Two cases of acute fibrinous and organizing pneumonia / 대한내과학회지

Acute fibrinous and organizing pneumonia (AFOP) is a histological pattern consisting of intra-alveolar fibrin in the form of fibrin "balls" and organizing pneumonia, without hyaline membranes or prominent eosinophil infiltration. Some reports suggest that the clinical course and pathological findings of AFOP are different from typical findings of bronchiolitis obliterans organizing pneumonia (BOOP) or eosinophilic pneumonia (EP), and its prognosis can be better or similar to that of diffuse alveolar damage (DAD). We report two cases of pathologically demonstrated AFOP experienced recently at our institute. One fatal case revealed a rapid development of respiratory failure and the need for mechanical ventilation. Another nonfatal case revealed subacute diffuse bilateral lung infiltration without the need for mechanical ventilation. Judging from our experience, the patient who required a mechanical ventilator had a poorer prognosis than the one who did not need a mechanical ventilator.

Two cases of acute fibrinous and organizing pneumonia / 대한내과학회지

Acute fibrinous and organizing pneumonia (AFOP) is a histological pattern consisting of intra-alveolar fibrin in the form of fibrin "balls" and organizing pneumonia, without hyaline membranes or prominent eosinophil infiltration. Some reports suggest that the clinical course and pathological findings of AFOP are different from typical findings of bronchiolitis obliterans organizing pneumonia (BOOP) or eosinophilic pneumonia (EP), and its prognosis can be better or similar to that of diffuse alveolar damage (DAD). We report two cases of pathologically demonstrated AFOP experienced recently at our institute. One fatal case revealed a rapid development of respiratory failure and the need for mechanical ventilation. Another nonfatal case revealed subacute diffuse bilateral lung infiltration without the need for mechanical ventilation. Judging from our experience, the patient who required a mechanical ventilator had a poorer prognosis than the one who did not need a mechanical ventilator.

A Case of Multiple Micronodular Pneumocyte Hyperplasia of the Lung in a Man with Tuberous Sclerosis / 결핵및호흡기질환

Tuberous sclerosis (TS) is an autosomal dominant disorder that is characterized by cutaneous lesions, seizures, mental retardation and hamartomas in various organs including the skin, kidney and brain. Pulmonary involvement is extremely rare, and occurs in approximately 0.1 to 1% of TS cases. Recent reports have indicated multiple micronodular pneumocyte hyperplasia (MMPH) as another rare form of pulmonary involvement of tuberous sclerosis. We report a case of a 35 year-old-male patient who had no pulmonary symptoms but showed multinodular pulmonary shadows on his chest CT scan. The patient was finally diagnosed with TS with MMPH of the lung. MMPH does not appear to have any malignant potential but the clinical significance of MMPH in TS patients is unknown.(Tuberc Respir Dis 2008;64:369-373)

Two Cases of Pulmonary Infection due to A. xylosoxidans Infection in an Immunocompentent Patient / 결핵및호흡기질환

lcaligenes xylosoxidans is a catalase and oxidase positive, motile, nonfermentative and gram-negative rod bacterium. A. xylosoxidans infection is a rare cause of pulmonary infection and little information concerning treatment is available. The majority of patients that develop A. xylosoxidans infection belong to a high-risk group due to an immunocompromised condition or due to pulmonary cystic fibrosis. We report two rare cases of immunocompentent patients that developed a pulmonary infection due to A. xylosoxidans. A 77-year-old man was admitted with a lung abscess. The patient denied having any prior medical illness. A culture of bronchial washing fluid showed the presence of A. xylosoxidans. Despite appropriate antibiotic treatment, the patient died from acute respiratory distress syndrome (ARDS). Another patient, a 61-year-old man without an underlying disease, was admitted with empyema. Under the condition of a closed thoracostomy, a high fever persisted and the empyema was also aggravated. A. xylosoxidans was detected from a culture of pleural fluid. Susceptible antibiotic treatment was provided and surgical intervention was performed. We report these cases with a review of the literature.

