Toru Kadowaki

Comparative Evaluation of Serum Markers in Pulmonary Sarcoidosis

BACKGROUND Although several serum markers have shown their ability to reflect lymphocytic alveolitis and disease progression in pulmonary sarcoidosis, to our knowledge no prior study has made comparative evaluations of these markers. METHODS Forty-three patients with pulmonary sarcoidosis were enrolled. BAL fluid (BALF) cells were analyzed, and serum levels of serum amyloid A (SAA), soluble interleukin 2 receptor (sIL-2R), lysozyme, angiotensin-converting enzyme (ACE), and the mucin-like, high-molecular-weight glycoprotein KL-6 were measured at disease presentation. Clinical data, including chest radiographs, were collected at presentation and during follow-ups. Univariate and multivariate analyses were used to identify markers best predictive of increased parenchymal infiltration. RESULTS Significantly higher serum levels of sIL-2R, lysozyme, and KL-6 were found in patients with parenchymal infiltration compared with those without parenchymal infiltration. The numbers of total cells and lymphocytes in BALF were significantly higher in patients with parenchymal infiltration. Serum levels of sIL-2R, lysozyme, and KL-6 were significantly correlated with the numbers of total cells, lymphocytes, and CD4(+) T lymphocytes in BALF. At the cutoff levels determined by receiver operating characteristic curves, sIL-2R, lysozyme, KL-6 serum levels, and the number of BAL lymphocytes showed significant correlations with increased parenchymal infiltrations by univariate analysis. However, multivariate analysis revealed that only KL-6 was a predictor of increased parenchymal infiltration. CONCLUSION Our results suggest that initial serum sIL-2R, lysozyme, and KL-6 levels may reflect lymphocytic alveolitis in pulmonary sarcoidosis. Furthermore, initial serum KL-6 tends to associate with increased parenchymal infiltration in pulmonary sarcoidosis.

Successful Treatment of Obstructive Sleep Apnea Syndrome Improves Autonomic Nervous System Dysfunction

Autonomic nervous system (ANS) dysfunction may be implicated in the subsequent development of cardiovascular disease in patients with obstructive sleep apnea syndrome (OSAS). To confirm the relation between OSAS and ANS dysfunction, we prospectively investigated ANS function in 7 patients with moderate or severe OSAS; 7 healthy age-matched volunteers were for control. We also studied ANS function before and after treatment in the patients with OSAS to evaluate the effect of OSAS treatment on ANS dysfunction. The body mass index of patients with OSAS was 32.2 (27.4–45) (median [range]) kg/m2. The patients were treated by nasal continuous positive airway pressure (n = 5) or uvulopalatopharyngoplasty (n = 2). The apnea/hypopnea index decreased markedly from 42.1 (30.6–77.2) events/hr of sleep before treatment to 2.3 (1.4–3.8) after treatment. To evaluate ANS function, the coefficient of variation of the RR interval (CV-RR) and corrected QT (QTc) interval on the electrocardiogram at rest and the heart rate (HR) responses to blood pressure (BP) changes during the Valsalva maneuver were studied. Baseline HR of OSAS patients was significantly higher than that of the control subjects (p < .05). The Valsalva ratio (VR), baroreflex sensitivity (BRS), and CV-RR values in patients with OSAS were significantly lower than those of the control subjects (all, p < .005). However, there were no significant differences in systolic and diastolic BP or QTc intervals. After treatment, VR, BRS, and CV-RR values increased significantly compared with those before treatment in patients with OSAS (all, p < .05). There were no significant differences in systolic and diastolic BP, HR, or QTc intervals measured before and after treatment. These results suggest that impaired ANS function is present in patients with OSAS and can be improved by successful treatment of OSAS.

A case of pulmonary typical carcinoid with an extensive oncocytic component showing intense uptake of FDG

Pulmonary carcinoid tumours, especially typical carcinoid, usually have lower FDG uptake than lung carcinoma.1 We present an unusual case of pulmonary carcinoid showing intense uptake of 18F-fluoro-deoxy-glucose (FDG). FDG-PET CT scan showed increased tracer concentration corresponding to the 3 cm round tumour in the left lingula (figure 1). The maximal standardised uptake value (SUV) of the tumour was 39. Bronchoscopy was performed to show an endobronchial red-coloured polypoid mass with a smooth surface in the left B5a. Cytology obtained by endobronchial brushing showed uniform round to oval …

An analysis of etiology, causal pathogens, imaging patterns, and treatment of Japanese patients with bronchiectasis

