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.

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.

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.

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.

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.

Careful history taking detects initially unknown underlying causes of aspiration pneumonia.

AIM: The majority of pneumonia in the elderly is attributed to aspiration. Identifying the cause of aspiration is essential for efficient treatment and prevention. However, the methodology on how to investigate the causes is not established. Therefore, we studied cases that were initially admitted for pneumonia and were newly diagnosed with an underlying cause of aspiration. This is the first study to analyze such cases collectively. METHODS: This was a retrospective study. Patients aged 65 years or older admitted for pneumonia from October 2012 to November 2018 and were newly diagnosed with a cause of aspiration after admission was included. Patients were excluded if they had hospital-acquired pneumonia, interstitial lung disease, or obstructive pneumonia or were immunocompromised. RESULTS: In total, 4043 patients were admitted for pneumonia and 125 cases who were newly diagnosed with causes of aspiration after admission were included in the study. This constituted 30.7% of suspected aspiration pneumonia cases in which there was no known cause of aspiration on admission. The most common conditions newly identified were neurologic disorders, upper gastrointestinal disorders, drug-induced conditions, and head and neck disease. Some were lethal. The diagnosis enabled treatment of the underlying condition and prevention of aspiration in most cases. The most common sign that lead to the diagnosis was symptoms seen from admission, followed by chronic symptoms. CONCLUSION: In 30.7% of those with suspected aspiration pneumonia with an unknown cause, a cause of aspiration was newly diagnosed. Careful history taking concerning neurological, gastrointestinal and drug-induced disorders is essential in elderly patients with pneumonia. Geriatr Gerontol Int 2020; 20: 785-790.

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.

Quantitative analysis of computed tomography of the lungs in patients with lymphangioleiomyomatosis treated with sirolimus.

OBJECTIVES: We aimed to study sirolimus-related lung parenchymal changes by quantitative analysis of computed tomography (CT) of the lungs in patients with lymphangioleiomyomatosis (LAM). METHODS: We studied 20 participants from the Multicenter Lymphangioleiomyomatosis Sirolimus Trial for Safety study, who had undergone both thin-section CT scans and pulmonary function tests at baseline, 12, and 24 months. Quantitative CT parameters such as CT-derived total lung capacity, percentage of low attenuation area (LAA%), lung density histogram, fractal property of low attenuation area, and airway dimensions were analyzed, and correlations were conducted between the longitudinal change in each quantitative CT measurement and changes in pulmonary function were examined. Among 20 participants, pre-trial (n = 8) and post-trial (n = 16) CT data were also analyzed to deduce pathophysiologic implications of the serial changes in CT parameters during trial periods. RESULTS: FEV1 significantly increased from baseline to 24 months (slope 3.71 ± 1.50 ml/month) whereas FVC didn't during sirolimus therapy. Strikingly, LAA%, and skewness and kurtosis of density histogram significantly increased from baseline to 24 months, while mean and mode CT values significantly decreased from baseline to 24 months. Statistically significant positive correlations were found between ΔFEV1 and Δskewness (r = 0.465, p = 0.045). Taking the changes in lung density during pre-trial period into consideration, sirolimus decreases the area of -800 to -750 Housefield unit (HU) density and inhibits the decrease of -950 to -800 HU area during treatment, then producing the increased LAA% during the trial and post-trial periods. Given few sirolimus-related changes in airway dimensions, possible changes in lung mechanics may have contributed to increased FEV1. CONCLUSION: Our study suggests that the lung density histogram parameters, kurtosis, and skewness, may be useful as indicators of the efficacy of sirolimus.

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.

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.

Localized Pleural Metastases of Renal Cell Carcinoma After Nephrectomy: A Case Report and Literature Review.

We herein report the case of a 61-year-old Japanese male with localized pleural metastases of renal cell carcinoma. The patient was admitted to our hospital because of dyspnea on exertion and left-sided pleural effusion. He had undergone right radical nephrectomy 10 years previously. Contrast-enhanced whole-body computed tomography revealed scattered nodular thickening of the left pleura with contrast enhancement and left-sided pleural effusion. Thoracoscopy performed under local anesthesia was applied to obtain a biopsy of the pleural nodules, and the specimen was consequently diagnosed as exhibiting pleural metastasis of renal cell carcinoma, clear cell type.

Successful treatment with carboplatin and pemetrexed for multiple lymph node metastases of lymphoepithelioma-like carcinoma from an unknown primary site.

We herein report the case of an 80-year-old Japanese man with multiple lymph node metastases of lymphoepithelioma-like carcinoma (LELC) from an unknown primary site. The patient was admitted to our hospital due to hoarseness and left supraclavicular lymphadenopathy. Contrast-enhanced whole-body computed tomography revealed mediastinal, left supraclavicular, and left axillary lymphadenopathy. A left supraclavicular lymph node biopsy was performed and the specimen was consequently diagnosed as exhibting LELC. The patient's Eastern Cooperative Oncology Group performance status was 0, therefore he was started on chemotherapy with carboplatin and pemetrexed. His lymph nodes responded well to four cycles of chemotherapy without any intolerable adverse effect.