Ground-glass Opacity Lung Research Articles

Adalimumab and Small Vessel Vasculitis: Old Dog New Tricks

SESSION TITLE: Fellow Case Report Poster - Diffuse Lung Disease I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Adalimumab (TNF Inhibitor) has been available since 2008 for the treatment of various autoimmune diseases. Despite clinical efficacy, many TNF inhibitors have a considerable side effect profile. There have been numerous case reports outlining the pulmonary side effects of adalimumab including, but not limited to, interstitial pneumonia, fibrosing alveolitis, and granulomatous pneumonitis. Here we present a case of a small size vessel pulmonary vasculitis attributed to adalimumab. We believe it is the first such case described. CASE PRESENTATION: 72 YO male who was diagnosed with Ulcerative Colitis in 2009, failed azathioprine and mesalamine. Started on Adalimumab 40mg subcutaneously every other week which was then increased to weekly injections that led to remission. Following the initiation of adalimumab, the patient started complaining of hemoptysis. CT chest showed progressive interstitial thickening, ground-glass opacities in both lungs, predominantly involving the middle lobe, lingua and both lower lobes. There was relatively mild stable architectural distortion and mild traction bronchiectasis. Due to the progression of disease seen on CT, the patient underwent a bronchoscopy which showed blood in the trachea and chronic bronchitic changes, however the bronchoscopist was unable to identify a source of bleeding. A work up that included autoimmune/vasculitis panel was negative. Due to his ongoing hemoptysis, he underwent a video assisted thoracoscopy which showed extensive fibrin thrombi involving microvascular bed and small caliber arteries. DISCUSSION: As his symptoms started shortly after initiating adalimumab, the findings were suspected to be related to adalimumab. Adalimumab was subsequently discontinued, and as a result the patient's cough and hemoptysis resolved within a few weeks. CONCLUSIONS: Hemoptysis can be attributed to many causes and therefore a thorough history is essential in narrowing an expansive differential diagnosis. It is imperative to realize that even if a medication has not caused a disease process previously if the history leads you towards that particular pathway, it is the practitioner's responsibility to follow the clues towards an answer. Irrespective of how old a medication may be there are always new ways a patient may react. Reference #1: http://www.pneumotox.com/search/results/56f1d7f1a8ac6/ Reference #2: Lauque D, Cadranel J, et al. Microscopic polyangiitis with alveolar hemorrhage. A study of 29 cases and review of the literature. Medicine (Baltimore). 2000 Jul. 79(4):222-33. [Medline]. DISCLOSURE: The following authors have nothing to disclose: Kumar Shah, Randolph Lipchik, Rose Franco No Product/Research Disclosure Information

Clinical, pathological, and radiological characteristics of solitary ground-glass opacity lung nodules on high-resolution computed tomography.

BackgroundLung nodules are being detected at an increasing rate year by year with high-resolution computed tomography (HRCT) being widely used. Ground-glass opacity nodule is one of the special types of pulmonary nodules that is confirmed to be closely associated with early stage of lung cancer. Very little is known about solitary ground-glass opacity nodules (SGGNs). In this study, we analyzed the clinical, pathological, and radiological characteristics of SGGNs on HRCT.MethodsA total of 95 resected SGGNs were evaluated with HRCT scan. The clinical, pathological, and radiological characteristics of these cases were analyzed.ResultsEighty-one adenocarcinoma and 14 benign nodules were observed. The nodules included 12 (15%) adenocarcinoma in situ (AIS), 14 (17%) minimally invasive adenocarcinoma (MIA), and 55 (68%) invasive adenocarcinoma (IA). No patients with recurrence till date have been identified. The positive expression rates of anaplastic lymphoma kinase and ROS-1 (proto-oncogene tyrosine-protein kinase ROS) were only 2.5% and 8.6%, respectively. The specificity and accuracy of HRCT of invasive lung adenocarcinoma were 85.2% and 87.4%. The standard uptake values of only two patients determined by 18F-FDG positron emission tomography/computed tomography (PET/CT) were above 2.5. The size, density, shape, and pleural tag of nodules were significant factors that differentiated IA from AIS and MIA. Moreover, the size, shape, margin, pleural tag, vascular cluster, bubble-like sign, and air bronchogram of nodules were significant determinants for mixed ground-glass opacity nodules (all P<0.05).ConclusionWe analyzed the clinical, pathological, and radiological characteristics of SGGNs on HRCT and found that the size, density, shape, and pleural tag of SGGNs on HRCT are found to be the determinant factors of IA. In conclusion, detection of anaplastic lymphoma kinase expression and performance of PET/CT scan are not routinely recommended.

