Successful Treatment of Tracheal Invasion Caused by Thyroid Cancer Using Endotracheal Tube Balloon Inflation under Flexible Bronchoscopic Guidance / 결핵및호흡기질환

Tracheal invasion is an uncommon complication of thyroid cancer, but it can cause respiratory failure. A rigid bronchoscope may be used to help relieve airway obstruction, but general anesthesia is usually required. Tracheal balloon dilatation and stent insertion can be performed without general anesthesia, but complete airway obstruction during balloon inflation may be dangerous in some patients. Additionally, placement of the stent adjacent to the vocal cords can be technically challenging. An 86-year-old female patient with tracheal invasion resulting from thyroid cancer was admitted to our hospital because of worsening dyspnea. Due to the patient's refusal of general anesthesia and the interventional radiologist's difficulty in completing endotracheal stenting, we performed endotracheal tube balloon dilatation and argon plasma coagulation. We have successfully treated tracheal obstruction in the patient with thyroid cancer by using endotracheal tube balloon inflation and a flexible bronchoscope without general anesthesia or airway obstruction during balloon inflation.

A Case of Alveolar Adenoma Involving Multiple Lung Nodules / 대한내과학회지

Alveolar adenoma is a very rare benign intraparenchymal lung tumor originating from type II pneumocytes. It can be mistaken for other benign tumors or lung cancer in radiological images. It is especially difficult to distinguish alveolar adenoma from sclerosing hemangioma. A small aspiration biopsy specimen, such as with percutaneous needle aspiration, is insufficient for a pathological diagnosis. Surgical resection is the only method by which a pathological diagnosis can be made and the disease treated. An alveolar adenoma presenting as multiple nodules is very rare and has to our knowledge not been reported in Korea previously. Here, we report a case of alveolar adenoma in multiple nodules in a 57-year-old female and review the literature.

Chronic Obstructive Pulmonary Disease Assessment Test Can Predict Depression: A Prospective Multi-Center Study

This study was conducted to investigate the association between the chronic obstructive pulmonary disease (COPD) assessment test (CAT) and depression in COPD patients. The Korean versions of the CAT and patient health questionnaire-9 (PHQ-9) were used to assess COPD symptoms and depressive disorder, respectively. In total, 803 patients with COPD were enrolled from 32 hospitals and the prevalence of depression was 23.8%. The CAT score correlated well with the PHQ-9 score (r=0.631; P or =21 had the highest accuracy rate (80.6%). Among the eight CAT items, energy score showed the best correlation and highest power of discrimination. CAT scores are significantly associated with the presence of depression and have good performance for predicting depression in COPD patients.

A Case of Multiple Pulmonary Nodular Pneumocystis jirovecii Pneumonia in an Acquired Immune Deficiency Syndrome Patient / 감염과화학요법

Pneumocystis jirovecii pneumonia (PCP) is a frequent manifestation of Acquired Immune Deficiency Syndrome (AIDS). The classic chest radiographic finding is perihilar ground glass opacities that may progress to more diffuse lung involvement. Atypical radiographic appearances include a normal chest film, lobar or segmental consolidation, cystic lesions, cavitation, pneumothorax, pleural effusion, and solitary or multiple pulmonary nodules. Although PCP is common in AIDS, presenting with nodular pulmonary densities is rare. We encountered the case of a 33-year-old man with AIDS whose chest radiography showed multiple bilateral nodular patterns suggestive of malignancy. We performed a transcutaneous lung biopsy and diagnosed him with PCP by Gomori methenamine-silver staining. Along with fungal and mycobacterial infections, intrathoracic Kaposi's sarcoma, and lymphoma, PCP should be considered in the differential diagnosis of nodular pulmonary disease in AIDS patients.

