When performing thoracoscopy in patients with pleural effusion of unknown origin, we used two bronchoscopes simultaneously, one for observation and one for biopsy.
A total of 50 patients with pleural effusion of unknown origin were studied. In all of those studies, pleural effusion was exudative, lymphocyte-dominant, had a low level of adenosine deaminase, no malignant cells, and no tuberculosis or other bacteria in pleural effusion smears. Fourteen were outpatients.
A catheter was inserted into the pleural space under local anesthesia, and 300ml to 500ml of pure oxygen was injected to create a pneumothorax. Two flexible fiberoptic bronchoscopes were used simultaneously, one for observation and one for biopsy. Approximately 1 hour after the examination, the out patients were able to return home.
Lesions in the pleural cavity were found in 42 of these 50 patients, and histological diagnosis was possible in 46.
This is a simple procedure with no major side effects. The equipment required is familiar to pulmonary physicians, and the diagnostic yield is high.

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The purpose of this study was to investigate body composition in patietns with chronic obstructive pulmonary disease, and its relation to pulmonary function. Seventeen men with pulmonary emphysema who were being treated as outpatients were divided into three groups, according to ideal body weight (IBW): group A, %IBW≥90%; group B, 90>%IBM≥80; and group C, %IBW<80. All underwent body composition analysis by dual energy X-ray absorptiometry. Fat mass and bone mineral content were significantly lower in groups B and C than in control subjects. Lean mass was significantly lower in group C than in control subjects. By contrast, group A did not differ significantly from control subjects.
Lean mass correlated significantly with %VC, FEV₁, RV/TLC, and MVV. These data suggest that lean mass is low in moderately and severely malnourished patietns, that bone mineral content and fat mass are low in mildly malnourished patients, and that abnormal body composition is associated with ventilatory impairment in patients with chronic obstructive pulmonary disease.

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Nasal intermittent positive pressure ventilation (NIPPV) is widely used in domiciliary treatment of chronic ventilatory disorders. The outcomes of long-term NIPPV were analyzed in 41 patients with hypercapnic respiratory failure due to pulmonary tuberculosis sequelae (PTS; n=17), neuromuscular disease (NMD; n=8), kyphoscoliosis (KS; n=7), chronic obstructive pulmonary disease (COPD; n=6), and miscellaneous diseases (n=3). Twenty-seven patients with chronic conditions but without acute exacerbations began receiving NIPPV, and fourteen patients began receiving NIPPV after an acute exacerbation. Outcome measures included the probability of continuing NIPPV, survival after starting NIPPV, survival after starting home oxygen therapy (HOT), arterial blood gases, nocturnal oxygen saturation, pulmonary function, and the number of hospital days. Two patients with PTS died, 7 and 40 months after starting NIPPV. Two patients (one with PTS and one with COPD) switched from NIPPV to intermittent positive pressure ventilation via a tracheostomy. The condition of one patient with NMD improved and NIPPV was discontinued. The three-year and five-year probabilities of continuing NIPPV in all patients were 82%, and 71%, respectively. The survival rates three and five years after starting NIPPV were 97% and 85%, respectively. The survival rates one to nine years, and ten to eleven years after starting HOT were 98% and 65%, respectively. The arterial PO₂ and PCO₂ nocturnal oxygen saturation, vital capacity, and forced expiratory volume, in one second all improved after NIPPV was begun. NIPPV also reduced the number of hospital days, particularly in patients with KS. In conclusion, the long-term outcome of NIPPV in patients with hypercapnic respiratory failure is encouraging.

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Metastasis of lung cancer to the digestive tract (excluding the esophagus) was confirmed by surgery or autopsy in 30 of the 1635 lung-cancer patients admitted to this Center during the 17-year period since 1977. The diagnosis was made before death in 7 and after death in 23. Metastasis of large cell carcinoma was the most common (3.7%), followed by adenocarcinoma (2.4%), small cell carcinoma (1.7%), and squamous cell carcinoma (0.7%). Metastasis to the stomach occurred in 0.4%, to the small intestine in 1.1% and to the colon in 0.5%. The overall percentage of metastasis to the digestive tract was 1.8%. Among the 298 cases diagnosed at autopsy, metastasis to the digestive tract occurred in 9.7%; stomach, 2.6%; small intestine, 5.7%; and colon, 3.0%. Eleven of the patients in whom the diagnosis was made at autopsy had abdominal symptoms while they were alive. In 11 cases diagnosed at autopsy, occult blood was positive in 9, but 6 of those 9 patients were asymptomatic. The occult-blood test is considered to be helpful as a supplementary diagnostic method in detecting metastasis of lung cancer to the digestive tract. Among the cases diagnosed while the patients were alive, metastasis was observed in the small intestine in 6 and in the colon in 1. The major manifestations were melena, ileus, intussusception, and perforation; 4 patients required emergency surgery. The prognosis was poor: the mean survival period from the onset of symptoms was 49 days. The direct cause of death was metastasis to the digestive tract in 5 cases. The possibility of metastasis to the digestive tract is high when progressive abdominal symptoms are observed and the stool is persistently positive on occult-blood tests.

