Chest Radiological Findings Research Articles

Clinical Use of Short-Course and Low-Dose Corticosteroids in Patients With Non-severe COVID-19 During Pneumonia Progression.

Background: The emerging coronavirus disease 2019 (COVID-19) has become a serious public health concern with a high number of fatalities. It is unclear whether corticosteroids could be a candidate for an early intervention strategy for patients with COVID-19.Methods: In this retrospective cohort study, we analyzed data from 28 corticosteroid-treated patients with non-severe but advanced COVID-19, in which short-course and low-dose corticosteroids were administered because of unremitting or worsening clinical conditions during hospitalization. To compare the effect of corticosteroids on viral clearance, 44 corticosteroid-untreated patients were included as controls.Results: At the time of admission, corticosteroid-treated patients (n = 28) had a more advanced baseline illness compared with corticosteroid-untreated patients (n = 44), as reflected by poorer blood laboratory parameters (lymphocytes, C-reactive protein, and lactate dehydrogenase) and more extensive chest computed tomography (CT) abnormalities. Corticosteroids were given because of radiological evidence of pneumonia progression (26/28) and/or unremitting fever (22/28) after admission. The median time from illness onset to corticosteroid treatment was 9 days (IQR, 7–10). The median duration and accumulated dose of corticosteroid treatment were 4.5 days [interquartile range (IQR), 3–5] and 140 mg of methylprednisolone (IQR, 120–200). Intravenous immunoglobulin (20 g per day for 3–5 days) was co-administered with corticosteroids. With the corticosteroid treatment, all patients achieved an abatement of fever within 1 day, and 78.6% (22/28) of the patients achieved radiological remission when evaluated about 3 days later. Only one (3.6%) patient progressed to severe COVID-19, and all patients recovered and were discharged without any sequela. The median time from illness onset to viral clearance was similar, as compared with 44 corticosteroid-untreated patients with relatively milder disease [18 (IQR 14.3–23.5) days vs. 17 (IQR, 12–20) days, p = 0.252]. When adjusted for age, sex, underlying comorbidities, baseline blood laboratory parameters, viral load, and chest radiological findings, the causal hazard ratio of corticosteroid treatment for the viral clearance was 0.79 (95%CI, 0.48–1.30, p = 0.34).Conclusion: Short-course and low-dose applications of corticosteroids, when co-administered with intravenous immunoglobulin, in non-severe COVID-19 patients during the stage of clinical deterioration may possibly prevent disease progression, while having a negligible impact on the viral clearance.

Symptomatic Infection is Associated with Prolonged Duration of Viral Shedding in Mild Coronavirus Disease 2019: A Retrospective Study of 110 Children in Wuhan.

Information regarding viral shedding in children with coronavirus disease 2019 (COVID-19) was limited. This study aims to investigate the clinical and laboratory characteristics associated with viral shedding in children with mild COVID-19. The clinical and laboratory information of 110 children with COVID-19 at Wuhan Children's Hospital, Wuhan, China, from January 30 to March 10, 2020, were analyzed retrospectively. The median age was 6 years old. The median period of viral shedding of COVID-19 was 15 days (interquartile range [IQR], 11-20 days) as measured from illness onset to discharge. This period was shorter in asymptomatic patients (26.4%) compared with symptomatic patients (73.6%) (11 days vs. 17 days). Multivariable regression analysis showed increased odds of symptomatic infection was associated with age <6 years (odds ratio [OR] 8.94, 95% confidence interval [CI]: 2.55-31.35; P = 0.001), hypersensitive C-reactive protein >3.0 mg/L (OR 4.89; 95% CI: 1.10-21.75; P = 0.037) and presenting pneumonia in chest radiologic findings (OR 8.45; 95% CI: 2.69-26.61; P < 0.001). Kaplan-Meier analysis displayed symptomatic infection (P < 0.001), fever (P = 0.006), pneumonia (P = 0.003) and lymphocyte counts <2.0 × 10/L (P = 0.008) in children with COVID-19 were associated with prolonged duration of viral shedding in children with COVID-19. Prolonged duration of viral shedding in children with COVID-19 was associated with symptomatic infection, fever, pneumonia and lymphocyte count less than 2.0 × 10/L. Monitoring of symptoms could help to know the viral shedding in children with COVID-19.

