An immunocompetent case of chronic pulmonary aspergillosis caused by Aspergillusviridinutans.

We encountered an extremely rare immunocompetent case of chronic pulmonary aspergillosis (CPA) caused by Aspergillus viridinutans. A 74-year-old woman was admitted with fever and hemoptysis. Chest computed tomography revealed a nodule in the left upper lobe. Bronchoscopy was performed, and the transbronchial biopsy specimen revealed Aspergillus fungi. Treatment of the nodule was initially ineffective with voriconazole but effective with liposomal amphotericin B. The causative organism was later identified as A. viridinutans based on the gene sequence of ß-tubulin. This is the first immunocompetent case of CPA caused by A. viridinutans.

Acute Hemorrhagic Rectal Ulcer Complicated by Cytomegalovirus Enteritis following Steroid Pulse Therapy for Acute Exacerbation of Interstitial Pneumonia.

We herein report a rare case of acute hemorrhagic rectal ulcer (AHRU) complicated by cytomegalovirus enteritis following steroid pulse therapy for interstitial pneumonia. An 86-year-old woman underwent steroid pulse therapy for interstitial pneumonia. She was bedridden with dyspnea and suddenly developed melena. Colonoscopy revealed AHRU, which did not improve with conservative treatment, but did improve with ganciclovir administration for cytomegalovirus enteritis. This gastrointestinal complication has not received much attention by pulmonologists who perform steroid pulse therapy for interstitial pneumonia. Delayed treatment of this complications can be fatal. Caution should be taken when administering steroid pulse therapy to bedridden patients with interstitial pneumonia.

Phase II study of irinotecan and amrubicin in patients with relapsed non-small cell lung cancer: Okayama Lung Cancer Study Group Trial 0402.

BACKGROUND: The survival advantage achieved by existing anti-cancer agents as second-line therapy for relapsed non-small cell lung cancer (NSCLC) is modest and further improvement of treatment outcome is desired. Combination chemotherapy with irinotecan and amrubicin for advanced NSCLC has not been fully evaluated. METHODS: The primary endpoint of this phase II clinical trial was objective response. Patients with NSCLC who had been treated previously with one or two chemotherapy agents were enrolled. Irinotecan and amrubicin were both administered on Days 1 and 8 of a 21-day cycle, at doses of 100 mg/m(2) and 40 mg/m(2), respectively. RESULTS: Between 2004 and 2006, 31 patients received a total of 101 courses; the median number of courses administered was three (range, one to six). Objective response was obtained in nine of the 31 patients (29.0% response rate; 95% confidence interval (CI), 12.1-46.0%). With a median follow-up time of 43.9 months, median survival time and the median progression-free survival time were 14.2 and 4.0 months, respectively. Myelosuppression was the most frequently observed adverse event, with grade 3/4 neutropenia in 51% of patients. Febrile neutropenia developed after nine courses (9%) and resulted in one treatment-related death. Cardiac toxicity and diarrhea, possibly specific for both agents, were infrequent and manageable. CONCLUSION: Combination chemotherapy with irinotecan and amrubicin is effective in patients with NSCLC but showed moderate toxicities in second- or third-line settings.

Dramatic Response to Alectinib in a Critically Ill Elderly Patient with Lung Adenocarcinoma Due to Trousseau Syndrome and Disseminated Intravascular Coagulation.

Lung cancer complicated with Trousseau syndrome (TS) or disseminated intravascular coagulation (DIC) has a severe prognosis. We herein report an elderly lung cancer patient who presented with a critically ill condition due to concomitant TS and DIC and responded dramatically to alectinib. There are no rules regarding treatment indications based on the age or severity of critically ill patients. If the patient's cancer cells are positive for anaplastic lymphoma kinase rearrangement, alectinib is worthwhile to administer, even in a critically ill condition. In our patient, anticoagulation failed to suppress the TS complications. We also report how to prevent the recurrence of TS.

A Fast-growing Benign Metastasizing Leiomyoma Mimicking Malignancy.

