Masamitsu Tatewaki

Sarcoidosis development during induction chemotherapy for lung cancer mimicked progressive disease.

We report a rare case of sarcoidosis that developed during induction chemotherapy for primary lung cancer, mimicking progressive disease. A 63-year-old man had an abnormal shadow in the right upper lung, and a bronchoscopic examination revealed a squamous cell carcinoma. Swelling of a pretracheal lymph node was also noted. Thus, we gave induction chemotherapy consisting of paclitaxel (days 1, 8) + carboplatin (days 1, 8) for two cycles under clinical staging of T2N2M0. After induction chemotherapy, 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed positive accumulation of FDG in mediastinal and bilateral hilar lymph nodes that had been negative in a previous FDG-PET examination, which led us to suspect disease progression. Transbronchial lymph node biopsy results showed sarcoid granulomas in the specimens. Following complete resection of the lung cancer, sarcoid granulomas were revealed in both nonneoplastic lung tissue and lymph nodes, which resulted in a diagnosis of lung cancer accompanied with sarcoidosis.

Anaphylaxis due to caffeine.

We report a rare case of anaphylaxis due to caffeine intake. A 27-year-old woman suffered her first episode of anaphylaxis and a positive skin prick test suggested that the anaphylaxis was due to an IgE-mediated hypersensitivity reaction to caffeine. She was diagnosed with caffeine allergy and has not had an allergic reaction after avoiding foods and drinks containing caffeine. Although caffeine is known to have antiallergic effects, this case shows that caffeine can be an allergen and cause anaphylaxis.

Effect of Thrombomodulin Alfa on Disseminated Intravascular Coagulation in Patients with Lung Cancer

Objective The mortality rate due to disseminated intravascular coagulation (DIC) is higher in patients with lung cancer than in those without. We examined the effect of treatment with thrombomodulin alfa (TM-α) for DIC in lung cancer patients. Methods Subjects were 57 patients with DIC (43 men, 14 women; mean age, 71.7 years), comprising 31 with lung cancer and 26 without. DIC patients with or without lung cancer did not differ significantly in their background characteristics. Results No significant difference was noted in the mortality rate between patients with lung cancer (61.3%) and those without (57.7%). However, the dose of TM-α was higher for survivors with lung cancer than for non-survivors (473.1 U/kg/day vs. 380.6 U/kg/day; p<0.01). Although no significant difference was noted in the DIC score between these four groups, the serum C-reactive protein level (6.9 mg/dL vs. 11.6 mg/dL; p<0.05) and prothrombin time-international normalized ratio (PT-INR; 1.10 vs. 1.52; p<0.05) were lower in survivors with lung cancer than in the non-survivors with lung cancer. The initial body temperature in non-survivors without lung cancer was lower than that in survivors without lung cancer (37.2℃ vs. 37.9℃, p<0.01), and the platelet count and the time to recovery from DIC in patients without lung cancer showed a significant negative correlation (r2=0.438, p<0.05). Conclusion Our findings suggest that although 380 U/kg/day of TM-α is the recommended dose for DIC treatment, a higher dose may reduce the mortality rate of lung cancer patients with DIC. Furthermore, TM-α should be initiated before worsening of DIC parameters.

Molecular biological analysis in a patient with multiple lung adenocarcinomas: Molecular analysis in lung ADC

The utility of molecular biological analysis in lung adenocarcinoma has been demonstrated. Herein we report a rare case presenting as multiple lung adenocarcinomas with four different EGFR gene mutations detected in three lung tumors. After opacification was detected by routine chest X‐ray, the patient, a 64‐year‐old woman, underwent chest computed tomography which revealed a right lung segment S4 ground‐glass nodule (GGN). Follow‐up computed tomography revealed a 42 mm GGN nodule with a 26 mm nodule (S6) and a 20 mm GGN (S10). Histopathology of resected specimens from the right middle and lower lobes revealed all three nodules were adenocarcinomas. Four EGFR mutations were detected; no three tumors had the same mutations. Molecular biological analysis is a promising tool for the diagnosis of primary tumors in patients with multiple lung carcinomas of the same histotype, enabling appropriate treatment.

