[A HEALTHY ADULT WITH DISSEMINATED NONTUBERCULOUS MYCOBACTERIAL INFECTION WITH MULTIPLE BONE LESIONS].

A 54-year-old man was admitted to our hospital because of fever, dyspnea, and low back pain. Chest computed tomography showed a 30-mm mass in the left lung and bilateral pleural fluids, multiple bone lesions, enlarged lymph nodes, and skin abscesses. Mycobacterium avium was isolated from his sputum, a pleural fluid sample, the right cervical lymph node, and a precordial skin abscess. We thus diagnosed his illness as disseminated nontuberculous mycobacterial infection (DNTM) and treated him with multiple chemotherapeutic agents. However, the disease progressed, and he ultimately died. He was not in an obvious immunocompromised state. DNTM with multiple bone lesions in a healthy adult is very rare and we therefore report this case.

Recurrence of lung adenocarcinoma after an interval of 15 years revealed by demonstration of the same type of EML4-ALK fusion gene.

We carried out an experiment on a 58-year-old man with multiple left lung tumors and swelling of multiple lymph nodes. For clinical staging and therapeutic purposes, bronchoalveolar lavage (BAL) cytology and lung biopsy were performed. The biopsy specimen revealed the left lower lung mass to be immunohistochemically ALK (anaplastic lymphoma kinase)-positive adenocarcinoma. Using the BAL specimen from the left lower lung, EML4 (echinoderm microtubule-associated protein-like 4)-ALK variant 1 fusion gene was detected by reverse transcription-polymerase chain reaction (RT-PCR). His past history showed that he had undergone an operation for lung adenocarcinoma of the right lower lobe 15 years before, and the pathological specimen at that time revealed that the lung adenocarcinoma with pleural invasion and single metastasis of mediastinal lymph node showed a mucinous cribriform pattern and/or signet-ring cell pattern. The typical histology led us to examine the ALK rearrangement in the primary lung cancer and mediastinal metastatic tumor. Immunohistochemistry (IHC) for ALK was positive, and ALK break apart fluorescence in situ hybridization (FISH) showed a positive result. Moreover, RT-PCR using formalin-fixed, paraffin-embedded tissue from the right lung cancer also demonstrated EML4-ALK variant 1 fusion gene. Although there is a possibility that the left lung cancer is de novo one with multiple metastases, detection of the same fusion gene of the very rare EML4-ALK variant 1 in both tumors suggests that the left cancer is a recurrence of the right lung cancer after an interval of 15 years.

[Case of pulmonary cryptococcosis which developed in a patient receiving abatacept therapy for rheumatoid arthritis].

A 59-year-old woman who had been receiving abatacept therapy for rheumatoid arthritis was noted to have multiple nodules in both lungs on routine chest X-ray films. Chest computed tomography (CT) revealed multiple nodules with small cavities in both lung fields. The Cryptococcus neoformans antigen was detected from her serum and bronchial lavage fluids, indicating a diagnosis of pulmonary cryptococcosis. Abatacept was discontinued, and antifungal treatment with fluconazole was started. The lung nodules gradually shrank, and the cavities disappeared. To the best of our knowledge, we describe the first case of pulmonary cryptococcosis associated with abatacept therapy.

[A case of small cell lung carcinoma without apparent primary lesion accompanying Lambert-Eaton myasthenic syndrome].

A 58-year-old man complaining of increasing weakness of muscular leg strength, diplopia and ptosis was admitted to our hospital. An electromyogram (EMG) showed typical waxing phenomenon in response to high-frequency repetitive stimulation. A diagnosis of Lambert-Eaton myasthenic syndrome (LEMS) was made from his symptoms and EMG results. A chest CT showed mediastinal lymph node swelling. No abnormal mass was seen in either lung field. His serum levels of a P/Q-type anti-voltage-gated calcium channel (VGCC) antibody, Pro-GRP, and NSE were high. FDG-PET showed accumulation of FDG to the mediastinal and left inguinal lymph nodes. The left inguinal lymphadenopathy was pathologically diagnosed as metastasis of small cell lung carcinoma. No tumor could be detected by bronchofiberscopy. No other distant metastasis was detected by brain MRI, abdominal CT, or FDG-PET. After 6 courses of chemotherapy for SCLC, a partial response and reduction of symptoms were obtained. For assessment of indistinguishable neuropathic symptoms, the possible diagnosis of paraneoplastic syndrome, such as LEMS, and the fact that early treatment for primary disease was effective, should be considered.

[Case of recurrence of AA type primary solitary pulmonary amyloidosis].

The patient was a 64-year-old asymptomatic man. His chest X-ray film, at age 61, showed a solitary nodule in the right middle lobe. Thoracoscopic surgery was performed. The nodule was pathologically diagnosed as a solitary nodular amyloidosis. After 3 years, his chest CT showed a solitary nodule in the left upper lung. Thoracoscopic surgery for the pulmonary nodule was performed again, and it was also pathologically diagnosed as a solitary nodular amyloidosis with AA type amyloid protein. Solitary nodular pulmonary amyloidosis is usually AL type, and few cases of solitary AA type amyloidosis have been reported. We reported a rare case of recurrence of solitary pulmonary amyloidosis.