We herein report a rare case of fast-growing benign metastasizing leiomyoma. A 52-year-old woman was admitted to our hospital with abnormal chest shadows. Chest computed tomography showed well-circumscribed cystic tumors. Because malignancy could not be completely distinguished in fast-growing tumors, video-assisted thoracic surgery was performed. The pathological findings revealed many cysts and the proliferation of smooth muscle cells. According to the Stanford criteria, the tumor was diagnosed as benign metastasizing leiomyoma. One possible reason for the fast growth of the tumor was enlargement of the cysts. Malignant diseases characterized by cystic tumors are rare but occasionally reported. Therefore, differentiation by a pathological examination is essential.

Dramatic improvement in innominate artery compression syndrome with only postural changes in a bedridden elderly patient.

We present the case of a bedridden elderly patient who demonstrated dramatic improvement in innominate artery compression syndrome with postural changes alone. A 94-year-old woman presented with dyspnea. Physical findings revealed stridor in the right-sided decubitus position. Her symptoms did not improve with conventional asthma treatment. Plain computed tomography revealed tracheal compression by the bent innominate artery. Contrast-enhanced computed tomography with postural changes altered the compression sites of the organs, resolving the tracheal stenosis. The number of similar bedridden elderly patients will increase in an aging society. We report this case to aid physicians in managing such patients.

A case of nonmucinous pulmonary micropapillary adenocarcinoma mimicking pulmonary tuberculosis.

We report a rare case of nonmucinous pulmonary micropapillary adenocarcinoma mimicking pulmonary tuberculosis. A 68-year-old woman was hospitalized with hemoptysis. Her computed tomography revealed cavities and tree-in-bud appearance similar to the extensive form of pulmonary tuberculosis. However, histopathological findings of transbronchial biopsies of all lesions revealed adenocarcinoma and no pulmonary tuberculosis. Tree-in-bud appearance may relate to the floating micropapillary tufts in alveolar spaces. If pulmonary carcinoma is complicated by pulmonary tuberculosis, patients must be isolated and disadvantaged in cancer treatments. Therefore, recognizing this case may be therapeutically useful for respiratory physicians treating both diseases.

Drug discontinuation after treatment with minimum maintenance dose of an antithyroid drug in Graves' disease: a retrospective study on effects of treatment duration with minimum maintenance dose on lasting remission.

According to the guideline issued by the Japan Thyroid Association in 2006 for treatment of Graves' disease, discontinuing antithyroid drug (ATD) therapy is recommended when serum free thyroxine (FT4) and thyroid stimulating hormone (TSH) concentrations have been maintained within the reference range for a certain period after treatment with one ATD tablet every other day (minimum maintenance dose therapy, MMDT). In this retrospective study, the relationship between MMDT duration and remission rate was investigated. The participants were 107 consecutive patients with Graves' disease whose ATD therapy was stopped according to the guideline. Serum FT4, TSH, and TSH receptor antibody (TRAb) levels were measured when ATD was discontinued and every 3 months thereafter. The percentage of patients in remission was 86.9% at 6 months, 73.8% at 1 year, and 68.2% at 2 years after ATD discontinuation. The remission rate increased with MMDT duration, being significantly higher in patients with MMDT durations of 19 months or more than those with MMDT durations of 6 months or less. In patients with MMDT durations of 6 months or less, the remission rate was significantly lower in TRAb-positive patients than in TRAb-negative patients at the time of withdrawal of ATD; however, this was not observed in patients with MMDT durations of 7 months or more. These findings suggest that in patients who discontinue ATD after a certain MMDT duration, the remission rate increases as the MMDT duration increases, and ATD should not be discontinued in TRAb-positive patients with MMDT durations of 6 months or less.

Persistent high TRAb values during pregnancy predict increased risk of neonatal hyperthyroidism following radioiodine therapy for refractory hyperthyroidism.