Predictive Value of the Neutrophil-to-Lymphocyte Ratio(NLR) for Diagnosis and Worse Clinical Course of the COVID-19: Findings from Ten Provinces in China

Background: Novel coronavirus pneumonia (NCP) is often changing rapidly and fatal. Early detection and early triage of coronavirus disease 2019 (Covid-19) is the key to success management of the disease. An easily obtainable yet accurate variable for both diagnosis and prognosis is urgently needed. We aim to report predictive Value of the Neutrophil-to-Lymphocyte Ratio(NLR) for diagnosis and worse clinical course of the COVID-19, which have not been well demonstrated. Methods: Our study consisted of two stages, at the first stage, a retrospective, single-center, cohort study including was conducted in Heilongjiang, on admission, demographic, clinical, and laboratory data were collected and compared between patients with COVID-19 and patients with non COVID-19; we used multivariable logistic regression methods to explore the risk factors associated with COVID-19;A receiver operating characteristic(ROC) analysis was conducted to calculate the area under the curve(AUC) to assess predictive value of NLR for diagnosis of COVID 19. At the second stage, we conducted retrospective, multi-center and large sample study in 43 hospitals from ten provinces of China, COVID-19 patients with laboratory-confirmed divided into three groups including mild cases, ordinary cases and severe cases. Multivariate logistic regression methods were used to identify the risk factors for the deterioration of COVID-19, along with, a receiver operating characteristic (ROC) curve was also drawn to assess impact on the clinical course of the COVID-19. Findings: We recruited a total of 635 patients with COVID-19 and 27 cases with non COVID-19(Viral pneumonia) from 28 January to 25 February. A total of 88 cases were enrolled with a retrospective, single-center, cohort study from Heilongjiang province, of these, COVID-19 cases were 61(69%) and non COVID-19 cases were 27(31%). On admission, fever (69%) was the most common symptoms, cough (56%) and fatigue(53%). An average(SD) of NLR of COVID-19 patients and non- COVID-19 patients were3.48±2.04 and 2.21±1.14, respectively. multivariable regression showed increasing odds of COVID-19 patients associated with NLR(odds ratio 1.752, 95% CI 1.111-2.763, per 1 unit increase; p=0.016). In addition, the area under the curve (AUC) of NLR was 0.707 and cutoff value was 2.22. At the second stage, 635 patients with COVID were enrolled with a retrospective, multi-center, large sample study in the 43 settings from 10 provinces, of these, mild case were 86(14%), ordinary cases [486(76%)],severe cases[63(10%)], common symptoms was at onset of disease were cough[356(56%)], an average of NLR of 635 patients was 4.04±4.68, and elevated NLR with the deterioration of clinical course[mild case(2.73±2.28), ordinary cases(3.58±3.07), severe cases(9.38±10.52), P<0.0001], in multivariable logistic regression model, compared to mild group, fever(OR 5.739, 95% CI 2.849-11.564) and cough(OR 3.265, 95% CI 1.675-6.331) were associated with ordinary cases, increasing odds of NLR was associated with ordinary cases (OR 1.199, 95% CI 1.010-1.422, per 1 unit increase; p=0.038). Fever(OR 7.587, 95% CI 2.601- 22.132),cough(OR 6.493, 95% CI 2.257-18.682) and shortness of breath(OR 4.133, 95% CI 1.125-15.179) were associated with severe cases, increasing odds of NLR (OR 1.342, 95% CI 1.122-1.605, per 1 unit increase; p=0.001), and increasing odds of age (OR 1.036, 95% CI 1.001- 1.073, per 1 unit increase; p=0.041) were associated with severe cases. The area under the curve (AUC) of NLR was 0.727 and cutoff value was 4.06, additionally, AUC of lymphocytes was 0.719 and cutoff value was 0.765. Interpretation: NLR as inflammatory markers with rapid, convenient characteristics, NLR≥2.22 could be utilized as a predicting indicator for the early recognition COVID-19 and facilitate detection timely; meanwhile, NLR≥4.06 and lymphocytes≤0.765 were as predicting indicator for severe COVID-19 and can facilitate to further prevent worse progress of clinical course. In addition, cough, shortness of breath, abnormal chest radiological findings were also associated with worse outcome. Funding Statement: The study was supported by“ National Science and Technology Major Project” (2018ZX10101001-005-003, 2018ZX10101001-005-004). Declaration of Interests: All authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by National Administration of Traditional Chinese Medicine, Administration of Traditional Chinese Medicine of 10 provinces and the institutional board of 43 participating setting.

