Plastic bronchitis caused by Haemophilus influenzae.

Plastic bronchitis is characterized by sputum obstructing the bronchus and causing atelectasis. Bronchoscopic removal of the clogged bronchial cast is typically performed, but small-diameter bronchoscopes with narrow suction ports cannot achieve adequate suction. Suction using a bronchoscope as a guide sheath may be effective for treating plastic bronchitis in children.

An Autopsy Case of An Acute Exacerbation of Idiopathic Pulmonary Fibrosis Triggered by the Inhalation of a Waterproofing Spray.

An 82-year-old Japanese man with idiopathic pulmonary fibrosis (IPF) experienced dyspnea after using a waterproofing spray in a closed room. He presented with hypoxemia and his chest computed tomography showed additive bilateral diffuse ground-glass attenuation on fibrosis, which was diagnostic of an acute exacerbation of IPF (AE-IPF). Combined treatment with high-dose corticosteroids and immunosuppressants were ineffective, and he later died of respiratory failure. Autopsy findings showed diffuse alveolar damage with honeycombing. His medical history and autopsy histopathology suggested AE-IPF caused by the inhalation of a waterproofing spray.

Effects of additive corticosteroid therapy on 90-day survival in patients with community-onset pneumonia.

INTRODUCTION: Systemic corticosteroid therapy is occasionally used as an additive therapy, especially for patients with severe pneumonia. However, its recommendation for use in patients with pneumonia varies worldwide, and its efficacy is unclear. METHODS: Adult Japanese patients hospitalized with community-onset pneumonia between January and December 2012 were analyzed using the Diagnostic Procedure Combination database. The patients were classified into mild-to-moderate and severe groups using the A-DROP (age, dehydration, respiration, orientation, and blood pressure) system. The 90-day survival rate was evaluated between the presence or absence of corticosteroid treatment using the Kaplan-Meier method in the overall, mild-to-moderate and severe groups, respectively. The patients' clinical characteristics were adjusted between the two groups using the inverse probability of treatment weighting method. RESULTS: Among 123,811, 110,534 patients were classified as mild-to-moderate grade (corticosteroid group: 8,465, non-corticosteroid group: 102,069) and 13,277 patients were classified as severe grade (corticosteroid group: 1,338, non-corticosteroid group: 11,939). The 90-day survival rate was higher in the non-corticosteroid group than in the corticosteroid group in patients with pneumonia of overall grade (weighted hazard ratio [HR]: 1.36; P < 0.001) and those with mild-to-moderate grade (weighted HR: 1.46; P < 0.001). However, there were no significant differences in the outcomes between the two groups in those with severe grade (weighted HR: 1.08; P = 0.38). CONCLUSIONS: Additive systemic corticosteroid therapy may be related to poor 90-day prognosis in patients with mild-to-moderate grade community-onset pneumonia, although it may not be positively associated with its prognosis in those with severe grade.

[A Case of a Bronchial Foreign Body (Artificial Tooth) in the Right Middle Bronchus Without Respiratory Symptoms].

Patients with bronchial foreign bodies often present with subjective symptoms, mainly cough, and removing the foreign bodies is difficult. Bronchial foreign bodies are mostly located in the right lower bronchus, and rarely in the right middle bronchus. An 85-year-old man had no subjective symptoms. He aspirated an artificial tooth during dental treatment the day before visiting our clinic, and consulted his home doctor. He was admitted to our hospital because a chest radiograph indicated the presence of a foreign body in the right middle and lower lung field. Chest computed tomography showed that the bronchial foreign body was located in the right middle bronchus, and it was accompanied by an artifact in the circumference of the lesion, and it seemed to be the metal piece of an artificial tooth. Three-dimensional CT showed the root of the artificial tooth located in center side of the right middle bronchus, and, considering the invasiveness, we decided to remove the tooth by flexible bronchoscopy. The bronchoscopy revealed a metal piece occluding the right middle bronchus without granulation, and we could remove the tooth immediately by grasping the root of the tooth with alligator forceps. We experienced a case of a foreign body located in the right middle bronchus without respiratory symptoms. It is important to carry out image examinations, because elderly patients may not exhibit respiratory symptoms.

[A Case of Papillary Thyroid Cancer Diagnosed as Recurrent Pulmonary Metastases Diagnosed by Transbronchial Biopsies 18 Years After Surgery].