Serum levels of TSH receptor antibody (TRAb) often increase after radioiodine treatment for Graves' disease, and high-serum levels of maternal TRAb in late pregnancy indicate a risk of neonatal hyperthyroidism. The aim of this retrospective study is to investigate the characteristics of Graves' women who had a history of radioiodine treatment for intractable Graves' disease, and whose neonates suffered from hyperthyroidism. The subjects of this study were 45 patients with Graves' disease who became pregnant during the period from 1988 to 1998 after receiving radioiodine treatment at Ito Hospital. 25 of the 45 subjects had had a relapse of hyperthyroidism after surgical treatment for Graves' disease. 19 pregnancies were excluded because of artificial or spontaneous abortion. In the remaining 44 pregnancies of 35 patients, neonatal hyperthyroidism developed in 5 (11.3%) pregnancies of 4 patients. Serum levels of TRAb at delivery were higher in patients whose neonates suffered from hyperthyroidism (NH mother) than those of patients who delivered normal infants (N mother). Furthermore, serum levels of TRAb in NH mother did not change during pregnancy, although those of 4 patients of N mother, in which serum levels of TRAb before radioiodine treatment were as high as in NH mother, decreased significantly during pregnancy. In conclusion, women who delivered neonates with hyperthyroidism following radioiodine treatment seem to have very severe and intractable Graves' disease. Persistent high TRAb values during pregnancy observed in those patients may be a cause of neonatal hyperthyroidism.

A Novel Type of Aspiration Presenting With Acute Respiratory Failure Caused by Upper Airway Obstruction Due to Diaper Pica.

We herein report an extremely rare case of acute respiratory failure due to pica of the high-molecular-weight polymers in a diaper (HMWPD). An 81-year-old woman was admitted to our hospital because of dyspnea. Several hours earlier, the facility staff saw her tearing the diaper and eating it. And several hours later, the staff found her complaining of dyspnea. Her chest computed tomography revealed airway foreign bodies. Immediately, flexible bronchoscopy was performed. The trachea and the bilateral bronchi were filled with the HMWPD. We tried to grasp the HMWPD with various common instruments, but the HMWPD could not be grasped. Finally, we performed direct bronchoscopic suction. All the HMWPD were removed successfully. The HMWPD have hygroscopic property resulting in volume expansion and the fatal consequence of upper airway obstruction. Physicians working in an emergency department should be aware of this acute respiratory failure due to diaper pica and its effective treatment.

Successful Treatment of Antifungal Combination Therapy with Inhaled Liposomal Amphotericin B and Oral Voriconazole for Intractable Chronic Progressive Pulmonary Aspergillosis.

We experienced a case of the successful treatment of intractable pulmonary aspergillosis with inhaled liposomal amphotericin B (L-AMB) and oral voriconazole (VRCZ). A 52-year-old man was admitted to our hospital with a fever. Chest computed tomography (CT) revealed an infiltrative shadow. Two separate sputum cultures detected Aspergillus niger. Although we treated the patient with single and combined antifungal agents, the infiltrative shadow worsened. After obtaining sufficient informed consent from the patient, we switched him to an inhaled L-AMB. The infiltrative shadow subsequently improved. The patient has remained well for one year without exacerbation. We herein report the usefulness of inhaled L-AMB and oral VRCZ.

PaO2-guided Low-dose Oxygen Therapy for Pneumatosis Cystoides Intestinalis to Prevent Acute Exacerbation of Interstitial Pneumonia.

We herein report the first case of low-dose oxygen therapy for pneumatosis cystoides intestinalis (PCI) using PaO2 as a therapeutic index to prevent acute exacerbation of interstitial pneumonia. An 86-year-old man was admitted to our hospital with abdominal distension. PCI was diagnosed by abdominal computed tomography. Low-dose oxygen therapy was started to avoid acute exacerbation of interstitial pneumonia. The oxygen dose was adjusted so that the PaO2 value was approximately 100 mmHg. After seven days of treatment, the colon gas had disappeared, and no acute exacerbation of interstitial pneumonia was observed. A PaO2 value around 100 mmHg is effective for PCI without inducing acute exacerbation of interstitial pneumonia.

Interstitial Pneumonia Secondary to Hermansky-Pudlak Syndrome Type 4 Treated with Different Antifibrotic Agents.

Hermansky-Pudlak syndrome (HPS) is an autosomal recessive hereditary disease that may be complicated by progressive and potentially fatal interstitial pneumonia. We herein report a 64-year-old woman with interstitial pneumonia associated with HPS type 4 whom we treated with nintedanib after pirfenidone proved ineffective. To our knowledge, there have been no previous reports of nintedanib being used to treat a patient with HPS type 4. There is a need for clinical trials of antifibrotic agents, including nintedanib, pirfenidone, and new therapeutic agents with different mechanisms of action in these patients.