鼓膜切開による高位内頸静脈損傷から動静脈空気塞栓症に至った1例(Systemic air gas embolism complicated with high jugular bulb injury: a case report)

患者は67歳の女性。約6か月前からの左低音性耳鳴を主訴に近医耳鼻咽喉科を受診し，左滲出性中耳炎と診断され，左鼓膜切開術を施行された。切開時に静脈性出血があり，直後に呼吸困難を訴え，意識が低下し救急要請された。救急隊接触時に室内大気下SpO2が80%であり，当科へ搬送された。当院到着時は意識清明で，高流量酸素投与下でSpO2 99%であった。経胸壁心臓超音波にて両心室内の微小気泡を認めた。頭部CTにて左内頸動脈内の気泡，左鼓室底の形成不全ならびに高位頸静脈球を認め，胸腹部造影CTにて肺動脈主幹部内の気泡，両側肺野に多発するすりガラス影を認めた。12誘導心電図で右心負荷所見を認めた。動静脈空気塞栓症と診断し，緊急で高気圧酸素治療を行い，その後は高濃度酸素投与や輸液療法を中心とした全身管理を行った。治療開始後速やかに呼吸状態は改善した。第3病日に施行した全身CTでは，動脈内空気塞栓像は消失し，第11病日に独歩退院した。高位頸静脈球は耳鼻咽喉科領域において比較的よくみられる解剖学的破格であるが，その損傷による動静脈空気塞栓症の報告はなく，非常に稀な合併症である。救急診療において，この解剖学的破格の認知および稀ではあるが，動静脈空気塞栓症を合併し得ることを認識すべきである。また，空気塞栓症に対し高気圧酸素治療が有効であり，専門施設への早期搬送も念頭において診療にあたる必要がある。 A 67–year–old woman, with a half–year history of tinnitus in the left ear, underwent tympanotomy for the treatment of otitis media with effusion in the left ear. During the procedure, moderate bleeding from the tympanum was observed; thereafter, she experienced dyspnea and lost consciousness and was transferred to our emergency department owing to low oxygen saturation. On admission, she was alert, and oxygen saturation improved. Electrocardiogram showed slight right heart strain pattern, and echocardiography showed microbubbles in both ventricles. Enhanced computed tomography (CT) revealed air in the left internal carotid artery and pulmonary artery, hypoplasty of the left tympanum bottom, and multiple ground glass opacity in both lungs. She was diagnosed with systemic air gas embolism (AGE) complicated with high jugular bulb injury. We administered hyperbaric oxygen therapy (HBOT) in addition to high flow oxygen supply and adequate rehydration therapy. Her respiratory condition quickly improved. CT performed on day 3 showed disappearance of intravascular air. She was discharged on day 11. High jugular bulb is a relatively common anatomical anomaly in otorhinolaryngology. Although AGE due to high jugular bulb injury is rare, physicians should recognize this fatal complication and consider transferring patients to specialized institutions equipped with an HBOT chamber. 頸静脈球はS状静脈洞から内頸静脈に移行する部位であり，通常，頸静脈球上縁は鼓室底よりも下方に存在するが，稀に鼓室底より高位に位置する解剖学的破格がある。 高位頸静脈球は耳鼻咽喉科領域で比較的よく遭遇するが，この損傷により動静脈空気塞栓症を発症したという症例報告は，我々が検索し得た範囲では自験例が初めてである。今回，我々は鼓膜切開による高位内頸静脈球損傷から動静脈空気塞栓症に至った1例を経験したので報告する。 なお，本論文は所属施設の倫理委員会の承認を得ており，個人情報保護に基づき匿名化されており，投稿にあたっては患者・家族に論文掲載に関して同意を得ている。 症 例：特記すべき既往のない67歳の女性 現病歴：入院約6か月前から続く左低音性難聴と耳鳴を主訴に近医耳鼻咽喉科を受診した。左滲出性中耳炎と診断され，診察室にて座位の姿勢で左鼓膜切開処置を施された。左鼓膜を切開した直後に，鼓室内から約30mLの静脈性の出血があった。直後に呼吸困難を自覚し，その後意識消失したため救急要請された。約2分後に意識は改善し，救急隊の現場到着時は意識清明であった。室内大気下の経皮的酸素飽和度（percutaneous saturation of oxygen: SpO2）が80%であったため，当院救命救急センターに搬送された。 来院時現症：意識清明，瞳孔不同なく左右ともに3mmで対光反射は迅速。血圧161/108mmHg，心拍数92/分，呼吸数25/分，SpO2 99%（リザーバーマスク10L/分投与下），体温35.8°C。眼瞼結膜の点状出血斑含め，全身にも点状出血斑なし。頸静脈怒張なし。四肢に粗大な運動麻痺はなく，知覚異常なし。左耳孔に希釈アドレナリン含有綿球を詰め込まれ止血処置されていた。 主要検査所見：白血球8,900/μL，血色素量13.2 g/dL，血小板247,000/μL，アルブミン4.0g/dL，ナトリウム137mEq/L，カリウム4.1mEq/L，クロール104mEq/L，クレアチンキナーゼ79U/L，AST 21U/L，ALT 13U/L，LDH 231U/L，尿素窒素13mg/dL，クレアチニン0.4mg/dL，BNP <5.8pg/mL，血糖107mg/dL，ヘモグロビンA1c（NGSP）6.1%，プロトロンビン時間（国際標準比）0.99，活性化プロトロンビン時間31.0秒，フィブリノゲン357mg/dL，D–ダイマー0.7μg/mL。血液ガス分析値（リザーバーマスク10L酸素投与下）；pH 7.463，PaO2 116.0torr，PaCO2 34.7torr，HCO3– 24.5mmol/L，Lac 1.0mmol/L。 胸部単純X線写真：心胸郭比54.5%（仰臥位）。全肺野で透過性低下あり。 頭部単純CT：左内頸動脈内に気泡像を認めた（Fig. 1a）。左鼓室底の形成不全を認め，左高位頸静脈球が鼓膜に隣接していた（Fig. 1b）。 Computed tomography of head and chest on admission. a) A head CT on admission shows an air bubble in the left internal carotid artery (up arrow). b) An enhanced head CT obtained on admission shows the left high jugular bulb adjoined the left tympanum and hypoplasty of the left tympanum bottom (down arrow). c) An enlarged enhanced chest CT on admission shows air bubbles in the main trunk of the pulmonary artery (triangle). d) A chest CT on admission shows multiple ground glass opacity and wedged shape consolidation in peripheral areas of both lungs. CT: computed tomography 胸腹部造影CT：肺動脈主幹部に気泡像を認めた（Fig. 1c）。