[A Case of Immune-Related Adverse Events Affecting the Lungs, Skin, and Pituitary Gland during Pembrolizumab Treatment].

The patient was a 69-year-old man diagnosed with stage ⅣB lung adenocarcinoma with 95% programmed death- ligand 1 expression, and pembrolizumab monotherapy was initiated. The patient exhibited fatigue from the 12th course(36 weeks after treatment initiation) of treatment. Chest computed tomography revealed scattered ground-glass opacities in the upper lobes of both lungs, and he was subsequently diagnosed with interstitial pneumonia. Fatigue persisted even after a drug holiday from pembrolizumab, and the patient was diagnosed with hypopituitarism based on the results of endocrinological examinations. Rashes appeared on both legs 40 weeks after treatment initiation, which led to the patient being diagnosed with a drug-induced skin disorder. All the adverse events resolved upon treatment with hydrocortisone. Immune- related adverse events due to pembrolizumab may occur in multiple organs simultaneously.

[A case of docetaxel-induced acute lung injury refractory to treatment].

A 59-year-old man was diagnosed with squamous cell cancer of the upper lobe of the left lung 11 months before his current admission. The clinical stage was T2N3M1(Stage IV). We started chemotherapy(carboplatin/gemcitabine), which was administered for 7 courses and discontinued 5 months before admission, but he subsequently showed a local relapse. Therefore, we restarted second-line chemotherapy(docetaxel)on admission. Only a single dose of docetaxel was administered, but the patient was diagnosed with respiratory failure 18 days afterwards. The chest roentgenogram and computed tomography showed ground-glass opacities. Bronchoalveolar lavage and blood test data showed no evidence of infection. We diagnosed the patient with acute lung injury induced by docetaxel. The patient was admitted to the intensive care unit, and therapy with steroids and sivelestat was initiated. In addition, artificial respiration, direct hemoperfusion with a polymyxin B-immobilized fiber column, etc., were performed. However, this intensive care regimen was unsuccessful, and the patient died 31 days after docetaxel administration. Docetaxel is generally used in the treatment of non-small-cell lung cancer. However, the present case showed that its use might lead to fatal drug-induced lung injury.

[Bronchial asthma-like symptoms induced by pulmonary embolism].

A 75-year-old woman who lived in a retirement home was admitted to the emergency room of our hospital because of acute respiratory failure with sudden onset of wheezing on awakening. A differential diagnosis of heart failure, showed that she had experienced an attack of bronchial asthma. She was therefore given beta-agonists via inhalation and theophylline and steroids intravenously. Her wheezing decreased but her respiratory failure persisted. Therefore, she was transferred to the intensive care unit and was referred to our department. Contrast-enhanced computed tomography of her chest showed pulmonary embolisms involving both lower lung lobes. Moreover, pulmonary perfusion scintigraphy showed defects in both lower lobes. Thus, pulmonary embolism was diagnosed. Subsequently, we started anticoagulant therapy, and her respiratory failure was saved. Pulmonary embolism is known to induce symptoms such as bronchial asthma, although such symptoms are rare.

[A case of bronchocentric granulomatosis associated with Aspergillus clusters that was difficult to distinguish from lung cancer].

A 69-year-old man was examined for investigation of a nodular shadow with calcification detected on computed tomography of the chest. He showed no features of allergic bronchopulmonary aspergillosis (ABPA), such as bronchial asthma or eosinophilia. We could not distinguish his disease status from lung cancer and performed upper lobectomy of his right lung. Pathological examination revealed bronchocentric granulomatosis (BCG) with Aspergillus clusters. Subsequent serological testing demonstrated high levels of IgE-RIST and IgE-RAST (Aspergillus) whereas anti-Aspergillus precipitating antibody was not detectable. We believe that Aspergillus clusters may have been present in this patient for several years, and the pathological findings might be manifested as an asymptomatic localized allergic inflammation. BCG is a pathological component of ABPA. This case, of a localized allergic reaction, is considered very valuable for understanding the underlying mechanism of the onset of ABPA.

[A case of pulmonary Mycobacterium abscessus infection with asbestosis in a patient given multidisciplinary treatment].

A 68-year-old man consulted our hospital because of a giant cavity in the upper lobe of the right lung, which was detected in a medical examination for asbestosis. Mycobacterium abscessus was cultured from his sputum in 2 separate cultures. Therefore we diagnosed pulmonary Mycobacterium abscessus infection and prescribed amikacin, imipenem/cilastatin, and clarithromycin. After 2 months, lobectomy of the upper lobe of the right lung was performed. The 3 antibiotics were continued for another 6 months, and the patient recovered completely. Mycobacterium abscessus infection is one of the most intractable non-tuberculous mycobacterial infections, and it is important to include surgery in the primary treatment plan.