Pulmonary flow assessment by phase-contrast MRI can predict short-term mortality of fibrosing interstitial lung diseases.

BACKGROUND: Phase-contrast magnetic resonance imaging (PC-MRI) can determine pulmonary hemodynamics non-invasively. Pulmonary hypertension causes changes in pulmonary hemodynamics and is a factor for acute exacerbation and death in interstitial lung diseases (ILD). PURPOSE: To determine associations between pulmonary hemodynamics measured by PC-MRI and short-term mortality in patients with ILD. MATERIAL AND METHODS: Pulmonary hemodynamics, measured by PC-MRI in 43 patients with ILD, were reviewed retrospectively. Evaluation parameters included heart rate, right cardiac output, average flow, average velocity, acceleration time, acceleration volume (AV), maximal change in flow rate during ejection (M), M/AV, maximum area, minimum area, and relative area change in the pulmonary artery (PA). All causes of death within one year from the day of the MRI examination were assessed by reviewing medical records. Associations between evaluation parameters and outcome were determined by univariate and multivariate Cox regression analysis. RESULTS: Six patients (13.9%) died by the one-year follow-up. Age (hazard ratio [HR] 1.116, 95% confidence interval [CI] 1.015-1.269), average flow (HR 0.932, 95% CI 0.870-0.984), average velocity (HR 0.778, 95% CI 0.573-0.976), right cardiac output (HR 0.870, 95% CI 0.758-0.967), AV (HR 0.840, 95% CI 0.669-0.985), M/AV (HR 1.008, 95% CI 1.001-1.014), and PA relative area change (HR 0.715, 95% CI 0.459-0.928) predicted death in univariate Cox analysis. Multivariate Cox analysis showed decreased right cardiac output (HR 0.547, 95% CI 0.160-0.912) and decreased PA relative area change (HR 0.538, 95% CI 0.177-0.922) were independently associated with death. CONCLUSION: Reduction in right cardiac output and decreased PA relative area change, detected by PC-MRI, were associated with increased mortality in ILD.

Pure red cell aplasia induced by lamivudine without the influence of zidovudine in a patient infected with human immunodeficiency virus.

We herein report the case of a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome who was diagnosed with drug-induced pure red cell aplasia consequent to lamivudine treatment. The patient was admitted to our hospital for treatment of increasing shortness of breath following physical effort. Upon admission, routine blood tests revealed a hemoglobin level of 7.6 g/dL and a hematocrit proportion of 21.2%, with normal leukocyte and platelet counts. After stopping the lamivudine treatment, the patient's hemoglobin concentration and hematocrit level returned to normal. A bone marrow examination showed an exclusive reduction in erythrocyte formation. This case indicates that lamivudine can induce severe anemia without the influence of zidovudine.

Increased expression of HBZ and Foxp3 mRNA in bronchoalveolar lavage cells taken from human T-lymphotropic virus type 1-associated lung disorder patients.

OBJECTIVE: Human T-lymphotropic virus type 1 (HTLV-I) causes adult T-cell leukemia/lymphoma (ATLL), and is associated with chronic inflammatory diseases, including inflammatory pulmonary diseases. HTLV-I bZIP factor (HBZ), which is expressed in all adult T-cell leukemia cells, plays a critical role in the development of lymphoma and systemic inflammation. HTLV-I is harbored by CD4(+) T cells that express forkhead box P3 (Foxp3), and HBZ interacts with Foxp3. This study investigated the chest computed tomography (CT) findings and expression of HBZ and Foxp3 in the bronchoalveolar lavage (BAL) cells from patients with HTLV-I-associated lung disorders. METHODS: CT scans obtained from 37 patients (10 men and 27 women, aged 37-77 years) with HTLV-I-associated lung disorders were retrospectively evaluated. The expression levels of HBZ and Foxp3 mRNA in BAL cells and the levels of inflammatory cytokines in the BAL fluid (BALF) from patients were compared with those in control subjects. RESULTS: CT scans frequently revealed a diffuse panbronchiolitis (DPB)-like pattern, along with a nonspecific interstitial pneumonia (NSIP) pattern. An analysis of the BALF revealed lymphocytosis and increased expression of HBZ mRNA in patients with HTLV-I-associated lung disorders. The expression of Foxp3 mRNA positively correlated with the percentages of lymphocytes present in the BALF. The inflammatory cytokine and IL-10 levels were significantly increased in the BALF from patients with HTLV-I-associated lung disorders. CONCLUSION: The NSIP pattern may be a manifestation of pulmonary involvement in HTLV-I-infected patients, as is the DPB-like pattern. HBZ and Foxp3 likely have a role in the development of lung inflammation.

