Middle Lung Fields Research Articles

Computed Tomography Scan in the Early Detection of Silicosis

We evaluated the ability of both the conventional and high resolution computed tomography (CCT and HRCT, respectively) scans of the thorax to detect early silicosis in subjects exposed to silica dust in the mines and foundries of Québec for an average of 29 +/- 2 yr. The study was limited to subjects with chest radiograph (CR) of the International Labor Organization (ILO) Categories 0 or 1 as determined independently a priori. All subjects had a standard high-kilovoltage posteroanterior and lateral CR, a set of 10 to 15 1 cm collimation CCT scans, and a set of three to five 2 mm collimation HRCT scans in the upper, middle, and lower lung fields. For each CR and sets of CT scans, readings were done independently by four experienced readers. For small opacities of the lung parenchyma on CR, 32 of the 51 subjects were normal (Group A), six were indeterminate (Group B), and 13 were abnormal (Group C). By the combined readings of HRCT and CCT, 13 of the subjects (40%) in Group A were abnormal (p less than 0.001); four of the subjects in Group B were abnormal, and in Group C, one subject was normal, one indeterminate, and 11 (84%) abnormal. For confluence of small opacities, 48 of the 51 subjects were negative (Group 0), and three were positive (Group 1) on the CR. By the CT scan, 42 of the 48 subjects in Group 0 were negative, and the three subjects in Group 1 were positive; thus the CT scan added six positive cases with confluence of small opacities (six of 48, 12.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary Embolization of a Vascular Ligature Clip as a Complication of Para-aortic Lymph Node Sampling

A case is reported of a 57-year-old woman who underwent cytoreductive surgery for stage III, grade 2 endometrioid cystadenocarcinoma of the ovary. During para-aortic lymph node sampling, hemostasis was achieved with medium and small metallic ligature clips. The immediate postoperative period was uneventful and the chest radiograph was unchanged from preoperative film. On the sixth postoperative day a chest radiograph showed a radio-opaque object consistent with a metallic ligature clip in the peripheral left middle lung field. The remaining postoperative course was uncomplicated and the patient is well 14 months postoperatively; the ligature clip is unchanged in position. This is an interesting and previously unreported complication of para-aortic lymph node sampling. The means by which the clip entered the vascular system is unknown. Nonsurgical removal of the clip was not feasible due to its peripheral location. No studies exist as to the long-term outcome of foreign bodies embolized to the peripheral lung.

Successful surgical treatment of synchronous bilateral double primary lung cancers in a patient with chronic obstructive pulmonary disease

A 66-year-old man was found to have a nodular shadow, 35 × 30mm, in the right middle lung field on a chest x-ray film during treatment for chronic obstructive pulmonary dinease. Fiberoptic bronchoscopy revealed a mass obstructing the right B6 with irregular mucosa extending to the right lower bronchus, and another small mass was detected on the left B3. Endobronchial biopsies of both lesions showed squamous cell carcinoma. The left lung tumor was not visible on chest x-ray films. Spirogram results were : FVC, 2.61 L; percent predicted FVC, 78.4 %; FEV1.0, 1.56 L; FEV1.0/FVC ratio, 59.8 %. Predicted postoperative FVC of 1.4-1.5 L and FEV1.0 of 0.8-9L after resection of the right lower lobe and left S1+2+S3 were determined by preoperative spirometry and quantitative 99mTc-MAA perfusion scan.Both tumors were resected, first by right lower sleeve lobectomy, with preservation of the middle lobe, for squamus cell carcinoma in the right S6 with superficial infiltration extending to the lower lobe bronchus. Two months later left S1+2 +S3 segmentectomy was performed for the early hilar squamous cell carcinoma of the left B3. Histological exmaination showed that the B3 lesion was composed, for the most part, of carcinoma in situ. Regional lymph nodes obtained during both operations were free of metastasis. Our diagnosis was multiple primary lung cancers according to the criteria suggested by Martini et al.The paient underwent curative resection without postoperative respiratory embarrassment. Spirogram and 99mTc-MAA perfusion and 81mKr ventilation lung scans were performed serially after operation. Spirometric results improved with time and have been stable since about six months after operation. Although a discrepancy was found between the distribution of perfusion and ventilation in the early postoperative period, it diminished several months after operation. The patient is at present disease-free with a adequate pulmonary function.

