The diagnostic yield using ultrasound-guided needle-aspiration for subpleural primary lung cancer is not affected by the radiological properties of the lesions resulting from computed tomography.

BACKGROUND: It is well known that ultrasound-guided needle-aspiration (USGNA) for intrapulmonary subpleural lesion in contact with the pleura is useful and safe, and its diagnostic yield is high. However, reports concerned with the analyses of cases with intrapulmonary subpleural lesion which could not be diagnosed using USGNA are limited. The objective of this study is to clarify the radiological properties of subpleural primary lung cancer which obstruct diagnosis by USGNA. METHODS: The consecutive cases with subpleural primary lung cancer whose radiological properties could be confirmed by thoracic computed tomography (CT) without contrast enhancement (CE), and examined by USGNA at our hospital between January 1999 and December 2014 have been analyzed. All cases were given pathological diagnoses of primary lung cancer. The diagnostic yield by USGNA was calculated, and the properties of the lesions of the subjects were analyzed by means of thoracic CT without CE images and pathological findings. RESULTS: 87 consecutive cases (41-86 year olds, 75 males, 12 females) were analyzed. The overall diagnostic yield by USGNA was 86.2%. There was no statistically significant difference regarding the diagnostic yield concerning radiological properties such as cavities, small airspaces and low density areas in the lesions and their sizes. However, the diagnostic yield for the cases with squamous cell carcinoma was statistically significantly low (p=0.02). CONCLUSION: Although the diagnostic yield of USGNA is not distorted by the radiological properties of lesions, it is statistically significantly low in cases with squamous cell carcinoma.

Do respiratory comorbidities limit the diagnostic usefulness of ultrasound-guided needle aspiration for subpleural lesions?

BACKGROUND: The usefulness of ultrasound-guided needle aspiration for subpleural lesions has been reported. However, no reports have evaluated its usefulness and safety in patients with respiratory comorbidities such as chronic obstructive pulmonary disease (COPD) and interstitial pneumonia (IP), which can increase the risk of iatrogenic pneumothorax. In this study, we evaluated the influence of chronic respiratory diseases (CRDs) on the usefulness and safety of ultrasound-guided needle aspiration for subpleural lesions. METHODS: Between January 2000 and September 2011, we examined 144 patients with intrapulmonary subpleural lesions. We retrospectively reviewed clinical data, including lesion size on thoracic computed tomography (CT), ultrasound findings, pathological findings obtained by ultrasound-guided needle aspiration, final diagnosis, and complications. RESULTS: A positive definitive diagnosis was obtained in 74.3% of all 144 patients; 84.7% patients with malignant diseases, including lung cancer; and 26.9% patients with benign diseases. Of the 144 patients, 64 belonged to the CRD group and 80 to the non-CRD group. The former included 31 patients with COPD, six with emphysematous changes on thoracic CT, 17 with IP, and 10 with other diseases. The positive rate of diagnosis for malignant diseases was 84.7% in the CRD group, which was the same as that in the non-CRD group. With regard to complications related to ultrasound-guided aspiration, there were only two cases of pneumothorax in the CRD group and one in the non-CRD group. CONCLUSION: Ultrasound-guided aspiration is safe and useful for subpleural lesions, particularly malignant lesions, even in patients with respiratory comorbidities such as COPD and IP.

Solitary fibrous tumor of the pleura: ultrasonographic imaging findings of 3 cases.

Solitary fibrous tumor (SFT) of the pleura is a rare tumor of mesenchymal origin. Although radiographic findings of thoracic computed tomography and magnetic resonance imaging in the evaluation of SFTs of the pleura have been documented, the value of ultrasonography is uncertain. We presented the ultrasonographic findings of 3 pathologically proven cases of SFTs arising from the visceral pleura. In all the cases, thoracic ultrasonography demonstrated homogeneous, hypoechoic, hemicycle, extrapulmonary lesions, which showed respiratory movement with the adjacent lung, consistent with pedunculated tumors. Preoperative thoracic ultrasonography could be useful in the evaluation of patients with pleural tumors, especially SFTs.

A case of diaphragmatic paralysis complicated by herpes-zoster virus infection.

Diaphragmatic paralysis is commonly caused by surgical and traumatic injuries, malignant neoplasm, and neurodegenerative disorders. However, in rare instances, diaphragmatic paralysis due to herpes-zoster virus infection has been reported. Here, we describe an 85-year-old woman who developed left hemidiaphragmatic paralysis within 19 days of the appearance of a typical herpes-zoster rash involving the C4-5 dermatome on the left side. Clinical and radiological findings revealed no local causes of phrenic nerve lesion. The hemidiaphragmatic paralysis was thought to be caused by herpes-zoster virus infection.