両側肺野末梢側に散在するすりガラス状陰影を認めた（Fig. 1d）。 経胸壁心臓超音波検査：駆出率69%，左房径28mm，右心系拡大なし，最大三尖弁圧較差22mmHg，下大静脈径9mm，卵円孔開存なし。両心室腔内に微小気泡像を認めた（Fig. 2）。 An echocardiogram on admission. An echocardiogram on admission shows micro bubbles in both ventricles (arrows). LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle 12誘導心電図検査：心拍数66/分の洞調律。正常軸。I誘導のS波，III誘導のQ波および陰性T波，いわゆるMcGinn–White patternがみられ，急性右心負荷所見を示唆する所見であった（Fig. 3a）。 An electrocardiogram on admission and on day 8. a) An electrocardiogram on admission shows S wave in I, Q wave in III, flat T wave in II, negative T wave in III and aVF ―the so called “McGinn–White pattern”. b) An electrocardiogram on day 8 shows disappearance of abnormal T wave change in II, III, and aVF. 来院後経過：当院到着時は意識清明であり，循環状態は維持され，呼吸状態も安定していた。全身CTにて，動静脈空気塞栓が確認されたため，高気圧酸素治療（hyperbaric oxygen therapy: HBOT）を米海軍治療表6欄に則り施行した。第2から4病日にかけて，米海軍治療表5欄に則り計3回HBOTを施行した。治療効果判定目的に，第3病日に頭部および胸部単純CT検査を施行したところ，内頸動脈および肺動脈内の気泡像は消失したが，肺野末梢側の楔状浸潤影の若干の増悪を認めた。しかしながら血液ガス分析では酸素化は著明に改善し，呼吸状態も改善傾向にあった。第3病日に頭部単純MRI検査を施行したが異常所見はなかった。第4病日には酸素投与を終了することができた。第5病日の胸部単純X線および胸部単純X線CTでは，肺野陰影は改善していた。第7病日の12誘導心電図では，右心負荷所見は消失していた（Fig. 3b）。同日に左鼓膜の診察を行ったところ，止血されており，左下象限に高位頸静脈球と思われる青色構造が透見できた。この時点で測定した平均聴力レベルは，右26.3デシベル，左81.3デシベルと高度の左混合性難聴を認めた。全身状態良好であり，第11病日に独歩退院した。 鼓膜切開に伴う頸静脈球損傷から動静脈空気塞栓症を来したが，早期のHBOTにより後遺症を残すことなく治療しえた1例であった。 頸静脈球はS状静脈洞から内頸静脈に移行するドーム状の部位である。通常，頸静脈球上縁は鼓室底よりも下方に位置するが，稀に鼓室底よりも高位に位置する解剖学的破格があり，高位頸静脈球と呼ばれる。古典的には八木ら 1の側頭骨単純X線写真によるI，II，IIIaおよびIIIbの4型分類があり（Fig. 4），東野ら 2は側頭骨CTを用いた内側型および外側型の2型分類を提唱している。本症例のCT所見では，左鼓室底の骨欠損がみられており，頸静脈球が鼓室内に露出していたことから，八木らの分類ではIIIb型，東野らの分類では外側型であった。高位頸静脈球は無症状のこともあるが，その位置や発達程度により難聴や耳鳴，めまいなどを呈し得る 3。本症例においても，来院の約6か月前からの低音性耳鳴の症状を呈しており，高位頸静脈球の症状と考えて矛盾しない。鼓膜切開術時の損傷により大出血を起こし得るため，疾患の存在や解剖学的位置を把握しておくことが重要である。 Variations of the superior bulb of the internal jugular vein. a) Type I has a normal structure. b) Type II shows that the superior bulb of the jugular vein is higher (high jugular bulb, HJB) compared to Type I. c) Type IIIa shows that the HJB is extended into the tympanic cavity, without affecting the jugular wall of the tympanic cavity. d) Type IIIb shows that the HJB is extended into the tympanic cavity, affecting the jugular wall of the tympanic cavity. 一方，静脈空気塞栓は，外科的手術や血管内治療，外傷などの静脈系の脈管への直接的な空気の流入により生じ，呼吸困難・低酸素血症などの呼吸不全，頻脈・血圧低下などの循環虚脱を来し得る 4, 5。また，動脈空気塞栓は，人工呼吸器関連肺損傷や潜水などの肺胞ガスの肺血管床への流入，心室中隔欠損・卵円孔開存・肺動静脈奇形などにより生じる 6, 7。脳動脈塞栓症状として意識障害・神経巣症状があり，大量の空気が動脈内に流入すると循環不全を来し，心肺停止に至る可能性がある病態である 8, 9。 本症例においては，胸部単純CTにて多発するすりガラス影を確認した。12誘導心電図にて右心系負荷所見を認め，動脈血酸素分圧の低下もみられたことから，静脈空気塞栓による肺障害と考えて矛盾しない所見であった。さらに経胸壁心臓超音波検査にて両心室腔内の気泡があり，頭部単純CTにて血管内気泡がみられ，動脈空気塞栓症も合併していた。経胸壁心臓超音波検査では右左シャント疾患などの器質的構造異常はなかったが，急性右心負荷時に膜様構造である卵円窩を介した右左シャントにより，動脈空気塞栓を発症した可能性が考えられた。静脈内空気流入量が多かった原因としては，患者が座位で処置を受けていたこと，鼓膜切開直後の出血に驚き，胸腔内圧が急激に強い陰圧となったことなどが挙げられる。 空気塞栓症の症状は軽症から重篤なものまで多岐にわたり，とくに緊急性の高い症状としては気泡による脳梗塞などの脳神経障害がある。その病態は，気泡による血流障害や血管内皮障害，気泡の直接的な組織障害が原因とされるが，未だ詳細は明らかではない 10, 11, 12。CTやMRIなどの画像検査では直接気泡を確認することがしばしば困難であり，さらに血管内気泡を確認できた場合であっても，必ずしも症状を呈さないという報告 13もある。本例でも頭部CTにて脳血管内気泡があったが，神経学的異常所見はなかった。このことから，必ずしも動脈ガス塞栓の画像所見と臨床症状の重症度が一致するとは限らない症例もあることが示唆される。 空気塞栓症は発症からHBOTなどの治療介入までの時間が迅速なほど，転帰は良好である 14。本症例では緊急でHBOTを施行でき，後遺症を残すことなく退院することができた。我々が検索し得た範囲では，高位頸静脈球損傷による空気塞栓は過去に報告はなかった。耳鼻咽喉科領域において比較的よく遭遇するこの解剖学的破格は，救急医療の日常診療でも遭遇し得るため，存在を認知することが必要である。さらに，稀ではあるが動静脈空気塞栓症を合併し得ることも認識しておかなければならない。高位頸静脈球損傷の合併症として空気塞栓症を来し得ること，その治療として早期のHBOTが有効であることを認識し，速やかにHBOTが施行可能な高次医療機関への搬送を考慮すべきである 15。 高位頸静脈球損傷による動静脈空気塞栓症を発症し，迅速なHBOT導入により後遺症を残すことなく治療し得た1例を経験した。鼓膜切開の合併症に高位頸静脈球損傷があり，出血性合併症の他に空気塞栓症を発症し得る。空気塞栓症と診断した場合には，速やかにHBOTを導入可能な施設への搬送に尽力すべきである。 本論文の投稿にあたって，開示すべき利益相反はない。