[Clinical features of diabetic patients with pulmonary tuberculosis admitted to a university hospital].

Diabetes mellitus (DM) is a risk factor of tuberculosis (TB). We studied the clinical presentation of pulmonary TB among patients with DM in comparison with patients without DM who were admitted into the hospital of the University of the Ryukyus from 2006 to 2010. The clinical data were collected from medical records retrospectively. Ten cases (25%) of hospitalized patients with pulmonary TB had DM. The DM group showed lower Body Mass Index and higher incidence of chronic heart failure and chronic renal failure. The DM group also were more likely to have cavitary lesion, had longer period of hospitalization, and higher mortality. Their causes of deaths were mainly the co-morbidities and associated complications. Further studies are warranted in order to fully elucidate the relationships between pulmonary TB and DM.

CT scans of the chest in carriers of human T-cell lymphotropic virus type 1: presence of interstitial pneumonia.

RATIONALE AND OBJECTIVES: To evaluate pulmonary findings on computed tomography (CT) scans in carriers of human T-lymphotropic virus type 1 (HTLV-1). MATERIALS AND METHODS: This retrospective study was approved by the Institutional Review Board at each institution, and informed consent was waived. Patients who were diagnosed with adult T-cell lymphoma/leukemia or collagen vascular disease were excluded from the study. Chest CT of 106 HTLV-1 carriers (54 females and 52 males; age range 44-94 years) were initially evaluated by two chest radiologists. Assessed CT findings included centrilobular nodules, thickening of bronchovascular bundles, ground-glass opacity, bronchiectasis, interlobular septal thickening, consolidation, honeycombing, crazy-paving appearance, enlarged lymph nodes, pleural effusion, and pericardial effusion. Three chest radiologists secondarily evaluated the CT scans with the abnormal findings to judge the presence of interstitial pneumonia patterns or a bronchiolitis/bronchitis pattern. RESULTS: Abnormal CT findings were found in 65 (61.3%) patients, including ground-glass opacity (n = 33), bronchiectasis (n = 28), centrilobular nodules (n = 25), and interlobular septal thickening (n = 19). Honeycombing (n = 5) and crazy-paving appearance (n = 3) were also observed. Based on the CT findings, 10 subjects were diagnosed with interstitial pneumonia (usual interstitial pneumonia pattern, n = 3; nonspecific interstitial pneumonia pattern, n = 5; organizing pneumonia pattern, n = 2; respectively). Twenty subjects were diagnosed with the bronchitis/bronchiolitis pattern. CONCLUSION: Although the bronchiolitis/bronchitis pattern is predominant on chest CT in HTLV-1 carriers, the HTLV-1 infection is associated with various interstitial pneumonias.

Scintigraphy and computed tomography findings for the diagnosis of bronchiolitis obliterans following peripheral blood stem cell transplantation.

We report a case of bronchiolitis obliterans (BO) associated with allogenic peripheral blood stem cell transplantation for acute leukemia. On inspiratory and expiratory chest computed tomography (CT), characteristic findings for BO, such as air-trapping, mosaic attenuation or bronchial wall thickening were not clearly observed. However, ventilation-perfusion lung scans of the chest demonstrated multiple matched defects, which suggested severe obstructive airway disease. In the diagnosis of BO after stem cell transplantation, lung scans should be recommended when representative findings are not obvious on chest CT.

Estimation of pulmonary vascular resistance in patients with pulmonary fibrosis by phase-contrast magnetic resonance imaging.

