Pulmonary flow assessment by phase-contrast MRI can predict short-term mortality of fibrosing interstitial lung diseases.

BACKGROUND: Phase-contrast magnetic resonance imaging (PC-MRI) can determine pulmonary hemodynamics non-invasively. Pulmonary hypertension causes changes in pulmonary hemodynamics and is a factor for acute exacerbation and death in interstitial lung diseases (ILD). PURPOSE: To determine associations between pulmonary hemodynamics measured by PC-MRI and short-term mortality in patients with ILD. MATERIAL AND METHODS: Pulmonary hemodynamics, measured by PC-MRI in 43 patients with ILD, were reviewed retrospectively. Evaluation parameters included heart rate, right cardiac output, average flow, average velocity, acceleration time, acceleration volume (AV), maximal change in flow rate during ejection (M), M/AV, maximum area, minimum area, and relative area change in the pulmonary artery (PA). All causes of death within one year from the day of the MRI examination were assessed by reviewing medical records. Associations between evaluation parameters and outcome were determined by univariate and multivariate Cox regression analysis. RESULTS: Six patients (13.9%) died by the one-year follow-up. Age (hazard ratio [HR] 1.116, 95% confidence interval [CI] 1.015-1.269), average flow (HR 0.932, 95% CI 0.870-0.984), average velocity (HR 0.778, 95% CI 0.573-0.976), right cardiac output (HR 0.870, 95% CI 0.758-0.967), AV (HR 0.840, 95% CI 0.669-0.985), M/AV (HR 1.008, 95% CI 1.001-1.014), and PA relative area change (HR 0.715, 95% CI 0.459-0.928) predicted death in univariate Cox analysis. Multivariate Cox analysis showed decreased right cardiac output (HR 0.547, 95% CI 0.160-0.912) and decreased PA relative area change (HR 0.538, 95% CI 0.177-0.922) were independently associated with death. CONCLUSION: Reduction in right cardiac output and decreased PA relative area change, detected by PC-MRI, were associated with increased mortality in ILD.

Scintigraphy and computed tomography findings for the diagnosis of bronchiolitis obliterans following peripheral blood stem cell transplantation.

We report a case of bronchiolitis obliterans (BO) associated with allogenic peripheral blood stem cell transplantation for acute leukemia. On inspiratory and expiratory chest computed tomography (CT), characteristic findings for BO, such as air-trapping, mosaic attenuation or bronchial wall thickening were not clearly observed. However, ventilation-perfusion lung scans of the chest demonstrated multiple matched defects, which suggested severe obstructive airway disease. In the diagnosis of BO after stem cell transplantation, lung scans should be recommended when representative findings are not obvious on chest CT.

[Clinical features of diabetic patients with pulmonary tuberculosis admitted to a university hospital].

Diabetes mellitus (DM) is a risk factor of tuberculosis (TB). We studied the clinical presentation of pulmonary TB among patients with DM in comparison with patients without DM who were admitted into the hospital of the University of the Ryukyus from 2006 to 2010. The clinical data were collected from medical records retrospectively. Ten cases (25%) of hospitalized patients with pulmonary TB had DM. The DM group showed lower Body Mass Index and higher incidence of chronic heart failure and chronic renal failure. The DM group also were more likely to have cavitary lesion, had longer period of hospitalization, and higher mortality. Their causes of deaths were mainly the co-morbidities and associated complications. Further studies are warranted in order to fully elucidate the relationships between pulmonary TB and DM.

Hepatocyte growth factor levels in Legionella pneumonia: a retrospective study.