High altitude pulmonary edema after successful treatment of acute mountain sickness with dexamethasone

Case report A 28-year-old previously healthy male mountaineer with a history of radiologically documented HAPE participated in a study conducted in the high altitude research laboratory of the Capanna Margherita (4559 m) in the Alps Valais. The results of this study have been reported in detail elsewhere [8-10]. The subject had ascended from 1170 to 4559 m within a 24 h period, starting the ascent on foot at 3220 m and staying overnight at 3611 m. After the first night spent at 4559 m, he presented with severe AMS manifested by headache resistant to acetaminophen, nausea, insomnia, lassitude and dizziness. Clinical examination revealed facial edema, rales dorsally over the right middle lung field, no neurological abnormalities and normal fundoscopy. The severity of AMS was assessed by the environmental symptom questionnaire (ESQ) [11], which suggests a criterion score of > 0.70 for the subscore AMS-C reflecting cerebral symptoms and> 0.60 for the subscore AMS-R reflecting respiratory symptoms. The scores of AMS-C and AMS-R were 2.08 and 1.39, respectively, in this patient. The postero-anterior chest X-ray at this time showed no evidence of interstitial or alveolar pulmonary edema (Fig. lA). The patient was treated orally with 8 mg dexamethasone at 8 a.m. and 4 mg at 4 p.m. Thereafter, treatment was discontinued because of recovery from AMS symptoms in the evening with AMS-C and AMS-R scores of 0.68 and 0.44, respectively. At 6 a.m. on the following day, he presented with the same symptoms and clinical findings as 24 h previously, with scores of 2.46 (AMS-C) and 0.68 (AMS-R). The chest radiograph now

ブドウ球菌性敗血症を併発したマイコプラズマ肺炎の1例

A 19-year-old young man was admitted to our hospital complaining of fever and general fatigue. There were infiltrative shadows and pleural effusions in the both lung fields. Mycoplasma pneumoniae infection was diagnosed because of the elevation of mycoplasma antibody titers in the serum and pleural fluid. There was no recovery in clinical symptoms in spite of the administration of the EM (1200 mg) and CLDM (1200 mg) combination chemotherapy. Three week after admission, a cavity-like shadow appeared in the lt. middle lung field on the chest X-ray film, suprative arthritis and penicillin resistant S. aureus by blood culture test were found. Mycoplasma pneumoniae infection followed by S. aureus bacteremia was diagnosed. After the administration of antibiotics (CTT, FMOX) the clinical symptoms and laboratory findings improved 2 month after admission. Clinical and basic studies about the dual infection between M. pneumoniae and several bacteria were discussed.

肺血流ＳＰＥＣＴシンチグラフィによる肺門周囲末梢肺野いわゆる肺門娘枝領域の血流状態について 正常例の検討

Alveoli in the hilar region comprise the peripheral area containing daughter branches from subsegmental or one more divisional peripheral bronchi. Pulmonary perfusion in hilar region was examined by SPECT (single photon emission CT) in ten normal volunteers. ROI (region of interest) in the axial images were set in the hilar region, the upper, middle and lower lung fields with 10.8 mm thickness. Counts/one pixel (C/P) were calculated in these ROI. There was a tendency of C/P increase from upper to lower lung field. And there were no significant differences in C/P increase between hilar region and other axial fields. In the chronic obstructive pulmonary diseases, however, ventilation studies in the previous reports using Xe dynamic CT or PET (positron emission tomography) showed differences between outer region and hilar region. This method will be expected to evaluate the pulmonary perfusion not only in the whole lung but in different lung areas, including the hilar region in the chronic obstructive pulmonary diseases.