A Case of Chylothorax after Tube Thoracostomy / 결핵및호흡기질환

Tube thoracostomy is known to cause complications such as bleeding or infection, but the incidence of chylothorax secondary to tube thoracostomy is under-reported, and therefore, we report this case. A patient was diagnosed as systemic lupus erythematosus with pleural and pericardial involvement. During repeated therapeutic thoracentesis, which were performed because of poor response to steroids and cylophosphamide, hemothorax developed and we therefore inserted a chest tube. The pleural effusion changed from red to milky color in several hours and we diagnosed the pleural effusion as chylothorax. Total parenteral nutrition based on medium-chain triglycerides was supplied to this patient and chylothorax was improved after 4 days.

A Case of Pseudomembranous Tracheobronchitis Complicated by Coinfection of 2009 Pandemic Influenza A/H1N1 and Staphylococcus aureus / 감염과화학요법

An influenza pandemic due to a novel influenza A/H1N1 virus occurred after April 2009. This virus has some characteristics that differentiate it from the seasonal influenza virus. The 2009 pandemic influenza A/H1N1 virus can frequently infect the lower respiratory tract, and it might cause acute tracheobronchitis as well as pneumonia. Viral-bacterial interaction is well known as an important mechanism of the pathogenesis of respiratory complications of influenza. Herein, we report on a case that presented with pseudomembranous tracheobronchitis complicated by coinfection with 2009 pandemic influenza A/H1N1 and Staphylococcus aureus. We also review the relevent literature.

The Clinical Significance of Bronchial Anthracofibrosis Associated with Coal Workers' Pneumoconiosis / 결핵및호흡기질환

BACKGROUND: In previous study, most patients with bronchial anthracofibrosis (BAF) were non-miners, and non-occupational old aged females. However, the clinical significance of BAF in patients with coal workers' pneumoconiosis (CWP) is unknown. METHODS: Among patients with CWP who transferred to our hospital for an evaluation of associated pulmonary diseases, 32 patients who had undergone a bronchofibroscopy (BFS) and chest computed tomography (CT) examination were evaluated for the association of the BAF using a retrospective chart review. RESULTS: Nine of the 32 CWP patients (28%) were complicated with BAF. Four of the 16 simple CWP patients (25%) were complicated with BAF. According to the International Labor Organization (ILO) classification by profusion, 2 out of 3 patients in category 1, 1 out of 8 patients in category 2 and 1 out of 3 patients in category 3 were complicated with BAF. Five out of 16 complicated CWP patients were complicated with BAF. Three out of 7 patients in type A and 2 out of 5 patients in type C were complicated with BAF. CWP patients with BAF had significantly greater multiple bronchial thickening and multiple mediastinal or hilar lymph node enlargement than the CWP patients without BAF. There was no difference in the other clinical features between the CWP patients with BAF and those without BAF. CONCLUSION: Many CWP patients were complicated with BAF. The occurrence of BAF was not associated with the severity of CWP progression. Therefore, a careful evaluation of the airway with a bronchoscopy examination and chest CT is warranted for BAF complicated CWP patients who present with respiratory symptoms and signs, even ILO class category 1 simple CWP patients.

Acute Mercury Vapor Inhalation Toxicity after Burning Charms: A Case Report / 대한구급학회지

Cinnabar is the mineral with mercury in combination with sulfur, and it has been used to make charms in China and Korea. If cinnabar is overheated, mercury vapor that is extremely hazardous or sometimes fatal can be released. We experienced 5 patients of a family who were exposed to mercury vapor when they burnt charms. One of them developed severe acute respiratory failure and the patient needed mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Despite treatment with cortiocosteroid, D-penicillamine, ECMO and plasmapheresis, the radiologic findings of a patient worsened and he died.