Association between CT-Diagnosed Pneumonia and Endoscopic Submucosal Dissection of Gastric Neoplasms

Background/Aims: This prospective cohort study aimed to elucidate the incidence and characteristics of pneumonia associated with endoscopic submucosal dissection (ESD) of gastric neoplasms using CT. Methods: We included consecutive 188 patients with gastric neoplasms treated with ESD. All patients underwent CT before ESD and the day after ESD. Pneumonia associated with ESD was defined as lung ground glass opacity or consolidation by CT the day after ESD. Results: In 188 patients, 28 patients had diabetes mellitus. Pneumonia was observed by CT in 21 patients (11.2%) after ESD. Of those, 7 patients had diabetes mellitus. By univariate analysis, compared with patients with non-pneumonia complications, risk factors for pneumonia were significantly increased in patients with diabetes mellitus (p = 0.01) and in those who underwent a long procedure time (p = 0.02). By multivariate analysis, pneumonia was significantly increased in patients with diabetes mellitus (OR 4.06, 95% CI 1.35-12.19) and in those who underwent a long procedure time (OR 1.01, 95% CI 1.00-1.02). Conclusions: The incidence of CT-diagnosed pneumonia associated with ESD was relatively high. Furthermore, it was revealed that diabetes mellitus and a long procedure time were risk factors of CT-diagnosed pneumonia.

Neuroendocrine Cell Hyperplasia of Infancy

Neuroendocrine cell hyperplasia of infancy (NEHI) is a disease of the unknown etiology which is one of the rare, insufficiently explored interstitial lung diseases. It might be encountered among children up to two years old and it is characterized by persistent tachypnea, crackles, hypoxemia without being oxygen-dependent and hyperplasia of bombesin-positive neuroendocrin cells of peripheral respiratory tracts in lung biopsy. The lung CT shows that there are mosaic attenuation air trapping involving more than four lung segments and ground glass opacity mostly marked in the middle lobe of the right lung and lingular segments of the left lung. А precise diagnosis establishment based on a combination of clinical signs and HRCT data is possible without implementation of invasive research methods, lung biopsy in particular. At present there is no specific treatment for this disease; infants diagnosed with NEHI require special monitoring since it is not known whether this disease has a connection with idiopathic diffusive hyperplasia of PNE-cells of adults (IDYPNC) and how this pathology might affect lung development and their function in adults. The most part of patients with NEHI have satisfactory clinical results and there have been no fatal cases. Despite such positive data on this understudied disease, infants with NEHI require special monitoring and comprehensive research since long-term effects of this disease in an older age are still undiscovered. In this article case of NEHI in 1,5 years old child with a complaint for tachypnea and cough is submitted.