PURPOSE: The aim of this study was to assess pulmonary vascular resistance (PVR) in patients with pulmonary fibrosis (PF) by phase-contrast magnetic resonance imaging (MRI). MATERIALS AND METHODS: Subjects were 11 healthy volunteers and 11 patients with PF. Using phase-contrast MRI, we measured pulmonary arterial blood flow and calculated the parameters of PVR. Parameters were compared between volunteers and patients using unpaired t-tests. The diagnostic capability of the parameters was evaluated by receiver operating characteristic (ROC) curve analysis. Patients underwent respiratory function tests (RFTs) and chest computed tomography (CT), and they were correlated with MRI parameters. RESULTS: Most MRI parameters were significantly different between volunteers and patients (t-test P values were <0.05 in 9 of 10 parameters). Regarding the RFT and CT visual score, only the %DLco/VA and acceleration time and the CT visual score and average flow volume had significant correlation [r = -0.667 (P = 0.024) and r = -0.6 (P = 0.031)], respectively. CONCLUSION: Our findings suggest that PVR derived from phase-contrast MRI is significantly higher in patients with PF than in volunteers. However, all but two of these parameters may not correlate with the severity of PF.

A case of pulmonary and hepatic cystic Echinococcosis of CE1 stage in a healthy Japanese female that was suspected to have been acquired during her stay in the United Kingdom.

We herein report a case of a young Japanese female who was confirmed to have cystic echinococcosis (CE) 1 stage based on the World Health Organization Informal Working Group on Echinococcosis pathological classification of CE, and she was also suspected to be infected with eggs of the G1 Echinococcus granulosus sensu stricto during her stay in the United Kingdom and therefore, suffered from synchronous pulmonary and hepatic CE. Oral albendazole was administered initially, but rupture of a lung hydatid cyst was observed. To avoid additional rupture, we performed two surgeries. CE is very rare in Japan; all CE cases in Japan during the past two decades have been confirmed to be imported, and almost all cases are hepatic CE. This case is the first case report of a Japanese patient who had concomitant giant lung and liver CE with early-stage CE1 and was successfully treated by surgery and pharmacotherapy with a serological follow-up.

[Comparison of pneumonia severity indices between modified A-DROP system and current A-DROP system predicting outcomes for patients hospitalized with community-acquired pneumonia].

BACKGROUND: The A-DROP is a predicting pneumonia severity index which is adopted in the Japanese Respiratory Society (JRS) guidelines. For community-acquired pneumonia, we made a modified A-DROP, adding two new index items to the current A-DROP. Then, we retrospectively compared the modified A-DROP with the current A-DROP regarding 30-day mortality. METHODS AND RESULTS: We analyzed consecutive 227 patients hospitalized with community-acquired pneumonia (mean age 79.0 years). The added index items were respiratory rate > or = 30/min and the presence or absence of underlying diseases. There were 16 fatalities (7.0%). In the extremely severe group, the sensitivities of the 30-day death and odds ratios were 19.9% and 9.5 in the current A-DROP, but 75.0% and 14.1 for the modified A-DROP, respectively. In addition, regarding the receiver-operating characteristic (ROC) area under the curve for the 30-day death ratio, the current A-DROP and modified A-DROP were 0.807 and 0.840, respectively. CONCLUSIONS: The modified A-DROP improved the ability to predict outcomes compared with the current A-DROP.

[A case of Pneumocystis jirovecii pneumonia after kidney transplantation with re-exacerbation following therapy].

A 55-year-old man who had a living kidney transplant 3 months previously was admitted complaining of 4 days of non-productive cough and fever. Because of his low oxygen saturation (SpO2 83% on room air), ground-glass opacities in both lung fields, and marked elevation of beta-D-glucan, a diagnosis of Pneumocystis jirovecii pneumonia (PCP) was considered. The diagnosis of PCP was confirmed by bronchoalveolar lavage. Subsequently, his oxygenation level decreased even after the administration of trimethoprim-sulfamethoxazole, therefore we concurrently administered 60 mg of prednisolone. His clinical symptoms and radiographic findings gradually improved. However, his respiratory condition and radiographic findings exacerbated again after the tapering of prednisolone. His condition improved after the prednisolone dose was returned to 30 mg per day. This case suggested that, in the treatment of PCP in patients without human immunodeficiency virus (HIV) infection, reduction of steroids may cause exacerbation of PCP, similar to immune reconstitution inflammatory syndrome which occurs in HIV patients.