The Influence of Adverse Drug Reactions on First-line Anti-tuberculosis Chemotherapy in the Elderly Patients / 결핵및호흡기질환

BACKGROUND: Pulmonary tuberculosis (TB) is still common disease among the elderly patients in Korea where the overall incidence of TB is decreasing. Adverse drug reactions (ADR) associated with anti-TB drugs occurs frequently. Especially the aged tends to have more frequent ADRs than younger ones. These ADRs can cause significant morbidity, compromise therapeutic effects of drugs and even induce drug resistance. Therefore we evaluated the effect of ADRs on the first-line anti-TB drugs in elderly patients with active pulmonary TB. METHODS: We retrospectively reviewed the charts and radiological findings of the patients with 65 and older who were bacteriologically confirmed as active TB and treated with standard anti-TB drugs for at least 6 months. Major ADR was defined with temporary or continuous stop of any first-line drugs intake. RESULTS: An ADR was noted in 54% of all patients. The incidence of major ADR was 32% in all elderly patients. Dermatologic ADR (9%) was the most common among the major ADRs. GI trouble (8%), arthralgia (6%), visual change (6%), hepatotoxicity (4%), and fever (1%) were also noted. The drugs responsible for major ADR were ethambutol (62%), pyrazinamide (35%), rifampin (18%) and isoniazid (9%). Major ADRs were associated with higher ESR level at the initiation of anti-TB drugs. CONCLUSION: First-line anti-TB drugs in elderly patients frequently caused the major ADRs. Therefore the elderly patients receiving anti-TB drugs should be closely monitored and better tolerable therapy should be considered as part of a TB research agenda.

A case of rifampicin-induced interstitial pneumonitis / 대한내과학회지

Rifampicin is a powerful agent for the treatment of pulmonary tuberculosis. However, it may induce several adverse effects, including rare cases of lung toxicity. Here, we report a case of rifampicin-induced interstitial pneumonitis. A 57-year-old woman diagnosed with cerebellar tuberculoma developed progressive dyspnea after the 5th day of anti-tuberculosis medication. Chest X-ray revealed newly developed ground glass opacities on both lower lung fields. Drug-induced pneumonitis was suspected and all anti-tuberculosis medications were halted. Transbronchial lung biopsy was consistent with desquamative interstitial pneumonitis. After clinical improvement, a rechallenge test with each anti-tuberculosis medication was attempted. No primary anti-tuberculosis drug except rifampicin triggered recurrence of symptoms, supporting a diagnosis of rifampicin-induced interstitial pneumonitis. Clinicians should be aware of this rare, but serious, side effect of rifampicin treatment.

A case of lemierre syndrome poorly responsive to medical treatment / 대한내과학회지

Lemierre syndrome is a rare clinical condition that is characterized by anaerobic oropharyngeal infections leading to septic thrombophlebitis of the internal jugular vein and frequent secondary metastatic infections. The accurate diagnosis and treatment, for early stage disease, is important because it may be associated with a high mortality rate if untreated. We present the case of a 34-year-old man who presented with a history of typical for the diagnosis of Lemierre syndrome. Supportive care with antibiotics did not improve the clinical condition. The clinical course improved after treatment with IV anticoagulant and surgical thrombectomy. In addition, he had the antiphospholipid syndrome, which is known to be a common cause of acquired arterial or venous thrombosis. Therefore, in this patient the associated antiphospholipid syndrome might precipitate an internal jugular venous thrombophlebitis after an oropharyngeal infection or might account for the poor response to medical treatment.

A Case of Pheochromocytoma that Initially Presented as Diffuse Alveolar Hemorrhage / 결핵및호흡기질환

A pheochromocytoma is a neuroectodermal tumor that originates from the chromaffin cells of the sympathetic system. Typical symptoms or signs are periodic attacks of paroxysmal hypertension, spell, palpitation, headache and sweating. However, the clinical presentation is quite variable. Therefore, an atypical clinical presentation sometimes makes a diagnosis difficult. Hemoptysis as a presenting symptom is very rare in pheochromocytoma. We recently experienced a patient with diffuse alveolar hemorrhage due to pheochromocytoma. A chest PA showed diffuse consolidation and ground glass opacities in both lungs. A chest CT showed diffuse consolidation and ground glass opacities in the central, middle and lower portion predominance of the lungs, sparing the costophrenic angles and apices of the lungs. In Korea, a case of pheochromocytoma that presented initially as massive hemoptysis due to diffuse alveolar hemorrhage has not been previously reported. We report the case with a review of the literature.