Transient Subpleural Curvilinear Shadow Caused by Pulmonary Congestion

We present two cases of transient subpleural curvilinear shadows (SCSs) on CT caused by pulmonary congestion. Subpleural curvilinear shadows, which are usually visible in the middle or lower dorsal lung field on CT, have been reported as the initial finding of pulmonary fibrosis. But SCS is not a specific finding since pulmonary congestion may be one cause of it.

Swyer-James Syndrome After Severe Pulmonary Infection Caused byMycoplasma pneumoniae

A 12-year-old female developed Swyer-James syndrome with a unilateral hyperlucent lung following a severe pulmonary infection with Mycoplasma pneumoniae. A chest radiograph taken 2 years previously showed no difference in radiolucency between left and right lungs. As far as we know, this is the second reported case of this syndrome secondary to a Mycoplasma pulmonary infection. 133Xe inhalation showed delayed washout of the isotope from the left lung, 99mTc-MAA perfusion scintigraphy showed a deficit of blood flow in left middle and lower lung fields, and 81mKr inhalation suggested nonfunctioning lung in the left lingular division and lower lobe. Such combined ventilation and perfusion scintigraphic imaging appears to be a very useful and safe diagnostic procedure in this syndrome. Patients suffering from severe Mycoplasma pulmonary infections should be monitored by chest x-ray and lung function tests following recovery from the acute disease.

Differential diagnosis of pulmonary emphysema using the CT index: LL%w

We measured the computed tomography (CT) index, LL%w, in 81 patients of chronic obstructive pulmonary disease (COPD) and asthma. In this study we defined LL%w as the mean value of the proportion of the low density area under -950 Hounsfield units in the six lung fields: upper, middle and lower lung fields bilaterally, at deep expiration. In order to examine the usefulness of LL%w in differentiating pulmonary emphysema (PE) from bronchial asthma (BA) and chronic bronchitis (CB), we excluded the overlapped cases of each diseases. Mean value (+/- standard deviation) of LL%w in PE was 24.6 +/- 20.2% (n = 40), whereas it was 0.5 +/- 0.8% (n = 27) in BA and 0.2 +/- 0.3% (n = 14) in CB respectively. There were clear statistically differences in the values of LL%w between clinically diagnosed emphysema and others. In this quantitative study we considered that the value of LL%w within 1% would be observed nonspecifically, because the frequent existence of low density areas originated in bronchial tangents and/or motion artifacts mainly in the left lower lung field. Thus we judged that cases with over 1% of LL%w had abnormal CT findings. The relationship between clinically diagnosed emphysema and CT abnormality (LL%w greater than 1%) was significant in the analysis of the four-fold table; The CT sensitivity for diagnosing PE was 100%, the CT specificity was 87.8%, and CT accuracy was 93.8%. When cases of LL%w greater than 1% were shown in BA or CB, it would be better to consider the existence of complicated emphysema or the presence of air trapping or air spaces of any origin.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical features of pulmonary tuberculosis in young and elderly men.

A comparison of the clinical features, predisposing factors, side effects by antitubercular drugs and diagnostic procedures in pulmonary tuberculosis in 37 younger and 35 elderly men was carried out. Elderly patients had a higher number of underlying diseases including cardiovascular diseases and hypertension than younger patients. The classic symptoms and signs of tuberculosis, such as productive cough, fever and general fatigue, were observed in relatively high proportions of both patients, whereas weight loss (43% vs. 16%) and crackles in the lung fields (49% vs. 16%) were significantly higher in the elderly patients than the younger ones. As for roentgenographic abnormalities, a higher involvement of middle and lower lung fields was seen in the elderly patients than in the younger. Although leukocytosis was noted in a significantly lower proportion of the elderly patients, neutropenia due to drug treatment was significantly higher (23%) than in younger patients (5%). In a mass survey, the detection of pulmonary tuberculosis in elderly men was significantly lower (23%) than that in younger men (54%). Although improved living conditions, better sanitation and the development of new chemotherapeutic agents have contributed to the decline of pulmonary tuberculosis in general populations, better procedures for early detection or diagnosis of pulmonary tuberculosis in the elderly people should be achieved as soon as possible.