BACKGROUND: Hepatocyte growth factor (HGF) is known to be involved in the resolution of pulmonary inflammation and repair of acute lung injury. Legionella pneumonia is sometimes complicated by acute lung injury. Our study aimed to determine the role of serum HGF levels in Legionella pneumonia. METHODS: Sera from patients with Legionella pneumonia (42 cases), other bacterial pneumonia (33 cases), pulmonary tuberculosis (19 cases), and normal controls (29 cases) were collected. The serum HGF levels for each serum sample were determined by sandwich ELISA. Clinical and laboratory data were collected by reviewing the medical charts. RESULTS: Serum HGF levels were higher in patients with Legionella pneumonia than in those with other bacterial pneumonia, pulmonary tuberculosis, and controls. The HGF levels were compared with white blood cell counts, C-reactive protein, Alanine amino-transferase, and lactate dehydrogenase (LDH). The HGF levels were correlated to serum LDH levels. Moreover, serum HGF levels were significantly higher in non-survivors than in survivors. CONCLUSIONS: HGF levels increased in severer pneumonia caused by Legionella, suggesting that HGF might play a significant role in the Legionella pneumonia.

Organizing pneumonia pattern in the follow-up CT of Legionella-infected patients.

The main aim of this study was to describe the appearance of the CT pattern of organizing pneumonia in Legionella-infected patients. Serial CT scans obtained from five sporadic cases of Legionella pneumophila pneumonia were retrospectively reviewed. The mean time of follow-up was 14 days. Chest CT was analyzed with regard to frequency and appearance of CT patterns of pulmonary abnormalities. Consolidation and ground-glass opacities, with or without an air bronchogram, were the most common abnormalities detected in CT scans during follow-up patients with L. pneumophila pneumonia. Two patterns were observed: subpleural and peribronchovascular. The subpleural pattern was seen in four patients and the peribronchovascular pattern in one. Interlobular septal thickening was seen in one patient. Pleural effusion was seen in one patient. The CT pattern of organizing pneumonia, a subpleural pattern, was frequently observed after treatment of L. pneumophila pneumonia.

[A case of Pneumocystis jirovecii pneumonia after kidney transplantation with re-exacerbation following therapy].

A 55-year-old man who had a living kidney transplant 3 months previously was admitted complaining of 4 days of non-productive cough and fever. Because of his low oxygen saturation (SpO2 83% on room air), ground-glass opacities in both lung fields, and marked elevation of beta-D-glucan, a diagnosis of Pneumocystis jirovecii pneumonia (PCP) was considered. The diagnosis of PCP was confirmed by bronchoalveolar lavage. Subsequently, his oxygenation level decreased even after the administration of trimethoprim-sulfamethoxazole, therefore we concurrently administered 60 mg of prednisolone. His clinical symptoms and radiographic findings gradually improved. However, his respiratory condition and radiographic findings exacerbated again after the tapering of prednisolone. His condition improved after the prednisolone dose was returned to 30 mg per day. This case suggested that, in the treatment of PCP in patients without human immunodeficiency virus (HIV) infection, reduction of steroids may cause exacerbation of PCP, similar to immune reconstitution inflammatory syndrome which occurs in HIV patients.

[Comparison of pneumonia severity indices between modified A-DROP system and current A-DROP system predicting outcomes for patients hospitalized with community-acquired pneumonia].

BACKGROUND: The A-DROP is a predicting pneumonia severity index which is adopted in the Japanese Respiratory Society (JRS) guidelines. For community-acquired pneumonia, we made a modified A-DROP, adding two new index items to the current A-DROP. Then, we retrospectively compared the modified A-DROP with the current A-DROP regarding 30-day mortality. METHODS AND RESULTS: We analyzed consecutive 227 patients hospitalized with community-acquired pneumonia (mean age 79.0 years). The added index items were respiratory rate > or = 30/min and the presence or absence of underlying diseases. There were 16 fatalities (7.0%). In the extremely severe group, the sensitivities of the 30-day death and odds ratios were 19.9% and 9.5 in the current A-DROP, but 75.0% and 14.1 for the modified A-DROP, respectively. In addition, regarding the receiver-operating characteristic (ROC) area under the curve for the 30-day death ratio, the current A-DROP and modified A-DROP were 0.807 and 0.840, respectively. CONCLUSIONS: The modified A-DROP improved the ability to predict outcomes compared with the current A-DROP.

