Kawamura T

IgG4-related disease in asbestos-related pleural disease.

A 67‐year‐old man with a history of asbestos exposure and rounded atelectasis complained of cough and swelling in the left submandibular region. Computed tomography showed an increase in size of the right lower lung lobe lesion, which was recognized as the pre‐existing rounded atelectasis, as well as swelling of the pancreas and submandibular glands. Biopsy from a submandibular gland and the pulmonary lesion led to a diagnosis of immunoglobulin G4‐related disease (IgG4‐RD). IgG4‐RD is a recently recognized disease that was first reported as an autoimmune disease; however, some reports have indicated another pathogenesis of an allergic nature that is characterized by type 2 helper T cell (Th2) inflammation. Additionally, it is recognized that long‐term exposure to asbestos can cause immune dysregulation. Here we present a case of IgG4‐RD associated with asbestos‐related pleural disease. Asbestos‐induced immune dysregulation may be one etiology of IgG4‐RD.

Factors associated with the relapse of cryptogenic and secondary organizing pneumonia

BACKGROUND Organizing pneumonia (OP) is a histopathological response pattern to lung inflammation. It is clinically classified into cryptogenic OP and secondary OP, which is associated with various clinical conditions. Rapid resolution with corticosteroids and frequent relapses are common in OP. However, few studies have investigated the factors associated with OP relapse. METHODS The medical records of 75 patients with biopsy-proven OP, diagnosed between January 2010 and August 2015, who underwent corticosteroid therapy were retrospectively reviewed. Initially, the patients were all treated successfully; however, 31 patients experienced relapse thereafter (R group), whereas the others did not (NR group; 44 patients). The clinical, radiological, and pathological characteristics and administered corticosteroid doses were compared between the two groups. RESULTS The neutrophil percentage in the bronchoalveolar lavage (BAL) fluid and the level of fibrin deposition in lung biopsy specimens were higher in the R group than in the NR group (P=0.01 and P=0.002, respectively). The multivariate analysis demonstrated that both factors were statistically significant predictors of OP relapse. CONCLUSIONS A high neutrophil percentage in the BAL and the level of fibrin deposition in lung biopsy specimens are considered predictive factors of OP relapse during the tapering or after the cessation of steroid therapy. Patients without these findings may be treated with low-dose corticosteroids.

Intrabronchial Infusion of Autologous Blood Plus Thrombin for Intractable Pneumothorax After Bronchial Occlusion Using Silicon Spigots: A Case Series of 9 Patients With Emphysema.

Background:Bronchial occlusion therapy using silicon spigots is effective for intractable pneumothorax. However, sometimes the pneumothorax is refractory to bronchial occlusion because of collateral ventilation. For such difficult pneumothoraces, we attempted an intrabronchial infusion of autologous blood plus thrombin to control collateral ventilation and stop air leaks. Methods:We performed bronchial occlusions using silicon spigots in patients with spontaneous pneumothorax secondary to emphysema and refractory to chest drainage, but which was inoperable owing to each patient’s poor surgical candidacy and poor overall health condition. When bronchial occlusion proved ineffective, we undertook intrabronchial infusion of autologous blood plus thrombin, 2 to 4 days after bronchial occlusion. A catheter was inserted into the subpleural area, through a gap between the silicon spigot and the bronchial wall, using a flexible bronchoscope under fluoroscopic guidance. Autologous blood, followed by a thrombin solution, was infused using the catheter. We repeated the same infusion a total of 4 to 6 times while changing the target bronchi. All interventions were performed under local anesthesia. Results:The subjects were 9 men, aged from 61 to 88 years, with smoking histories. Three patients also had interstitial pneumonia, and 6 patients had undergone pleurodesis in vain before bronchial occlusion. For 4of the 9 patients, autologous blood plus thrombin infusions successfully stopped air leaks, and in 3 patients, intrabronchial infusions and pleurodesis halted leaks altogether. Conclusion:Intrabronchial infusion of autologous blood plus thrombin was effective for intractable pneumothoraces that could not be clinically managed, even by bronchial occlusion using silicon spigots.

A case of diffuse panbronchiolitis, associated with severe pulmonary hypertension, managed with bilateral lung transplantation from a brain-dead donor

Diffuse panbronchiolitis (DPB) is a chronic respiratory disease that mainly involves the respiratory bronchioles, and has historically been associated with a very poor prognosis. The development of long-term low dose macrolide therapy in the 1980s has dramatically improved the prognosis of DPB. Nevertheless, some cases are resistant to macrolide therapy, and ultimately develop severe respiratory failure and pulmonary hypertension; in such cases lung transplantation is a viable treatment option. Here we report the case of a 40-year-old patient with a 20-year history of DPB, who underwent bilateral lung transplantation due to severe respiratory failure with pulmonary hypertension.

Effects of bronchoscopic lung volume reduction using transbronchial infusion of autologous blood and thrombin in patients with severe chronic obstructive pulmonary disease.

