[FAMILIAL OCCURRENCE OF SUMMER-TYPE HYPERSENSITIVITY PNEUMONITIS IN DEFECTIVE HOME].

A 53-year-old-woman presented our hospital with 1 month history of exertional dyspnea and mild fever. When examined, temperature was 37.2℃ and her respiratory rate of 22/min with an O2 saturation of 95% (02 4L/min), the rest of her vital signs were normal. The Chest X-ray was significant for ground-grass attenuation, and computed tomography showed diffuse nodular lesions bilaterally. She reported that the floorboard in the living room had been rotten last two months, and her husband was admitted to another hospital with similar symptoms the day before. We suspected that she and her husband have familial hypersensitivity pneumonitis although their children who live in the same house don't have any symptoms. After the admission, her respiratory status improved without treatment. The trans-bronchial lung biopsy specimens showed lymphocytic infiltration in alveolar area, and epithelioid cell granuloma consisted of CD68-positive macrophages. These findings corresponded to subacute hypersensitivity pneumonitis. The bronchoalveolar lavage revealed predominant lymphocytes of 92%, with a low CD4/8 ratio of 0.39. Serum anti-Trichosporon asahii antibodies were positive. With the result of positive environmental challenge test in her house, which showed elicited dyspnea and temperature increase up to 38℃ a few hours after she came back home, the patient was diagnosed as having summer-type hypersensitivity pneumonitis. Her husband was also diagnosed as the same disease, and symptoms improved with antigen avoidance and prednisolone. The patient was discharged to her relative's place for the moment of house repair. The patient's symptoms did not recur after her house was repaired.

A case of adult onset Still's disease complicated with cryptogenic organizing pneumonia.

Only a few pathologic reports exist describing adult onset Still's disease (AOSD) with pulmonary involvement. We report this very rare case of AOSD complicated with cryptogenic organizing pneumonia (COP). A 32-year-old woman was referred with high spiking fever, salmon-pink rash in her arms and legs, and polyarthralgia. The laboratory data showed marked increases in white blood cell count, an erythrocyte sedimentation rate, and C reactive protein, ferritin, and liver dysfunction. All cultures remained negative, as were autoantibodies and rheumatoid factor. The patient was strongly suspected of AOSD according to specific diagnostic criteria. However, chest X ray disclosed an infiltrative shadow accompanied by air bronchogram in the upper lobe of the right lung and therapy with antibiotics was initiated. As the patient did not respond to antibiotics and a remittent fever of over 38°C, a flexible bronchoscopy was performed. Organizing pneumonia was diagnosed by transbronchial lung biopsy (TBLB) histology and radiologically, and the lesions were thought to be due to pulmonary involvement of AOSD. Therefore, she was diagnosed with AOSD complicated with COP. Oral treatment with prednisolone (30 mg/day) resulted in rapid disappearance of the infiltrative shadow. Symptoms and markers of inflammation also improved. Clinicians should be aware that COP can be a complication of AOSD.

[A case of multiple and metachronous pleural tuberculomas during the course of anti-tuberculous chemotherapy and follow-up of a caseous pneumonia].

A 21-year-old woman was admitted to our hospital because of high fever, a productive cough and general fatigue. Her chest radiography scan revealed dense consolidation with air-bronchograms in the left lower lobe. Bacterial pneumonia was diagnosed and she was treated with antibiotics, although the specific cause could not be identified. After one month, a bronchoscopy was performed due to lack of improvement of consolidation in chest radiography. A smear examination of the bronchial washing specimen was positive for acid-fast bacilli (AFB) and Mycobacterium tuberculosis (MTB) was confirmed by PCR. After anti-tuberculous drugs (INH, RFP, EB, and PZA) were prescribed for 6 months, chest X-ray findings improved markedly. Two pleural tuberculomas were found in the left upper and lower lung fields 3 months after beginning therapy, and a new pleural tuberculoma appeared in the left upper lung fields 6 months after finishing therapy. Histopathological findings (HE stain) of a CT-guided needle lung biopsy showed epithelioid cell granulomas without caseous necrosis with multinuclear giant cells which were negative for acid-fast bacterium. All of the pleural tuberculomas improved without any additional therapy 18 months after finishing therapy. It was thought that such cases of multiple and metachronous pleural tuberculomas during the course of anti-tuberculous chemotherapy and follow-up of caseous pneumonia are rare. We suggest the possibility that the pleural tuberculomas were due to a paradoxical or hypersensitive reaction to the anti-tuberculous chemotherapy in this case.

[The sequential changes of the serum levels of KL-6, SP-D, and DLCO were followed for a long term in a case of acute bird fancier's lung].

The sequential changes of the serum levels of KL-6, SP-D, and DLco were followed for a long term in a case of acute bird fancier's lung, A 52 years-old-male was admitted to our hospital because of cough, dyspnea on exertion and fever. He has been breeding 12 pigeons in home for the last five years. HRCT of the chest demonstrated diffuse centrilobular nodules and ground-glass opacities with mosaic pattern in bilateral lung fields. Bronchoalveolar lavage (BAL) showed an increased number of lymphocytes with a increased CD4/CD8 ratio, and transbronchial lung biopsy (TBLB) specimen revealed alveolitis with infiltration of lymphoid cells and Masson body in the air spaces. He was diagnosed as having bird fancier's lung because of the elevated antibodies against pigeon dropping extracts (PDE) in the serum and BALF. Respiratory failure continued after complete avoidance of contact with pigeons for a week. Clinical symptoms and chest X-ray findings improved markedly after administration of steroid, and he left the hospital to move into a new house. The serum levels of KL-6 and SP-D were unchanged by antigen avoidance, although those were returning to normal gradually after treatment of steroid. SP-D and KL-6 returned to normal in 8 months and 18 months respectively and DLco was also improved slowly in parallel with a decrease of these markers. These results suggest that the serum KL-6 level and DLco reflect the disease activity showing gradual recovery of alveolitis in such a long period.

[Case of secondary chronic necrotic pulmonary aspergillosis that developed after pneumococcal pneumonia complicated by lung abscess formation].

The patient was a 61-year-old man. From the end of May 2007 he suffered from pain in the left anterior chest, had fever and consulted our hospital on May 27. On admission chest CT revealed consolidation in the left lung. In venous blood and sputum culture Streptococcus pneumoniae was identified as the causative organism, but despite improvement as a result of treatment, the upper lobe of the left lung showed cavity formation. Inside the cavity, fluid level formation was observed and percutaneous cavernous drainage was performed. Pus culture revealed infection with Aspergillus fumigatus, and we diagnosed chronic necrotizing pulmonary aspergillosis (CNPA). In addition to intravenous antifungal drug administration, 20 mg of amphotericin B (AMPH-B) was administered intracavitary. As symptoms and laboratory findings improved, the patient was discharged on October 12. We reported this case because pneumococcal pneumonia complicated by lung abscess formation is relatively rare, and topical treatment was effective against CNPA.