TU‐H‐CAMPUS‐JeP2‐03: Machine‐Learning‐Based Delineation Framework of GTV Regions of Solid and Ground Glass Opacity Lung Tumors at Datasets of Planning CT and PET/CT Images

Purpose:In radiation treatment planning, delineation of gross tumor volume (GTV) is very important, because the GTVs affect the accuracies of radiation therapy procedure. To assist radiation oncologists in the delineation of GTV regions while treatment planning for lung cancer, we have proposed a machine‐learning‐based delineation framework of GTV regions of solid and ground glass opacity (GGO) lung tumors following by optimum contour selection (OCS) method.Methods:Our basic idea was to feed voxel‐based image features around GTV contours determined by radiation oncologists into a machine learning classifier in the training step, after which the classifier produced the degree of GTV for each voxel in the testing step. Ten data sets of planning CT and PET/CT images were selected for this study. The support vector machine (SVM), which learned voxel‐based features which include voxel value and magnitudes of image gradient vector that obtained from each voxel in the planning CT and PET/CT images, extracted initial GTV regions. The final GTV regions were determined using the OCS method that was able to select a global optimum object contour based on multiple active delineations with a level set method around the GTV. To evaluate the results of proposed framework for ten cases (solid:6, GGO:4), we used the three‐dimensional Dice similarity coefficient (DSC), which denoted the degree of region similarity between the GTVs delineated by radiation oncologists and the proposed framework.Results:The proposed method achieved an average three‐dimensional DSC of 0.81 for ten lung cancer patients, while a standardized uptake value‐based method segmented GTV regions with the DSC of 0.43. The average DSCs for solid and GGO were 0.84 and 0.76, respectively, obtained by the proposed framework.Conclusion:The proposed framework with the support vector machine may be useful for assisting radiation oncologists in delineating solid and GGO lung tumors.

Auto Detection of Lung Ground-Glass Opacity Nodules Based on High-Pass Filter and Gaussian Mixture Model

Auto Detection of Lung Ground-Glass Opacity Nodules Based on High-Pass Filter and Gaussian Mixture Model

A case of Pneumocystis jiroveci pneumonia after bendamustine-based chemotherapy for refractory diffuse large B-cell lymphoma.

A case of Pneumocystis jiroveci pneumonia after bendamustine-based chemotherapy for refractory diffuse large B-cell lymphoma.

R331W Missense Mutation of Oncogene YAP1 Is a Germline Risk Allele for Lung Adenocarcinoma With Medical Actionability.

Adenocarcinoma is the most dominant type of lung cancer in never-smoker patients. The risk alleles from genome-wide association studies have small odds ratios and unclear biologic roles. Here we have taken an approach featuring suitable medical actionability to identify alleles with low population frequency but high disease-causing potential. Whole-genome sequencing was performed for a family with an unusually high density of lung adenocarcinoma with available DNA from the affected mother, four affected daughters, and one nonaffected son. Candidate risk alleles were confirmed by matrix-assisted laser desorption ionization time of flight mass spectroscopy. Validation was conducted in an external cohort of 1,135 participants without cancer and 1,312 patients with lung adenocarcinoma. Family follow-ups were performed by genotyping the relatives of the original proband and the relatives of the identified risk-allele carriers. Low-dose computed tomography scans of the chest were evaluated for lung abnormalities. YAP1 R331W missense mutation from the original family was identified and validated in the external controls and the cohort with lung adenocarcinoma. The YAP1 mutant-allele carrier frequency was 1.1% in patients with lung adenocarcinoma compared with 0.18% in controls (P = .0095), yielding an odds ratio (adjusted for age, sex, and smoking status) of 5.9. Among the relatives, YAP1-mutant carriers have overwhelmingly higher frequencies of developing lung adenocarcinoma or ground-glass opacity lung lesions than those who do not carry the mutation (10:0 v 1:7; P < .001). YAP1 mutation was shown to increase the colony formation ability and invasion potential of lung cancer cells. These results implicated YAP1 R331W as an allele predisposed for lung adenocarcinoma with high familial penetrance. Low-dose computed tomography scans may be recommended to this subpopulation, which is at high risk for lung cancer, for personalized prevention and health management.