A Case of the Minimal Change Nephropathy Associated with Small Cell Lung Cancer / 결핵및호흡기질환

Nephrotic syndrome is a relatively rare complication of malignancy. A few cases of nephrotic syndrome accompanying Hodgkin's disease, non-Hodgkin lymphoma, leukemia and other malignancies have been reported since the first case of the nephrotic syndrome associated with extrarenal malignancy was reported in 1922. Hodgkin's disease and solid tumors are known to be the most common malignancies accompanying nephrotic syndrome. The pathologic findings of kidney in patients with Hodgkin's disease commonly show minimal change nephropathy. Membranous glomerulonephropathy is the most common pathologic feature in patients with solid tumors. Although membranous glomerulonephropathy related to small cell lung cancer has rarely been reported in Korea, minimal change nephropathy accompanying small cell lung cancer has never been reported. We present here a case of a 70 year-old male with minimal change nephropathy that was related to small cell lung cancer. We detected small cell lung cancer during the diagnosis work-up of nephrotic syndrome. We suggest that nephrotic syndrome can be a manifestation of underlying malignancy.

A Case of Pleural Metastasis from Papillary Tthyroid Carcinoma / 결핵및호흡기질환

Lung cancer, breast cancer and lymphoma are the common oncologic causes of malignant pleural effusion, comprising more than the half of the causes. However, an endocrinologic carcinoma associated malignant effusion is very rare. Recently, we encountered a case of papillary thyroid carcinoma causing malignant effusion. An 83-year-old female patient presented with dyspnea due to massive pleural effusion in her left side. The pleural biopsy, pleural fluid cytology and breast needle aspiration biopsy results were consistent with a metastatic papillary thyroid carcinoma. Thyroid ultrasonography showed two thyroid masses, but the patient refused a thyroid biopsy. This case highlights the need for considering the possibility of papillary thyroid carcinoma when the cause of malignant pleural effusion cannot be found because one of the rare clinical manifestations of a papillary thyroid carcinoma can be dyspnea due to malignant effusion.

A Case of Pleural Metastasis from Papillary Tthyroid Carcinoma / 결핵및호흡기질환

Lung cancer, breast cancer and lymphoma are the common oncologic causes of malignant pleural effusion, comprising more than the half of the causes. However, an endocrinologic carcinoma associated malignant effusion is very rare. Recently, we encountered a case of papillary thyroid carcinoma causing malignant effusion. An 83-year-old female patient presented with dyspnea due to massive pleural effusion in her left side. The pleural biopsy, pleural fluid cytology and breast needle aspiration biopsy results were consistent with a metastatic papillary thyroid carcinoma. Thyroid ultrasonography showed two thyroid masses, but the patient refused a thyroid biopsy. This case highlights the need for considering the possibility of papillary thyroid carcinoma when the cause of malignant pleural effusion cannot be found because one of the rare clinical manifestations of a papillary thyroid carcinoma can be dyspnea due to malignant effusion.

Localized Fibrosing Mediastinitis with Superior Vena Caval(SVC) Syndrome / 결핵및호흡기질환

Fibrosing mediastinitis is a rare disease that is characterized by the proliferation of dense fibrous tissue of the mediastinum. The pathogenesis of fibrosing mediastinitis is unknown in most cases. However, histoplasmosis, tuberculosis, autoimmune disease, radiation therapy, and other idiopathic fibroinflammatory diseases have been implicated in some cases. Most clinical features are related to an obstruction or compression of the mediastinal structure. Fibrosing mediastinitis is often progressive and occurs diffusely throughout the mediastinum. We encountered a case of fibrosing mediastinitis of a very focal lesion without evidence of mediastinal involvement. The condition was confirmed by biopsy and graft bypass surgery was performed because of SVC syndrome.