Measuring thyroglobulin autoantibodies by sensitive assay is important for assessing the presence of thyroid autoimmunity in areas with high iodine intake.

There is some debate over the clinical utility of measuring serum TgAb to assess the presence of thyroid autoimmunity. To clarify the relationship between TgAb levels and thyroid autoimmunity, a histological examination of thyroid tissue was carried out on unselected living individuals with detectable serum TgAb. 146 patients with a pathological diagnosis of follicular adenoma were selected as subjects. Focal lymphocytic infiltration (FLI) was defined as lymphocytic aggregates of more than 200 in number. A thyroid gland in which 0-1 FLI was observed in a few visual fields of low magnification (20 x 4) in thyroid tissue adjacent to a tumor was judged to be normal and a thyroid gland in which 2 or more FLI were observed was diagnosed as focal lymphocytic thyroiditis (FLT). Serum levels of TgAb and TPOAb were measured by radioimmunoassay. Out of the 146 patients, 18 had detectable serum TgAb and 16 had detectable serum TPOAb. All but one (i.e. 94%) of the 18 TgAb positive patients had FLT and 14 out of the 16 TPOAb positive patients had FLT. The sensitivity (17/32; 53.1%) and specificity (113/114; 99.1%) of TgAb for detecting FLT were higher than those (14/32; 43.7% and 112/114; 98.2%) of TPOAb, but the differences were not significant. In 9 patients who were TgAb positive (but TPOAb negative), 8 (88.9%) had FLT. These results throw doubt on the Laboratory medicine practice guidelines published in Thyroid 2003, in which measuring TgAb is not usually necessary for detecting autoimmune thyroid disease. At least measuring TgAb by sensitive assay is useful for assessing the presence of thyroid autoimmunity in Japan, an area with high iodine intakes.

Comparison of methimazole and propylthiouracil in patients with hyperthyroidism caused by Graves' disease.

CONTEXT: Although methimazole (MMI) and propylthiouracil (PTU) have long been used to treat hyperthyroidism caused by Graves' disease (GD), there is still no clear conclusion about the choice of drug or appropriate initial doses. OBJECTIVE: The aim of the study was to compare the MMI 30 mg/d treatment with the PTU 300 mg/d and MMI 15 mg/d treatment in terms of efficacy and adverse reactions. DESIGN, SETTING, AND PARTICIPANTS: Patients newly diagnosed with GD were randomly assigned to one of the three treatment regimens in a prospective study at four Japanese hospitals. MAIN OUTCOME MEASURES: Percentages of patients with normal serum free T(4) (FT4) or free T(3) (FT3) and frequency of adverse effects were measured at 4, 8, and 12 wk. RESULTS: MMI 30 mg/d normalized FT4 in more patients than PTU 300 mg/d and MMI 15 mg/d for the whole group (240 patients) at 12 wk (96.5 vs. 78.3%; P = 0.001; and 86.2%, P = 0.023, respectively). When patients were divided into two groups by initial FT4, in the group of the patients with severe hyperthyroidism (FT4, 7 ng/dl or more, 64 patients) MMI 30 mg/d normalized FT4 more effectively than PTU 300 mg/d at 8 and 12 wk and MMI 15 mg/d at 8 wk, respectively (P < 0.05). No remarkable difference between the treatments was observed in patients with initial FT4 less than 7 ng/dl. Adverse effects, especially mild hepatotoxicity, were higher with PTU and significantly lower with MMI 15 mg/d compared with MMI 30 mg/d. CONCLUSIONS: MMI 15 mg/d is suitable for mild and moderate GD, whereas MMI 30 mg/d is advisable for severe cases. PTU is not recommended for initial use.

Comprehensive pulmonary rehabilitation according to severity of COPD.