Extent of Lung Involvement and Serum Cryptococcal Antigen Test in Non-Human Immunodeficiency Virus Adult Patients with Pulmonary Cryptococcosis.

Background:Serum cryptococcal antigen (CrAg) test is the most used noninvasive method to detect cryptococcal infection. However, false-negative CrAg test is not uncommon in clinical practice. Then, the aim of this study was to investigate the factors associated with false-negative CrAg test among non-human immunodeficiency virus (HIV) adult patients with pulmonary cryptococcosis and its clinical features.Methods:One hundred and fourteen non-HIV adult patients with pulmonary cryptococcosis, proven by biopsy, were retrospectively reviewed. Finally, 85 patients were enrolled; 56 were CrAg positive (CrAg+ group) and 29 were negative (CrAg− group). It was a cross-sectional study. Then, baseline characteristics, underlying diseases, clinical symptoms, laboratory findings, and chest radiological findings were reviewed and analyzed. Chi-square test was used to analyze categorical variable. Odds ratio (OR) was used to measure correlation. Student's t-test was obtained to analyze continuous variable.Results:No difference in baseline characteristics, underlying diseases, clinical symptoms, and laboratory findings were found between two groups (P > 0.05 in all). Nevertheless, diffuse extent lesion was 82.1% in CrAg+ group and 10.3% in CrAg− group (χ2= 40.34, P < 0.001; OR = 39.87).Conclusions:Among patients with limited pulmonary involvement, a negative serum CrAg does not preclude the diagnosis of pulmonary cryptococcosis. However, among patients with extensive pulmonary involvement, serum CrAg is a useful diagnostic tool for pulmonary cryptococcosis. Furthermore, we also noticed that the untypical and mild presentations with extensive pulmonary lesion might be the features of pulmonary cryptococcosis, which needs further investigation.

Abstract P-167: CLINICAL ANALYSIS OF HUMAN BOCAVIRUS INFECTION IN CHILDREN WITH SEVERE LOWER RESPIRATORY TRACT INFECTION

Aims & Objectives: To explore the clinical characteristics of human bocavirus (HBoV) infection in the children with severe lower respiratory tract infection. Methods The clinical data of the hospitalized children with sputum HBoV-positive from September 1st, 2016 to March 31, 2017 at the pediatric intensive care unit of Children’s Hospital Affiliated to Capital Institute of Pediatrics was analyzed retrospectively. Results A total of 17 children were included in the study. The ratio of male to female was 15:2. The diagnostic age was 4 months to 4 years and 10 months old. 82.4% of the patients were infants below 2 years old. Autumn and winter were high-occurrence seasons. The main clinical manifestations were respiratory system involvement, including fever, cough, wheezing, and dyspnea. The main abnormal chest radiological findings were patchy shadows and consolidation. Type I respiratory failure occurred in 11 cases (64.7%), while type II respiratory failure occurred in 6 cases (35.3%). All of the patients need respiratory support with mechanical ventilation. Among them, 6 patients (35.3%) were treated by non-invasive ventilation, and 11 patients (64.7%) were treated by invasive ventilation. Other organ dysfunction was mild. The length of hospital stay ranged from 3 days to 13 days. The cure rate was 100%. Conclusions HBoV infection in the children with severe lower respiratory tract infection was common in infants under 2 years old, with acute onset and rapid recovery. The obvious clinical symptoms were fever, cough, wheezing and dyspnea. Although respiratory failure was common, other organ dysfunction was mild, which led to a good prognosis.