[Clinical analysis of mortality in elderly patients with community-acquired pneumonia].

AIM: Community-acquired pneumonia remains a common and serious disease for elderly persons. The incidence and mortality rates of pneumonia are higher in the elderly. We analyzed the mortality and prognostic factors in 200 elderly patients with community-acquired pneumonia. METHODS: The subjects were 200 elderly patients aged 65 years or older who needed hospitalization after initial visit to Geriatric Medicine, Juntedo Tokyo Koto Geriatric Medical Center, between January 2005 and December 2006. The subjects were divided into two groups, those who died, and those who survived on admission, we examined mortality rates and compared the background, underlying disease, laboratory data, chest X-ray findings, severity classification using A-DROP, between the two groups. RESULTS: The mortality rate was 15.0%. Circulating diseases, cerebrovacscular diseases and dementia were the most common underlying diseases. It took a longer period to enter the hospital in the cases that died. In laboratory findings, total protein, serum albumin and percutaneous oxygen saturation were lower, and BUN was higher in the fatality group. There were many more patients who had extending infiltration shadow on chest X-ray films and severe condition on A-DROP classification in the fatality group. CONCLUSIONS: We concluded that delay of diagnosis and treatment, dehydration, low levels of protein and albumin were important prognostic factors. The extent of infiltration shadow in chest X-ray findings was also important. A-DROP might be useful for estimating the prognosis in elderly patients with community-acquired pneumonia. We should consider the prognostic factors and severity at the initial stage when treating elderly patients with pneumonia.

Cyclospora infection in an immunocompetent patient in Japan.

Cyclospora cayetanensis is a coccidian protozoa that was newly recognized in 1979 in Papua New Guinea. We report the case of a 42-year-old French man who had visited Vietnam and presented with fever and watery diarrhea that had lasted for more than 2 weeks. The patient was diagnosed with C. cayetanensis infection by examination of a stool smear using UV fluorescence microscopy. Based on this rare case, we recommend that Cyclospora infection might be considered in the differential diagnosis of traveler's diarrhea in immunocompetent patients.

[Clinical study on lung disease caused by non-tuberculous mycobacteriosis in the elderly].

AIM: This study was done to clarify the characteristics of elderly patients with nontuberculous mycobacteriosis. METHODS: We investigated the clinical features of 10 patients at an advanced age who had been given diagnosis of nontuberculous mycobacteriosis. RESULTS: Mycobacterium avium intracellulare complex (MAC) were detected in all cases. The age of the patients ranged from 65 to 92. Four cases had underlying respiratory diseases (old pulmonary tuberculosis in 3 cases, pulmonary emphysema in 1 case, bronchiectasia in 1 case). Six cases suffered from dementia. The symptoms were relatively nonspecific, such as low grade fever, fatigue, appetite loss in almost all cases in this study. On computed tomography (CT) scans of the chest, mainly small nodular infiltrates were seen. MAC was detected in clinical samples such as sputum, gastric juice and bronchial lavage. The examination of gastric juice was performed in 6 out of the 10 cases. Gastric juice samples were smear-positive for acid-fast bacilli in 5 of 6, and culture-positive for MAC in 5 of 6. The detection of MAC in gastric juice samples was higher than that in sputum samples on admission. CONCLUSION: Gastric juice might be useful to differentiate infection from casual isolation of MAC in elderly patients.

Seroprevalence of IgG anti-toxoplasma antibodies in asymptomatic patients infected with human immunodeficiency virus in Japan.

The seroprevalence of IgG antibodies to Toxoplasma gondii was assessed in 56 non-hemophiliac human immunodeficiency virus (HIV)-infected adult patients in Japan. Seroprevalence of T. gondii infection was only 5.4%, which is lower than reported for most other countries. Given these results, patients in Japan displaying lesions of the central nervous system and antibodies to T. gondii have a high probability of toxoplasmosis.

Clinical characteristics of 8 sporadic cases of community-acquired Legionella pneumonia in advanced age.

