A case of severe bronchial asthma controlled with tacrolimus.

Background. The control of severe bronchial asthma, such as corticosteroid-resistant asthma, is difficult. It is also possible that immunosuppressive agents would be effective for bronchial asthma. Case Summary. A 55-year-old Japanese female presented with severe bronchial asthma controlled with tacrolimus. She had been diagnosed with bronchial asthma during childhood. Her asthma worsened, and a chest radiograph showed atelectasis of the left lung. Bronchoscopy revealed the left main bronchus to be obstructed with viscous sputum consisting of 82% neutrophils and no eosinophils. The atelectasis did not improve with corticosteroid treatment, but was ameliorated by administration of tacrolimus. Discussion. This patient had severe asthma due to neutrophilic inflammation of the airways. Tacrolimus is effective for treating severe asthma, for example, in corticosteroid-resistant cases.

Pulmonary tuberculosis with atypical histopathological manifestations.

This report presents a case of pulmonary tuberculosis with atypical histopathological manifestations in an immunocompetent patient. A 37-year-old Japanese man was admitted due to multiple small nodules on chest computed tomography (CT). He was diagnosed with pulmonary tuberculosis following a culture of acid-fast bacterium from suction sputum specimens obtained by bronchoscopy. The histopathological findings from video-assisted thoracoscopy revealed small, sporadically organized, and fibrotic lesions with infiltration of eosinophils, plasma cells, and lymphocytes. The administration of antitubercular drugs eliminated the abnormal shadows on chest CT. Extreme care must be taken in the diagnosis of a patient with inexplicable histopathological findings.

[Case of infectious spondylitis presenting as exudative pleural effusion].

A 59-year-old woman with lumbago, presented with cough and right chest pain. Her chest X-ray showed right pleural effusion, and laboratory studies revealed elevated levels of serum C-reactive protein. Right bacterial pleuritis and empyema was diagnosed based on an analysis of the pleural effusion and pus. She was treated with antibiotics and both the right pleural effusion and pus were drained with a chest tube. Staphylococcus aureus was cultured from the pleural effusion and pus. Her fever and chest pain improved after this treatment, however, the lumbago took a sharp turn for the worse. A spinal MRI showed an increased signal intensity at the level of T11-12, thus suggesting a disk space infection and spondylitis with an epidural abscess. Thereafter, she developed left pleural effusion, and the effusion was drained. Her infection was cured with long-term administration of antibiotics. However, the infectious spondylitis relapsed after four months, and she therefore had to undergo surgery. This case suggested that infectious spondylitis produced the exudative pleural effusion. Bacterial pleuritis, empyema and exudative pleural effusion must therefore be treated while keeping in mind the possibility of infectious spondylitis.

[A case of multicentric Castleman's disease with pulmonary involvement].

A 46-year-old man with polyclonal hypergammaglobulinemia was admitted to our hospital because of an abnormality on his chest radiograph findings. His chest CT showed a localized ground-glass opacity 21 mm in size in the right upper lobe, and some small nodules in all lung fields. He underwent video-assisted thoracoscopic surgery to establish a diagnosis. The histopathologic findings of the surgical specimens revealed the infiltration of lymphocytes and plasma cells. We diagnosed multicentric Castleman's disease. He did not wish to be treated because he had no symptoms. We took a wait-and-see approach and carefully followed him up. Multicentric Castleman's disease is extremely rare.

Chest pain relieved with a bronchodilator or other asthma drugs.

BACKGROUND: Although many patients who experience chest pain or pressure consult their physicians, unfortunately a large number of them do not, and consequently they remain undiagnosed and untreated. Chest pain, in a subset of these patients, may be relieved with a bronchodilator or other asthma drugs. METHODS: This retrospective study included twenty cases of chest pain that were relieved with asthma drugs. Chest pain was categorized into three types: chest pain variant asthma, bronchial asthma with chest pain, and non-asthmatic allergic chest pain. Chest pain variant asthma was defined as chest pressure that improved in response to a bronchodilator, without the characteristic attacks of bronchial asthma. Bronchial asthma with chest pain was defined as chest pressure, with the characteristic attacks of bronchial asthma that improved following the administration of a leukotriene receptor antagonist, systemic corticosteroid, or bronchodilator. Non-asthmatic allergic chest pain was defined as chest pressure without the typical asthma attack, but with chest pressure that improved in response to a leukotriene receptor antagonist or systemic corticosteroid, but not a bronchodilator. RESULTS: Fourteen cases of chest pain were diagnosed as variant asthma, three cases were diagnosed as bronchial asthma with chest pain, and three cases were diagnosed as non-asthmatic allergic chest pain. CONCLUSIONS: The results suggest that the mechanism underlying chest pain that is relieved with asthma drugs can involve either an airway constriction pathway or a non-constrictive pathway presumably airway inflammation. Analysis of the patient's response to treatment with asthma medication is useful for the correct diagnosis of the source of chest pain.

