A combined small cell lung carcinoma patient with only small cell carcinoma components in mediastinal lymph node metastasis and chondrosarcoma-like components in liver metastasis.

A 69-year-old ex-smoker Japanese man presented with a left mediastinal lymph node and left upper lobe tumour. Bronchoscopic biopsy specimens from the enlarged left mediastinal lymph node and left upper lobe tumour revealed small cell lung carcinoma (SCLC). He was treated with first-line chemotherapy with carboplatin, etoposide, and atezolizumab for four courses and subsequent atezolizumab maintenance therapy. However, his left upper lobe lung tumour only increased in size, and left upper lobectomy revealed combined SCLC (adenocarcinoma and chondrosarcoma-like features). Four months after lobectomy, liver metastasis of chondrosarcoma-like features (similar to pathological findings of the left upper lobe tumour) were observed. Combined SCLC, including sarcomatous components, is rare and poorly responds to chemotherapy. The metastases of combined SCLC in this patient were of only one type of histological component, making diagnosis and treatment difficult. If treatment for SCLC responds inadequately, considering combined SCLC and actively re-examining histological diagnosis is necessary.

Infectious respiratory pathogens among patients with acute exacerbation of idiopathic pulmonary fibrosis during the coronavirus disease 2019 pandemic in Japan.

BACKGROUND: Few studies have investigated the prevalence of pathogens in patients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF), specifically, the interactions between respiratory pathogens and AE-IPF during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES: We aimed to analyze pathogens in patients with AE-IPF between September 2020 and December 2022. METHODS: This retrospective observational study was conducted at our hospital between September 2020 and December 2022. In patients with AE-IPF, pre-hospitalization polymerase chain reaction (PCR) tests for respiratory pathogens, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were performed using multiplex PCR or Smart Gene assay with nasopharyngeal swab specimens. Microbiological assays, including Gram staining, sputum cultures, blood cultures, and urinary antigen tests for Streptococcus pneumoniae and Legionella pneumophila, were also performed. RESULTS: Forty-nine patients with AE-IPF were included. The median age was 75 years old and 42 (86 %) were male. Only one of the 49 patients (2 %) was positive for SARS-CoV-2. Two of 28 patients (7 %) were positive for human rhinovirus/enterovirus. No bacteria were detected in sputum culture, blood culture, or urinary antigen tests. CONCLUSIONS: The detection frequency of SARS-CoV-2 infection in patients with AE-IPF was lower than that of human rhinovirus/enterovirus. Continuous analysis for the presence of pathogens is necessary for appropriate infection control because respiratory viruses may increase as the coronavirus pandemic subsides.

Acute pneumonitis caused by oral intake of incense.

Incense is typically burned for use, with bronchitis and pneumonia reported as potential side effects. Physicians should be cautious as inappropriate oral ingestion of incense can lead to acute pneumonitis.

[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.

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.