The value of assessment of area of ground glass opacity in lungs cast by high-resolution computed tomography on the prognosis of patients with acute paraquat intoxication

To assess the value of the area of ground glass opacities (GGOs) in lungs displayed by high-resolution computed tomography (HRCT) in paraquat (PQ) poisoned patients in evaluating prognosis. Clinical and imaging data of 137 patients with acute PQ poisoning admitted to Affiliated Hospital of the Medical College of Chinese People's Armed Police Forces from January 2012 to August 2014 were analyzed retrospectively. The plasma concentration of PQ on admission and the area of GGOs were compared between two groups. The lung HRCT within 10 days of poisoning was performed every 3 days, and the areas of GGOs were evaluated on five levels, including aortic arch, aortic pulmonary window, left upper lobe bronchial, right inferior pulmonary vein, and left diaphragmatic dome. Receiver operating characteristic curve (ROC) was plotted to evaluate the value of all the parameters for prognosis. Among 137 patients, 45 died within 28 days after poisoning, with the mortality rate of 32.85%. The plasma PQ level in the non-survivors was significantly higher than that in the survivors (mg/L: 7.06 ± 0.67 vs. 3.51 ± 0.34, t = 5.280, P = 0.000). The areas of GGOs at three time points in the non-survivors were significantly higher than those in the survivors [ 1-3 days: (32.0 ± 5.0)% vs. (2.5 ± 0.4)%, t = 7.860, P = 0.000; 4-6 days: (45.5 ± 5.7)% vs. (2.8 ± 0.5)%, t = 12.420, P = 0.000; 7-10 days: (68.0 ± 4.8)% vs. (3.0 ± 0.6)%, t = 23.950, P = 0.00 ]. ROC analysis demonstrated that the area under the ROC curve (AUC) of GGOs in 7-10 days was 1.000, which could be used to determine the prognosis, but it was too late for the treatment. The AUC of GGOs in 4-6 days was 0.979, with the threshold of > 12.0%, the specificity of 96.15%, the sensitivity of 85.19%, the positive predictive value of 88.46%, and the negative predictive value of 94.94%, which presented good effect in predicting prognosis in the early stage of acute PQ intoxication. But plasma PQ concentration was relatively poor for determining prognosis, AUC was 0.821, with the threshold of > 1.95 mg/L, the specificity of 34.52%, the sensitivity of 88.64%, the positive predictive value of 41.49%, and the negative predictive value of 85.29%. The area of GGOs displayed by HRCT can be used to evaluate the fully developed acute PQ lung injury, and it is superior to plasma PQ concentration. The area of GGOs displayed by HRCT 4-6 days after intoxication can be used for the evaluation of PQ induced pulmonary injury in the early stage and the evaluation of clinical prognosis.

Exercise-Induced Pulmonary Edema in a Triathlon.

Introduction. Family physicians have more opportunities to attend athletic competitions as medical staff at first-aid centers because of the increasing popularity of endurance sports. Case. A 38-year-old man who participated in a triathlon race experienced difficulty in breathing after swimming and was moved to a first-aid center. His initial oxygen saturation was 82% and a thoracic computed tomography scan showed bilateral ground glass opacity in the peripheral lungs. His diagnosis was noncardiogenic pulmonary edema associated with exercise or swimming: exercise-induced pulmonary edema (EIPE) or swimming-induced pulmonary edema (SIPE). Treatment with furosemide and corticosteroid relieved his symptoms of pulmonary edema. Discussion. Noncardiogenic pulmonary edema associated with endurance sports is not common, but knowledge about EIPE/SIPE or neurogenic pulmonary edema associated with hyponatremia, which is called Ayus-Arieff syndrome, is crucial. Knowledge and caution for possible risk factors, such as exposure to cold water or overhydration, are essential for both medical staff and endurance athletes. Conclusion. To determine the presence of pulmonary edema associated with strenuous exercise, oxygen saturation should be used as a screening tool at a first-aid center. To avoid risks for EIPE/SIPE, knowledge about these diseases is essential for medical staff and for athletes who perform extreme exercise.

A Case of Statin-Induced Interstitial Pneumonitis due to Rosuvastatin.

Statins lower the hyperlipidemia and reduce the incidence of cardiovascular events and related mortality. A 60-year-old man who was diagnosed with a transient ischemic attack was started on acetyl-L-carnitine, cilostazol, and rosuvastatin. After rosuvastatin treatment for 4 weeks, the patient presented with sudden onset fever, cough, and dyspnea. His symptoms were aggravated despite empirical antibiotic treatment. All infectious pathogens were excluded based on results of culture and polymerase chain reaction of the bronchoscopic wash specimens. Chest radiography showed diffuse ground-glass opacities in both lungs, along with several subpleural ground-glass opacity nodules; and a foamy alveolar macrophage appearance was confirmed on bronchoalveolar lavage. We suspected rosuvastatin-induced lung injury, discontinued rosuvastatin and initiated prednisolone 1 mg/kg tapered over 2weeks. After initiating steroid therapy, his symptoms and radiologic findings significantly improved. We suggest that clinicians should be aware of the potential for rosuvastatin-induced lung injury.

Non Infectious Cavitary Exogenous Lipoid Pneumonia: A Case-Based Short Review

Lipoid pneumonia (LP) is due to the accumulation of either endogenous or exogenous lipids in the alveoli. The exogenous LP (ELP) results from the chronic aspiration or inhalation of animal, vegetable, or mineral oils or fatty substances that by reaching the pulmonary alveoli cause a foreign body-type inflammatory reaction of lung parenchyma, associated with fibrosis, necrosis, and possible cavitation. Pulmonary reaction is characterised by symptoms and radiological findings that are common to other pulmonary diseases. The radiologic presentation of ELP includes lung consolidations and ground-glass opacities, with predominant involvement of the lower lobes. Thickening of interlobular septa, adipose or not adipose single mass, and poorly marginated nodules may also occur. Cavitation, when present, is mainly associated with infection by non-tuberculous mycobacteria or fungi. Thus in patients exposed to lipoid aspiration presenting with cavitated mass on CT scan, possible infection should be thoroughly ascertained, and adequate treatment promptly initiated. Hereby, we report three cases of non-infectious cavitary exogenous lipoid pneumonia. In all three patients, one with acute onset and two with chronic recurrent form, the ELP diagnosis was confirmed by both cytological and histological findings, whereas microbiological examination gave negative results. Moving from these three cases, we review the pathogenesis, clinical and radiological manifestation of ELP.