The Effect and Safety of Alveolar Recruitment Maneuver using Pressure-Controlled Ventilation in Acute Lung Injury and Acute Respiratory Distress Syndrome / 결핵및호흡기질환

BACKGROUND: Alveolar recruitment (RM) is one of the primary goals of respiratory care for an acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). The purposes of alveolar recruitment are an improvement in pulmonary gas exchange and the protection of atelectrauma. This study examined the effect and safety of the alveolar RM using pressure control ventilation (PCV) in early ALI and ARDS patients. METHODS: Sixteen patients with early ALI and ARDS who underwent alveolar RM using PCV were enrolled in this study. The patients' data were recorded at the baseline, and 20 minutes, and 60 minutes after alveolar RM, and on the next day after the maneuver. Alveolar RM was performed with an inspiratory pressure of 30 cmH2O and a PEEP of 20 cmH2O in a 2-minute PCV mode. The venous O2 saturation, central venous pressure, blood pressure, pulse rate, PaO2/FiO2 ratio, PEEP, and chest X-ray findings were obtained before and after alveolar RM. RESULTS: Of the 16 patients, 3 had extra-pulmonary ALI/ARDS and the remaining 13 had pulmonary ALI/ARDS. The mean PEEP was 11.3 mmHg, and the mean PaO2/FiO2 ratio was 130.3 before RM. The PaO2/FiO2 ratio increased by 45% after alveolar RM. The PaO2/FiO2 ratio reached a peak 60 minutes after alveolar RM. The PaCO2 increased by 51.9 mmHg after alveolar RM. The mean blood pressure was not affected by alveolar RM. There were no complications due to pressure injuries such as a pneumothorax, pneumomediastinum, and subcutaneous emphysema. CONCLUSION: In this study, alveolar RM using PCV improved the level of oxygenation in patients with an acute lung injury and acute respiratory distress syndrome. Moreover, there were no significant complications due to hemodynamic changes and pressure injuries. Therefore, alveolar RM using PCV can be applied easily and safely in clinical practice with lung protective strategy in early ALI and ARDS patients.

A Case of Bronchiolitis Obliterans Organizing Pneumonia from Epstein-Barr Virus / 결핵및호흡기질환

In the average adult with a normal immune state, Epstein-Barr virus pneumonia is very rare, especially in the form of interstitial lung disease. According to recent studies, the Epstein-Barr virus is also associated with lymphocytic interstitial pneumonia, AIDS and Langerhans cell histiocytosis, but not with sarcoidosis. BOOP is caused by lung injury due to an infection or drug intoxication, and is related to connective tissue disease or bone marrow transplantation, but is sometimes idiopathic. We experienced a patient with symptoms and signs of interstitial lung disease, with confirmed BOOP and EBV ingection from an open lung biopsy and serologic examination, respectively Herein, this case is reported, with a review of the literature.

A Case of Endobronchial Metastasis from Renal Cell Carcinoma 7 Years after Nephrectomy / 결핵및호흡기질환

A distant metastasis from a renal cell carcinoma is quite common after a radical nephrectomy. For this reason, a5 year scheduled follow up is recommended. However, a distant metastasis 5 years after the resection is quite rare. We encountered an endobronchial metastasis from a renal cell carcinoma that was discovered 7 years after the radical nephrectomy, and did not present during the 5 year scheduled follow up regimen. We report this case with a review of the literatures.

A Case of Benign Metastasizing Pulmonary Leiomyoma / 결핵및호흡기질환

A benign metastasizing pulmonary leiomyoma (BMPL) is a rare disease that usually occurs in women with a prior or coincident history of uterine leiomyoma. Although leiomyoma is histologically benign, it has the potential to metastasize to a distant site such as the lung. A 35 year old woman who had undergone a hysterectomy due to uterine leiomyoma 5 years prior was admitted for an investigation of multiple pulmonary nodules on a routine chest roentgenogram. An open lung biopsy was taken to make a pathological diagnosis. The microscopic finding of the nodules was leiomyoma and was similar to those of the uterine leiomyoma that had been resected 5 years ago. The woman underwent wedge resections of all pulmonary nodules. This is the first case of BMPL in Korea, which was treated with wedge resections of all multiple pulmonary nodules.