BACKGROUND Bronchiectasis (BE), a syndrome that presents with persistent or recurrent bronchial sepsis related to irreversibly damaged and dilated bronchi, has not been well-characterized in Asians. This study aims to review the etiology, causal pathogens, imaging patterns, and treatment of BE and to define the prognostic factors for acute exacerbation in a Japanese population. METHODS We performed a retrospective cohort study of 147 patients (104 women; median age, 73 years; range, 30-95 years) with BE at our institution using high-resolution computed tomography to identify imaging patterns and the area of pulmonary involvement. RESULTS Common BE etiologies were idiopathic (N=50 [34%]), sinobronchial syndrome (N=37 [25%]), non-tuberculous mycobacteriosis (NTM; N=26 [18%]), and previous respiratory infection (N=21[14%]). Pseudomonas aeruginosa was the most common causal pathogen (24%). Common imaging patterns were cylindrical (66%) and mixed including cylindrical pattern (47%). The median number of involved lobes was 2; 49% of the patients had ≥ 3 involved lobes, and 49% had middle lobe and left lingula dominant BE. Patients with predominantly lower lobe BE comprised 4% of the NTM group and 48% of the non-NTM group (P<0.001). In multivariate analysis, cystic BE was a predictor for frequent exacerbations in non-NTM patients (OR=7.947; P=0.004) which led to increased hospital admissions (OR=4.691; P=0.004). CONCLUSIONS Idiopathic and sinobronchial syndrome were common causes of BE. Etiology did not contribute to imaging pattern or predictors of exacerbations. Cystic BE was a predictor for frequent exacerbations in the non-NTM BE patients.

Bacterial tracheobronchitis. A rare cause of adult airway stenosis.

Bacterial tracheobronchitis is a rare cause of airway stenosis in adults. This report describes a 73‐year‐old woman with a recent history of polysialadenitis, who presented with severe airway obstruction due to infection and stenosis of tracheal and bronchial tissue. Tissue culture of the bronchial mucosa showed growth of methicillin resistant Staphylococcus epidermidis (MRSE). Sputum culture showed growth of MRSE, Pseudomonas aeruginosa, Enterobacter cloacae and Enterococcus faecalis; the same organisms were cultured from the salivary glands. Tracheostomy and antibiotic therapy were effective in controlling the disease.

Sarcoid-like reaction in Cryptococcus neoformans infection

We report a patient with Cryptococcus (C.) neoformans infection, who developed a case of sarcoid-like reaction (SLR). There have been reports of SLRs associated with malignancies. Although differentiating sarcoidosis from SLR is difficult, the patient was diagnosed as SLR because propionibacterium acnes bacterial (PAB) antibody staining of biopsy specimens was negative and the chest radiological findings improved after antifungal treatment. To our knowledge, this is the first report of SLR occurring during cryptococcal infection, and we believe that cryptococcal infection should be considered as a potential cause of SLR.

Domiciliary High-Flow Nasal Cannula Oxygen Therapy for Patients with Stable Hypercapnic Chronic Obstructive Pulmonary Disease. A Multicenter Randomized Crossover Trial