Clinical study of intra-operative computed tomography guided localization with a hook-wire system for small ground glass opacities in minimally invasive resection

背景与目的肺磨玻璃样微小结节（ground glass opacity, GGO）病灶的定位是微创手术切除的技术难点。各种定位方法均有报道，但每一种方法均有其不足。本研究拟通过评价术中CT引导下Hook-wire定位对GGO微创切除的价值，初步探索肺部 < 10 mm的GGO积极手术治疗的必要性和可行性。方法2009年10月-2013年10月共32例GGO患者，41个GGO，行胸腔镜微创切除术，麻醉插管后皆在手术体位下行计算机断层扫描（computed tomography, CT）CT引导Hook-wire定位。记录术中CT引导下Hook-wire定位技术的失败率、并发症、胸腔镜手术转为开胸手术的几率、住院时间等，计算病灶组织学分型中的恶性几率，讨论肺部 < 10 mm的GGO积极手术治疗的必要性。结果共32例患者（男性15例，女性17例）行41个GGO胸腔镜微创切除术，其中2个病灶、3个病灶和5个病灶同时微创切除患者数量分别是3例、1例、1例。病灶直径2 mm-10 mm（平均5 mm），病灶距离胸膜垂直距离5 mm-24 mm（平均12.5 mm）。术中CT引导下Hook-wire定位成功率100%，严重并发症发生率0，转化为开胸手术比率为0，CT定位时间平均8.4 min（4 min-18 min），微创切除病灶所需时间平均32 min（14 min-98 min），中位住院时间为8 d（5 d-14 d）。GGOs术后组织学诊断结果为：原位腺癌（肺泡癌）19例，约46.3%，腺癌8例，约19.5%，大细胞癌1例，约2.4%，不典型腺瘤样增生9例，约22%，炎性病灶4例，约9.8%。结论肺部GGO是恶性病灶的几率很大，对典型GGO患者积极微创手术治疗是非常必要的；术中CT引导下Hook-wire定位技术极大提高GGO微创切除可行性、并发症发生率低，对于GGO的鉴别诊断及治疗具有很好的临床价值。

A Resected Case of Solitary Pulmonary Capillary Hemangioma Showing Pure Ground Glass Opacity

A 53-year-old Japanese woman was referred to our hospital for pure ground glass opacity (GGO) in the left upper lung on computed tomography. 18F-fluorodeoxyglucose positron emission tomography revealed no abnormal uptake in the lesion. After 4 months of follow-up, we strongly suspected the lesion to be a bronchioloalveolar carcinoma and decided to perform a surgery for diagnosis. Planning to perform lingual segmentectomy by video-assisted thoracic surgery (VATS) with mini thoracotomy, we finally performed the left upper lobectomy to guarantee the optimal margin by VATS, because the lesion was not identified by palpation. Final pathological diagnosis was a solitary pulmonary capillary hemangioma (SPCH). We herein report a resected case of SPCH showing pure GGO and review all reported SPCH cases.

FRI0313 Detection of anti-granulocyte macrophage colony-stimulating factor autoantibody in systemic lupus erythematodes

BackgroundSystemic lupus erythematodes(SLE) causes various symptoms in the respiratory system. Ground glass opacity (GGO) with SLE is conventionally considered interstitial pneumonia caused by the deposition of immune complexes. However, in...

Ground-Glass Opacity in Lung Metastasis from Breast Cancer: A Case Report

A 43-year-old woman with breast cancer who was on neoadjuvant chemotherapy presented with cough, sputum and mild fever. High-resolution computed tomography showed diffuse ground glass opacities in bilateral lungs and subpleural patchy consolidations. Initially, she was thought to have pneumonia or interstitial lung diseases such as drug-induced pneumonitis and treated with antibiotics and steroids. She subsequently got breast cancer surgery because of disease progression, and concurrent thoracoscopic lung biopsy revealed metastatic carcinoma of the lung from breast cancer. The diagnosis of suspected interstitial lung disease can be made without lung biopsy, but malignancy should always be considered and lung biopsy should be performed in the absence of a definitive clinical diagnosis.