Legionella spp are well recognized as one of the etiologic factor in pneumonia, but it is difficult to distinguish the clinical features of Legionella infection from pneumonia due to other causes. The objective of the present study was to examine the clinical characteristics of community-acquired Legionella pneumonia in elderly patients. We reviewed the clinical, laboratory and radiographic findings in 8 patients diagnosed as having pneumonia caused by Legionella. The diagnosis was confirmed by the presence of urinary antigen, bacterial culture, polymerase chain reaction (PCR) and serum antibody. There were 6 men and 2 women, whose ages ranged from 76 to 85 years. All patients had fever and hypoxia, four patients had respiratory symptoms. The initial chest X-ray findings were varied--consolidation, ground glass opacity, pleural effusion and linear shadow. Urinary antigen was positive in 4 patients, bacterial culture in 2, PCR on the sputum in 3 and serum antibody in 2 patients. As pneumonia caused by Legionella often becomes life-threatening, especially in elderly people, it is imperative to diagnose it at the initial stage. In this study, urinary antigen proved to be the most useful diagnostic means. However, it is important to confirm the diagnosis through plural examinations.

Susceptibility of medical students to vaccine-preventable viral diseases: a serological study.

As a measure for the prevention and control of nosocomial infections in medical school students, we examined the students' titers of antibodies to measles, rubella, varicella, and mumps viruses to determine whether vaccination was required. We also analyzed and discussed correlations among antibody titers to the viruses. Subjects were 363 Juntendo University students, ranging from freshmen to seniors. EIA was used to measure IgG antibody titers. Eight subjects (2.2%) had negative titers for measles, 36 (9.9%) for rubella, 8 (2.2%) for varicella, and 10 (2.7%) for mumps. Seronegative subjects were vaccinated against each virus and high seroconversion rates were obtained: 100% for measles and rubella, 67% for varicella, and 89% for mumps. In addition, we used Pearson's test to search for correlations among the antibody titers for each virus. A weak correlation was observed among antibody titers for measles, rubella, and mumps but not for varicella. These results suggest that MMR vaccine might be effective in people with low levels of antibody to measles, rubella, and mumps.

[Usefulness of low-dose single-slice CT (SSCT) for mass screening to detect various thoracic diseases including lung cancer].

This study assessed the usefulness of SSCT for mass screening retrospectively in 8885 subjects (6781 men, 2104 women) who had received mass screening to detect thoracic disease by using SSCT from 1999 to 2003. In the 8885, 119 (1.3%) lesions were detected as active thoracic disease. These 119 lesions comprised 39 neoplasms and 80 instances of non-neoplastic disease. Of those with neoplastic lesions, 25 had lung cancer (adenocarcinomas, 20; Squamous, 3; carcinoids, 2), 7 had mediastinal tumors and 7, others. Non-neoplastic cases comprised 39 of COPD (pulmonary emphysema), 17 of pulmonary tuberculosis, 8 of non-tuberculous mycobacteriosis and 16 others. Surgical treatment was performed in 46 cases: 25 of lung cancer, 14 of non-cancerous neoplasms, 3 of pulmonary sequestration and 4 others. In the lung cancer cases, the post-surgical staging was I or II (stage I, 20; stage II, 5). Low-attenuation areas (LAA) were seen on multiple CT slices in 2.2% of all subjects (195). These 195 cases had no respiratory symptoms such as exertional dyspnea, But 39 of them had an FEV1.0% (FEV1.0/FVC) of less than 70%. All 39 had a history of smoking, We suggested that SSCT screening is a useful method of mass screening to detect thoracic neoplastic lesions as well as non-neoplastic lesions.

[Campylobacter fetus subsp. fetus sepsis: a case report and review of the literatures in Japan].

We report a 32-year-old female with eating disorder whose body weight was only 20 kg. She was admitted to the hospital with severe low nutrition, low proteinemia, liver dysfunction, hypokalemia and hypoglycemia. On the third hospital day, she had a high fever and Campylobacter fetus subsp. fetus (C. fetus) was isolated from the blood. After treatment with meropenem (1 g/day) intravenous drip injection, her condition improved. C. fetus sepsis is not common disease in Japan. A review of 37 cases of this disease in Japan revealed that the age range of adult patients was 20 to 60 years old. The male-to-female ratio was 4.6 to 1.0. Seventy-eight percent of the patients had underlying diseases which were composed of 11 patients with liver disease, 6 patients with blood dyscrasia and some with diabetes mellitus, heart disease, other malignant tumor and collagen disease. There was no case with eating disorder. All apparent sources of infection in Japan originate from eating raw food. Gastrointestinal symptoms were observed in only 16% of the patients. Recent recommendations for the treatment of C. fetus sepsis are to use gentamicin, imipenem and meropenem. Some strains of C. fetus have resistance to erythromycin, ciprofloxacin. The mortality of this infection is 14% in Japan.

