Isolation of Mycobacterium talmoniae from a patient with diffuse panbronchiolitis: a case report.

BACKGROUND: Mycobacterium (M) talmoniae isolated from a patient with cystic fibrosis was first described in 2017, and cases of M. talmoniae remain exceedingly rare. CASE PRESENTATION: A 51-year-old woman had respiratory symptoms for 10 years. Diffuse panbronchiolitis (DPB) was detected at the first visit at our hospital. A cavity lesion in the apex of the left lung was found, and sputum and bronchoalveolar lavage fluid were acid-fast bacillus (AFB) smear- and culture-positive besides Pseudomonas aeruginosa. M. talmoniae was finally identified, and the standard combination therapy for non-tuberculous mycobacteria (NTM) was administered for 2 y referring to the drug-susceptibility test. Thereafter, the AFB culture was negative, the wall thickness of the lung cavity was ameliorated, and oxygen saturation improved. CONCLUSIONS: We encountered a rare case of M. talmoniae with DPB, for which standard combination therapy was effective. M. talmoniae may be considered a potential pathogen of lung disease, especially in patients with bronchiectatic lesions.

Identification of intestinal abnormalities in patients with active pulmonary tuberculosis using small bowel capsule endoscopy.

Background and study aims Mycobacterium tuberculosis is often detected in the feces of patients with active pulmonary tuberculosis. However, no study has examined the small intestine using small bowel capsule endoscopy (SBCE). This study aimed to investigate intestinal abnormalities in patients with active pulmonary tuberculosis. Patients and methods SBCE was performed in sputum/feces smear-positive pulmonary tuberculosis patients. From December 2013 to November 2016, 15 patients were enrolled from a dedicated tuberculous ward. The primary outcome was intestinal abnormalities identified by SBCE. Results Fourteen patients (median age 81 years, range 29 - 91; 3 female) underwent SBCE to the terminal ileum. The video was not recorded for one patient who was excluded from the analysis. Intestinal lesions, including 5 annular ulcers in 4 patients, were observed in 64 % (9/14). In subgroup analysis, prevalence tended to be higher in patients undergoing SBCE within 1 month of anti-tuberculous therapy ( P  = 0.051). Distribution of small intestinal lesions tended to be distal. Four of five annular ulcers were located close to the ileocecal valve. Conclusion Prevalence of intestinal lesions in patients with pulmonary tuberculosis is higher than expected before (UMIN 000017292).

Multiple pulmonary Aspergillus fumigatus cysts and cavities that disappeared with anti-fungal agents.

A 26-year-old man with a 10-year history of asthma was admitted to our hospital with a six-week history of dry cough and slight fever. We observed the left pneumothorax with multiple cysts and cavities and performed partial cystectomy of the left upper lung. Y-shaped mycelia were detected in the resected tissue, and Aspergillus fumigatus was cultured. Pulmonary aspergillosis was diagnosed from the histopathological and bacteriological findings, and the patient demonstrated positive immunological reactions to A. fumigatus. After administration of an intravenous antifungal agent for one month and an oral antifungal agent for another three months, all cysts and cavities disappeared. Aspergillus infection usually results from saprophytic growth within pre-existing cavities. In this case, multiple cysts and cavities may have been caused by Aspergillus, possibly through a check-valve mechanism.

Intestinal perforation due to paradoxical reaction during treatment for miliary tuberculosis.

A 61-year-old man was being treated for poor nutritional status. He had been on weekly methotrexate 6 mg and daily tacrolimus 1 mg and prednisolone 18 mg for 8 years due to dermatomyositis. On further workup, he was initially detected to have ileocecal ulcer with subsequent development of diffuse miliary shadows on chest radiograph. He was diagnosed as having ileocecal with miliary tuberculosis (TB). While receiving anti-tuberculous therapy, there was initial improvement of TB-related symptoms and he had no conditions that interfered with the efficiency of the anti-tuberculous therapy. However, he developed intestinal perforation. Emergency surgery for resection of the ileocecal ulcer and ileocolostomy led to improvement and he was finally discharged. Recently, cases of intestinal TB have been rare and perforation due to TB is extraordinary. In this case, paradoxical reaction and poor nutritional status may have contributed to the intestinal perforation.

[PULMONARY AND INTESTINAL TUBERCULOSIS DEVELOPING ACUTE TUBERCULOUS PERFORATION OF THE INTESTINE DURING ANTITUBERCULOSIS THERAPY].