Clinical analysis of human bocavirus infection in children with severe lower respiratory tract infection

Objective To explore the clinical characteristics of human bocavirus(HBoV) infection in the children with severe lower respiratory tract infection. Methods The clinical data of the hospitalized children with sputum HBoV-positive were analyzed retrospectively, who were hospitalized at the Pediatric Intensive Care Unit of Children′s Hospital Affiliated to Capital Institute of Pediatrics from September 1, 2016 to March 31, 2017. Results A total of 17 children were included in the study.The ratio of male to female was 152.The diagnostic age ranged from 4 months to 4 years and 10 months old.82.4%(14/17 cases) of the patients were infants less than 2 years old.Autumn and winter were high-occurrence seasons.Pediatric Critical Illness Scores(PCIS) were 68-88 scores(median 82 scores). PCIS was less than 70 scores in 1 case, and between 70 scores and 80 scores in 7 cases, and more than 80 scores in 9 cases.The main clinical manifestations were respiratory system involvement, including dyspnea in 17 cases (100%), fever in 14 cases (82.4%), cough in 16 cases(94.1%), wheezing in 13 cases (76.5%), and moist rales in 13 cases (76.5%). The main abnormal chest radiological findings showed patchy shadows in 7 cases (41.2%) and consolidation in 6 cases (35.3%). The oxygenation index was 73.9-296.0 mmHg(1 mmHg=0.133 kPa), and median was 176 mmHg. The oxygenation index was between 100-200 mmHg in 7 cases(41.2%), and less than 100 mmHg in 2 cases(11.7%). Type Ⅰ respiratory failure occurred in 11 cases (64.7%), while type Ⅱ respiratory failure occurred in 6 cases (35.3%). All of the patients need respiratory support with mechanical ventilation.Among them, 6 patients (35.3%) were treated by non-invasive ventilation and their ventilation time were 25-128 h(median 65 h), while 11 patients (64.7%) were treated by invasive ventilation and their ventilation time was 42-178 h(median 70 h). Other organ or system dysfunction is mild.The length of hospital stay ranged from 3 days to 13 days.The cure rate was 100%. Conclusions HBoV infection in the children with severe lower respiratory tract infection is common in infants under 2 years old, with acute onset and rapid recovery.The obvious clinical symptoms are fever, cough, wheezing and dyspnea.Although respiratory failure is common, other organ or system dysfunction is mild, which may bring about a good prognosis. Key words: Child; Human bocavirus; Severe; Lower respiratory tract infection

Development of interstitial pneumonia during treatment with eribulin: a case report

BackgroundEribulin is typically used to treat patients with advanced breast cancer, and anti-cancer agents often cause the development of interstitial pneumonia in Japanese patients with advanced cancer. However, few case reports have addressed eribulin-induced interstitial pneumonia. Herein, we report a rare case of interstitial pneumonia—specifically, organized pneumonia—during treatment with eribulin in a patient with advanced breast cancer.Case presentationA 52-year-old Japanese woman was diagnosed as having advanced breast cancer 3 years before the admission described in the present report. She had received eribulin as third-line chemotherapy. Five days after her second treatment with eribulin, she was admitted to our hospital with dyspnea and dry cough. Upon admission, a chest computed tomography scan showed consolidation, with air bronchograms along the bronchovascular bundle of both lower lobes. The patient’s serum levels of sialylated carbohydrate antigen Krebs von den Lungen-6 were high, as were her surfactant protein-D levels. There was no evidence of heart failure, renal failure, or infection. Based on the clinical cause, as well as on the findings of organized pneumonia, the patient was diagnosed as having interstitial pneumonia and treated with corticosteroids. After the initiation of steroid treatment, her respiratory condition and chest radiological findings improved.ConclusionsThis case reveals an association between eribulin treatment and interstitial pneumonia. To our knowledge, this is the first case report to describe eribulin-induced organized pneumonia. Clinicians should be aware that interstitial pneumonia can develop during treatment with anti-cancer agents.

Screening for Latent Tuberculosis Infection in Patients with Hematologic Malignancies Using Interferon-Gamma Release Assays (IGRAS)

