Systemic lymph node tuberculosis presenting with an aseptic psoas abscess caused by a paradoxical reaction after nine months of antituberculosis treatment: a case report.

INTRODUCTION: A paradoxical reaction during antituberculosis treatment is defined as the worsening of pre-existing tuberculosis lesions or the appearance of a new tuberculosis lesion in patients whose clinical symptoms improved with antituberculosis treatment. The median onset time to the development of a paradoxical response has been reported to be about 60 days after the start of treatment. We report the case of a patient with a paradoxical reaction presenting as a psoas abscess after nine months of antituberculosis treatment. To the best of our knowledge, this manifestation has not previously been reported. CASE PRESENTATION: A 23-year-old Japanese man presented to our hospital with lower abdominal pain. Computed tomography showed that he had mediastinal and abdominal para-aortic lymph node swellings. Fluorine-18 fluorodeoxyglucose positron emission tomography showed hot spots in these lymph nodes and in his right cervical lymph node, suggesting a lymphoma. The examination of an abdominal lymph node biopsy specimen showed lymph node tuberculosis, so antituberculosis treatment was started. However, after nine months of treatment, he experienced right flank pain. Abdominal computed tomography showed a right psoas abscess and abdominal para-aortic lymph node swelling. The abscess was treated by percutaneous drainage. After repeated drainage, the psoas abscess subsided and disappeared. The purulent fluid yielded no microorganisms, suggesting a paradoxical reaction. CONCLUSION: Attention should be paid to paradoxical reactions occurring during antituberculosis treatment for systemic lymph node tuberculosis.

Impulse oscillometry; therapeutic impacts of transdermal long-acting Beta-2 agonist patch in elderly asthma with inhaled corticosteroid alone.

Growing interest had been focused on the involvement of the small airways in asthma, and impulse oscillometry (IOS) has been utilized as pulmonary functions for detecting large and small airways diseases separately. IOS can measure respiratory resistance and reactance at multiple frequencies, not available by spirometry or body plethysmography, is non-invasive techniques and convenient for elderly patients with a low dependency on cooperation during tidal breathing. IOS indices were well correlated with not only predicted FEV1 but also FEF25-75, residual volume/total lung capacity, delta N2 of a single nitrogen washout test which representing air trapping and inhomogeneous ventilation in the distal lung. These parameters and QOL scores were improved by additional transdermal long-acting beta-2 agonist patch even in well-controlled elderly asthma treating with inhaled corticosteroids alone. IOS may have a complementary role of spirometry in detecting subtle airways changes in general practice. However, systemic studies are required to investigate the clinical implication of each IOS index.

[Further examination of COPD using spirometry, respiratory function test, and impulse oscillometry].

Spirometry is essential for diagnosis and staging of chronic obstructive pulmonary disease (COPD). Characteristic of physiological change of small airways in COPD is heterogeneous distribution of small airway narrowing, resulting in air-trapping and nonhomogeneous ventilation. FEF25-75, residual volume/total lung capacity, delta N2 in phase III slope of single breath N2 washout test, closing volume, static and dynamic compliance, and carbon monoxide diffusing capacity (transfer factor) are measured for detecting small airways disease. Impulse oscillometry is also useful for assessment of small airways disease, especially indices of frequent resonance (Fres) and frequent dependent of resistance change of R5-R20; resistance at 5 Hz minus resistance at 20 Hz. Impulse oscillometry seems to have a complemental role of spirometry in managing COPD.

Increased microcirculation in subepithelial invasion of lung cancer.

BACKGROUND AND OBJECTIVE: Mucosal irregularity and hypervascularity associated with primary lung cancer in large airways are observed by bronchoscopy. The aim of this study was to evaluate microcirculation at subepithelial invasion sites of lung cancer. METHODS AND PATIENTS: Between July 2001 and June 2007, 12 patients who had subepithelial invasion sites of lung cancer in the large airways (aged 52 to 74 years, 12 males) were enrolled into this study. They were 6 patients with adenocarcinoma, 4 patients with squamous cell carcinoma, and 2 patients with small cell carcinoma. We compared 12 control subjects without endobronchial abnormality (aged 51 to 83 years, 9 males and 3 females). The patients underwent conventional bronchoscopy and subsequent high magnification bronchovideoscopy with the conventional imaging and the narrow band imaging (NBI). For evaluating microcirculation of subepithelial invasion, hemoglobin index was calculated. RESULTS: In high magnification view, aberrant microvessels and/or irregular mucosal thickening were observed at subepithelial invasion sites of lung cancer. Irregularly enlarged microvessels were increased and formed an aberrant microvessel network on the surface of irregular mucosa. The diameter of aberrant microvessels was significantly increased compared to normal microvessels. By switching to NBI, the aberrant microvessels were more clearly visualized. The levels of hemoglobin index were significantly higher in subepithelial invasion sites of lung cancer compared to normal mucosa. CONCLUSION: In subepithelial invasion of lung cancer, aberrant microvessels are thought to be characteristic and subepithelial microcirculation may be increased.

