[A case of pulmonary epithelioid hemangioendothelioma that required differentiation from malignant mesothelioma].

A 77-year-old woman presented with a 3-month history of right chest pain and a low-grade fever. Right pleural effusion had been detected at another hospital. Her chest CT scan revealed right pleural effusion, right pleural thickening, and bilateral multiple lung nodules. No specific findings were obtained from an examination of the pleural effusion. Thoracoscopic pleural and lung biopsies were conducted. Histologically, the tumor had an infiltrative growth pattern in the fibrously-thickened parietal pleura, visceral pleura, and lung parenchyma. The tumor was composed of epithelioid and spindle cells, and in some sections, the tumor cells had intracytoplasmic vacuoles, and had formed an immature vascular lumen. Proliferation in a papillary fashion in the alveolar spaces and vascular involvement of tumor were also seen. Immunohistochemically, the tumor cells were positive for factor VIII-related antigen, CD31, and CD34, and negative for calretinin and WT-1. The tumor was therefore diagnosed as pulmonary epithelioid hemangioendothelioma (PEH), which is a rare, low-to-moderate grade vascular tumor of the lung. This disease should be included in the differential diagnosis together with malignant pleural mesothelioma, in cases demonstrating unusual pleural thickening.

[A case of Hodgkin's lymphoma in a patient with sarcoidosis].

A 61-year-old woman was admitted to our hospital for examination of an abnormal shadow on her chest X-ray film taken in October 2006. Chest CT film taken in November 2006 revealed lymphadenopathy in the left side of the neck, as well as in the supraclavicular, axillary, mediastinal, and hilar areas, as well as around the pancreas. Diffuse small nodules were seen along the bronchovascular bundles and interlobular pleura. Bronchoscopic examination revealed lymphocyte accumulation and increased CD4/8 ratio in bronchoalveolar lavage fluid. Based on noncaseating epithelioid cell granulomas seen in transbronchial lung biopsy, we diagnosed having sarcoidosis. In April 2008, she complained of abdominal discomfort and a skin lesion. New lymphadenopathy was palpated on the right side of the neck and the left axillary region. On a chest X-ray film and chest CT film, multiple swollen lymph nodes which became even more swollen than those in November 2006 were observed. She received surgical resection of the neck lymph nodes and a pathological diagnosis of Hodgkin's lymphoma was established. This was a rare case of sarcoidosis-lymphoma syndrome.

[Case of multiple pulmonary arteriovenous fistulas detected during treatment for severe pneumonia].

A 55-year-old woman who developed severe hypoxemia associated with severe pneumonia was admitted to our hospital for mechanical ventilation. She was treated with antibiotics under a diagnosis of mycoplasma pneumonia. Although most clinical findings improved, hypoxemia remained. As a chest CT film showed multiple nodules and an enhanced CT film revealed arterial filling in the nodules, multiple pulmonary arteriovenous fistulas (PAVFs) were considered to be an underlying cause of hypoxemia. Transcatheter coil embolization for 5 PAVFs, significantly ameliorated hypoxemia in the patient. PAVF is a congenital desease, and in many cases, is asymptomatic. Therefore, it was rare for PAVFs to be detected in a middle-aged patient with prolonged hypoxemia associated with pneumonia.

[A case of lung cancer with hyperthyroidism].

We here report a case of metastasis from lung cancer to the thyroid. On presentation, this patient showed painful anterior cervical swelling and right supraclavicular lymph node swelling. Laboratory data showed primary hyperthyroidism. Although subacute thyroiditis was suspected, echo-guided needle aspiration biopsy and lymph node biopsy revealed poorly differentiated squamous cell carcinoma. As a result, primary lung cancer with thyroid metastasis was diagnosed based on mediastinal enlargement on chest X ray films and normal findings in organs other than the lung and thyroid. Chemotherapy for lung cancer induced a decrease in the size of tumor and the normalization of thyroid function. However, 2 months after the normalization, cervical swelling enlarged and a lung mass in right upper lobe and skin tumor appeared. Despite treatment with chemotherapy, she died. Postmortem revealed that the right upper lung carcinoma was the primary lesion and immunohistochemical staining for surfactant protein was positive in the thyroid, skin tumor and lymph node, which revealed these carcinomas had metastasized from lung cancer. To the best of our knowledge, thyrotoxicosis induced by thyroid metastasis of lung cancer is an uncommon case.