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The action of the anti-asthmatic drug sodium cromoglycate (SCG) on airway inflammation remains uncertain. Using Evans blue dye as a maker of plasma leakage, we studied the effect of SCG on neurogenic vascular extravasation evoked by hypertonic saline (HTS) in the rat trachea. Inhalation of HTS (5-15%) caused a concentration-dependent increase in plasma leakage, but inhaled 0.9% NaCl had no effect. Inhalation of SCG did not affect the baseline level of vascular permeability, but it inhibited the effect of HTS in a dose-dependent manner: plasma extravasation induced by 10% NaCl was significantly reduced by 2 minutes of inhalation of SCG at concentrations of 10 and 50mg/ml (p<0.05 and p<0.01, respectively). SCG (10mg/ml) also inhibited the changes in microvascular permeability caused by aerosols of substance P (10^-4M), whereas it did not affect the responses to aerosols of platelet-activating factor (3×10^-4M). A similar dose of SCG did not significantly alter microvascular leakage caused by 5% NaCI. However, phosphoramidon, a selective inhibitor of neutral endopeptidase, potentiated the response to 5% NaCl, an effect that was inhibited by SCG (p<0.05). These results suggest that SCG inhibits HTS-induced airway vascular permeability, presumably through a tachykinin-antagonist-like property, and that this inhibition is exaggerated when the activity of endogenous neutral endopeptidase is low.

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A 54-year-old woman was admitted to Nayoro City Hospital because of a suspicion of farmer's lung (FL). She had been working on her farm for the previous 16 years. Every April she experienced fever, coughing, and dyspnea. Fine crackles were *audible over both lung fields. On admission, arterial blood gas analysis showed hypoxemia, and pulmonary-function testing revealed restrictive lung disease and a low diffusing capacity. A chest X-ray film revealed radio-opacity throughout the lower lung fields. A ⁶⁷Ga scintigram showed abnormal uptake in the lungs. Examination of bronchoalveolar lavage fluid revealed an abnormally high number of lymphocytes and a high CD4/CD8 ratio in the lymphocytes. Histological examination of a specimen obtained by transbronchial lung biopsy revealed interstitial pneumonitis. A precipitation test was positive for anti-Micropolyspora faeni antibody. After admission, symptoms resolved with no treatment. FL was diagnosed from anamnesis and the results of examinations.
On admission, the level of soluble interleukin 2 receptor in serum was twice the upper limit of the normal value, and it decreased over time, along with the severity of the disease.
Serial measurements of levels of this receptor are clinically important for detecting the progression of adult T cell leukemia. This case suggests that they can also be useful for evaluating the severity of FL.

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A 72-year-old woman was admitted to our hospital because of dyspnea and abnormal shadows on a chest X-ray film. The X-ray film revealed diffuse reticular and patchy shadows in both lung fields. Drug-induced pneumonitis was suspected, and all drug treatment was stopped. The symptoms were relieved and the X-ray findings improved markedly.
In bronchoalveolar lavage fluid, the lymphocyte percentage was high and the CD4/CD8 ratio was low. Microscopic examination of open-lung biopsy specimens showed pneumonitis, dominant lymphocyte invasion within peribronchiolar and alveolar interstitia. The result of leukocyte migration inhibition test was positive for Hangeshashin-to and Byakkokaninjin-to, and lymphocyte stimulation test was positive for Hange, an ingredient of Hangeshashin-to.
Based on these findings, we diagnosed as pneumonitis induced by Hangeshashin-to. To our knowledge, there has been no previous report of pulmonary hypersensitivity induced by Hangeshashin-to in Japan.

