A Case of Pulmonary Actinomycosis Associated With Aspiration of Cedar Leaves.

The aspiration of foreign bodies may induce various infectious diseases, including actinomycosis, and its association with foreign bodies has been reported. We encountered a patient who developed Actinomyces-induced lung abscess associated with aspiration of cedar leaves. The patient was a 56-year-old Japanese woman who aspirated decorative cedar leaves contained in a lunch box while eating a meal, and coughing and bloody phlegm occurred thereafter. A mass was noted in the right lower lobe of the lung on plain chest computed tomography on the first consultation, and granules of Actinomyces were noted on transbronchial lung biopsy. Long-term antibiotic administration was performed, but no improvement was obtained. Thus, right lower lobectomy was performed. On postoperative pathologic examination, cedar leaves were present in the bronchus, bacterial colonies adhered to these, and there was surrounding inflammatory cell infiltration, mainly involving histiocytes and lymphocytes. This is the first report of Actinomyces associated with aspiration of cedar leaves. When the foreign body cannot be removed, it may be difficult to improve the condition by antibiotic administration alone, and surgery may be necessary.

Postobstructive pulmonary edema that developed immediately after the removal of an endobronchial foreign body.

The patient was a 5-year-old boy who was transported to our hospital for a paroxysmal cough, disturbance of consciousness, tonic-clonic convulsions and labored breathing. The patient's respiratory failure persisted after the convulsions remitted, and the presence of an endobronchial foreign body was suspected based on the findings of chest CT performed the following day. A peanut was subsequently removed from the right main bronchus using a bronchoscope with tracheal intubation and bag valve mask ventilation. Immediately after removal, the patient rapidly developed exacerbated hypoxemia, and a reduction in right lung lucency was noted on chest radiography. He was therefore diagnosed with type II postobstructive pulmonary edema, and his condition improved within a short period of time.

Hemothorax with a high carbohydrate antigen 19-9 level caused by a bronchogenic cyst.

A 58-year-old man presented with right-sided chest pain. Radiography and computed tomography showed a pleural effusion in the right chest and a mass in the right hilum. Thoracentesis showed a hemothorax. The carbohydrate antigen (CA) 19-9 level in the pleural effusion was very high, requiring differentiation from malignancy. Positron emission tomography showed no significant fluorodeoxy glucose (FDG) accumulation. Magnetic resonance imaging revealed a cystic lesion. The tumor was resected for both a diagnosis and treatment. A pathological examination demonstrated a bronchogenic cyst. An immunohistochemical study suggested that the cyst was the source of the hemothorax and the high CA19-9 level.

CT-guided ultrathin bronchoscopy: bioptic approach and factors in predicting diagnosis.

BACKGROUND: The diagnostic sensitivity of current bronchoscopy for peripheral lung cancer is inadequate because the bronchoscope insertion range is limited and confirmation of the position of the biopsy apparatus at the lesion under X-ray fluoroscopy is inaccurate. The combination of ultrathin bronchoscopy and computed tomography (CT) is effective for solving these problems. OBJECTIVE: This study was a retrospective study analyzing prospectively collected data to identify factors contributing to the diagnosis and the appropriate biopsy method in CT-guided ultrathin bronchoscopy for peripheral lung cancer. METHODS: The subjects comprised 86 patients (88 lesions) who underwent CT-guided ultrathin bronchoscopy and were finally diagnosed with peripheral lung cancer. We evaluated the diagnostic yield according to specific factors and also according to the sample collection method. RESULTS: Sixty-nine lesions were diagnosed as lung cancer, and the diagnostic yield was 78.4% (80.3% in lesions ≤2 cm in diameter). Multivariate analysis showed that the factors contributing to the diagnosis were the observation range by ultrathin bronchoscopy and the presence/absence of the involved bronchus or pulmonary artery. Pathological evaluation facilitated histological diagnoses in 53 (65.4%) of 81 lesions. In 16 lesions, only the cytological diagnosis was positive. CONCLUSION: CT-guided ultrathin bronchoscopy may be particularly useful for lesions for which the involved bronchus or pulmonary artery can be confirmed, and observation of bronchi of the 6th generation or more is possible. Since the specimen preparation rate is low, the combination of histopathological diagnosis with cytological diagnosis particularly that of the discharge attached to the forceps, is optimal.

Diagnosis of peripheral pulmonary lesions using a bronchoscope insertion guidance system combined with endobronchial ultrasonography with a guide sheath.

We developed a bronchoscope insertion guidance system that produces virtual images by extracting the bronchi by automatic threshold adjustment, and searching for the bronchial route to the determined target. We used this system in combination with a thin bronchoscope and endobronchial ultrasonography with a guide sheath (EBUS-GS), and evaluated its practicability, usefulness and safety. The subjects were 31 patients with 32 peripheral pulmonary lesions. Computed tomography (CT) data were transferred into this system, and virtual bronchial images were automatically produced by setting the lesion as the target. While virtual images with the target were displayed for comparison with real images by the system, a thin bronchoscope was advanced to the target bronchus. Transbronchial biopsy (TBB) was then performed by EBUS-GS. The system automatically produced virtual images to a median of fifth- (third- to seventh-) order bronchi. In all patients, the thin bronchoscope could be guided along the planned route, and observation to a median of fifth- (third- to seventh-) order bronchi was possible. Thirty lesions (93.8%) were successfully visualized by EBUS, and 27 (84.4%) could be pathologically diagnosed. In lesions < or =30mm in size, the EBUS visualization yield was 91.7% (22/24), and the diagnostic yield was 79.2% (19/24). The median total examination time was 22.3 (9.8-41.5) min. In summary, using the bronchoscope insertion guidance system, virtual images can be readily produced, and the bronchoscope can be successfully guided to the target. This method is promising as a routine examination method in the biopsy of peripheral pulmonary lesions.