Insidious Onset of Amiodarone Pulmonary Toxicity Presented with Hemoptysis / 결핵및호흡기질환

Amiodarone is widely used to control fatal arrhythmia. However, amiodarone therapy is associated with a relatively high incidence of pulmonary toxicity, up to 5 to 10%. Typical symptoms are nonspecific and often manifest as nonproductive cough, dyspnea and interstitial infiltrates in patients with acute pneumonitis or chronic fibrosis. However, hemoptysis is a very rare symptom of amiodarone pulmonary toxicity. We report a case of amiodarone pulmonary toxicity, who presented with hemoptysis and was successfully treated with the cessation of amiodarone, with review of the relevant literature.

A Case of Miliary Tuberculosis Mimicking ARDS due to Bilateral Severe Pneumonia / 결핵및호흡기질환

Miliary tuberculosis is the most serious form of tuberculous disease, but is rarely complicated with acute respiratory distress syndrome (ARDS). When a patient with miliary tuberculosis initially presents with ARDS, the mortality is much higher. Therefore, the early detection of miliary tuberculosis as the underlying cause of ARDS is very important for the prognosis and survival of the patient. The diagnosis of miliary tuberculosis may be easy if the patient presents typical clinical manifestations associated with the characteristic pattern of miliary nodules on chest radiology. However, the diagnosis of miliary tuberculosis when complicated with ARDS can be difficult due to the nonspecific radiologic patterns, such as diffuse bilateral consolidation and ground glass opacity, without miliary nodular infiltration. However, these nonspecific patterns are known as less likely findings of miliary tuberculosis. We experienced a pregnant woman with miliary tuberculosis, mimicking ARDS due to bilateral severe pneumonia. She was admitted, via the emergency room, with sudden onset of fever, chill, cough and dyspnea. The initial chest PA and HRCT showed diffuse bilateral consolidation and ground glass opacity, without miliary nodular infiltration. All bacteriological studies, including blood and sputum cultures, tuberculosis-PCR and serologic study for infectious disease were negative. However, the definite diagnosis of unusual miliary tuberculosis as the underlying cause of ARDS was confirmed from the radiological finding and transbronchial fiberoptic lung biopsy. We report this case, with a review of the literature.

Clinical Features of Simple Bronchial Anthracofibrosis which is not Associated with Tuberculosis / 결핵

BACKGROUND: Bronchial anthracofibrosis (BAF) is a dark black or brown pigmentation of multiple large bronchi associated with a fibrotic stenosis or obliteration that is incidentally found during a diagnostic bronchoscopy. Some reporters have suggested endobronchial tuberculosis or tuberculous lymphadenitis as a possible cause of BAF. However, some BAF patients do not have any medical history of tuberculosis. The aim of this study was to elucidate the clinical features of simple BAF patients, which were not associated with tuberculosis. METHODS: We reviewed the patients' charts retrospectively and interviewed all BAF patients who were followed up for 1 year or more. Among the 114 BAF patients, 43 patents (38 %) had no associated tuberculosis, cancer and pneumoconiosis. The clinical characteristics, radiological findings and associated pulmonary diseases of these patients were evaluated. RESULTS: Most patients were non-smokers, old aged, housewifes who resided in a farming village. The common respiratory symptoms were dyspnea, cough and hemoptysis. The predominant X-ray findings were a multiple bronchial wall thickening(89%), bronchial narrowing or atelectasis (76%) and a mediastinal lymph node enlargement with/without calcification (78%). Pulmonary function test usually showed mild obstructive ventilatory abnormalities but no patient showed a restrictive ventilatory pattern and the patients were frequently affected with chronic bronchitis(51%), post-obstructive pneumonia(40%) and chronic asthma(4%). CONCLUSION: Because BAF is frequently associated with chronic bronchitis and obstructive pneumonia as well as tuberculosis, a careful clinical evaluation and accurate differential diagnosis is more essential than empirical anti-tuberculous medication.