We report a 79-year-old woman, who had undergone surgery for papillary thyroid carcinoma 18 years previously and lung adenocarcinoma 15 years previously. She didn't receive any follow-up because she had no recurrence for 5 years in both diseases. She visited a local doctor with precordial pain and thorax discomfort as her chief complaints, where chest computed tomography indicated a 14 mm-sized nodule in the right lower lobe and 5-7 mm-sized small nodules in both lungs. Using endobronchial ultrasonography with a guide sheath (EBUS-GS) for the diagnosis in our department, the lesions were confirmed by ultrasonography, and a transbronchial biopsy was carried out under fluoroscopy. Pathologically, a sufficient amount of tumor cells were collected, and the findings of adenocarcinoma were obtained. Her condition was diagnosed as recurrent pulmonary metastases of thyroid papillary carcinoma because of the atypical columnar epithelial cells with nuclear variants and the papillary proliferation of intranuclear inclusion, and because of the positive findings in immunohistochemical staining for thyroglobulin. Since papillary thyroid carcinoma is positive for thyroid transcription factor-1 (TTF-1), which is widely used as a marker of lung adenocarcinoma, it cannot be used to differentiate between the two. It is often difficult to diagnose papillary thyroid carcinoma by bronchoscopy, because its progress is slow and the origin of the metastatic lung tumor is not in the bronchus, unlike primary lung cancer. However, a devised transbronchial biopsy procedure for slowly progressive metastatic lung tumors such as papillary thyroid carcinoma is considered to be a useful technique for diagnosis.

Evaluation of histological specimens obtained by two types of EBUS-TBNA needles: a comparative study.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration is a standard method for obtaining specimens of mediastinal and hilar lesions. Several types of needles of various sizes and materials are available. This study aimed to compare the quality of specimens collected using two needles, cobalt chromium and stainless steel for endobronchial ultrasound-guided transbronchial needle aspiration. METHODS: This retrospective study included data of patients who underwent EBUS-TBNA with a 22-gauge needle made from either stainless steel (41 lesions, 121 punctures) or cobalt chromium (47 lesions, 145 punctures). Histological data per puncture, diagnostic yield per lesion, procedure time and complication rates were compared. RESULTS: There were no significant differences between the groups in the baseline characteristics of the patients or lesions or in the complication rates. The rate of diagnostic histological specimens in each sample (71.0% vs. 58.7%, P = 0.039), fewer samples with cartilage alone (1.4% vs. 6.6%, P = 0.047) and fewer samples containing cartilage (7.6% vs. 16.5%, P = 0.034) were seen in the cobalt chromium needle group than in the stainless steel needle group. In both groups, the rate of specimens that only contained blood clots in each sample and diagnostic yield per lesion were similar, but the procedure time was significantly shorter (22 min vs. 26 min, P = 0.007) in the cobalt chromium needle group. CONCLUSION: Compared with stainless steel needles, cobalt chromium needle for EBUS-TBNA showed lower cartilage contamination and a higher ratio of obtaining diagnostic specimens in each sample. Bronchoscopists should consider using the optimal needle gauges and materials for collecting adequate specimens.

Quantitative analysis of endobronchial ultrasound elastography in computed tomography-negative mediastinal and hilar lymph nodes.

