography scan showed a lung abscess in the left upper lobe which extended into the chest wall. Surgical debridement of the chest wall abscess and percutaneous transthoracic tube drainage of the lung abscess were performed. A culture of the drainage specimen yielded S. pneumoniae. The patient showed a remarkable improvement after the initiation of intravenous antibiotic therapy.