Allergic bronchopulmonary aspergillosis associated with aspergilloma / 대한내과학회지

Aspergilloma and Allergic Bronchopulmonary Aspergillosis (ABPA) are different types of spectrum of pulmonary aspergillosis. ABPA results from hypersensitivity reaction to Aspergillus species and is known to be usually associated with bronchial asthma and cystic fibrosis. Aspergilloma results from simple colonization of this fungus within cavitary lung lesion or bronchiectasis. But rarely some patients can present together with ABPA and aspergilloma. We experienced a case of ABPA associated with aspergilloma in a 38 year-old male. The diagnosis was confirmed by asthma, immediate cutaneous reactivity to A. fumigatus, IgG antibody to A. fumigatus, elevated total and specific IgE antibodies to A. fumigatus, central bronchiectasis and peripheral eosinophilia coincident with radiographic infiltrates. During follow-up management with steroid, left pneumonectomy was done because of spontaneous pneumothorax with persistent air-leak and multidrug resistance pulmonary tuberculosis in association with aspergilloma. His respiratory symptoms and ABPA activity was much more improved after removal of aspergilloma. These findings suggest that surgical resection of aspergilloma can be considered to reduce antigenic source of colonized fungi in ABPA patients when associated with aspergilloma.

The Changes of Cuff Pressure from Endotracheal Intubation for Long-term Mechanical Ventilation / 결핵

BACKGROUND: A tracheal stenosis is caused by mucosal ischemic injury related to a high cuff pressure (Pcuff) of the endotracheal tube. In contrast, aspiration of the upper airway secretion and impaired g as exchange due to cuff leakage is related to a low Pcuff. To prevent these complications, the Pcuff should be kept appropriately because the appropriate Pcuff appears to change according to the patients' bedside. To address the necessity of continuous Pcuff monitoring, the change in the Pcuff was evaluated at various Vcuff levels on a daily basis in patients with long-term mechanical ventilation. The utility of mercury column sphygmomanometer for the continous monitoring Pcuff was also investigated. METHOD: The change in Pcuff according to the increase in Vcuff was observed in 17 patients with prolonged endotracheal intubation for mechanical ventilation for 2 week or more. This maneuver measured the change in Pcuff daily during the mechanical ventilation days. In addition, the Pcuff measured by mercury column sphygmomanometer was compared with the Pcuff measured by an automatic cuff pressure manager. RESULTS: There were no statistically significant changes of Pcuff during more than 14 days of intubation for mechanical ventilation. However the Vcuff required to maintain the appropriate Pcuff varied from 1.9cc to 9.6cc. In addition, the intra-individed variation of the Pcuff was observed from 10cmH2O to 46cmH2O at constant 3cc Vcuff. The Pcuff measured by the bedside mercury column sphymomanometer is well coincident with that measured by the automatic cuff pressure manager. CONCLUSION: Continuous monitoring and management of the Pcuff to maintain the appropriate Pcuff level in order to prevent cuff related problems during long-term mechanical ventilation is recommended. For this purpose, mercury column sphygmomanometer may replace the specific cuff pressure monitoring equipment.