[A case of transcatheter coil embolization for pulmonary arteriovenous malformation complicated with hepatic arteriovenous malformation].

A 57-year-old woman in whom pulmonary arteriovenous malformation (PAVM) associated with hereditary hemorrhagic telangiectasia (HHT) had been diagnosed after a chest X-ray film showed an abnormal shadow at the age of 39. After diagnosis, she suffered two ischemic brain attacks, presumably caused by PAVM. She was admitted to our hospital for evaluation and treatment of PAVM on February 9, 2008. We confirmed two PAVMs in right S(3)a and left S(9)a by chest CT scan and angiography. In addition, abdominal CT revealed hepatic arteriovenous malformation (HAVM). HAVM were thought to increase venous return to the right heart, (which might cause pulmonary hypertension after the embolization of PAVMs), leading to right heart failure. In order to prevent neurological events in future, we performed an embolization of PAVM with individual coils at monthly intervals. Six months after the last embolization treatment, she showed no symptoms of right heart failure and the size of PAVMs decreased. It is considered important for a patient with PAVM associated with HHT to undergo a thorough examination for arteriovenous malformation in other organs, before coil embolization.

[A case of solitary splenic metastasis following operation for pulmonary pleomorphic carcinoma: detected at an early stage by FDG-PET].

A 58-year-old man was admitted our hospital. Chest computed tomography (CT) showed a nodular opacity in the left upper lobe and a swollen lymph node in the left hilar region. 18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed abnormal uptakes in the same field. Since thoracoscopic lung biopsy revealed that the tumor was poorly differentiated adenocarcinoma, a left upper lobectomy and lymph node dissection were performed. Histological findings showed numerous spindle cells, thus it was diagnosed as pleomorphic carcinoma, pT2N1M0. After three months, a FDG-PET was performed, which detected a tiny lesion in the spleen. However an abdominal CT scan and ultrasonography (US) performed in the same period showed no abnormal findings. After about 2 months, a solitary low density area (5.0 cm) was seen in the spleen on an abdominal CT scan. We performed splenectomy under a diagnosis of a solitary splenic metastasis of the lung cancer. Pathological confirmation was obtained. Our findings demonstrated that whole-body scanning by FDG-PET was able to detect a rare postoperative splenic recurrence earlier than CT or US scan.

Decreased subepithelial microvasculature observed by high magnification bronchovideoscope in the large airways of smokers.

OBJECTIVE: A fine vascular network is developed in the subepithelial layer of bronchial mucosa. Cigarette smoking is thought to influence angiogenesis. However, the bronchial microvasculature in smokers has not been fully investigated. The aim of this study was to determine the characteristics of the subepithelial microvessels in the large airways of smokers. METHODS: Between August 2000 and July 2004, 12 current smokers and 12 nonsmokers were enrolled in this study. The nonsmokers had no abnormal findings in the large airways in the examination of conventional bronchoscopy. Smoking histories varied from 20 to 50 years. The average smoking index was 31.3+/-19.9 (mean+/-SD) pack-years. High magnification bronchovideoscopy was used in this study, which provides information on bronchial mucosa with a maximum magnification of 110 times. To evaluate the characteristics of subepithelial microvessels, 4 parameters were compared between the two groups: 1) vessel area ratio, 2) vessel length ratio, 3) vessel area to length ratio, and 4) hemoglobin index. RESULTS: Subepithelial microvessels of large airways were narrow and sparsely distributed in smokers. Vessel area ratio, vessel length ratio, vessel area to length ratio and hemoglobin index were significantly lower in the smokers than in the nonsmokers (p<0.0001, p<0.0001, p<0.0001, p=0.0002, respectively). CONCLUSION: Subepithelial microvessels of smokers were decreased and narrow, which suggested a decrease in microcirculation in the subepithelial layer of the large airway.

Reduction of eosinophils in small airways by inhaled steroids is insufficient in patients with adult asthma.