Surgical treatment of Hodgkin's disease with mediastinal and pulmonary involvement

A 32-year old male complained of an irritative cough, chest pain and fever. Laboratory examination showed leucocytosis and accelerated ESR. On chest x-ray films, infiltration from the hilum to the left middle lung field was noted. Hodgkin's disease was suspected from the appearance of the x-rays and a cervical lymphnode biopsy. The mediastinal mass and the left upper lobe were resected en bloc. Histologically, both the mediastinal mass and the lung lesions were Hodgkin's disease (nodular sclerosing type). It is rare for Hodgkin's disease to be present as a mediastinal mass and pulmonary involvement at the beginning of the disease. COPP therapy was started nine days after the operation. The swollen cervical lymph nodes disappeared at the end of 3 courses, and temperature, ESR and leucocyte counts became normal. Complete remission has continued for seven months after surgery during which time five courses of COPP therapy have been administrated.

The alteration in the pattern of pulmonary metastasis with adjuvant chemotherapy in osteosarcoma.

Alterations in the pattern of pulmonary metastasis of patients with osteosarcoma treated with adjuvant chemotherapy were studied. Thirty two patients who were treated with both radical surgery and adjuvant chemotherapy were observed (chemotherapy group). As a control, sixty two patients treated with radical surgery alone were also assessed (non-chemotherapy group). The chemotherapy group demonstrated a reduction in the number and a delay in the appearance of metastases. The tumour doubling time did not differ between the chemotherapy and non-chemotherapy groups. The initial site of metastasis among the chemotherapy group was most commonly in the lower lung field, whereas among the non-chemotherapy group it was usually to the middle lung field. The chemotherapy group survived longer than the non-chemotherapy group after developing pulmonary metastases. Histological examination showed that the metastatic foci stimulated the primary sites.

CEA-Producing Adenocarcinoma of the Lung Complicated by Active Tuberculosis in the Same Mass a Case Report

A coin lesion in the left middle lung field on the X-ray film and a high CEA level were noted in July, 1982. A culture of scrapings from the lesion grew out tubercle bacilli. After antitubercular therapy, the size of the shadow decreased temporarily but increased again from about May, 1986. Adenocarcinoma cells were detected in smears obtained at bronchoscopy, and a diagnosis of pulmonary tuberculosis complicated by lung cancer was made. A left lower lobectomy was performed. Histopathological studies revealed that foci of adenocarcinoma were the main constituents of the mass which had infiltrated around the focus of tuberculosis.Immunohistochemical staining for CEA in this specimen showed that CEA was localized in the cytoplasm of the adenocarcinoma cells.

Regional respiratory clearance of aerosolized 99mTc-DTPA: posture and smoking effects.

We studied 10 healthy nonsmokers and 8 healthy smokers, in both the upright and supine position, to investigate whether regional differences in respiratory clearance of technetium-99m-labeled diethylenetriamine pentaacetic acid 99mTc-DTPA (RC-DTPA) existed and to assess the influence of posture and smoking on the regional RC-DTPA. RC-DTPA was assessed by the lung clearance rates (%/min) of aerosolized 99mTc-DTPA (0.8 micron MMD; 2.4 GSD), using data corrected for recirculating radioactivity, in the upper (zone 1), middle (zone 2), and lower (zone 3) posterior lung fields. In nonsmokers, RC-DTPA in zone 1 was faster than in zone 2 or 3 in both the upright (P less than 0.001) and supine positions (P less than 0.0). No effect was produced by changes in posture on the regional RC-DTPA. In smokers, RC-DTPA was increased in all zones compared with the nonsmokers (P = 0.004), with a further increase in RC-DTP in zone 1 in the upright posture compared with the other regions (P less than 0.001). We conclude that in nonsmokers regional RC-DTPA is faster in zone 1 than in other zones, and this is not related to recirculation of radioactivity; posture does not modify the regional RC-DTPA of nonsmokers; smoking increases RC-DTPA in all zones and more in zone 1 in the upright posture.