The Effect of Antihistamine of Endotoxin-induced Acute Lung Injury / 결핵

BACKGROUND: Sepsis-induced acute lung injury (ALI) is caused by many cellular and humoral mediators induced by an endotoxin. Histamine, which is widely distributed in the lungs and has been considered as an importa nt mediator of sepsis. It increases P-selectin expression on the endothelial cell surfaces and induces IL-8 secretion. Therefore, an endotoxin-induced histamine may be related to neutrophil-mediated ALI by inducing the migration and activation of neutrophils in the lung tissue. However, the role of endogenous histamine in endotoxin-induced ALI had not been clarified. The purpose of this study was to investigate how endotoxin-induced ALI is influenced by endogenous histamine and to identify the possible mechanism of action. METHODS: The study consisted of 4 groups using Sprague-Dawley rats : 1) control group, where the rats were infused intratracheally by normal saline, 2) an endotoxin group, where lipopolysaccharide (LPS) was administered intratracheally 3) the H2 receptor antagonist-treated group (H2 group) and 4) the H1 receptor antagonist-treated group (H1 group), where H2 receptor blocker (ranitidine) and H1 receptor blocker (pyrilamine) were co-treated intravenously with the intratracheal administration of an endotoxin. The lung leak index using I125-BSA, the total protein and LDH concentration in the lung lavage fluid, myeloperoxidase (MPO) activity in the lung tissue, the pathologic score and the total number of neutrophils, TNF-alpha, IL-Ibeta and IL-10 in lung lavage (BAL) fluid were measured in each group as the indices of lung injury. RESULTS: Compared to the control group, the endotoxin group exhibited significant increasis in all lung injury indices. Significant reductions in the encotoxin-mediated increases in lung leak index (p<0.05) were observed in both the H1and H2 groups. In addition, the total protein (p<0.05) and LDH concentration (p<0.05) in the BAL fluid were also lower in the H2 group compared to the endotoxin group. However, there was no change in the MPO activity in the lung tissue, the pathologic score and the total number of neutrophils in the BAL fluid in both the H2and H1 groups compared to the endotoxin group. The increases in TNF-alpha, IL-Ibeta and IL-10 concentrations in the BAL fluid observed in the endotoxin group were not reduced in the H2and H1 groups. CONCLUSION: Antigistamine attenuated the enhanced alveolar-capillary permeability induced by the endotoxin via the H2 receptor. However the attenuation mechanism may not be related to the pathogenesis of neutrophil dependent lung injury.

A Case of the Localized Tension Pneumothorax Mimicking Giant Bullae / 결핵

Background: A 35-year-old woman was admitted to the emergency room with sudden dyspnea that developed one day prior. The initial Chest X-ray showed multiple bullous changes at the right middle and lower lung field and long standing fibrotic tuberculous changes at the right upper lung field. The left lung field was totally collapesed by an fibrotic old tuberculous lesion. In spite of supportive medical care with oxygen therapy after admission, the radiographic lesions were no significant change but the respiratory distress had worsend. The patient suffered respiratory failure and receive mechanical ventilatory support. The HRCT showed a localized tension pneumothorax mimicking multiple giant bullae at the right lower lung field. Immediately after a closed thoracostomy with a 32 French chest tube and air drainage, her vital signs and dyspnea were gradually improved. The patient was successfully weaned from mechanical ventilation after 5 days of mechanical ventilatory support. The patient had receive talc pleurodesis through a chest tube to prevent the recurrence of the life-threatening localized pneumothorax. The patient was discharged without recurrence of the pneumothorax.

A Case of Rasmussen Aneurysm Treated by Pulmonary Arterial Embolization / 결핵

A 42 year-old male with a history of multidrug-resistant pulmonary tuberculosis suddenly developed massive hemoptysis. Embolization of a bronchial artery branch and the collateral systemic arteries did not resolve the recurrent bleeding. Spiral computerized tomography(spiral CT) of the chest showed contrast enhanced nodules within a large cavity at the left lower lobe in the arterial phase suggesting a Rasmussen aneurysm. A pulmonary angiogram showed abnormal vascular nodules at that site. Coils were deployed at both the proximal and distal vessels of this aneurysmal sac for embolization. Transcatheter arterial embolization is a safe and effective means of controlling bleeding from this pulmonary arterial pseudoaneurysm. Here we report a case of a Rasmussen aneurysm diagnosed by spiral CT, which was successfully treated by pulmonary arterial embolization with a coil.