Hepatocyte growth factor levels in Legionella pneumonia: a retrospective study.

BACKGROUND: Hepatocyte growth factor (HGF) is known to be involved in the resolution of pulmonary inflammation and repair of acute lung injury. Legionella pneumonia is sometimes complicated by acute lung injury. Our study aimed to determine the role of serum HGF levels in Legionella pneumonia. METHODS: Sera from patients with Legionella pneumonia (42 cases), other bacterial pneumonia (33 cases), pulmonary tuberculosis (19 cases), and normal controls (29 cases) were collected. The serum HGF levels for each serum sample were determined by sandwich ELISA. Clinical and laboratory data were collected by reviewing the medical charts. RESULTS: Serum HGF levels were higher in patients with Legionella pneumonia than in those with other bacterial pneumonia, pulmonary tuberculosis, and controls. The HGF levels were compared with white blood cell counts, C-reactive protein, Alanine amino-transferase, and lactate dehydrogenase (LDH). The HGF levels were correlated to serum LDH levels. Moreover, serum HGF levels were significantly higher in non-survivors than in survivors. CONCLUSIONS: HGF levels increased in severer pneumonia caused by Legionella, suggesting that HGF might play a significant role in the Legionella pneumonia.

Pneumocystis jirovecii pneumonia and alveolar hemorrhage in a pregnant woman with human T cell lymphotropic virus type-1 infection.

Acute lung injury during pregnancy results in morbidity and mortality in both the mother and the fetus. Pneumocystis jirovecii pneumonia (PCP) is a rare disease but may occur in pregnant immune-suppressed women. Here, we describe a case of acute lung injury due to PCP and alveolar hemorrhage in a pregnant woman who was a human T lymphotropic virus type-1 (HTLV-1) carrier. PCP should be considered in the differential diagnosis of pulmonary complications during pregnancy in HTLV-1 endemic areas.

Organizing pneumonia pattern in the follow-up CT of Legionella-infected patients.

The main aim of this study was to describe the appearance of the CT pattern of organizing pneumonia in Legionella-infected patients. Serial CT scans obtained from five sporadic cases of Legionella pneumophila pneumonia were retrospectively reviewed. The mean time of follow-up was 14 days. Chest CT was analyzed with regard to frequency and appearance of CT patterns of pulmonary abnormalities. Consolidation and ground-glass opacities, with or without an air bronchogram, were the most common abnormalities detected in CT scans during follow-up patients with L. pneumophila pneumonia. Two patterns were observed: subpleural and peribronchovascular. The subpleural pattern was seen in four patients and the peribronchovascular pattern in one. Interlobular septal thickening was seen in one patient. Pleural effusion was seen in one patient. The CT pattern of organizing pneumonia, a subpleural pattern, was frequently observed after treatment of L. pneumophila pneumonia.

[Secondary organizing pneumonia after pneumococcal pneumonia].

A 28-year-old woman was admitted to our hospital complaining of a 7-day chilly sensation with fever. She was given a diagnosis of pneumococcal pneumonia because of infiltration on chest radiography, sputum gram staining and testing positive for a pneumococcal urinary antigen. A 10-day course of antibiotics showed improvements in symptoms and infiltration. However, her X-ray film revealed severe volume loss in the right lung. Organizing pneumonia was diagnosed with lymphocytosis in BALF and Masson bodies upon TBLB examination. Administration of prednisolone obtained rapid improvement of the volume loss. This case was interesting, showing an organizing tendency in the acute-stage pneumococcal pneumonia.

Computed tomographic features of 23 sporadic cases with Legionella pneumophila pneumonia.