Survey on the proper use of an adrenaline auto-injector in 551 Japanese outdoor workers after Hymenoptera stings

Sex Men 1179 (96.6) Women 29 (2.4) Unknown 12 (1.0) Age (years) 10e19 13 (1.1) 20e29 125 (10.2) 30e39 307 (25.2) 40e49 320 (26.2) 50e59 250 (20.5) 60e69 174 (14.3) 70 27 (2.2) Unknown 4 (0.3) Questionnaire 1: A Hymenoptera sting after prescription of an adrenaline autoinjector Yes 551 (45.2) No 662 (54.3) Unknown 7 (0.6) 2: Systemic reaction after a Hymenoptera stingy Yes 65 (11.8) No 475 (86.2) Unknown 11 (2.0) 3: Use of an adrenaline auto-injector after a Hymenoptera stingy Yes 46 (8.3) No 503 (91.3) Unknown 2 (0.4) 4: Hospital visit immediately after use of an adrenaline auto-injectorz Yes 39 (84.8) No 6 (13.0) Unknown 1 (2.2) 5: Re-prescription of an adrenaline auto-injector Yes 701 (57.5) No 146 (12.0) First prescription, before expiration day 356 (29.2)

THU0389 Cluster Analysis of Patients with Serum Igg4 Elevation; Igg4-Related Disease (IGG4RD) as A Distinct Disease in Patients with Igg4 Elevation and Existence of Non-IGG4RD Patients with Non-Sclerosing Lesions Similar to Those in IGG4RD

Background IgG4 related disease (IgG4RD) is a multi-organ affecting disease characterized by fibro-sclerosing lesions with IgG4+ cell infiltration. Serum IgG4 elevation is a critical clue for diagnosis of IgG4RD. However, there are patients of non-IgG4RDs whose IgG4 levels are elevated. Clinical features of these patients have not been fully elucidated. Objectives To clarify clinical features of patients with serumIgG4 elevation, particularly, to determine whether IgG4 RD is a distinctive disease in patients with IgG4 elevation and whether there is a subset of non-IgG4RDs which have strong similarity to IgG4RD. Methods For determination of the prevalence of patients with serum IgG4 elevation, consecutive 185 patients who admitted our department during 2 months were enrolled. For clarification of clinical features of patients with IgG4 elevation (IgG4>135mg/dl), 68 cases with IgG4 elevation were selected from consecutive 350 patients receiving IgG4 test in clinical practice at our hospital and their medical records were reviewed retrospectively. IgG4RD was diagnosed by comprehensive diagnostic criteria for IgG4-related disease (Mod Rheumatol.22:21-30; 2012). Cluster analysis according to organ involvements was performed through Wards method. Results Prevalence of serum IgG4 elevation in general inpatients was 9/1850 (4.9%). Only 1 of 9 was IgG4RD. Among 68 cases with IgG4 elevation who received IgG4 test in clinical practice, IgG4RD was 41%. Cluster analysis according to organ involvements revealed 5 clusters; cluster1: multiple sclerosing lesions with salivary, orbital and retroperitoneal lesions, 2: sclerosing lesions with autoimmune pancreatitis, 3: pulmonary inflammation, 4 varieties of inflammatory diseases including connective tissue diseases, and 5: pleuritis. Cluster 1 and 2 were divided from other ones at 1st node. IgG4RD existed only cluster 1 and 2. In addition to sclerosing lesions, non-sclerosing lesions were found in 13% of cluster 1, 43% of cluster 2, 33% of IgG4RD and 70% of non-IgG4RDs. Non-sclerosing lesions were developed as organ limited inflammation in most cases of IgG4RD and non-IgG4RDs, which was contrast to sclerosing lesions in IgG4RD affecting multi-organs. Among non-sclerosing lesions, IgG4+ cells were observed. Pathological examination of non-sclerosing lesions revealed IgG4+ cell inflammation in 4/5 in IgG4RD and 8/21 in I non-IgG4RDs. The lesions in non-IgG4RDs were indistinguishable from those in IgG4RD. Patients of non-IgG4RDs with IgG4+ cells had similar clinical features to IgG4RD including high IgG4 levels, low CRP levels and good response to glucocorticoid in addition to pathological findings. Conclusions IgG4RD is a minor, but a distinctive disease in patients with serum IgG4elevation, characterized by sclerosing lesions affecting multiple organs. IgG4RD causes non-sclerosing lesions with IgG4+ cells as well as sclerosing ones. Among non-IgG4RDs, there are patients with IgG4 + non-sclerosing lesions indistinguishable from those of IgG4RD and they had similar clinical features to IgG4RD. It might be necessary to provide a position to these cases in “the extended spectrum of IgG4RD” defined as having IgG4+ cell inflammation and serum IgG4 elevation. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.4032