Background: The development of interferon-gamma release assays (IGRAs) is important in the diagnosis- of latent tuberculosis infection (LTBI). Objectives: The aim of this study was to evaluate the role of QuantiFERON®-TB Gold In-Tube test (QFT-GIT) in detection of LTBI in patient with hematological malignancy and to identify individuals who are at increased risk for the development of tuberculosis (TB). Methodology: the study was conducted on 52 newly diagnosed patients with hematologic malignancies at National Cancer Institute, Cairo University. The interferone- gamma secreted by T-lymphocytes following stimulation by antigens unique to Mycobacterium tuberculosis was measured. The QFT results were evaluated in relation to different clinical and hematologic parameters and outcome after induction therapy. Results: Nine out of 52 cases (17.5%) were positive for QFT. The patients included were 30 males (58%) and 22 females (42%), with a mean age of 42.75±15.39 years. Out of the 52 patients, 21 (40%) were Leukemic, while 31 patient (60%) had lymphoma. Among the QFT positive cases, 6/9 were lymphoma (67%) and 3/9 were leukemic cases (33%). Manifestations of infection were observed in 13/52 (25%) of cases and 55.5% of positive QFT cases (5/9) while positive chest radiological findings were reported in 44.4% of positive QFT cases (4/9). Lymph node enlargement were reported in 6/9 (66.7%) of QFT positive cases. After induction chemotherapy, 8 patients had an unfavorable outcome, 4 of whom were QFT positive. Conclusion: Interferon-Gamma Release Assays (IGRAs) can aid in diagnosing latent tuberculosis infection in patients with hematologic malignancies. This may prevent the spread of infection and identify who would benefit from treatment of latent TB infection.

Radiological Findings of Pulmonary Tuberculosis in Patients with and Without HIV Infections

Introduction: Radiological manifestation of pulmonary tuberculosis in HIV positive patients is different with HIV negative patients. We aim to determine the differences in chest radiological findings of Pulmonary Tuberculosis among HIV and non-HIV infected patients in HTAA. Materials and method: A retrospective study was conducted in Chest Clinic, Hospital Tunku Ampuan Afzan, Kuantan Pahang. There were 101 chest radiographs with sputum smear-positive retrieved and reviewed. Socio-demographic status and chest radiographs findings were documented and analyzed. Results: Of the 101 patients, 12 patients were HIV positive. Of the 89 HIV negative patients, 96% had consolidation change on chest radiograph, in contrast with HIV positive patients, only 4% among them had this appearance and this is statistically significant (p value less than 0.05). Mediastinal lymphadenopathy is significantly higher (17%) in HIV positive patients compared to HIV negative patients (1%). Normal chest radiographs were more common in HIV positive patients (33%) as compared to HIV negative patients (2%). Conclusion: HIV positive patients with pulmonary tuberculosis exhibit different radiological manifestation on chest radiograph when compared to HIV negative patients.

Plasma cell-free DNA levels and integrity in patients with chest radiological findings: NSCLC versus benign lung nodules

Effective discrimination between lung cancer and benign tumours is a common clinical problem in the differential diagnosis of solitary pulmonary nodules. The analysis of cell-free DNA (cfDNA) in blood may greatly aid the early detection of lung cancer by evaluating cancer-related alterations. The plasma cfDNA levels and integrity were analysed in 65 non-small cell lung cancer (NSCLC) patients, 28 subjects with benign lung tumours, and 16 healthy controls using real-time PCR. The NSCLC patients demonstrated significantly higher mean plasma cfDNA levels compared with those with benign tumours (P = 0.0009) and healthy controls (P < 0.0001). The plasma cfDNA integrity in healthy individuals was significantly different than that found in patients with NSCLC or benign lung tumours (P < 0.0003). In ROC curve analysis, plasma cfDNA levels >2.8 ng/ml provided 86.4% sensitivity and 61.4% specificity in discriminating NSCLC from benign lung pathologies and healthy controls. cfDNA integrity showed better discriminatory power (91% sensitivity, 68.2% specificity). These data demonstrate that plasma cfDNA concentration and integrity analyses can significantly differentiate between NSCLC and benign lung tumours. The diagnostic capacity of the quantitative cfDNA assay is comparable to the values presented by conventional imaging modalities used in clinical practice.

Successful Additional Corticosteroid Treatment in a Patient with Mycoplasma pneumoniae Pneumonia in whom a Monobacterial Infection was Confirmed by a Molecular Method Using Bronchoalveolar Lavage Fluid.

A 23-year-old Japanese woman was admitted to A hospital due to pneumonia. IgM for Mycoplasma pneumoniae was positive, and the patient was treated with imipenem/cilastatin, clindamycin, pazufloxacin and minocycline. However, both the chest radiological findings and the symptoms became exacerbated, and she was therefore transferred to our hospital. The bronchoalveolar lavage fluid was obtained, and a 16S rRNA gene sequencing analysis revealed a monobacterial infection of Mycoplasma pneumoniae. Therefore, corticosteroid treatment in addition to minocycline was administered, and the patients symptoms, laboratory data and chest radiographs improved. Corticosteroid therapy may therefore be considered for patients with refractory M. pneumoniae pneumonia.