A CASE OF THYMOMATOUS MYASTHENIA GRAVIS WITH LUNG CANCER

A case of myasthenia gravis with thymoma and lung cancer is reported. A 68-year-old woman was hospitalized with myasthenia gravis and complaints of ptosis, diplopia and neck fatigability. Chest roentogenograms revealed a tumor shadow in the right middle lung field after admission. Brushing smear cytology by bronchoscopy indicated primary epidermoid carcinoma of the lung. The patient received prednisolone on alternate days. The dose was increased stepwisel from 30mg per day to 100mg to prevent acute deterioration of myasthenia gravis after thymectomy. Extended thymectomy reverling a thymoma, which was not clear by chest roentogenogram, tomogram, or CT scanning, and right upper lobectomy with lymph node dissection was performed. The postoperative course was uneventful, and the patient was discharged 47 days after surgery. Clinicopathological correlations of thymoma and lung cancer as well as of myasthenia gravis and lung cancer are discussed.

The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS.

We reviewed the medical records and chest radiographs of 23 adult patients with culture-proved tuberculosis and verified acquired immune deficiency syndrome. Seventeen patients, including 8 with disseminated tuberculosis, had positive sputum or bronchial washing cultures for Mycobacterium tuberculosis. Their initial pretreatment radiographs revealed hilar and/or mediastinal adenopathy in 10 patients (59%), localized pulmonary infiltrates limited to the middle or lower lung fields in 5 patients (29%), localized pulmonary infiltrates involving an upper lobe in 3 patients (18%), diffuse miliary or interstitial infiltrates in 3 patients (18%), no pulmonary infiltrates in 6 patients (35%), and no abnormalities in 2 patients (12%). Pulmonary cavitation was not seen. Only 1 patient (6%) had a chest radiograph typical of adult onset reactivation tuberculosis (i.e., localized pulmonary infiltrate involving the upper lung fields without hilar or mediastinal adenopathy). Six patients (35%) had pulmonary infiltrates that may have been caused by concomitant nontuberculous infection. Six patients had positive cultures for M. tuberculosis from extrapulmonary sites only. Three (50%) of these patients had hilar and/or mediastinal adenopathy. None of them had pulmonary infiltrates on their initial chest radiograph.

Antimoniosis: a particular form of pneumoconiosis. I. Etiology, clinical and X-ray findings.

The occupational exposure, clinical findings, lung function and radiological characteristics of 51 workers in an antimony smelting plant are presented. The workers were exposed to the airbone dust containing a high concentration of antimony trioxide (up to 88%) and antimony pentoxide. A particular X-ray picture was characterized by numerous small opacities densely distributed in the middle and lower lung fields, opacities of p, pinhead type. Sporadically pq type was seen, but never r type nor massive fibrosis (pmf). The pneumoconiotic changes developed after at least one decade of work. Nothing particular in clinical findings and lung function could be distinguished from other types of simple pneumoconioses. This pneumoconiosis is called--antimoniosis. No systemic manifestation of antimony oxide intoxication was found, with the exception of skin changes, "antimony dermatosis".

Chest radiological features of pulmonary histiocytosis X: a report based on 50 adult cases.