BACKGROUND: Endobronchial ultrasound (EBUS) elastography assists in the differentiation of benign and malignant lymph nodes (LNs) during transbronchial needle aspiration (TBNA). However, previous studies have not compared B-mode sonographic images (BSIs) and EBUS elastography images (EEIs) with final pathological diagnoses in radiologically normal-sized (computed tomography [CT]-negative) LNs. METHODS: Consecutive patients with CT-negative LNs, who received EBUS-TBNA, were retrospectively reviewed. Images of BSIs and EEIs of each LN were stored and independently evaluated. EEIs were assessed by calculating the stiffness area ratio (SAR, blue/overall areas). The receiver operating characteristic curve was used to calculate the cutoff value for the SAR. Diagnostic test parameters were evaluated for each EBUS finding. RESULTS: A total of 132 patients (149 LNs) were enrolled, and the median SAR of malignant LNs was significantly higher than that of benign LNs (0.58 vs. 0.32, P < 0.001). At the SAR cutoff of 0.41, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy rate (DAR) of elastography were 88.2%, 80.2%, 78.9%, 89.0%, and 83.9%, respectively. The logistic regression analysis showed that elastography was the strongest predictor of malignancy (odds ratio, 18.5; 95% confidence interval [CI]: 6.48-52.6; P < 0.001). The highest NPV (96.6%) was achieved with a combination of BSIs and EEIs. CONCLUSIONS: EBUS elastography predicted malignant LNs with a high DAR and NPV in CT-negative LNs. The NPV was highest when EEIs were combined with BSIs. Therefore, the combined evaluation of CT-negative LNs using EEIs and BSIs may help bronchoscopists perform EBUS-TBNA more efficiently. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Endobronchial ultrasound elastography accurately predicted malignancy with a high diagnostic accuracy rate and negative predictive value in radiologically normal-sized lymph nodes. The additional use of B-mode sonographic features resulted in a higher negative predictive value. WHAT THIS STUDY ADDS: Endobronchial ultrasound elastography can guide the accurate collection of specimens with transbronchial needle aspiration, even in radiologically normal-sized lymph nodes. It can also readily distinguish benign and malignant lymph nodes, thus avoiding unnecessary punctures.

A Case of Pulmonary Infectious Bulla Caused by Mycobacterium Avium.

A 37-year-old Japanese man presented with a bulla with niveau-like opacity in the right upper lung on chest radiography. Air-fluid level gradually increased despite broad-spectrum antibiotic therapy. Right upper lobectomy was performed, and epithelioid granuloma with mycobacteria was histopathologically observed. Bacterial culture of the fluid was negative, but mycobacterial culture was positive for Mycobacterium avium; therefore, the patient was diagnosed with pulmonary infected bulla caused by Mycobacterium avium. He was further treated with antimycobacterial agents after resection of the infected bulla. To our knowledge, this is the first report of pulmonary infected bulla caused by only Mycobacterium avium in the English literature.

[A Retrospective Study of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) Performed on Tuberculous Lymphadenitis Cases].

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been reported to be useful not only for the diagnosis of lymph node metastasis of lung cancer but also for benign diseases. We retrospectively analyzed the results of patients with tuberculous lymphadenitis (TL) who had undergone EBUS-TBNA between November 2010 and January 2016. EBUS-TBNA was performed in 427 cases during that period. Six cases were finally diagnosed as TL. The punctured lymph node was 8 lesions. Pathological findings consistent with TL were obtained in all 6 cases (100%), and the tissue specimens were positive in Ziehl-Neelsen staining in 3 of the 6 cases (50%). In all 6 cases, the acid-fast bacteria (AFB) smear test of the needle rinse fluid was negative, 2 cases were positive for AFB culture (33.3%), and 2 cases were positive for Mycobacterium tuberculosis (MTB)-PCR test (33.3%). In this study, the positive rate of mycobacterial culture and the MTB-PCR test of the needle rinse fluid was low, though the concordance rate of pathological findings with TL was high (100%). The results suggest that EBUS-TBNA should be carefully evaluated in patients with TL, considering the low positive rate of mycobacterial culture and MTB-PCR test in the needle rinse fluid.

[Evaluation of the Influence of the Experience and Training of EBUS-TBNA on Diagnostic Rate and Safety].

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been widely used in Japan. The guidelines of the American College of Chest Physicians has recommended that EBUS-TBNA should be performed by well-trained operators who can perform highly accurate procedures, but the indicators of the degree of experience and training are unclear. In our department, physicians who do not have enough experience perform EBUS-TBNA under the supervision of bronchoscopic instructors who have EBUS-TBNA techniques (Board Certified Member of the Japan Society for Respiratory Endoscopy) after guidance and training in EBUS-TBNA using a simulator as an operator and helper. In order to evaluate the influence of the experience and training of EBUS-TBNA on diagnostic accuracy and safety, we retrospectively compared the diagnostic accuracy and safety of EBUS-TBNA performed by physicians within one year of experience of EBUS-TBNA and those performed by physicians with more than one year of experience. A total of 111 cases (148 lesions) who were eventually diagnosed as having primary lung cancer and underwent EBUS-TBNA in our department between April 2014 and January 2016 were divided into two groups. Group A (43 cases, 57 lesions) was examined by third-year doctors within one year of experience of EBUS-TBNA, and group B (68 cases, 91 lesions) was examined by doctors with four or more years of experience and with more than one year of experience of EBUS-TBNA. Diagnostic rate, examination time, and complications were evaluated. There were no significant differences between the two groups in the diagnostic rate (A, 89.5% vs. B, 90.1%, P = 1.0) or examination time (A, 27 min vs. B, 23 min, P = 0.149), and no complications were observed in either group. This study suggests that even less-experienced physicians may safely perform EBUS-TBNA as well as moderately-experienced physicians with more than 1 year experience of EBUS-TBNA with similar diagnostic rates when proper training and supervision are supplied.