Radiotherapy of Brain Metastases from Lung Cancer

PURPOSE : Brain metastasis is estimated to occur in 10~45% of solid cancer patients, and is the most common intracranial tumor in adults. Several neurologic symptom palliations are made with steroid therapy and whole brain irradiation. MATERIALS AND METHODS : We evaluated respectively the clinical characteristics and treatment outcome for 44 patients with metastatic brain tumor from lung cancer during the period from April 2000 to December 2003. RESULTS : Median age of the patients was 61 years. The male : female ratio was 2.7 : 1. Synchronous and metachronous brain metastasis was seen in 18 (40.9%) and 26 patients (59.1%), respectively and median duration between the diagnosis of lung cancer and brain metastases was 6 months (range 1~18 months) in metachronous cases. Pathologic types of lung cancer were as follows : small cell lung cancer in 11 patients and non-small cell lung cancer in 33 patients (squamous cell carcinoma-13, adenocarcinoma-11, large cell carcinoma- 3, others-6). The most common symptom of brain metastasis was headache, which was in 27 patients (61.4%). Seven patients (15.9%) had a single brain metastasis while 37 patients (84.1%) had multiple brain metastases. The total radiation dose to whole brain ranged from 30 to 40 Gy (median 30 Gy). In 29 patients (65.9%) neurological symptoms were resolved after whole brain irradiation. Median survival was 18 weeks for patients with steroid therapy and whole brain radiotherapy. CONCLUSION : In present study, we confirmed that whole brain irradiation is an effective palliative treatment for patients with metastatic brain tumors from lung cancer

A Case of Gastric Ectopic Pancreas Complicated by Pancreatitis and Pseudocyst Formation / 대한소화기내시경학회지

Ectopic pancreas rarely produces clinical symptoms. Most commonly reported symptoms were abdominal pain, epigastric discomfort, nausea, vomiting, and bleeding. However, presentation of specific symptoms due to its size and location, including obstructive jaundice, and pyloric obstruction are possible. Ectopic pancreas is subject to various pathological changes occurring in the pancreas itself; namely, cyst, pancreatitis, hemorrhage, necrosis, and neoplastic change. We present a case of 60-year old woman with right upper quadrant pain in whom the surgical pathologic diagnosis was ectopic pancreas of the stomach complicated by pancreatitis and pseudocyst formation.

Relationship Between Age and Pleural Fluid Adenosine Deaminase Activity in Patients with Tuberculous Pleural Effusion / 결핵

BACKGROUND: ADA is an enzyme found in most cells, and is involved in purine metabolism, but its chief role concerns the proliferation and differentiation of lymphocytes, especially T-lymphocytes. For that reason ADA has been looked on as a marker of cell-mediate immunity, which is th key mechanism of the tuberculous pleural effusion. Thus, the pleural fluid ADA activity is increased in the tuberculous pleural effusion.Age associated immune deline is characterized by decreases in both B and T-lymphocyte function and the former may be largely a result of the latter. Therefore, the epleural fluid ADA activity would be lower in old rather than in young, patients with tuberculous pleural effusion. We studied the relationship between age, and pleural fluid ADA activity, in patients with tuberculous pleural effusion. METHODS: In the 46 patients with tuberculous pleural effusion enroll in this study, the pleural fluid ADA activities were measured by means of an automated kinetic method. RESULTS: The mean age of the patients was 53.0+/-22.0 years, with a male to female ratio of 30 : 16. The patients were divided into two groups, young patients, regarded as or=65 years with 28 and 18 patients, respectively. The pleural fluid ADA activity in both groups show significant differences : 99.4+/- 22.6 IU/L(young patients) Vs. 75.8+/-30.9 IU/L(old patients)(p<0.05), but a negative correlation with age (r=-0.311, p<0.05). CONCLUSION: Although pleural fluid ADA activity was not adequately increase, tuberculous pleural effusion, in older patients, would have to be considered clinically suspicious tuberculous pleural effusion.

