[A case of secondary pulmonary cryptococcosis presenting with multiple cystic shadows].

An 80-year-old woman with a history of rheumatoid arthritis and steroid diabetes had been given a diagnosis of multiple bilateral pulmonary cystic lesions 16 months previously, and these lesions were observed to gradually increase on follow-up. She presented with a fever of 38 degrees C, cough, and sputum for 2 weeks, and the pulmonary cystic lesions had enlarged, and therefore she was admitted. A chest X-ray film revealed multiple cystic lesions 4 cm in greatest dimension in both the left upper and middle lung fields, and chest computed tomography (CT) scans revealed that the lesions of the left S1+2 had niveau formation with a partially thickened wall. However, the lesions in the left S4 and S5 areas and the right S8 area had thin, smooth walls. Transbronchial lung biopsy of the left S4 lesion yielded granuloma formation and yeast-like fungus bodies within multinucleated giant cells, while bronchial lavage fluid culture showed cryptococcus neoformans. It is known that pulmonary cryptococcosis presents various images and histopathologic findings, according to the immune interactions between the fungus body and the host. We report a rare case that presented with multiple cryptococcal cystic lesions.

[A case of pulmonary tuberculosis with multiple pneumatoceles in adult].

We describe a 32-year-old woman suspected of having pulmonary tuberculosis due to abnormal shadows found on her chest x-ray in a community health examination in September 2002. However, she consistently refused further examinations and treatment. In January 2005, she complained of a cough and sputum, by October she developed diarrhea, and by December a sore throat and fever. She was admitted to our hospital on January 23, 2006. Her chest radiograph revealed multiple thin-walled cystic lesions and infiltrative shadows in both upper lobes of the lung, a giant thin-walled cystic lesion in the superior segment of the left lower lobe, and diffuse particulate shadows. Since acid-fast staining of her sputum smear and a PCR test to detect tubercle bacilli both were positive, a diagnosis of pulmonary tuberculosis was made and we treated her with antituberculotic agents. Ten days after starting the treatment, her cystic lesions decreased or disappeared. Although she was seemingly healthy, her pulmonary tuberculosis became more severe since she failed to follow her treatment regimen. She therefore developed nutritional disorders and cellular immunity dysfunction that induced a sequence of changes, e.g. poor granuloma formation, excaration of caseous necrofic material by draining bronchi, and a check-valve mechanism. We speculate that these symptoms caused the formation of pneumatoceles. To our knowledge, this is the first case of pneumatocele formation found in a patient with pulmonary tuberculosis reported in Japan.

Peripheral hemophagocytosis: An early indicator of advanced systemic inflammatory response syndrome/hemophagocytic syndrome.

Peripheral hemophagocytosis (PHP) is seen in patients with hemophagocytic syndrome (HPS), a clinical status in which activated macrophages play a role in its pathogenesis. The inflammatory state, systemic inflammatory response syndrome (SIRS), is also associated with activated macrophages. However, the link between HPS and SIRS and the clinical implications of PHP remain to be determined. In the present work, we examined the clinical utility and impact of the detection of PHP and the link between HPS and SIRS. We studied the clinical and laboratory profiles of 322 SIRS patients (174 men; mean age, 68 +/- 22 years; range, 16-99 years) who visited an urban hospital specializing in respiratory, cardiovascular, digestive, renal diseases, general surgery, and orthopedics in Japan. Peripheral hemophagocytosis was detected in 40 (23 men; mean age, 81.3 +/- 8.7 years; range, 63-98 years) of 322 patients on 3 +/- 2 days after SIRS diagnosis as determined with a "blunt-edged-smear" method differing from the conventional "feather-edged smear" method. The incidence of advanced SIRS and ensuing death in the SIRS+ PHP- group (37 and 21 of 40, respectively) was significantly greater than in the SIRS+ PHP- group (82 and 17 of 282) (P < 0.01). The duration from SIRS diagnosis to recovery in 19 SIRS+ PHP- surviving patients (26 +/- 18 days) was longer than that in 19 age-matched SIRS+ PHP- surviving patients who initially presented comparable clinical profiles (6 +/- 3 days) (P < 0.001). Bone marrow analysis in all 7 patients having PHP and SIRS showed no HPS initially (<3% hemophagocytes), but all subsequently developed HPS at 7 +/- 1 days after the diagnosis, confirmed by the presence of 9% +/- 13% hemophagocytes in the bone marrow. Electron microscopic and immunohistochemical analyses revealed that PHP was derived from hemophagocytes in the bone marrow. The present data strongly suggest that PHP detection could serve as an early indicator for advanced SIRS and/or HPS and that the use of the blunt-edged method is preferable for PHP detection.

[A case of rapidly progressing pulmonary aspergillosis presenting various forms of shadow].

A 66-year-old woman who had a history of bullous pemphigoid was admitted to our hospital with abnormal shadows on chest radiography. She was being treated with prednisolone, which suggested that she might be in an immunosuppressed state. The chest radiograph and CT scan disclosed an infiltrative opacity, rapidly progressive cavitation, subsequent mycetoma formation, and a nodular shadow with a clear margin. Histological examination revealed a fungus ball in the cavitary lesion and a small mass of hyphae in necrotic tissue. After transbronchoscopic infusion of fluconazole, the cavitary lesion showed a marked resolution on the chest CT scan, and the infiltrative shadow and the nodule disappeared. It is said that aspergillosis is a spectrum of conditions whose precise manifestation is determined by the state of the lung tissue and by the patient's immune status. We report this rare case of pulmonary aspergillosis presenting various forms of shadow.