[Secondary organizing pneumonia after pneumococcal pneumonia].

A 28-year-old woman was admitted to our hospital complaining of a 7-day chilly sensation with fever. She was given a diagnosis of pneumococcal pneumonia because of infiltration on chest radiography, sputum gram staining and testing positive for a pneumococcal urinary antigen. A 10-day course of antibiotics showed improvements in symptoms and infiltration. However, her X-ray film revealed severe volume loss in the right lung. Organizing pneumonia was diagnosed with lymphocytosis in BALF and Masson bodies upon TBLB examination. Administration of prednisolone obtained rapid improvement of the volume loss. This case was interesting, showing an organizing tendency in the acute-stage pneumococcal pneumonia.

Nonspecific interstitial pneumonia pattern as pulmonary involvement in human T-cell lymphotropic virus type 1 carriers.

It is well established that diffuse interstitial shadows are observed in human T-cell lymphotropic virus type 1 (HTLV-1) carriers. However, the pathological pattern of nonspecific interstitial pneumonia (NSIP) has rarely been reported. Here, we describe the clinical features of four patients with histologically proven NSIP and HTLV-1 infection. The patients, one woman and three men, had a median age of 59.5 years. High-resolution computed tomography of the lungs was performed in all patients, and no apparent honeycomb formations were detected. The present study demonstrates that the NSIP pattern is a significant pathological classification of interstitial pneumonia associated with HTLV-1 carriers.

Pulmonary complications in human T-cell lymphotropic virus type 1 carriers with Sjögren's syndrome, three case reports and literature review.

In this study, we report three cases diagnosed with human T-cell lymphotropic virus type 1 (HTLV-1) and Sjögren's syndrome (SS) who developed pulmonary complications. Radiologic and pathologic findings were evaluated. Although the histologic diagnosis was considered to be hypersensitivity pneumonitis in case 1, and discordant usual interstitial pneumonia (UIP) in cases 2 and 3, lymphocytic alveolitis was observed in all cases. We also did a literature review and concluded that, although the pathologic diagnosis of pulmonary complications in HTLV-1 carriers with SS may vary, lymphocytic infiltrations are commonly observed.

Epidemiology of influenza from 2007 to 2008 in naha area, okinawa prefecture: surveillance of rapid antigen test results.

The incidence of influenza in the Naha city area in the southernmost part of Japan was surveyed in 2007 and 2008. Patients who had influenza-like symptoms and visited one of four general hospitals in Naha City, Okinawa, Japan were included in this study. The nasal or throat swab samples were applied to the rapid test for detecting influenza A and B virus antigens. The positive rate of influenza A and/or B virus antigen was 26.2% (8,480/32,380). Most cases (82.9%) were influenza A. In 2007, influenza A cases were detected during the entire year, and an epidemic peak was also noted in July, while no outbreak occurred in the summer of 2008. The surveillance of the rapid influenza virus antigen test seemed to provide reliable epidemiological data. This finding warrants further study in this region, including study of the influences of climate and socio-behavior patterns of the residents in the region on influenza epidemics.

[Tuberculosis of the tongue initially suspected of tongue cancer: a case report--including the search for recent 16 cases in Japan].