BACKGROUND: Recent reports suggest that small airway as well as large airway involvement in asthma is important. We investigate the therapeutic effects of a meter-dose inhaler of chrolofluorocarbon-beclomethasone dipropionate (CFC-BDP) and dry-powder fluticasone (DP-FP). METHODS: Lung specimens obtained at operation due for small size lung cancer in 16 asthmatic patients and 16 controls were evaluated immunohistochemically using antibodies of EG2 (eosinophil), AA1 (mast cell), CD68 (macrophage), and CD34 (pluripotent hematopoietic stem cell). We calculated the number of each cell type in 5 fields in the inner and outer areas of large airways (luminal diameter; > or =2 mm) and small airways (<2 mm) using computer software. RESULTS: In asthmatic patients eosinophils were significantly increased in both inner and outer areas of small airways and the number of CD34+ cells was significantly elevated in inner areas as compared with controls. Although the density of eosinophils in the inner area of large airways was significantly suppressed (p < 0.02), there was no such suppression in the inner areas of small airways in asthmatic patients treated with CFC-BDP or DP-FP. CONCLUSIONS: It was speculated that inhaled CFC-BDP and DP-FP might deposit mainly in large airways and fail to fully reach small airways, consequently allowing eosinophilic inflammation to continue in small airways.

Interferon-gamma up-regulates expression of cysteinyl leukotriene type 2 receptors on eosinophils in asthmatic patients.

STUDY OBJECTIVES: Cysteinyl leukotrienes (cysLTs) are strong bronchoconstrictive mediators that play a key role in asthma inflammation. They act through specific receptors including cysLT type 1 receptor (CysLT1R) and cysLT type 2 receptor (CysLT2R). Although these two receptors are co-expressed on inflammatory cells, little is known about CysLT2R in patients with asthma. The aims of this study were to investigate the changes in cysLT receptors (CysLTRs) during asthma exacerbations and to determine which cytokine modulates CysLTR expression on eosinophils. METHODS: We assessed protein expression and messenger RNA of CysLT1R and CysLT2R in peripheral blood eosinophils and measured urinary leukotriene E(4) levels in 36 patients with stable asthma, 23 subjects with asthma exacerbation, and 15 healthy subjects. We also evaluated the modulation of these receptors by interleukin (IL)-1beta, IL-4, IL-5, IL-13, interferon (IFN)-gamma and tumor necrosis factor-alpha in cultured eosinophils. RESULTS: Expression of both CysLT1R and CysLT2R on eosinophils during asthma exacerbations was significantly higher (p < 0.05) than in stable asthma and healthy subjects. A greater expression of CysLT2R in exacerbation was found in nonatopic asthmatics. Only IFN-gamma up-regulated cell-surface expression of CysLT2R in a dose-dependent manner and enhanced messenger RNA levels. No cytokine affected CysLT1R expression or messenger RNA level. CONCLUSIONS: CysLT2R expression on eosinophils was increased in patients, especially in nonatopic subjects, during asthma exacerbation, and was up-regulated by IFN-gamma; therefore we speculate that a pathway through CysLT2R might modulate exacerbations of asthma.

Elevated serum surfactant protein A and D in a case of acute eosinophilic pneumonia.

A 29-year-old man was admitted to our hospital because of fever elevation, dry cough, malaise, skin eruption, and dyspnea with hypoxemia. His serum levels of surfactant protein (SP) -A and SP-D were markedly high, but serum KL-6 was not. He was diagnosed as acute eosinophilic pneumonia (AEP) on the basis of CT imaging, bronchoalveolar lavage findings and the clinical course. He showed good response to steroid therapy and serum levels of SP-A and SP-D returned to almost normal levels. Our experience suggested that serum SP-A and SP-D might be helpful markers for monitoring the clinical course in AEP.

Increased airway vascularity in newly diagnosed asthma using a high-magnification bronchovideoscope.

Hypervascularity in the bronchial wall is part of airway remodeling, but has remained an ill-defined process in asthma pathogenesis. Previous morphologic assessment has been limited to biopsy specimens, and therefore a high-magnification bronchovideoscope (side-viewing type) was developed for less invasive examination of subepithelial vessels. We evaluated vascularity in the lower trachea, using this novel scope in 12 normal control subjects, 13 patients with chronic obstructive pulmonary disease, and 24 subjects with stable asthma; 8 were steroid naive with newly diagnosed asthma (Group A) and 16 had been treated with inhaled corticosteroids for more than 5 years (Group B). The redness of bronchial mucosa in patients with asthma observed by conventional fiberoptic bronchoscopy proved to be due to a fine vascular network. Morphometric measurements of subepithelial vessels showed that both vessel area density and vessel length density were significantly (p<0.0001) increased in subjects with asthma as compared with control subjects and patients with chronic obstructive pulmonary disease. The degree of increase in vessels did not differ between Group A and Group B. The increase in subepithelial vessels of the airway is present even in newly diagnosed asthma. This novel bronchovideoscope is useful for assessment of vessel network in the surface of the airway lumen in vivo.