UNLABELLED: Intestinal tuberculosis (TB) was recognized as the most common complication with a high frequency of active pulmonary TB during the TB epidemic period. However, intestinal TB has become a rare disease, and intestinal perforation due to intestinal TB is extremely rare. We herein report two cases of tuberculous intestinal perforation. CASE 1: A 41-year-old man was admitted to our hospital complaining of persistent cough and anorexia. He was in poor nutritional condition, and his body mass index (BMI) and prognostic nutrition index (PNI) were 13.4 and 36.4, respectively. He was diagnosed with pulmonary TB and received anti-TB therapy. On the 51st day of hospitalization, he developed intestinal perforation. Pathologically caseating epithelioid granulomas were noted at the ulcer lesion. CASE 2: A 61-year-old man was admitted to our hospital due to miliary TB caused by intestinal TB. He had taken oral immunosuppressive drugs and steroids for dermatomyositis over the previous eight years and had a poor nutritional condition, with a BMI of 13.4 and a PNI of 14.4. While receiving anti-TB therapy, he developed intestinal perforation on the 97th day of hospitalization. The patient's poor nutritional condition and immune reconstitution may have contributed to the intestinal perforation.

[A case of postural hypoxemia with a final diagnosis of myasthenia gravis].

We present a case of postural hypoxemia with a final diagnosis of myasthenia gravis (MG). A 62-year-old man experienced double vision in his left eye from December 2008 and received a diagnosis of diabetic neuropathy. From mid-December he began to experience breathing difficulties at night when in a supine position and was admitted to our hospital. Bilateral diaphragmatic elevation was observed on a chest X-ray film, and lower lung atelectasis and an anterior mediastinal tumor were observed on chest CT. However, his breathing difficulties only occurred when he was in a supine position. Therefore, we performed blood gas analysis in supine and sitting positions. Hypoxemia, hypercapnia and an increase in A-aDO2 were observed in the supine position, leading to a diagnosis of postural hypoxemia. Due to the exacerbation of his double vision, the patient was referred to the ophthalmology and neurology departments where he tested positive for anti-acetylcholine receptor antibodies and also on a tensilon test, resulting in a final diagnosis of MG. During the tensilon test, the patient's breathing difficulties in the supine position improved, and therefore his postural hypoxemia was thought to have resulted from diaphragmatic muscle weakness as a result of MG. MG respiratory failure is typically of the acute fulminating type and is considered to be a critical condition. However, it should be noted that there are cases, such as the present one, in which MG presents as postural hypoxemia.

[A case of pyothorax-associated pleural angiosarcoma diagnosed by autopsy].

A 76-year-old man with a dry cough visited our hospital in June 2006. A chest X-ray showed opacification of the left hemithorax and CT demonstrated a soft tissue mass with pleural calcification. At first, we considered he had acute bronchitis with an old tuberculous pyothorax. But, his condition deteriorated with the additional complaint of a left chest pain and shortness of breath in September 2006. Consequently, he was admitted to our hospital. CT demonstrated that the soft tissue mass was growing and was invading the left rib and submammary tissue. Neither CT nor sonographically guided fine needle biopsies and cytological examinations were helpful in diagnosing this disease. He died of respiratory failure 2 months after admission. Autopsy revealed pyothorax and a hemorrhagic tumor from the left side of the thoracic cavity to the chest wall. Microscopic examination showed that atypical cells had proliferated and formed vascular structures, which were stained positively with anti-factor VIII antibody. Finally, the diagnosis was made of pyothorax-associated pleural Angiosarcoma. Angiosarcoma is rare and difficult to diagnosis, however, we have to keep in mind the presence of disease pyothorax-associated pleural angiosarcoma.

[A case of teratoma with malignant transformation in the anterior mediastinum].

A 32-year-old woman was admitted to our hospital complaining of anterior chest pain for 3 months. Chest radiograph revealed a 30-mm mass in the anterior mediastinum. Contrast-enhanced CT scanning revealed a nonhomogeneous cystic mass with a fat or oil component and a thick wall with calcifications. The mass seemed to have invaded the pericardium and great vessels. Thoracotomy demonstrated hairs in the cystic lesions, with hard components that invaded the pericardium and great vessels. Due to extensive vascular invasion, the mass was incompletely resected. Pathologic examination demonstrated the presence of adenocarcinoma, so we diagnosed this case as teratoma with malignant transformation.