[A case of pulmonary tuberculosis and tuberculous pleuritis during treatment with etanercept for rheumatoid arthritis].

A 64-year-old woman, afflicted with rheumatoid arthritis, consulted our hospital because of her clinical deterioration. Her doctor started treating her with etanercept and prednisolone 10 mg/day but without preventive chemotherapy for tuberculosis, because her chest CT showed only mild interstitial pneumonia, and her tuberculin test showed a slightly-positive reaction. Her symptoms improved, but her chest X-ray showed infiltration after two and a half months treatment, and right pleural effusion after four and a half months treatment. A diagnosis of pulmonary tuberculosis and tuberculous pleuritis was made because of an increase of adenosine deaminase in pleural effusion. She was treated with isoniazid, rifampicin, and ethambutol, resulting in a successful clinical course. Her sputum culture was positive, and a nucleic-acid amplification of Mycobacterium tuberculosis complex was positive. When prescribing etanercept, we should pay close attention to the possibility of tuberculosis.

Sjögren's syndrome with multiple cystic lesions and pulmonary arteriovenous fistulae.

A patient presented with Sjögren's syndrome associated with pulmonary multiple cystic lesions and a pulmonary arteriovenous fistulae. A histological examination of the lungs during the autopsy revealed the stenosis of the bronchiole lumens with hyperplasia of goblet cells, proliferation of smooth muscles in the inner wall of the bronchioli and retention of mucus in the airway lumens. These small airway changes were accompanied with chronic inflammatory changes of the airways in Sjögren's syndrome and led to the formation of cystic lesions via a ball-valve mechanism. Arteriovenous fistulae were situated around the cystic lesions. There may have been a correlation between the formation of the fistulae and cysts, but no mechanism was indicated in the histological findings. This report reveals that chronic inflammatory changes of the airways in Sjögren's syndrome are sufficient to cause the formation of cystic lesions.

[A case of idiopathic pulmonary alveolar proteinosis with multiple localized ground-glass opacities].

A 58-year-old Japanese female consulted our staff with multiple localized ground-glass opacities in chest CT. She underwent video assisted thoracoscopic surgery for diagnosis. Histopathologic finding from surgery specimen in one of ground-glass opacities revealed bronchioloalveolar carcinoma. Six months later, we performed second video assisted thoracoscopic surgery, and histopathologic finding of all other ground-glass opacities revealed pulmonary alveolar proteinosis. Serum anti GM-CSF antibody elevated, and she was diagnosed as having idiopathic pulmonary alveolar proteinosis. A case of idiopathic pulmonary alveolar proteinosis presenting multiple localized ground-glass opacities is rare. And, differentiating ground-glass opacities of pulmonary alveolar proteinosis and bronchioloalveolar carcinoma by chest CT is difficult.

[A case of smoking-induced chest pain improved with beta2-stimulant].

A 24-year-old Japanese man presented with a complaint of chest pressure. He began to have severe chest pressure several times a day. The attack was frequently induced by smoking. During an attack, we gave him an inhalation with procaterol hydrochloride, and his chest tightness disappeared. He was suspected to have chest pain variant asthma. We asked him to stop smoking, and gave him corticosteroid, and his chest pressure did not reappear. This disease is relatively unknown. There is a need for a better dissemination of knowledge about this disease.

[Case of hepatopulmonary syndrome with no vascular dilation in chest CT].

A 69-year-old man afflicted with alcoholic liver cirrhosis complained of dyspnea on effort. His chest CT shows moderate emphysema, and no vascular dilation. An intrapulmonary shunt study using 99mTc-MAA revealed 43% shunt to whole body. Hepatopulmonary syndrome was diagnozed, and he was treated with home oxygen therapy. There is a possibility that the chest CT of patient with hepatopulmonary syndrome complicating emphysema shows no vascular dilation.

[A case of hyper-IgE syndrome complicated by chronic necrotizing pulmonary aspergillosis].

A 46-year-old man afflicted with recurring infection and bone fracture consulted our hospital because of general malaise and increase of sputum. He was given a diagnosis of chronic necrotizing pulmonary aspergillosis, and underwent right lower lobectomy. Six months later, chronic necrotizing pulmonary aspergillosis become exacerbated. Slightly improvement was obtained with voriconazole. Two months later, this disease become reactivated, and slightly improved with itraconazole and amphotericin B. Subsequently, hyper-IgE syndrome was diagnosed in him by pathognomonic face, recurring infection and bone fracture, chronic necrotizing pulmonary aspergillosis, elevated IgE, and eosinophilia. We suggested that the pathogenic cause of chronic necrotizing pulmonary aspergillosis in this case was hyper-IgE syndrome. After that, chronic necrotizing pulmonary aspergillosis was reexacerbated. We added micafungin, increased itraconazole, interferon gamma, and so on. As a result, his chest radiograph and symptoms improved slowly. Cases of hyper-IgE syndrome are rare.