Pancoast's syndrome in a patient with B-cell lymphoma diagnosed and confirmed with immunoglobulin gene rearrangement.

Pancoast's syndrome due to malignant lymphoma is extremely rare. A case of diffuse large B-cell lymphoma presenting as Pancoast's syndrome is described. A 66-year-old man complained of pain and weakness of the right arm, and CXR revealed a right apical lung tumour. Histological findings were consistent with it being a diffuse large cell type lymphoma and Southern blot analysis revealed clonal rearrangement of the immunoglobulin heavy-chain JH. Thus, the tumour in this patient was diagnosed to be diffuse large B-cell lymphoma. Malignant lymphoma is an extremely rare cause of Pancoast's syndrome and only five cases have been described. This is the first reported case of Pancoast's syndrome caused by B-cell lymphoma, which was accurately diagnosed by analysis of gene rearrangement.

CD4+ T cells in lung tissue predict responsiveness to cyclosporin A in interstitial pneumonia.

OBJECTIVE: A limited number of case studies have demonstrated the steroid-sparing and disease stabilization effects of cyclosporin A (CsA) combined with corticosteroid in patients with chronic interstitial pneumonia (IP). Although CsA is known to inhibit the proliferation and function of CD4+ T cells, it is not clear what type of IP is responsive to CsA administration. METHODOLOGY: In order to evaluate whether any lymphocyte subsets in alveolar tissue predict the responsiveness to CsA, morphometric analysis was performed on lung tissue obtained from six IP patients who were treated with a combination of CsA and steroid because the therapeutic effect of steroid alone had been limited. RESULTS: Cell densities of CD4+ T cells were significantly decreased in the alveolar tissues obtained from CsA responders (n = 3) compared to non-responders (n = 3) (120 +/- 86/mm2 vs 503 +/- 172/mm2, P=0.0495). CD4/CD8 ratios of CsA responders were also significantly lower than those of non-responders (0.315 +/- 0.070 vs 1.975 +/- 0.965, P=0.0463). However, cell densities of CD8+ T cell and areas of B cells aggregates were similar in both groups. CONCLUSIONS: The present observations, contrary to expectation, reveal that lower cell densities of CD4+ T cells and lower CD4/CD8 ratios are associated with responsiveness to CsA in combination therapy, suggesting that pharmacological actions other than suppression of CD4+ T cells explain the efficacy of CsA in patients with chronic IP.

Increased circulating CD16+ CD14dim monocytes in a patient with pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is characterized by filling of the alveoli with a periodic acid-Schiff-positive proteinaceous material. Although the pathogenesis of primary or idiopathic PAP remains unknown, it has been proposed that a deficiency or loss of responsiveness of the monocyte/macrophage lineage to granulocyte-macrophage colony stimulating factor (GM-CSF) is involved in PAP. Secondary PAP is associated with haematological malignancies, especially in myeloid disorders. Herein, we report on an adult with PAP associated with myelodysplastic syndrome (MDS). The CD16+ CD14dim monocytes comprise 5-10% of circulating monocytes in healthy volunteers. Flow cytometric analysis of the patient in the present study revealed increased CD16+ CD14dim monocytes in the peripheral blood. It has been demonstrated that the expression of CD16 and CD14 is regulated by macrophage colony stimulating factor (M-CSF) and GM-CSF. Hence, serum cytokines were analysed in our patient and the concentration of serum GM-CSF was found to be less than the lower limit of the assay. In addition, serum M-CSF and granulocyte colony stimulating factor levels were only slightly increased above the normal range. These results suggest that the increase in the CD16+ CD14dim subpopulation in the circulation of our patient indicates another pathogenetic mechanism for secondary PAP, such as hyperresponsiveness of the monocyte/macrophage lineage to these cytokines.

Exogenous lipoid pneumonia following ingestion of liquid paraffin.

An asymptomatic patient with exogenous lipoid pneumonia (ELP) due to silent aspiration of liquid paraffin ingested as a lubricant was diagnosed by bronchoalveolar lavage (BAL). BAL fluid separated into oily upper phase and lower aqueous phase spontaneously. Microscopic analysis of BAL cells revealed the presence of lipid-laden alveolar macrophages. Classic histochemical staining and electron microscope examination indicated that neutral lipid was dominant but phospholipid was also present in the lipid-laden macrophages. Together with the history of ingestion of liquid paraffin, we identified that the ingested liquid paraffin was the origin of the neutral lipid in the lipid-laden macrophages observed in the BAL fluid.