A virtual bronchoscopic navigation system for pulmonary peripheral lesions.

STUDY OBJECTIVES: We performed ultrathin bronchoscopy for pulmonary peripheral lesions using a system that displays virtual bronchoscopy (VB) images to the lesion simultaneously with actual images and navigates the bronchoscope to the target bronchus. We then evaluated the system with regard to its usefulness and problems. DESIGN: A pilot study. SETTING: A tertiary teaching hospital. PATIENTS: The subjects were consecutive patients with small pulmonary peripheral lesions (< or = 30 mm). INTERVENTIONS: Using this system, the rotation, advancement, and retreat of VB images were possible, and the bronchus into which the bronchoscope was to be advanced was displayed. VB images were displayed along with actual images, and the ultrathin bronchoscope was advanced to the target bronchus under direct vision. Under CT and radiographic fluoroscopy, a pair of forceps was inserted into the lesion via the bronchoscope. Thin-section CT images were obtained; after confirming the advancement of the bronchoscope into the target bronchus and the arrival of the forceps at the lesion, a biopsy was performed. RESULTS: Study subjects included 37 patients with 38 lesions. VB images to a median of the sixth- (third- to ninth-) order bronchi could be produced. Using this system, the ultrathin bronchoscope could be advanced into the planned route for 36 of the 38 lesions (94.7%). The system was used for a median of 2.6 min, and the median examination time was 24.9 min. The biopsy forceps could be advanced to the lesion in 33 of the 38 lesions (86.8%), and diagnosis was possible for 31 lesions (81.6%). CONCLUSIONS: This navigation system is useful for ultrathin bronchoscopy for pulmonary peripheral lesions.

A barium marking method using an ultrathin bronchoscope with virtual bronchoscopic navigation.

CT scanning in a 77-year-old woman showed a ground-glass opacity pattern shadow(9 x 7 mm) in the right lower lobe. To allow identification of the location of the lesion during thoracoscopic surgery, preoperative barium marking was performed using an ultrathin bronchoscope and virtual bronchoscopic navigation. Virtual bronchoscopy was performed based on thin-section CT images, and virtual bronchoscopic images to the target sites were obtained. Subsequently, using virtual bronchoscopic images to right B8aiibetax, B6biibeta for navigation, an ultrathin bronchoscope was advanced to this site under direct observation. A special catheter for ultrathin bronchoscopy was advanced to sites near the lesion, and barium was infused. Barium was clearly observed by radiographic fluoroscopy during thoracoscopic surgery and was useful for determining the area for resection. Pathological examination of the resected specimen revealed atypical adenomatous hyperplasia. There were no complications with this method, and a number of target areas could be readily marked in a short time. This method may be useful before thoracoscopic surgery for small peripheral pulmonary lesions.

[A barium marking method using an ultrathin bronchoscope with virtual bronchoscopic navigation].

CT scanning of a 77-year-old woman showed a ground-glass opacity pattern shadow (9 x 7 mm) in the lower lobe of the right lung. To allow identification of the location of the lesion during thoracoscopic surgery, preoperative barium marking was performed using an ultrathin bronchoscope and virtual bronchoscopic navigation. Virtual bronchoscopy was performed based on thin-section CT images, and virtual bronchoscopic images to the target sites were obtained. Subsequently, using virtual bronchoscopic images to the right B8aii beta x, B6bii beta for navigation, an ultrathin bronchoscope was advanced to this site under direct observation. A special catheter for ultrathin bronchoscopy was advanced to sites near the lesion, and barium was infused. The barium was clearly observed by fluoroscopy during thoracoscopic surgery and was useful for determining the resection area. Pathological examination of a resected specimen revealed atypical adenomatous hyperplasia. There were no complications with this method, and a number of target areas could be readily marked in a short time. This method may be useful before thoracoscopic surgery for small peripheral pulmonary lesions.

[CT-guided transbronchial diagnosis using ultrathin bronchoscope for small peripheral pulmonary lesions].

We performed computed tomography (CT)-guided transbronchial diagnosis on 23 patients, using an ultrathin bronchoscope (external diameter, 2.8 mm) for small peripheral pulmonary lesions (< or = 2 cm). The mean size of the lesions was 1.4 x 1.1 cm. After examination using a conventional bronchoscope (external diameter, 6.3 mm), an ultrathin bronchoscope and a biopsy apparatus were advanced to the lesion under CT and X-ray fluoroscopic guidance. The location of the biopsy apparatus at each lesion was confirmed by thin-section CT, and a biopsy was performed. The ultrathin bronchoscope reached the 5th-11th bronchus (mean, 7.1 +/- 1.5th), at a point 3.6 +/- 0.9 bronchi peripheral to the site reached using a conventional bronchoscope. In 20 of the 23 patients, the biopsy apparatus could be guided to the lesion. The diagnosis rate, by disease, was 81.8% (9/11) for lung cancer, 66.7% (2/3) for metastatic lung cancer, and 77.8% (7/9) for inflammation; the overall rate being 78.3% (18/23). CT-guided transbronchial diagnosis using an ultrathin bronchoscope is useful for diagnosing small peripheral pulmonary lesions because the bronchoscope can be readily inserted into peripheral areas and guided to lesions, and the site of sample collection can be accurately determined.