[A Case of Left Upper Lobe Lung Cancer Successfully Diagnosed by Transesophageal Endoscopic Ultrasound with Bronchoscope-Guided Fine Needle Aspiration Alone].

A 58-year-old Japanese woman with fever and cough visited A hospital. Her chest X-ray and CT showed a tumor attached to the mediastinum in the left upper lobe with mediastinal lymphadenopathy (#4R). After an introduction from A hospital to our hospital, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the mediastinal lymphadenopathy and a simultaneous approach to the mass lesion in the left upper lobe were performed. In spite of twice aspiration by EBUS-TBNA for mediastinal lymphadenopathy, we failed to obtain enough specimens, and, as the mass lesion in the left upper lobe was invisible in the endobronchial ultrasound, we could not approach it. Then using the same ultrasound bronchoscope, we subsequently performed a transesophageal endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) to the mass lesion in the left upper lobe twice, with the result that sufficient tissues were obtained. Then we changed from the ultrasound bronchoscope to a normal bronchoscope and we performed brushing and transbronchial lung biopsy for the left upper lobe mass lesion. Pathological results revealed that only the specimens obtained by EUS-B-FNA were diagnostic for adenocarcinoma; the other specimens obtained using EBUS-TBNA and normal bronchoscope failed to be diagnostic. EUS-B-FNA in combination with EBUS-TBNA has been recommended for the diagnosis of mediastinal and near-mediastinal lesions in the guidelines of the American College of Chest Physicians in 2013, but EUS-B-FNA has not been widely used in Japan. As shown in our present patient who was successfully diagnosed as having lung cancer by EUS-B-FNA alone, respiratory physicians should be aware of being skillful at performing EUS-B-FNA to accurately and effectively approach target lesions.

Fatal Acute Exacerbation of Familial Interstitial Pneumonia Complicated with Dyskeratosis Congenita after Influenza Virus B Infection.

Dyskeratosis congenita (DC) is occasionally complicated in patients with familial interstitial pneumonia (FIP). However, there have been no reports of FIP patients with DC that develop acute exacerbation (AE). We herein report a FIP patient with DC that showed AE of FIP after influenza virus B infection. Although DC is a rare disease in clinical practice, physicians should keep in mind that FIP combined with DC has the potential to cause AE.

[A Case of Drug-Induced Lung Injury Caused by Kamikihito].

An eighty-nine-year-old Japanese male was admitted to our hospital due to dry cough and dyspnea. Respiratory symptoms appeared soon after an administration of an oriental medicine, Kamikihito for tinnitus. Upon admission, chest computed tomography showed patchy consolidations and ground-glass opacities in the right upper lobe of the lungs, and ground-glass opacities in the bilateral lower lobes. Sulbactam-ampicillin combination (SBT/ABPC, 3 g × 2/day) was started in addition to the change or cessation of several other drugs, including Kamikihito, resulting in respiratory symptoms and chest radiographic exacerbations. Bronchoalveolar lavage fluid obtained from the right S3 showed an increase in the total cell number of lymphocytes. A drug lymphocyte stimulation test (DLST) for Kamikihito was also positive. Kamikihito-induced lung injury was most likely, and treatment with prednisolone (50 mg/day) was started. His respiratory symptoms and chest radiographic findings improved rapidly soon after initiating oral prednisolone. This is the first report of Kamikihito-induced lung injury.

In-hospital airborne tuberculous infection from a lesion of calcified pleural thickening during thoracic surgery in a patient with lung cancer.