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A 63-year-old man was admitted to our hospital with obstructive pneumonia. The chest X-ray film and computed tomogram showed an infiltrative shadow in the right lower lung field. Examination with a fiberoptic bronchoscope showed a mass in the right basal bronchus. These findings suggested the diagnosis of lung cancer with obstructive pneumonia. Histopathological examination of a specimen obtained by transbronchial biopsy revealed sulfur granules with infiltration of neutrophils, which led to the diagnosis of endobronchial actinomycosis. After three months of treatment with penicillin, the mass disappeared. Comparison of bronchoscopic findings before and after penicillin treatment clearly showed the efficacy of therapy.

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A 47-year-old man was admitted to the emergency room in November 1994 with left-sided chest pain. Two days before admission, he had fallen two meters and hit the left side of his chest. A chest roentgenogram showed patchy infiltrative shadows and a pleural effusion confined to the right lung field. Bloody fluid was obtained from the right B³b by bronchoalveolar lavage. Specimens obtained from the right lung by transbronchial lung biopsy revealed deposition of hemosiderin and precipitation of fibrin, which were consistent with lung contusion. The abnormal shadows on the chest roentgenogram disappeared spontaneously within one week. Review of the literature suggests that contra coup pulmonary contusion is rare, and that the mechanism might involve injury of small vessels by high-speed vibration of the contralateral part of the mediastinum.

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A 52-year-old man had been asymptomatic except for nasal speech since his third decade of life. A chest roentgenogram obtained during a health screening one year before admission revealed elevation of the right hemidiaphragm and infiltrates in the right lower lung field. Because the pulmonary shadows had gradually increased, he was admitted to the hospital, for further examination. Based on physiological findings and on the results of electromyography, myotonic dystrophy was diagnosed. The chest roentgenographic abnormalities were regarded as resulting from complications of this disease. Arterial blood gas analysis showed hypercapnic hypoxia and a spirogram showed that the vital capacity and maximum voluntary ventilation were about half of their respective predicted values. The hypercapnic ventilatory response was also abnormally low. An overnight study of oxygen saturation showed episodes of marked desaturation, and polysomnography revealed central sleep apnea. Inhalation of capsaicin showed an abnormally high cough threshold. Patients with undiagnosed myotonic dystrophy rarely present with chest roentgenographic abnormalities.

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A 43-year-old woman was admitted to the hospital with hypoventilation, which developed when she took sedatives because of an operation on an adrenal gland tumor. Central alveolar hypoventilation syndrome was diagnosed after neurophysiological and pulmonary-function tests. Magnetic resonance imaging and vertebral angiography revealed that tortuous and elongated vertebral arteries compressed the ventral sides of the medulla oblongata, which may have caused the hypoventilation. Mechanical ventilation during sleep improved her condition. Home mechanical ventilation was prescribed and she has been well during follow up as an outpatient.

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We examined a 63-year-old female, who was referred to our hospital for a thorough examination of abnormal findings on the X-ray which were first detected in May, 1992, and suggested a tumor. After hospital admission, a bracheobronchial lymph node biopsy was performed, and the results suggested a pseudo-lymphoma. However, because the possibility of a malignant tumor was not completely negated and the patient, as well as her family, hoped to receive surgical treatment, we performed the tumor resection. The tumor had a clear border. S⁶ was 3×3.5×4cm, S⁸ was 2×2.5×3cm, and evaluation according to the tumor node metastasis (TNM) classification was T₁N₀M₀, i. e., Stage I. In addition to an ordinary histopathological examination, an immunohistochemical examination was conducted for CD19⁺, CD20⁺, CD22⁺, IgD^-, CD5^-, CD10^-. Overall, the tumor was diagnosed as a MALT lymphoma. Investigated IgH, TCRβ, bcl-1 and bcl-2 genes did not show reconstitution. Because it is difficult to differentiate a malignant lymphoma, primarily developed in the lung, from a MALT lymphoma on a morphological examination of a tissue specimen, immunohistochemical and genetic examinations are helpful for making a diagnosis.