Rationale: A growing evidence base suggests a benefit of using high‐flow nasal cannula oxygen therapy in the acute setting. However, the clinical benefit of domiciliary use of high‐flow nasal cannula oxygen therapy in patients with chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease remains unclear. Objectives: To evaluate the efficacy and safety of high‐flow nasal cannula oxygen therapy use in patients with stable chronic obstructive pulmonary disease. Methods: We conducted a multicenter, randomized crossover trial comparing high‐flow nasal cannula oxygen therapy plus long‐term oxygen therapy with long‐term oxygen therapy only in 32 adults with stable hypercapnic chronic obstructive pulmonary disease. Participants were randomized to receive either 6 weeks of high‐flow nasal cannula oxygen therapy/long‐term oxygen therapy using the myAIRVO 2 device followed by another 6 weeks of long‐term oxygen therapy only or long‐term oxygen therapy only followed by high‐flow nasal cannula oxygen therapy/long‐term oxygen therapy. The primary outcome was the change in quality of life as assessed by St. Georges Respiratory Questionnaire for chronic obstructive pulmonary disease. A linear mixed‐effects model was used to account for treatment effect, time effect, allocation effect, and participant effect. Results: Of 32 study participants, 29 completed the study. At the end of 12 weeks, high‐flow nasal cannula oxygen therapy/long‐term oxygen therapy treatment improved the mean total St. Georges Respiratory Questionnaire for chronic obstructive pulmonary disease score compared with long‐term oxygen therapy only (7.8 points; 95% confidence interval, 3.7 to 11.9; P < 0.01). Similarly, high‐flow nasal cannula oxygen therapy/long‐term oxygen therapy treatment improved the arterial partial pressure of carbon dioxide (adjusted treatment effect, −4.1 mm Hg; 95% confidence interval, −6.5 to −1.7 mm Hg), pH (adjusted treatment effect, +0.02; 95% confidence interval, 0.01 to 0.02), and median nocturnal transcutaneous carbon dioxide pressure (adjusted treatment effect, −5.1 mm Hg; 95% confidence interval, −8.4 to −1.8 mm Hg). High‐flow nasal cannula oxygen therapy/long‐term oxygen therapy treatment did not improve the arterial partial pressure of oxygen, dyspnea, spirometry, lung volume, 6‐minute walk test, or physical activity. The most frequent high‐flow nasal cannula oxygen therapy‐related adverse event encountered was nocturnal sweating (n = 6 [20.7%]). Four severe adverse events occurred (two in each group) and were deemed unrelated to the intervention. Conclusions: Six weeks of treatment with high‐flow nasal cannula oxygen therapy improved health‐related quality of life and reduced hypercapnia in patients with stable hypercapnic chronic obstructive pulmonary disease. &NA; Clinical trial registered with www.clinicaltrials.gov (NCT02545855) and www.umin/ac.jp (UMIN000017639).

Pulmonary tumor thrombotic microangiopathy associated with lung cancer

We describe a case of pulmonary tumor thrombotic microangiopathy (PTTM) associated with lung cancer. A 63-year-old woman, who had been treated for lung cancer, was admitted to our hospital because of progressive dyspnea. Chest CT films showed reticular shadows in the middle and left upper lobes, and echocardiography revealed severe pulmonary hypertension. Because drug induced pneumonitis and either pulmonary thromboembolism or pulmonary tumor embolism were suspected, corticosteroid and anti-coagulant therapy were administered. Despite these treatments, she died 50 days after admission. Postmortem examination revealed PTTM associated with lung cancer. PTTM should be considered in cancer patients who show progressive respiratory failure and pulmonary hypertension.

Low-intensity noninvasive ventilation: Lower pressure, more exacerbations of chronic respiratory failure.

Background: For patients with chronic respiratory failure (CRF) who are treated with noninvasive positive pressure ventilation (NPPV), a little is known regarding the effects of low-intensity NPPV (LI-NPPV) on the clinical course of CRF and the frequency of adjustments in these patients. Objectives: This study investigated the effects of LI-NPPV on the clinical course of patients with CRF as compared with patients who were treated with conventional NPPV (C-NPPV) and determined how frequently NPPV was adjusted during therapy. Methods: Clinical data from 21 patients who received long-term NPPV were retrospectively analyzed. Patients were categorized into two groups based on the level of initial pressure support (PS): C-NPPV group (PS ≥ 10 cm H2O) and LI-NPPV group (PS < 10 cm H2O). Results: Patients in the LI-NPPV group had significantly more exacerbations of CRF (P < 0.05). There was no significant difference in the number of patients who required adjustments of NPPV settings between the two groups. There was no significant difference in PaCO2levels 1 month after the start of NPPV between the two groups; however, PaCO2levels were significantly lower after 1 year in the C-group (P < 0.001). Seventy-one percent of LI-NPPV patients and 43% of C-NPPV patients needed NPPV adjustments. Conclusions: Attention should be paid to CRF patients who are initially administered LI-NPPV; they should be carefully observed because they can develop more exacerbations of CRF than patients undergoing C-NPPV. If possible, higher initial PS should be administered to prevent CRF exacerbations.

Myeloperoxidase antineutrophil cytoplasmic antibody‐positive bronchiectasis in an elderly patient

A 76‐year‐old man with bronchiectasis was hospitalized for a 2‐month history of continuous fever due to exacerbation of the disease. The patient had suffered from bronchiectasis for approximately 50 years. Pseudomonas aeruginosa was persistently detected in his sputum. The patients serum was positive for myeloperoxidase antineutrophil cytoplasmic antibody (MPO‐ANCA), but there were no symptoms of vasculitis. Antibiotic therapy effectively resolved the disease exacerbation leading to a decrease in the level of MPO‐ANCA.