OBJECTIVE: To describe the chest computed tomographic (CT) findings of Legionella pneumophila pneumonia. METHODS: CT scans obtained from 23 sporadic cases of L. pneumophila pneumonia were retrospectively reviewed. Chest CT findings were analyzed with regard to the patterns and distributions of pulmonary abnormalities. We also analyzed the histopathology of lungs from guinea pigs with experimentally induced L. pneumophila pneumonia. RESULTS: Consolidation and ground-glass opacity (GGO) were the main findings of CT scans in L. pneumophila pneumonia. The distribution of opacities was categorized as non-segmental (n=20) and segmental (n=4). Non-segmental distribution may follow an onset of segmental distribution. Pleural effusion was observed in 14 (58.3%) patients, of which 13 were accompanied with non-segmental distribution. Abscess formation was observed in only one immunocompromised patient. In the animal pneumonia model, the lesions comprised of terminal bronchioles, alveolar spaces, and interstitia. Small bacilli were observed to be contained by many macrophages within the alveoli. CONCLUSION: Non-segmental distribution was significantly more frequent than segmental distribution in L. pneumophila pneumonia. It is possible that L. pneumophila infection initially results in segmental pneumonia, which progresses to typical non-segmental distribution.

Lung abscess caused by Legionella species: implication of the immune status of hosts.

Legionella pneumonia typically presents as lobar pneumonia with multiple-lobe involvement, but Legionella lung abscess is rare. To identify the predisposing factors for Legionella abscess, we analyzed 62 of the 79 case reports on Legionella abscess found in literature; 28 (45.2%) were of hospital-acquired infection and 28 (45.2%), community-acquired infection. Seventeen patients (27.4%) died. L. pneumophila serogroup 1 was the most common, but other serogroups of L. pneumophila, L. micdadei, L. bozemanii, L. dumoffii, and L. maceachernii were also isolated from the abscess. Corticosteroids were administered for underlying diseases to 43 (69.4%) patients. Peripheral neutrophil counts were higher in patients with abscess than in those with only pulmonary infiltration. In certain cases, Legionella abscess developed during neutropenia recovery. However, lymphocyte counts were low in most cases. Clinical factors like corticosteroid treatment, which causes impaired cellular immunity and subsequent neutrophil accumulation in the lesion, might function as predisposing factors for Legionella abscess.

Active tuberculosis in patients undergoing hemodialysis for end-stage renal disease: a 9-year retrospective analysis in a single center.

OBJECTIVE: Tuberculosis (TB) in patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD) is commonly thought to be associated with a very poor prognosis. Moreover, it is difficult to diagnose. This report was designed to describe this condition and to determine the mortality rate and risk factors associated with mortality. In addition, the study evaluated the usefulness of QuantiFERON TB-2G((R)) (QFT-2G). METHODS: Retrospective study PATIENTS: Patients with confirmed TB admitted between January 2001 and May 2009 were retrospectively identified and enrolled. The clinical, radiological, and bacteriological data at the time of admission were recorded. A multivariate analysis was performed to identify the predictive factors for mortality. RESULTS: A total 19 TB patients (6 females; median age, 73 years) were included. TB occurred in most cases within 1.3 years from the initiation of dialysis. Most patients presented with fever (84.2%) and extrapulmonary TB (57.9%). The mortality rate within 24 weeks of the initiation of TB treatment was 36.8%. The factors associated with mortality were: a short duration of dialysis (HR 8.86, 95% CI 1.03-75.7, p=0.04), and underweight (HR 10.88, 95% CI 1.28-92.6, p=0.02). The sensitivity of QFT-2G, acid-fast smear, and polymerase chain reaction was 50, 80, and 88.2% respectively. CONCLUSION: These data indicate a high incidence of TB in the early stages of HD and a high mortality rate among these patients. The clinical utility of QFT-2G was found to be limited. Hypoalbuminemia might therefore be related to either indeterminate or negative results of QFT-2G.

Malignant epithelioid angiomyolipoma in the kidney and liver of a patient with pulmonary lymphangioleiomyomatosis: lack of response to sirolimus.

A 26-year-old woman with lymphangioleiomyomatosis (LAM) was hospitalized for the surgical excision of a giant abdominal tumor of right kidney origin. The pathological diagnosis of the tumor was conventional angiomyolipoma (AML). After 8 months, 2 liver tumors appeared and grew rapidly. The tumors were resected, and the pathological finding of these tumors was epithelioid AML. Thereafter, metastatic multiple lung tumors appeared, and there was local recurrence of the liver tumors. Sirolimus, an mTOR protein inhibitor, was used to treat epithelioid AML. However, the drug did not inhibit the rapid growth of the tumor at all. This finding suggests that sirolimus might not be effective against epithelioid AML, and in such cases, complete surgical resection should be the treatment of choice.