A 75-year-old Japanese man underwent thoracic surgery to treat a large lung cancer lesion in the left upper lobe with calcified pleural thickening. Postoperatively, viable Mycobacterium tuberculosis was detected in the margin of the resected thickened calcified pleural lesion. Therefore, an infection control investigation of medical staff who had come in contact with the patient was conducted. Consequently, two of the 14 healthcare professionals who had been in the operating room were diagnosed with latent tuberculous infections. Therefore, strict precautions against airborne infections are required to prevent the in-hospital transmission of M. tuberculosis in such cases.

[Efficacy and safety of azithromycin infusion in patients with mild or moderate community-acquired pneumonia].

Azithromycin (AZM) is one of 15-membered rings macrolide antibiotics with wide spectrum of antimicrobial efficacy for Gram-positive and -negative bacteria and also atypical bacteria. So far, there had been no reports of the prospective studies evaluating efficacy and safety of AZM infusion in patients with mild or moderate community-acquired pneumonia (CAP). This study was conducted to evaluate prospectively the efficacy and safety of AZM in patients with mild or moderate CAP. AZM 500 mg was intravenously administered once daily, and the clinical efficacy were evaluated by clinical symptoms, peripheral blood laboratory findings and chest X-rays. Sixty-four patients were firstly registered, and eventually 61 and 62 patients were enrolled for the evaluation of clinical efficacy and safety of AZM, respectively. The efficacy of AZM in 61 patients evaluated was 88.5%. In addition, the efficacies of AZM in each pneumonia severity index by A-DROP system by the Japanese Respiratory Society (JRS) guideline in CAP were 85.2% in mild and 91.2% in moderate. Furthermore, the efficacy of AZM in each differentiation between suspicion of bacterial pneumonia and that of atypical pneumonia by JRS guideline in CAP were 91.7% in suspicion of atypical pneumonia, and its efficacy was high than that of bacterial pneumonia. Nineteen patients (20 cases; 15 with liver dysfunction, 4 with diarrhea, 1 with vascular pain) out of 62 patients were reported to have possible adverse effects of AZM. All of the patients with these adverse effects demonstrated mild dysfunction and continued AZM treatment, and these dysfunctions normalized soon after cessation of AZM. In conclusion, AZM is effective drug for patients with mild or moderate CAP, and we believe that it may be one of effective choice in the treatment of CAP patients who need hospitalization.

[Efficacy and safety of levofloxacin in patients with nursing and healthcare-associated pneumonia].

Levofloxacin (LVFX) is one of respiratory quinolones with wide spectrum of antimicrobial efficacy for Gram-positive and -negative bacteria and also atypical bacteria, and 500 mg of intravenous LVFX infusion has recently been able to use once daily based on pharmacokinetics-pharmacodynamics in Japan. So far, there had been no reports of the prospective studies evaluating efficacy and safety of LVFX in patients with nursing and healthcare-associated pneumonia (NHCAP). This study was conducted to evaluate prospectively the efficacy and safety of LVFX in patients with NHCAP categories B and C (other antibacterial agents were allowed to use with LVFX) according to Japanese guideline for NHCAP by the Japanese Respiratory Society (JRS). LVFX 500 mg was intravenously administered once daily, and the clinical efficacy and safety were evaluated by clinical symptoms, peripheral blood laboratory findings and chest X-rays. Sixty-two patients (average age was 81.2 years old, female/male was 22/40) were firstly registered and evaluated for the safety of LVFX, and eventually 54 patients were enrolled for the evaluation of clinical efficacy of LVFX. The percentage of these 54 patients aged over 65 years old was 96.3%, NHCAP category B/C was 33/21. The efficacy of LVFX in all 54 patients evaluated was 85.2% (categories B/C of NHCAP was 81.8/90.5%). In addition, the efficacies of LVFX in each pneumonia severity category by A-DROP system by JRS in NHCAP patients were 100% in mild, 86.7% in moderate, 77.8% in severe/very severe. Nine patients (2 with liver dysfunction, 6 with renal dysfunction and 1 with thrombocytopenia) out of 62 patients were reported to have possible adverse effects of LVFX. All of the patients with liver and renal dysfunctions after starting LVFX administration demonstrated mild dysfunctions and continued LVFX treatment, and these dysfunctions normalized soon after cessation of LVFX. LVFX was changed to other antibacterial agent in one patient with thrombocytopenia, and also thrombocytopenia was normalized thereafter. In conclusion, LVFX is effective and relatively safe for categories B and C in patients with NHCAP.