BACKGROUND Existing medical treatments have limitations in the management of very severe chronic obstructive pulmonary disease (COPD). METHODS We performed bronchoscopic lung volume reduction (BLVR) using transbronchial infusion of autologous blood and thrombin (BLVR with blood) in three patients with very severe COPD whose dyspnea could not be relieved by maximum medical management. Two patients underwent BLVR with blood in the left and right lungs at intervals of a half-year or a year, and one patient underwent this procedure in only the right lung. We assessed the changes in pulmonary function, exercise capacity and quality of life before and after BLVR with blood in a total of five procedures. RESULTS The subjects were 58- to 74-year-old males. Their forced expiratory volume in one second (FEV1) percent predicted ranged from 14.8% to 23.4%. BLVR with blood achieved significant improvements as follows (values before → after the procedure, mean ± standard deviation): FEV1 0.45r the L → 0.76r the L (P=0.004), inspiratory capacity 1.50cityo L → 2.05±.05c L (P=0.015), 3-minute walk test 46.8nuteo m → 89.6±34.5 m (P=0.004). Lung function peaked several months after BLVR with blood and returned to nearly the baseline level in 6 months, but exercise capacity was better than that at baseline for at least 12 months. St. Georges Respiratory Questionnaire (SGRQ), measured in two patients before and 12 months after the procedure, showed remarkable improvements (-15.6 and -11.9 units). CONCLUSIONS BLVR with blood is an effective palliative treatment for very severe COPD.

Nontuberculous mycobacterial lung disease accompanied by organizing pneumonia.

We herein report our experience with patients who had nontuberculous mycobacterial lung disease (NTM disease) accompanied by organizing pneumonia (OP). Out of 98 NTM disease patients who had undergone a biopsy or surgical resection, 11 patients had OP that was revealed histologically. After excluding six patients who had OP-related diseases (idiopathic interstitial pneumonia, rheumatoid arthritis, etc.), the remaining five patients were studied. Two of them (a 73-year-old man and a 66-year-old woman) showed common clinical feature: acute-onset symptoms of cough and fever, infiltrating shadows and dramatic improvement following treatment with a corticosteroid and anti-mycobacterial therapy. Our cases demonstrate that NTM disease is sometimes accompanied by OP histologically, and some such cases show common clinical features.

Genetic homology between bacteria in pus from the pyothorax and bacteria in the oral cavity in patients with pyothorax

Introduction: The bacteria responsible for pyothorax may be derived from the oral cavity; however, it has not been proven yet. Objective: Our aim was to study if there is genetic homology between the bacteria in pus from the pyothorax and the bacteria in the oral cavity using Next-Generation Sequencing technology (NGS) in patients with pyothorax. Methods: Two patients with pyothorax were studied. We aspirated pus from the pyothorax by fine-needle biopsy and sampled the bacteria in the oral cavity with a sponge. Cultured bacteria from the pus were isolated and identified by their 16S rRNA gene sequence. Then, we obtained its whole genome sequence by NGS using the MiSeq (illumina) platform. Based on this sequence and an already-known sequence of the same bacterial species, we generated five specific primers for the isolated pyothorax strain. We amplified total DNA that had been extracted from the oral bacteria using these specific primers by the PCR method and performed DNA sequencing. Results: In both patients, we identified the Streptococcus anginosus group from the pus. In each patient, the sequence of the oral bacterial DNA that had been amplified by specific primers for the pyothorax strain completely matched the DNA sequence of the isolated pyothorax strain, while it did not match already-known sequences of the same bacterial species. Conclusion: This study demonstrated genetic homology between the bacteria in pus from the pyothorax and oral bacteria at the strain level in pyothorax patients. This study proved for the first time that pyothorax is caused by oral bacteria, although the number of cases was limited.

Prognostic implications of smoking in patients with advanced lung adenocarcinoma excluding positive mutations

Background: Lung adenocarcinoma in never-smoker patients often expresses mutations including EGFR or ALK, which leads to better prognosis in never-smoker patients with indication of tyrosine kinase inhibitors (TKI). But little is known about the influence of smoking on prognosis in patients with advanced lung adenocarcinoma excluding positive mutations. Objective: This study examined the influence of smoking on overall survival of patients with stage IV lung adenocarcinoma excluding those treated with TKI on the basis of positivity of mutations. Methods: We retrospectively analyzed 129 consecutive stage IV lung adenocarcinoma cases with wild-type EGFR and without positive ALK mutations treated in our hospital between January 2011 and December 2014. Results: Out of 129 patients, 104 (81%) had a smoking history. Median age (range) and male-to-female ratio were 64 years (40-89) and 94:10 in the smoker group and 71 years (42-80) and 3:21 in the never-smoker group. PD-1 inhibitor was administrated in one smoking patient. Overall survival rate was significantly higher in never-smoker patients (p=0.031, log-rank), and median survival of patients with smoking history was 9.3 months, and 19.1 months in never-smoker patients. Conclusions: These data suggest that smoking history was a poor prognostic factor in advanced lung adenocarcinoma patients excluding positive mutations.

Comparison of Family History and Past History in Lung Cancer Patients and Emphysema Patients.

肺癌および肺気腫症例の入院患者について既往歴, 家族歴を比較検討した. 気腫群は呼吸不全などのため入院を要した症例であり, 肺癌群より高齢, 喫煙指数高値であった. 既往歴では虚血性心疾患が肺癌群で有意に多かった. 消化性潰瘍の既往は両群に頻度の差はないが罹患年齢分布に相違がみられ, 肺癌群では50才に, 肺気腫群では40才台と60～70才の2相性にピークがみられた. 家族歴では良性疾患についての両群間の差はみられなかったが, 肺癌群には肺気腫群の約2倍の頻度で癌患者がみられた. 肺癌家族にみられる癌の種類は本邦における一般的な癌頻度と大差なかった. この傾向は血縁者のみでなく配偶者にもみられた. 喫煙は肺癌の危険因子とされるが, 逆に重喫煙にもかかわらず肺癌を発症していない者は肺癌発症に対する感受性が低下している可能性も否定できない. 対象とした肺気腫群はこのモデル例と考えられ, 上記の比較は肺癌危険因子を探る上で示唆的と考える.