[A case of pulmonary sarcoidosis demonstrating panlobular ground-glass opacity with mosaic distribution].

A 68-year-old woman presenting dyspnea on exertion was admitted. Hypoxemia and a considerably elevated level of serum KL-6 were noted. Chest high-resolution computed tomography (HRCT) scans demonstrated panlobular ground-glass opacities with a mosaic distribution and hilar and mediastinal lymphadenopathy. Bronchoalveolar lavage revealed an increased percentage of lymphocytes and an elevated CD4/CD8 ratio, implicating a diagnosis of sarcoidosis. However, as we could not exclude other diffuse lung diseases because of unusual HRCT pattern in sarcoidosis, video-assisted thoracoscopic lung biopsy was performed. The histology of epithelioid cell granulomas in the specimens of the lung and the lymph nodes confirmed a diagnosis of sarcoidosis. The lung specimens corresponding to areas of increased opacity demonstrated diffuse alveolitis with minimal fibrosis between individual granulomas. Immunohistochemistry for KL-6 provided positive results on alveolar lining cells in areas of alveolitis but not on granulomas. After steroid treatment, the ground-glass opacities disappeared and the serum KL-6 level normalized. We discuss this rare case of pulmonary sarcoidosis presenting panlobular ground-glass opacities with mosaic distribution.

Influence of age on symptoms and laboratory findings at presentation in patients with influenza-associated pneumonia.

Influenza virus infection is a major respiratory infectious disease that generally induces pneumonia. The clinical manifestations of influenza virus infection and community-acquired pneumonia (CAP) differ between elderly persons and younger adults. To determine the clinical features of influenza-associated pneumonia, we studied 21 adult patients with influenza-associated pneumonia, as indicated by positive test results for influenza virus antigen. At presentation, the higher-age patients (> or =75 years; n=12) with influenza-associated pneumonia had lower body temperature than did the lower-age (<75 years) patients (n=9). Conversely, the laboratory data indicated significantly higher C-reactive protein (CRP) concentration in higher-age patients than that in lower-age patients. None of the 18 patients undergoing neuraminidase inhibitor therapy died, but two of three patients who did not receive this therapy died from complications of advanced pneumonia. In this study, vaccination did not appear to be an important factor for prevention of pneumonia. High-age patients with CAP have lower body temperature, raising the possibility that diagnosis and treatment may be delayed in these patients. Increased CRP levels in these patients at presentation, however, could contribute to early detection of this serious pulmonary complication.

[A case of psittacosis with wandering infiltrates developing to acute respiratory distress syndrome].

A 52-year-old woman visited a local hospital with a high fever, non-productive cough and general fatigue. Her chest X-ray showed infiltrate in the right middle lung field. Computed tomography scans revealed ground-glass opacity and surrounding ring-shaped air-space consolidation, the "reversed halo sign". Cefpirom was administered, but her symptoms persisted and the infiltrate migrated to the left upper lobe. As cryptogenic organizing pneumonia was suspected, she was then treated with intravenously pulsed methylprednisolone followed by prednisolone. Despite these therapies, acute respiratory failure occurred and she was therefore transferred to our hospital. On admission, severe hypoxemia and diffuse bilateral infiltrates on chest images suggested acute respiratory distress syndrome. As we obtained information that a parakeet had recently died at her home, minocycline was administered, resulting in prompt improvement of the symptoms, respiratory insufficiency and pulmonary infiltrates. Finally, elevated antibody titers against Chlamydophila psittasi confirmed a diagnosis of Psittacosis. Sequential chest computed tomography scans in this case indicate that absorption of marginal air-space consolidation with extended central ground glass attenuation in concordance with a new infiltrate on another lung field appeared to create wandering infiltrate. Wandering infiltrate on chest X-ray in psittacosis may be a sign of disease progression.

[A case of drug-induced pneumonitis due to bepridil].

A 66-year-old man had been given bepridil for the treatment of atrial fibrillation since April 28, 2002. The patient developed exertional dyspnea with hypoxemia in the middle of June 2002 and was admitted to our hospital. The chest X-ray and chest CT scans showed diffuse reticulonodular infiltrates in the lower lung fields. Pulmonary function tests revealed depletion of diffusion capacity for carbon monoxide. Bronchoalveolar lavage fluid contained increased percentages of lymphocytes, neutrophils and eosinophils, and a CD4/8 ratio was low. The transbronchial lung biopsy specimens demonstrated alveolar septal thickening with infiltration of mononuclear cells and intraalveolar organization. As drug-induced pneumonitis was suspected, bepridil was discontinued, resulting in improvement of dyspnea and hypoxemia. The patient was then treated with corticosteroid, which led to complete resolution of infiltration on chest X-ray. According to the clinical data consistent with drug-induced pneumonia, the prompt improvement after cessation of bepridil and the absence of other possible causes, we diagnosed this case as bepridil-induce pnemonitis.

[A case of pulmonary langerhans cell histiocytosis presenting disappearance of coalescing air wall cysts after smoking cessation].

A 17-year-old adolescent was admitted to Oita University Hospital with non-productive cough and exertional dyspnea. She had been smoking approximately 10 cigarettes per day for two years. When the patient was three years old, she underwent surgical removal of skull tumor of Langerhans cell histiocytosis. Initial chest CT scans showed coalescing thick-walled air cysts surrounded by micronodules in both lungs, most predominantly in the middle and upper lung fields. Bronchoalveolar lavage fluid contained 2.3% of CD1a-positive cells and video-assisted thoracoscopic lung biopsy disclosed granulomatous lesions consisting of histiocytic cells containing S-100 protein but without CD68 antigen allowing a diagnosis of pulmonary Langerhans cell histiocytosis. She stopped smoking, resulting in spontaneous resolution of the coalescing air cysts which were replaced by funicular scarring within two years. In case of extra-pulmonary Langerhans cell histiocytosis in children, the close relationship between cigarette smoking and pulmonary involvement should be informed to the parents to prevent the patient starting smoking in the future.

Elevated concentrations of soluble IL-2 receptor in both bronchoalveolar lavage fluid and serum in a patient with BOOP.

Activated soluble IL-2 receptor (sIL-2R) levels are elevated in a variety of diseases associated with T-cell activation. There are no reports of sIL-2R elevations in broncholitis obliterans organizing pneumonia/cryptogenic organizing pneumonia (BOOP/COP), although activated T cells are increased in BOOP/COP. We present a patient with BOOP/COP with an elevated concentration of soluble IL-2 receptors in both serum and bronchoalveolar lavage fluid. Concomitant resolution of the high serum sIL-2R and the roentogenographic findings after steroid treatment suggested that serum sIL-2R levels increase in response to a localized lymphocytic inflammatory reaction in the lung.