An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital

ObjectivesTo investigate the association of different chronic comorbidities, considered singularly and together in Cumulative Illness Rating Scale (CIRS) indexes, with pneumonia diagnosis in a group of elderly frail hospitalized patients. Design and methodsWith a retrospective cohort design, all clinical records of frail (Rockwood ≥5) nonterminal patients ≥65years old acutely admitted over a 8-month span in an internal medicine ward were evaluated. Pneumonia status and its categorization (community-acquired, CAP, vs healthcare-associated, HCAP) were defined according to chest radiology findings and validated criteria. Chronic comorbidities, CIRS Comorbidity Score and CIRS Severity Index were collected for each participant through a standardized methodology. Multivariate logistic regression models were applied to assess the association of each comorbid condition or scores with pneumonia. Results1199 patients (546M, median age 81.9, IQR 72.8–87.9years), of whom 239 with pneumonia (180 CAP, 59 HCAP) were evaluated. CIRS Comorbidity Score was significantly associated with pneumonia, both at an age- and sex-adjusted model and at a multivariate model (OR for each unitary increase 1.03, 95% CI 1.001–1.062, p=0.04), together with provenience from nursing home (OR 1.96, 95% CI 1.41–2.73, p<0.001). Among single comorbidities, only COPD (OR 2.7, 95% CI 1.9–3.6, p<0.001) and dementia (OR 2.3, 95% CI 1.7–3.3, p<0.001) were associated with pneumonia, while stroke, cancer, cardiovascular, chronic liver and kidney disease were not. ConclusionsIn a small cohort of elderly frail hospitalized patients, measures of multimorbidity, like CIRS, are significantly associated with the risk of pneumonia. COPD and dementia are the main conditions concurring to define this risk.

Transbronchial lung biopsy in patients with diffuse parenchymal lung disease without 'idiopathic pulmonary fibrosis pattern' on HRCT scan - Experience from a tertiary care center of North India.

Background:Diffuse parenchymal lung diseases (DPLD) are a group of disorders characterized by chest radiological findings of bilateral diffuse shadowing. Lung biopsy is generally required to make an etiological diagnosis of DPLD's. Transbronchial lung biopsy (TBLB) is a minimally invasive method to achieve a lung sample which has been found to be a useful diagnostic tool in patients with DPLD. As per American Thoracic Society guidelines for management of idiopathic interstitial pneumonias, TBLB is not required in patients who have findings consistent with idiopathic pulmonary fibrosis (IPF) on HRCT scan thorax. Some Indian researchers have evaluated, on a small number of subjects, the role of TBLB in patients with DPLD, but they had not excluded patients with ‘IPF pattern’. This study was planned to assess TBLB in patients with DPLD after excluding patients with ‘IPF pattern’.Materials and Methods:A prospective non-randomized study on 49 patients with DPLD without a characteristic ‘IPF pattern’ were subjected to TBLB.Results:The overall diagnostic yield of TBLB was 85.7%. Non-specific interstitial pneumonitis, tuberculosis and sarcoidosis were the most common histology patterns found (22.4, 18.4 and 16.3%, respectively). Procedure-related mortality was nil. Iatrogenic pneumothorax occurred in five patients (10.2%). Minor complications included hemorrhage and transient hypoxia.Conclusion:TBLB is a safe and effective tool in the diagnosis of DPLD.