A 56-year-old man, having no particular past history, was admitted to our hospital, with a 9-month history of painful ulcerated lesion of the tongue and a 6-month history of productive cough. A physical examination revealed swelling of his cervical lymph nodes, and a chest roentgenogram on admission showed cavities in the both upper lung fields and nodular shadows over the both lung fields. He was initially suspected of having both cancer of the tongue and pulmonary tuberculosis, but finally diagnosed as secondary tuberculosis of the tongue due to sputum smear-positive pulmonary tuberculosis by biopsy of the tongue and sputum examination. He was treated with isoniazid, rifampicin, ethambutol and pyrazinamide, and his pain and ulcerated lesion of the tongue rapidly improved. Due to our search for recent 16 cases of tuberculosis of the tongue in Japan, we found that the patients of tuberculosis of the tongue were more likely to have concurrently sputum smear-positive pulmonary tuberculosis. In some cases, the delay in diagnosis was seen. These cases suggest that refractory ulcerated cases of the tongue should be subjected to the biopsy and examination for acid fast bacilli of the tongue with suspicion of tuberculosis of the tongue, and then a chest roentgenogram with suspicion of pulmonary tuberculosis.

Human T-cell leukemia virus type I infects human lung epithelial cells and induces gene expression of cytokines, chemokines and cell adhesion molecules.

BACKGROUND: Human T-cell leukemia virus type I (HTLV-I) is associated with pulmonary diseases, characterized by bronchoalveolar lymphocytosis, which correlates with HTLV-I proviral DNA in carriers. HTLV-I Tax seems to be involved in the development of such pulmonary diseases through the local production of inflammatory cytokines and chemokines in T cells. However, little is known about induction of these genes by HTLV-I infection in lung epithelial cells. RESULTS: We tested infection of lung epithelial cells by HTLV-I by coculture studies in which A549 alveolar and NCI-H292 tracheal epithelial cell lines were cocultured with MT-2, an HTLV-I-infected T-cell line. Changes in the expression of several cellular genes were assessed by reverse transcription-polymerase chain reaction, enzyme-linked immunosorbent assay and flow cytometry. Coculture with MT-2 cells resulted in infection of lung epithelial cells as confirmed by detection of proviral DNA, HTLV-I Tax expression and HTLV-I p19 in the latter cells. Infection was associated with induction of mRNA expression of various cytokines, chemokines and cell adhesion molecule. NF-kappaB and AP-1 were also activated in HTLV-I-infected lung epithelial cells. In vivo studies showed Tax protein in lung epithelial cells of mice bearing Tax and patients with HTLV-I-related pulmonary diseases. CONCLUSION: Our results suggest that HTLV-I infects lung epithelial cells, with subsequent production of cytokines, chemokines and cell adhesion molecules through induction of NF-kappaB and AP-1. These changes can contribute to the clinical features of HTLV-I-related pulmonary diseases.

Legionella pneumophila infection induces programmed cell death, caspase activation, and release of high-mobility group box 1 protein in A549 alveolar epithelial cells: inhibition by methyl prednisolone.

BACKGROUND: Legionella pneumophila pneumonia often exacerbates acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Apoptosis of alveolar epithelial cells is considered to play an important role in the pathogenesis of ALI and ARDS. In this study, we investigated the precise mechanism by which A549 alveolar epithelial cells induced by L. pneumophila undergo apoptosis. We also studied the effect of methyl prednisolone on apoptosis in these cells. METHODS: Nuclear deoxyribonucleic acid (DNA) fragmentation and caspase activation in L. pneumophila-infected A549 alveolar epithelial cells were assessed using the terminal deoxyribonucleotidyl transferase-mediated triphosphate (dUTP)-biotin nick end labeling method (TUNEL method) and colorimetric caspase activity assays. The virulent L. pneumophila strain AA100jm and the avirulent dotO mutant were used and compared in this study. In addition, we investigated whether methyl prednisolone has any influence on nuclear DNA fragmentation and caspase activation in A549 alveolar epithelial cells infected with L. pneumophila. RESULTS: The virulent strain of L. pneumophila grew within A549 alveolar epithelial cells and induced subsequent cell death in a dose-dependent manner. The avirulent strain dotO mutant showed no such effect. The virulent strains of L. pneumophila induced DNA fragmentation (shown by TUNEL staining) and activation of caspases 3, 8, 9, and 1 in A549 cells, while the avirulent strain did not. High-mobility group box 1 (HMGB1) protein was released from A549 cells infected with virulent Legionella. Methyl prednisolone (53.4 muM) did not influence the intracellular growth of L. pneumophila within alveolar epithelial cells, but affected DNA fragmentation and caspase activation of infected A549 cells. CONCLUSION: Infection of A549 alveolar epithelial cells with L. pneumophila caused programmed cell death, activation of various caspases, and release of HMGB1. The dot/icm system, a major virulence factor of L. pneumophila, is involved in the effects we measured in alveolar epithelial cells. Methyl prednisolone may modulate the interaction of Legionella and these cells.