Natural History of Pure Ground-Glass Opacity Lung Nodules Detected by Low-Dose CT Scan

Although focal ground-glass opacity (GGO) lung nodules are generally reported to grow slowly, their natural course is unclear. The purpose of this study was to elucidate the natural course of screening-detected pure GGO lung nodules in patients with no history of malignancy. We retrospectively reviewed the database of subjects who had undergone screenings involving low-dose CT scans. We included patients with pure GGO lung nodules who were followed for > 2 years after the initial screening. Between June 1997 and September 2006, 122 pure GGO nodules were found in 89 patients. The median nodule size was 5.5 mm (range, 3-20 mm) in the largest diameter on initial low-dose CT scan. The median follow-up period per patient was 59 months. On a per-person basis, the frequency of growth was 13.5% (12 of 89 patients). On a per-nodule basis, the frequency of growth was 9.8% (12 of 122 nodules). Nodule growth was significantly associated with initial size and new development of an internal solid portion. The median volume doubling time was 769 days for growing pure GGO nodules. A total of 11 growing nodules were surgically validated, and all lesions were confirmed as primary lung cancer. About 90% of the screening-detected pure GGO lung nodules did not grow during long-term follow-up in subjects with no history of malignancy and most growing nodules had an indolent clinical course. A strategy of long-term follow-up and selective surgery for growing nodules should be considered for pure GGO lung nodules.

口腔癌の同時化学放射線療法後にS-1誘発性の重篤な薬剤性肺障害を発症した1例

A 70-year-old woman with multiple oral cancers received concurrent chemoradiation therapy with S-1 (50 mg/day). The patient received S-1 for 33 days and a total radiation dose of 66 Gy. The patient complained of a mild fever after therapy. She was treated in the department of pulmonary medicine in this hospital for subsequent dyspnea and hypoxemia. Computed tomography (CT) showed extensive groundglass opacity and diffuse consolidation changes in both lungs. She required endotracheal intubation, ventilator support, oxygen therapy, and steroid pulse therapy. These treatments remarkably improved her symptoms, and the abnormal findings on CT also resolved. A drug-induced lymphocyte stimulating test for S-1 demonstrated a positive reaction. These findings indicated a diagnosis of lung injury with acute respiratory distress syndrome induced by S-1. Drug-induced lung injury should to be considered in the differential diagnosis when patients treated with S-1 therapy present with fever and dyspnea.

Non‐human immunodeficiency virus Pneumocystis jiroveci pneumonia

We read with great interest the recent two studies by Hardak et al. and Enomoto et al. about the diagnosis of Pneumocystis jiroveci pneumonia (PJP) in non-human immunodeficiency virus (HIV)-infected patients.1, 2 Here, we would like to describe a case of PJP and highlight several important issues regarding the diagnosis of this disease in non-HIV-infected patients. A 32-year-old lady, who underwent allogeneic peripheral blood stem cell transplantation for leukaemia 6 months earlier, was admitted to the hospital for high fever, dry cough and progressive dyspnoea for 5 days. Chest radiography showed alveolar opacities in the bilateral lower lungs (Fig. 1a), while thin-section chest computed tomography showed major findings of subpleural consolidation, with peripheral distribution and focal ground glass opacities (GGO) in the bilateral lower lungs (Fig. 1b,c). The results of the microbiology study were inconclusive. To achieve a definitive diagnosis, surgical lung biopsies by thoracoscopy were obtained. Thoracoscopic biopsy of the right middle and lower lungs showed PJP. After a 2-week treatment, there was evolutional change from consolidation to GGO with crazy-paving pattern (Fig. 1d). The lower lung opacities resolved after 4 weeks of sulfamethoxazole-trimethoprim treatment, and she was discharged. (a) Chest radiograph showing alveolar opacities in the bilateral lower lungs and a right-sided port-a catheter; (b and c) computed tomography (CT) imaging revealed subpleural consolidation and focal ground glass opacities (GGO) with a peripheral distribution; (d) compared with the initial chest CT, there was note of evolutionary change from consolidation to GGO with crazy-paving pattern after 2 weeks of treatment. The clinical course of PJP in non-HIV-infected patients is substantially different from those of HIV-infected patients.2, 3 The disease usually presents with a more acute and fulminant course in non-HIV-infected patients.3 In contrast, the presentation is usually indolent in HIV-infected patients. In addition, the mortality rate is higher among non-HIV-infected patients.2, 3 Table 1 summarizes the differences of PJP between HIV-infected and non-HIV-infected patients. Typical computed tomography findings of PJP include diffuse GGO in a mosaic pattern, distributed mostly at the central and upper lungs, with peripheral sparing.4 However, atypical imaging presentation, such as dense consolidation and atypical distribution of the involved lungs, is not unusual in non-HIV-infected patients.3 The greater consolidation and less GGO in chest computed tomography of non-HIV-infected patients may reflect more extensive lung inflammation due to more inflammatory cells and fewer Pneumocystis organisms.5 Therefore, a consolidation-predominant pattern should not preclude a suspicion of PJP. Early diagnosis of PJP usually relies on a high index of suspicion. In non-HIV-infected patients, transplantation and corticosteroid use are two important risk factors. A susceptible host with risk factors presenting with atypical pneumonia should elicit a suspicion of this disease regardless of typical chest imaging presented. Furthermore, the imaging pattern of PJP varies with HIV-infected status and disease stage.3 Evolutionary changes may occur after treatment. In this presented case, the subpleural lesions changed from consolidation to GGO with crazy-paving pattern after 2 weeks of treatment (Fig. 1d). Nevertheless, initial GGO lesions may progress to alveolar consolidation in few days, if no definite treatment is provided. In conclusion, PJP in non-HIV-infected patients has different clinical and radiographical presentations from that in HIV-infected patients. The clinical and radiographical features from HIV-infected patients cannot be totally applied to diagnose PJP in non-HIV-infected patients.