The efficacy and safety of low-dose sirolimus for treatment of lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare disease caused by dysregulated activation of the mammalian target of rapamycin (mTOR). Sirolimus, an inhibitor of mTOR, has been reported to decrease the size of angiomyolipomas and stabilize pulmonary function in patients with LAM. However, the optimal dose for the treatment of LAM remains unclear. We conducted a retrospective, observational study of 15 patients with LAM who underwent sirolimus therapy for more than 6 months. The efficacy was evaluated by reviewing the patients' clinical courses, pulmonary function and chest radiologic findings before and after the initiation of sirolimus treatment. All patients had blood trough levels of sirolimus lower than 5ng/mL. Sirolimus treatment improved the annual rates of change in FVC and FEV1 in the 9 patients who were free from chylous effusion (FVC, -101.0 vs. +190.0mL/y, p=0.046 and FEV1, -115.4 vs. +127.8mL/y, p=0.015). The remaining 7 patients had chylous effusion at the start of sirolimus treatment; the chylothorax resolved completely within 1-5 months of treatment in 6 of these cases. These results resembled those of previous studies in which blood trough levels of sirolimus ranged from 5 to 15ng/mL. Low-dose sirolimus (trough level, 5ng/mL or less) performed as well as the higher doses used previously for improving pulmonary function and decreasing chylous effusion in patients with LAM.

Pulmonary sclerosing hemangioma: a unique epithelial neoplasm of the lung (report of 26 cases)

BackgroundPulmonary sclerosing hemangioma (SH) is an uncommon tumor. The aim of this study was to identify the origin of pulmonary SH and summarize its clinicopathologic features.MethodsData of 26 cases of pulmonary SH were collected and reviewed, including their clinical symptoms, chest radiological examinations, treatments, and pathological findings.ResultsFemale patients of pulmonary SH were markedly frequent (n=23, 88.46%). Solitary mass or nodule in the lung fields was the most common manifestation (n=24, 92.31%), especially in the right middle lobe (n=9, 34.62%). There were two kinds of tumor cells: lining cells and round cells. All tumors contained a mixture of papillary, solid, sclerotic, and hemorrhagic patterns. Immunohistochemistry with a variable number of antibodies was performed for some cases. All of the detected specimens revealed strong reaction of lining cells with epithelial markers, such as thyroid transcription factor-1 (TTF-1), epithelial membrane antigen (EMA), cytokeratin (CK), pancytokeratin (PCK), and cytokeratin 7 (CK-7), while round cells were positive with TTF-1 and EMA. Until the end of last contact, none of the patients died or suffered from the recurrence of the disease after surgical treatment.ConclusionsPulmonary SH is a unique neoplasm of the lung with a characteristic solitary mass or nodule. Pulmonary epithelium might be the primary origin of the tumor cells.

A non-HIV case with disseminated Mycobacterium kansasii disease associated with strong neutralizing autoantibody to interferon-γ

Disseminated non-tuberculous mycobacterium (dNTM) infection is rare in humans without human immunodeficiency virus (HIV) infection. Previous reports have shown autoantibodies to human interferon-gamma (IFN-γ), which play important roles in mycobacterium infection, in the sera of patients with non-HIV dNTM disease. Herein, we describe a 53-year-old male who was strongly suspected to have multicentric Castleman disease (MCD) based on bone marrow study and chest radiological findings. However, Mycobacterium kansasii was detected in respiratory samples including pleural effusion. We initiated anti-mycobacterial therapy under intensive care; he died on the 48th hospital day. We detected no hematological disorders, ruling out MCD postmortem. However, we detected M. kansasii in pulmonary, liver, spleen and bone marrow tissues. Moreover, anti-IFN-γ autoantibody was detected with strong neutralizing capacity for IFN-γ. We consider our present report to contribute to understanding of the relationship between anti-IFN-γ autoantibody and disease development.

A case of bilateral multiple pulmonary chondroma: necessity of follow-up for Carney’s triad

We report a case of pulmonary bilateral multiple chondromas that were possibly an initial clinical presentation of Carney's triad. A 56-year-old Japanese non-smoking asymptomatic woman was admitted to the hospital for further examination of small, multiple, bilateral nodules in the lungs. Although chest radiological findings suggested that the nodules were possibly metastatic pulmonary tumors, the malignant origin was not detected. During diagnostic video-assisted thoracic surgery, wedge resections including the nodules were performed. Since pathological examination showed nodules were surrounded by fibrous and eosinophilic stroma, we diagnose the nodules as chondromas. These chondromas were possibly components of Carney's triad, because each nodule had a thin fibrous pseudocapsule and did not have an entrapped epithelium and fat. Some patients die of Carney's triad because of malignant alteration of lesions. Therefore, the patients with Carney's triad should be taken a medical check periodically. This patient was scheduled to undergo the check-up for several years.