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A 78-year-old man was admitted to our hospital in October 1994 because of renal dysfunction. The level of anti-myeloperoxidase antibody in serum was 500EU/ml, and examination of a specimen obtained by open renal biopsy revealed crescentic glomerulonephritis. A chest roentgenogram revealed no abnormality. Administration of prednisolone was started at 50mg/day, and the dosage was then tapered. Renal function remained stable, but on interstitial shadow appeared on the chest roentgenogram. Pulmonary function tests showed a restrictive ventilatory abnormality and a low diffusing capacity.
A thoracoscopic lung biopsy was done in April 1995, and microscopic examination of the specimen showed interstitial pneumonia with relatively young granulation.
The dosage of prednisolone was increased to 50mg/day, after which the interstitial shadow decreased and pulmonary function improved.
The level of anti-myeloperoxydase antibody in serum was 16EU/ml (weakly positive). Alveolar hemorrhage can occur in cases of rapidly progressive glomerulonephritis. In addition, interstitial pneumonia or pulmonary fibrosis can also complicate this condition. In the present case, glomerulonephritis associated with anti-myeloperoxydase antibody co-existed with interstitial pneumonia. This case is valuable because both renal biopsy and lung biopsy specimens were available.

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A 61-year-old man with a history of hypertension and diabetes mellitus had a tooth extracted. Nine days later, he was admitted to the hospital with complaints of high fever, dyspnea, and anterior chest pain. Physical examination revealed a drowsy man with a fever of 38.2°C, blood pressure of 66/44mmHg, and marked redness and swelling from the neck to anterior part of the chest. Laboratory examination indicated severe infection and multiple organ failure, consisting of cardiac, respiratory, renal, and hepatic failure, with disseminated intravascular coagulation. Chest X-ray and CT-scan films showed abscesses extending from the neck to the mediastinum, and bilateral pleural effusion. Immediately, he was treated with catecholamines, furosemide, mechanical ventilation with a high concentration of oxygen, continuous drainage, repeated skin incisions, and broad-spectrum antibiotics. In addition, steroid pulse therapy was administered for persistent respiratory failure. On the 28th hospital day, a fistula developed between the trachea and the mediastinum, and an intratracheal tube had to be inserted through the fistula. On the 212th hospital day, after intravenous hyperalimentation, continuous intravenous insulin infusion, and administration of broad-spectrum antibiotics, catecholamines, and furosemide, the patient was weaned from mechanical ventilation. A restrictive ventilatory defect due to ankylosis and atrophy of underused muscles was noted after weaning, but the PaO₂ was high with a low dose of oxygen (1 to 2l/min), and 21 months later, the blood gases were normal while the patient was breathing room air. As of January, 1996, he was undergoing rehabilitation to promote his recovery from ankylosis, muscle atrophy, and speech dysfunction.

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A 59-year-old woman was admitted our hospital because of an abnormal shadow on a chest X-ray film. A chest CT scan showed a large anterior mediastinal tumor and a pericardial effusion. Percutaneous needle biopsy revealed that the tumor was an advanced thymic cancer (squamous cell carcinoma). The patient underwent 1 course of systemic chemotherapy (CDDP+VDS) with concurrent radiation therapy (24Gy). In addition, one more course of chemotherapy (CDDP+VDS) was given. A chest CT scan done after therapy showed an approximately 75% reduction in tumor size (partial response) and disappearance of the pericardial effusion. The levels of tumor markers (SCC 8.3ng/ml, CYFRA 21-1 183ng/ml) also decreased to within the normal range. Finally, the thymic carcinoma and small pulmonary metastatic lesions were all resected. Examination of the resected tumor revealed extensive necrosis and only a few cancer cells. These results show that concurrent chemo-radiation therapy can be effective against inoperable squamous cell carcinoma of the thymus.

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A 66-year-old man was admitted to Nara Medical University Hospital because of sputum production and fevre. A chest X-ray film obtained on admission revealed many cysts and an infiltrative shadow in the right upper lung field. The patient was treated with antimycobacterial drugs (isoniazid 400mg, streptomycin 0.75g, and rifampicin 450mg) because acid-fast bacilli were detected in his sputum. Although the symptoms and laboratory data improved, a new infiltrative shadow developed in the right lower lung field two months after the start of treatment. Transbronchial biopsy specimens showed intraluminal organizing exudate and alveolitis. The new lesion resolved when treated with the same antimycobacterial drugs. Mycobacterium xenopi was cultured from the sputum 80 days later. This is the third reported case of atypical mycobacteriosis (non-tuberculous mycobacteriosis) due to M. xenopi in Japan with the “initial aggravation” seen in some patients with typical pulmonary tuberculosis.

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A 49-year-old woman was found to have emphysema associated with α1-antitrypsin deficiency in February 1975. She was followed until her death in October, 1994. The Pi phenotype was M null and the genotype was M malton. She had been on home oxygen therapy since 1987. An autopsy revealed the typical bullous lungs with panacinar emphysema. We know of no previous case in Japan of emphysema associated with α1-antitrypsin deficiency.

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