[Case of miliary tuberculosis during treatment with infliximab for rheumatoid arthritis].

A 70-year-old woman afflicted with rheumatoid arthritis was consulted another hospital because of fever and abnormality in chest X-ray. She had been treated with methotrexate and infliximab for seven months. She was diagnosed as methotrexate-induced pneumonia, and was administrated large therapeutic doses of corticosteroid, but finding of her chest X-ray exacerbated. Her sputum examination was positive for Mycobacterium tuberculosis complex by nucleic-acid amplification test, and she was diagnosed as miliary tuberculosis. She was treated with INH, RFP, EB, and PZA, and showed good clinical response to treatment. When infliximab is prescribed, we have to bear in mind possible complication of tuberculosis.

[A case of chest pain variant asthma with headache].

A 37-year-old man consulted our hospital because of severe constricting pain at the right side of the chest and head. Since his chest pain and headache improved with inhaled procaterol hydrochloride, chest pain-variant asthma was diagnosed. Not so many articles have been reported that concerned with this disease. There is a need for a better dissemination of knowledge about this disease.

[Case of chest pain variant asthma].

A 39-year-old man consulted our hospital because of severe constrict pain at the sternal area and heavy sensation in chest. His chest pain improved with procaterol hydrochloride, he was diagnosed as having chest pain variant asthma. His symptoms improved with corticosteroid and cysteinyl leukotriene antagonist. Not so many articles have been reported that concerned with this disease. There is a need for a better dissemination of knowledge about this disease.

[A case of chest pain variant asthma].

A 45-year-old woman afflicted with bronchial asthma consulted our hospital because of severe constricting pain at the sternal area. Her chest pain improved with montelukast, and she was diagnosed to have chest pain variant asthma. Chest pain variant asthma is rare.

[Case of both T- and B-cell markers positive pyothorax-associated lymphoma].

A 84-year-old man with a history of pulmonary tuberculosis admitted to our hospital due to painful swelling in right front chest wall. His chest CT shows a tumor at right chest wall and right chronic empyema. Histopathologic findings from biopsy revealed both T- and B-cell markers positive non-Hodgkin's lymphoma, and we diagnosed him pyothorax-associated lymphoma. Irradiation resulted in tumor shrinkage, and a pain of tumor disappeared. T- and B-cell markers positive pyothorax-associated lymphoma is rare.

[A case of tuberculosis showing immune reconstitution syndrome after the initiation of antiretroviral therapy for HIV infection].

Abstract A 27-year-old man admitted for high fever, wet cough and abnormality on his chest radiograph. He was diagnosed as pulmonary tuberculosis, and started treatment with INH, RFP, EB, and PZA. After other examinations, he was diagnosed as having a acquired immunodeficiency syndrome, too. We gave him zidovudine and lamivudine/ abacavir sulfate to treat HIV infection. After starting treatment with anti-tuberculosis drugs his fever alleviated, but after 10 days from the start of anti-HIV drugs, he showed high fever, and abnormality of his chest radiograph exacervated. We diagnosed him as immune reconstitution syndrome, and gave him prednisolone 30 mg/day. His symptoms improved gradually.

[A case of Mycobacterium intracellulare infection with chronic empyema].

A 83-year-old man had been treated for pulmonary infiltration was referred to a nearby hospital because of slight fever and cough. His chest radiograph and CT showed right chronic empyema, and in which pleural aspirate was smear positive for acid-fast bacilli and positive for PCR-Mycobacterium intracellulare. He was diagnosed as chronic empyema caused by M. intracellulare. A month later exacerbation of bronchopleural fistula was observed and M. intracellulare infection expanded into the lung. He was treated with combined use of ethambutol, rifampicin, clarithromycin, and streptomycin for six months, and his chest radiograph showed improvement, however, finally he died as he was in advanced age and emaciation due to chronic lung infection.

[A case of cystic bronchial typical carcinoid].

A 53-year-old man was admitted with a nodular lesion on chest radiograph. Chest CT scan showed a cystic nodule in right S4 which gradually enlarged during follow-up without therapy. Two years after the first examination, we performed middle lobectomy using video assisted thoracoscopy. Histologically, the tumor was found to be typical carcinoid by immunostaining.

[Case of endometrial tuberculosis].

A 66-year-old woman was referred to our hospital because of lochiorrhea. Uterus MRI and ultrasonography showed hydrometra. Endometrium biopsy revealed epithelioid cell granuloma, and vaginal discharge and endometrium culture was positive for M. tuberculosis. She was diagnosed as endometrial tuberculosis. After treatment with INH, RFP, and EB for 9 months, she recovered.