A new classification for the severity of COPD was proposed at GOLD 2003: stage I: FEV(1) > or = 80% predicted; stage II: 50% < or = FEV(1)<80%; stage III: 30% < or = FEV(1)<50%; and stage IV: FEV(1) < 30%. To elucidate the acute effects of pulmonary rehabilitation (PR) on patients with different stages of COPD, data on pulmonary function, arterial blood gas analysis, the 6-min walk test, respiratory muscle strength, and activities of daily living were analyzed before and after our comprehensive 4- to 8-week inpatient PR program between 1992 and 2003. A total of 225 patients (201 men and 24 women; 21 with stage II, 79 with stage III, and 125 with stage IV COPD) was assessed. There were significant differences in FEV(1)% predicted and % residual volume in stages III and IV, in % vital capacity in stages II, III and IV, and in % total lung capacity in stage II when comparing the changes between pre- and post-PR. Significant differences of PaO(2) in stages III and IV and PaCO(2) in stage IV were found when comparing the changes between pre- and post-PR. The 6-min walk distance was significantly increased after PR by an average of approximately 50m for all staged patients. Respiratory muscle strength was also significantly increased in stages III and IV. Activities of daily living were significantly improved in all stages. These results showed that patients with COPD had benefited from PR regardless of disease severity. The effects included improvement in pulmonary function, arterial blood gas analysis, 6-min walk distance, respiratory muscle strength, and activities of daily living although there were some differences among the three stages.

Distance and oxygen desaturation in 6-min walk test predict prognosis in COPD patients.

The aim of the present study was to predict the prognosis of Chronic obstructive pulmonary disease (COPD) patients who underwent comprehensive pulmonary rehabilitation (PR). A total of 144 patients who performed PR between 1992 and 1999 was assessed. After PR, 67 patients underwent lung volume reduction surgery (LVRS). Baseline data before PR consisted of body mass index, serum albumin levels, use of supplement oxygen at home, pulmonary function, arterial blood gas analysis, and distance and fall of hemoglobin oxygen saturation (DeltaSpO(2)) in 6-min walk test. In addition to pre-PR factors, treatment with LVRS was taken into the analysis. The prognostic significance of variables influencing survival was determined by univariate analysis with Log rank test or multivariate analysis using Cox's proportional hazard model. By a median follow-up time of 8.4 years, the median survival time was 8.1 years (95% confidence interval: 6.9-9.4 years). Albumin level, PaCO(2), distance and DeltaSpO(2) were significant prognostic factors in univariate analysis. LVRS did not affect the prognosis. The multivariate analysis showed short distance and increase of DeltaSpO(2) as significant independent predictors of the risk of death. 6-min walk test was very useful for predicting the prognosis of the COPD patients.

[Basic policy for postsurgical follow-up of patients with differentiated thyroid carcinoma--guidelines from abroad].

Basic policy for postsurgical follow-up of patients with differentiated thyroid carcinoma has not been officially announced from both Japan Thyroid Association and the Japanese Society of Thyroid Surgery. In this review, guidelines from the American Thyroid Association Guidelines Taskforce and the European Thyroid Cancer Taskforce were introduced. Essentially, the initial surgical procedure for most patients with thyroid cancer is a near-total or total thyroidectomy, in both guidelines. And postoperative radioiodine remnant ablation is recommended to destroy residual thyroid tissue in an effort to decrease the risk for recurrent locoregional disease and to facilitate long-term surveillance with whole-body iodine scans and/or stimulated thyroglobulin measurements. Basic policy for postsurgical follow-up of patients with differentiated thyroid carcinoma is written on the above mentioned condition.

Gingival metastasis in lung cancer.

Gingival metastasis is an extremely rare manifestation of lung cancer, and exhibits rapid growth with various clinical symptoms. Physicians must appropriately manage patients with lung cancer who develop gingival metastasis. Clinical records of patients with lung cancer treated at the Department of Internal Medicine II, Okayama University Hospital, between 1976 and 1998 were retrospectively reviewed. The medical literature was searched by Medline to identify reports of gingival metastasis from lung cancer. Three of 729 (0.41%) lung cancer patients developed gingival metastasis in our hospital between 1976 and 1998, and 9 additional cases of this type of metastasis were found in the literature. All were male, and median age was 57.5 years (range, 47 to 70). There were no clear correlations between development of gingival metastasis and either histologic type or location of the primary lesion. Chemotherapy or radiotherapy was effective for treatment of gingival metastasis, and the quality of life was improved. However, survival after development of gingival metastasis was very short, with median survival of only 4 months.