Elevated levels of beta-D-glucan in bronchoalveolar lavage fluid in patients with farmer's lung in Miyazaki, Japan.

BACKGROUND: Farmers may be often exposed to beta-D-glucan in moldy hay, since straw for feed can be stored throughout the year. OBJECTIVES: The aim of the present study was to clarify whether levels of beta-D-glucan, which modifies immune responses, are high in the respiratory tract in farmer's lung and whether beta-D-glucan participates in the pathogenesis of this condition. METHODS: We measured beta-D-glucan levels in the bronchoalveolar lavage fluid (BALF) of 10 patients with farmer's lung, 4 with summer-type hypersensitivity pneumonitis (HP) and 10 healthy volunteers. Interleukin (IL)-8 and tumor necrosis factor (TNF)-alpha levels in BALF were measured by enzyme-linked immunosorbent assay (ELISA). We investigated the effects of beta-D-glucan on nuclear factor (NF)-kappaB activation and on the release of IL-8 and TNF-alpha from small airway epithelial cells (SAECs) in vitro. RESULTS: beta-D-Glucan levels in the BALF of farmer's lung patients were increased compared to those in patients with summer-type HP and in healthy volunteers. Additionally, IL-8 levels in BALF were higher in farmer's lung than in summer-type HP, and TNF-alpha levels were equal in the two patient groups but raised compared to those in healthy volunteers. High, but not low, concentrations of beta-D-glucan were found to induce NF-kappaB activation in SAECs. IL-8 levels in the supernatant obtained from SAEC cultures were increased following the addition of beta-D-glucan in vitro. CONCLUSION: BALF from farmer's lung patients showed high beta-D-glucan levels, which may enhance the expression and release of cytokines through NF-kappaB activation in respiratory epithelial cells.

[A case of lung adenocarcinoma keeping complete remission by treatment with gefitinib].

A 74-year-old smoking man was admitted because of lung cancer with metastatic brain tumor. Examinations for lung cancer and brain tumor showed adenocarcinoma (clinical stage IV). Four courses of chemotherapy were not effective. Administration of gefitinib started from June 2003, but was halted after only two months because of skin rash. Lung tumor disappeared on chest computerized tomography in January 2004 and no recurrence has been detected as of March 2006. This is a rare male super-responder to gefitinib.

[A case of giant tumorous shadow by pulmonary tuberculosis].

A 63-year-old woman who had been treated for myelodysplastic syndrome had a high fever. Chest radiography and computed tomography revealed a giant tumorous shadow from the right mediastinum to the hilum. She was treated with antibiotics but with little effect. The culture of bronchial washing fluid and sputum revealed Mycobacterium tuberculosis infection. There were no malignant cells in the sputum or bronchial washing fluid. Tumor markers were within normal limits. She was treated with isoniazid, rifampicin, streptomycin and pyrazinamide. On the sixth day of treatment, high fever disappeared, and sputum culture for tuberculosis became negative after two months. The size of the mass decreased with clinical improvement. The final diagnosis was pulmonary tuberculosis with mediastinal lymphadenopathy. Since the patient was a compromised host, the giant mass was considered to be induced by atypical response to mycobacterial infection.

[A case of paragonimiasis westermani with a worm migration track on chest CT].

A 59-year-old man with rusty-colored sputum was admitted for evaluation of a nodular shadow on his chest radiograph. Chest computed tomography (CT) revealed nodules and nodular opacities with a cavity in the right S3. Chest CT also showed clearly a double linear shadow other than the bronchovascular bundle, with a different course from that of the bronchovascular bundle, suggesting a worm migration track. The diagnosis of paragonimiasis westermani was confirmed by detection of Paragonimus eggs in a bronchoscopic aspirate smear and by immunoserological examination. The linear lesion on the chest CT is uncommon in paragonimiasis, but the finding is thought to be useful for the diagnosis of this disease.