This study describes the chest radiographs of 50 adult patients with histologically verified histiocytosis X, proposes a radiological classification, and examines the role of radiology in assessing the prognosis of the disease. Radiologically the lesions predominate in the middle and lower lung fields, usually sparing the costophrenic angles, and are typically micronodular, reticular, or cystic. These features are especially suggestive of histiocytosis X if lung volume is normal or increased, there is an associated pneumothorax, they occur in a young male and there are no other intrathoracic changes (pleural or mediastinal). The three evolutionary patterns of improvement, stabilisation, and worsening are analysed with respect to the initial radiological features; one which carries a good prognosis is sparing of both costophrenic angles.

Bronchopulmonary diseases due to the hard metal dust

In Japan the extrinsic asthmatic bronchitis and the interstitial lung disease were legally recognized as occupational bronchopulmonary diseases due to the hard metal dust for the first time in February, 1981. But their pathogeneses are still unknown. In 1981, we examined clinically 247 workers employed in a hard metal factory (14 powder workers, 20 press operators, 40 shapers, 29 sintering workers, 119 grinders, and 25 others). The clinical evaluation was based on respiratory questionnaires, physical examinations, chest X-ray films and pulmonary function tests (VC, FEV, DLCO). These thorough investigations for all workers exposed to hard metal dust was thought to be the first trial conducted in this country. As a result, 27 workers with chronic bronchitis were found, but the relation between the chronic bronchitis and the exposure to the hard metal dust could not be confirmed. Three workers complained of asthmatic attacks without any relation to such dusty work. Pulmonary function tests revealed seven workers with restrictive ventilatory impairment, two with obstructive impairment and one with mixed impairment. Out of the seven, one with restrictive disorder revealed micronodulations on the chest X-ray film, and four of them had old tuberculous scars and/or pleural adhesions. Two of them had neither respiratory symptoms nor abnormal chest X-ray findings. Two with obstructive impairment and one with mixed ventilatory impairment complained of persistent coughs and sputa and/or asthmatic attacks. Chest roentgenograms taken from three workers engaged in shaping, press operation and powder handing, respectively, showed diffuse micronodulations mainly in bilateral middle lung fields. The findings were nearly the same as those in chest X-ray films taken three years ago. Two of them had been exposed exclusively to the hard metal dust and had had the longest exposure history among the workers in this factory. These radiological changes may represent nuisance particle shadows which were due to accumulations of hard metal dust predominantly of tungsten carbide. Serial chest roentgenograms of one worker, who had been employed as a press operator for 5 years and then as a shaper for 4 years, revealed progressive reticulonodular opacities with confluent tendency in upper and middle zones bilaterally. Previously he had been exposed to iron and sand dusts for only one year. Lung specimens obtained by means of transbronchial lung biopsy showed peribronchiolar and perivascular fibrosis with black deposited particles and peribronchiolar cellular aggregation. Particles in speciments examined by X-ray microanalysis were identified as tungsten. This case is highly suspected to be related to hard metal dust inhalation and to his individual susceptibility. Japan Association of industrial Health has not yet proposed recommendations to the industry as to the threshold limit values for cobalt, tungsten etc. Therefore, all the hard metal industries have to undergo thorough medical and environmental evaluations by themselves to take preventive and precautionary actions without delay.

Legionnaires' Disease in an Immunologically Normal Child

Legionnaires' disease is being recognized more frequently in children. Recent reports of cases in a child with lymphocytic leukemia 1 and in one with Down's syndrome 2 emphasize the possibility that immunocompromise is an antecedent risk factor. We report a case of Legionnaires' disease in an immunologically normal child. Report of a Case. —A 4-year-old girl was referred to Naval Regional Medical Center, Portsmouth, Va, for fever, dyspnea, and an abnormal chest roentgenogram on March 1, 1980. Her illness had begun five days previously with mild congestion and generalized malaise. Four days prior to admission, a school physical examination had revealed an erythematous throat but with no complaints. A throat culture had been done. During the 72 hours before admission, she had had temperature of 39.5 °C, and right-sided chest and shoulder pain had developed with rapid, shallow respirations. Chest roentgenogram revealed a right middle lung field perihilar infiltrate. She