Relationship Between Age and Pleural Fluid Adenosine Deaminase Activity in Patients with Tuberculous Pleural Effusion / 결핵

BACKGROUND: ADA is an enzyme found in most cells, and is involved in purine metabolism, but its chief role concerns the proliferation and differentiation of lymphocytes, especially T-lymphocytes. For that reason ADA has been looked on as a marker of cell-mediate immunity, which is th key mechanism of the tuberculous pleural effusion. Thus, the pleural fluid ADA activity is increased in the tuberculous pleural effusion.Age associated immune deline is characterized by decreases in both B and T-lymphocyte function and the former may be largely a result of the latter. Therefore, the epleural fluid ADA activity would be lower in old rather than in young, patients with tuberculous pleural effusion. We studied the relationship between age, and pleural fluid ADA activity, in patients with tuberculous pleural effusion. METHODS: In the 46 patients with tuberculous pleural effusion enroll in this study, the pleural fluid ADA activities were measured by means of an automated kinetic method. RESULTS: The mean age of the patients was 53.0+/-22.0 years, with a male to female ratio of 30 : 16. The patients were divided into two groups, young patients, regarded as or=65 years with 28 and 18 patients, respectively. The pleural fluid ADA activity in both groups show significant differences : 99.4+/- 22.6 IU/L(young patients) Vs. 75.8+/-30.9 IU/L(old patients)(p<0.05), but a negative correlation with age (r=-0.311, p<0.05). CONCLUSION: Although pleural fluid ADA activity was not adequately increase, tuberculous pleural effusion, in older patients, would have to be considered clinically suspicious tuberculous pleural effusion.

Influence of Age on The Adenosine Deaminase Activity in Patients with Exudative Pleural Effusion / 결핵

BACKGROUND: Pleural fluid adenosine deaminase (ADA) activity can be helpful in a differential diagnosis of an exudative pleural effusion because it is increased in a tuberculous pleural effusion. The ADA activity is determined mainly by the lymphocyte function. Age-associated immune decline is characterized by a decrease in T-lymphocyte function. For that reason, the pleural fluid ADA level would be lower in older patients with exudative pleural effusion. This study focused on the influence of age on the pleural fluid ADA activity in patients with exudative pleural effusion. METHODS: A total of 81 patients with exudative pleural effusion were enrolled in this study. In all patients, the pleural fluid ADA activity was measured using an automated kinetic method. RESULTS: The mean age of the patients was 52.7+/-21.2 years. In all patients with exudative pleural effusion, the pleural fluid ADA activity revealed a significant difference between young patients (under 65 years of age) and old patients (at or over 65 years of age) : 82.8 +/- 48.0 IU/L in young patients Vs. 57.7+/-37.2 IU/L in old patients (p0.05), and did not show any correlation with age (r=-0.263, p>0.05). The diagnostic cutoff value of pleural fluid ADA activity for tuberculous pleural effusion was lower in the older patients (25.9 IU/L) than in the younger patients (49.1 IU/L) or all patients (38.4 IU/L) with exudative pleural effusion. CONCLUSION: Tuberculous pleural effusion is an important possibility to consider in older patients with a clinical suspicion of a tuberculous pleural effusion, although no marked increase in the pleural fluid ADA activity is usually detected. For a diagnosis of a tuberculous pleural effusion in old patients, the cutoff for the pleural fluid ADA activity should be set lower.

Clinical Significance of Plasma TGF-β1 in Coal Workers' Pneumoconiosis / 결핵

BACKGROUND: Coal workers' pneumoconiosis is a fibrotic lung disease resulting from chronic inhalation of coal dust. The precise mechanism of lung fibrosis in coal workers' pneumoconiosis is uncertain. However, a relationship between the stimulation of fibroblast proliferation and collagen production by mediators released from inflammatory and resident lung cells is thought to be a major factor. The transforming growth factor-β(TGF-β), a multifunctional cytokine and growth factor, plays a key role in the scarring and fibrotic processes due to its ability to induce extracellular matrix proteins and modulate the growth and immune function of many cell types. To determine the involvement of TGF-βin the development of lung fibrosis in coal workers' pneumoconiosis, the TGF-β1 level in plasma was measured in patients with coal workers' pneumoconiosis. METHODS: Plasma was collected from 40 patients with coal workers' pneumoconiosis (20 with simple coal workers' pneumoconiosis and 20 with complicated coal workers' pneumoconiosis) and from 10 normal controls. The ELISA method was used to measure the plasma TGF-β1 concentration. RESULTS: Compared to the control group (0.63±0.18 ng/mL), there was no significant difference in the plasma TGF-β1 level in patients with simple coal workers' pneumoconiosis (0.64±0.17 ng/mL) (p>.05). However, in patients with complicated coal workers' pneumoconiosis the plasma TGF-β1 level (0.79±0.18 ng/mL) was significantly higher than in patients with simple coal workers' pneumoconiosis and control group (p<0.05). CONCLUSION: The data suggests that TGF-β1 has some influence in the development of lung fibrosis in coal workers' pneumoconiosis.