Detection of Legionella pneumophila serogroup 1 antigen in respiratory samples using an immunochromatographic membrane test.

The immunochromatographic membrane test (ICT) efficacy of Legionella antigen detection (Binax Now Legionella) was evaluated using respiratory samples, including bronchial washings (44 cases) and sputum (128 cases), from suspected Legionella pneumonia patients. The ICT results using respiratory samples agreed well with isolation of L. pneumophila SG1 and ICT using urines.

[A-DROP system might result in underestimation of severity of cases with Legionnaires' disease].

Fifteen cases of legionella pneumonia experienced in our department or associated hospital were included in this study. Each case was classified with the A-DROP system of the Japanese Respiratory Society Guidelines, and guidelines from the Infectious Diseases Society of America (IDSA) (1998) and then we compared the severity of the cases of pneumonia. Although 10 cases were classified as intermediate, 3 as severe, and 2 as extremely severe with the A-DROP system, most cases were classified as severe according to the IDSA guidelines. Among 5 fatal cases, three were ranked as intermediate with the A-DROP system. However all the fatal cases were ranked as severe in the IDSA guidelines. This study suggested that the A-DROP system might underestimate the severity of pneumonia in cases with legionella pneumonia.

Congenital cystic adenomatoid malformation presenting as repeated pneumonia in a young adult.

Computed tomography (CT) of an 18-year-old man with a history of repeated episodes of pneumonia demonstrated consolidation containing multiple cysts in the right lower lobe. Additional CT angiography and thin-section CT of the lesion revealed neither a supplying systemic artery nor an abnormal bronchus. Lobectomy was performed, and histological examination showed many cysts resembling enlarged bronchioles, diagnosed as congenital cystic adenomatoid malformation.

[A case of acute eosinophilic pneumonia that developed after changing cigarette brands].

A 20-year-old man visited a clinic with high fever and a dyspnea. The chest X-ray film and CT showed multiple patchy ground glass opacities in all lung fields with thickened interlobular septa and bilateral pleural effusions. Examination of bronchoalveolar lavage fluid led to a diagnosis of acute eosinophilic pneumonia. The patient was a current smoker and he had changed the brand of cigarette he smoked from one with a filter to another brand without filter, one week before disease onset. His symptoms improved after the administration of methylprednisolone. This case suggested that the presence of a filter or a difference in ingredients, or both, between brands of cigarette might contribute to the development of acute eosinophilic pneumonia.

[A case of multisystem Langerhans' cell histiocytosis with lung deterioration over 15 years].

We report a case of multisystem Langerhans cell histiocytosis (LCH) with lung, bone and pituitary involvement. A 20-year-old man developed thirst, polydipsia and polyuria in 1983. He had right femur pain from 1988 and osseous LCH was diagnosed based on the operated specimen in 1989. From July 1990, he had right chest pain on coughing and dyspnea and was admitted in November 1990. LCH involving the lungs was diagnosed by CT images and diabetes insipidus was also detected. Steroid therapy was started from 1991, but he discontinued it in 1998. Though he stopped smoking, his clinical symptoms worsened and he experienced bilateral pneumothoraces in 2002 and since then he has been receiving home oxygen therapy. Pulmonary LCH is thought to have a good prognosis, but in recent studies, its survival rate appears low. We report a case of multisystem LCH with lung deterioration over about 15 years.