Adenovirus pneumonia in an immunocompetent adult

Adenovirus pneumonias are reported relatively commonly in pediatric or immunocompromised patients, but the clinical presentation of adenovirus pneumonia in immunocompetent hosts is not well known. We treated an immunocompetent 42-year-old man with mild adenovirus pneumonia following pharyngitis and conjunctivitis. Diagnosis was established on the basis of chest radiologic findings, detection of adenovirus type 7 DNA by PCR assay in material obtained from bronchoalveolar lavage (BAL), and a greater than fourfold rise in adenovirus-specific antibody titers during the course of illness. The patient's self-limiting symptoms improved within 2 weeks, and chest radiologic findings improved within 4 weeks. PCR assay of material obtained by BAL was useful for the rapid diagnosis of adenovirus pneumonia.

Gradual Progression of Intrapulmonary Lymph Nodes Associated with Usual Interstitial Pneumonia in Progressive Systemic Sclerosis on Chest Radiographs and CT

Progressive systemic sclerosis (PSS) is a chronic, multisystemic disease, which is characterized by vascular changes, fibrosis, and inflammation of the skin and visceral organs. Pulmonary involvement occurs frequently in patients with PSS and is now considered as the main cause of death among these patients (1). Lung abnormalities are often subtle, most frequently occurring at the lung bases, and progressively expanding to involve the lower two-thirds of the lungs (2). High resolution CT (HRCT) findings of interstitial fibrosis in PSS include fine reticular opacities, ground-glass opacity, consolidation, traction bronchiectasis, honeycombing, and coarse or irregular reticulations. The presence of faint parenchymal micronodules on CT scans is not unexpected, as focal lymphoid hyperplasia (follicular bronchiolitis) has been reported as a frequent histologic feature. Subpleural micronodules may reflect lung involvement at the pleural parenchymal interface, as small lymphoid aggregates adjacent to the pleura have been observed in lower lobe biopsies of patients with PSS (3). However, the radiologic detection of progressive intrapulmonary lymph nodes (IPLNs) with PSS has not yet been reported. In this review, we report the serial chest radiologic findings in one case of PSS with multiple growing lung nodules, which turned out to be IPLNs on video-assisted thoracoscopic lung biopsy (VATS).

Patients in whom active tuberculosis was diagnosed after admission to a Japanese university hospital from 2005 through 2007

To identify problems in early diagnosis of tuberculosis and to design countermeasures against the disease, we examined the status of active tuberculosis among patients admitted to a university hospital that did not have an isolation ward for tuberculosis. Between 2005 and 2007, we analyzed demographic characteristics, disease type, chest radiologic findings, and the process leading to diagnosis. Active tuberculosis was diagnosed after admission in 55 patients (34 males and 21 females): pulmonary tuberculosis, 26; tuberculous pleuritis, 13; tuberculous meningitis, 6; miliary tuberculosis, 4; tuberculous pericarditis, 3; lymph-node tuberculosis, 2; and tracheal and bronchial tuberculosis, 1. Although radiographic examinations provided abundant information, chest radiography showed normal findings in 7 patients (12.7%). Computed tomographic scanning was useful for detailed evaluation of abnormalities. Twenty patients (36.4%) were given diagnoses at departments other than ours (Department of Pulmonary Medicine). Numbers of days between hospital admission and diagnosis of tuberculosis (50th percentile/80th percentile) were 8.0/37.8 for miliary tuberculosis, 8.0/8.0 for tracheal and bronchial tuberculosis, 7.5/17.8 for tuberculous pleuritis, 7.0/8.8 for tuberculous pericarditis, 6.0/15.6 for pulmonary tuberculosis, 3.5/4.4 for lymph-node tuberculosis, and 1/1 for tuberculous meningitis. Early diagnosis of tuberculosis requires adherence to the following precautions. Tuberculosis should be suspected in any patient with respiratory symptoms. Sputum tests for acid-fast bacteria should be performed at least three times initially. If findings on chest X-ray films are equivocal, high-resolution computed tomography should be performed to confirm details of shadows and to detect minimal pulmonary shadows or cavitary lesions. Physicians from all specialties should be repeatedly informed about the risk of tuberculosis and should include tuberculosis in the differential diagnosis in patients suspected to have pulmonary diseases.