Relationship Between Tumor Angiogenesis, sgtage and Prognosis in Non-Small Cell Lung Cancer / 결핵

BACKGROUND: Tumor angiogenesis is required for tumor growth and metastasis. In this study, we investigated the correlation between the intensity of angiogenesis and stage, nodal status, histologic type, metastasis and survival rate of non-small cell lung cancer. METHOD: Formalin fixed, paraffin embedded surgical specimens of 45 patients who had surgically resected primary non-small cell lung cancers without pre or post perative adjuvant chemotherapy or radiotherapy were examined. The microvessel count(MVC) was demonstrated by immunohistochemical staining for CD31(platelet ednothlial cell adhesion molecule, PECAM). RESULTS: Microvessel counts(MVCs)in stage IIIA and IIIB were higher than in stage I and II(p0.05). However, in adenocarcinoma, the MVC in patients with lymph node metastasis was significantly higher than that seen in patients without lymph node metastasis(p0.05). However, in stage IIIA and IIIB or N1~3 stage, the MVC in adenocarcinoma was higher than that in squamous cell carcinoma(p0.05). The survival rate in patients with high MVCs was lower than that in patients with low MVCs(P<0.05). CONCLUSION: In non-small cell lung cancer, MVC correlated relatively well with pathologic stage, nodal status (limited in patients with adenocarcinoma), histologic type, postoperative metastasis and survival rate. However, in the same histologic type and stage, MVC was not significantly related to the duration of survival. Therefore the assessment of the intensity of angiogenesis in non-small cell lung cancer may be helpful in predicting prognosis and in selecting patients for systemic adjuvant therapy of potential metastasis according to the results.

Evaluation of the Solitary Pulmonary Nodule by Spiral Computed Tomography with Contrast Enhancement / 결핵

BACKGROUND: Clinical and Radiographic studies to differentiate benign from malignant pulmonary nodules have previously focused on clinical status and the morphologic and the computed tomographic attenuation characteristics of the lung nodules. Distinctive differences in the vascularity and pathophysiology of malignant versus benign pulmonary nodules were identified. We evaluated the diagnostic method for differentiating malignant from benign solitary pulmonary nodule by contrast enhancement on the spiral CT. METHOD: Sixteen patients with solitary pulmonary nodule were examined(Tuberculoma 8, primary lung cancer 8). Serial thin section on the spiral CT was performed before and after(45second, 2min, 5min) the onset of the injection of 100mL of nonionic contrast material(2mL/sec). RESULTS: There was no difference in size of nodule and pre-contrast CT number (Hounsfield unit) between benign and malignant nodules. At forty-five second after the onset of the injection, malignant neoplasms(19.6+/-7.9 HU) enhanced significantly more than tuberculomas(4.9+/-9.4 HU, p=0.008). At 2 minute and 5 minute after, malignant neoplasms(34.0+/-19.2HU, 340+/-15.4HU) enhanced significantly more than tuberculomas (6.7+/-9.7HU, p=0.007 and 7.7+/-11.5HU, p=0.011). On cut-off value 20HU(contrast enhancement) 2 minute after the injection of contrast media, sensitivity was 87% and specificity was 87%. No correlation between the contrast enhancement and size of the nodules was observed. CONCLUSION: Studies with the use of an intravenously administered noniodinated contrast medium in examining the enhancement properties of lung nodules was performed. The contrast enhancement was useful in differential diagnosis of solitary pulmonary nodules.