[Case of tuberculous pleurisy distinguished from pleurisy caused by Mycoplasma infection].

We report a case of tuberculous pleurisy that required differentiation from pleurisy caused by Mycoplasma infection. A 28-year-old woman presented to a clinic with fever and pain on the left side of her chest. A chest radiograph revealed pleural effusion in the left thorax, and the condition was diagnosed as bacterial pleurisy. The patient was referred to our hospital because of an increase in the pleural effusion despite antibiotic treatment. Mycoplasma infection was suspected because the patient was young, the white blood cell count was not elevated, and the result of the ImmunoCard Mycoplasma test (IC) for Mycoplasma pneumoniae-specific IgM antibodies was positive. However, the fever persisted even after treatment with azithromycin and pazufloxacin. The left pleural effusion was exudative, with lymphocytosis and high adenosine deaminase (ADA) levels. The results of the QuantiFERON test were positive. Therefore, tuberculous pleurisy was diagnosed, and the effusion subsided after treatment with standard anti-tuberculosis chemotherapy. Although detection of Mycoplasma infection using the IC is rapid and simple, the accuracy of this test is poor. The patient was first diagnosed with pleurisy of Mycoplasma origin because of a single high-particle agglutination titer of 1: 320 and because of the presence of exudative pleural effusion with lymphocytosis and elevated ADA levels, which has been reported in patients with Mycoplasma infection. The results of the IC test and the ADA level of the pleural effusion might not be reliable when distinguishing between tuberculous pleurisy and pleurisy caused by Mycoplasma infection.

[An elderly case of anomalous systemic arterial supply to the normal basal segment of the left lower lobe and summary of reports of the disease in Japan].

A 69-year-old asymptomatic woman was admitted because of an abnormal chest shadow. Chest X-ray films showed a tumorous shadow behind the heart. Chest CT scans showed an aberrant artery branching from the thoracic aorta and supplying the left basal segment, but the bronchial tree was normal. The left lung vein was normal but wide, and the left lower pulmonary artery could not be observed. Based on these findings, we diagnosed anomalous systemic arterial supply to the normal basal segment of the left lower lobe. Because this patient had a high risk of heart failure and pulmonary hypertension, we decided to perform a left lower lobectomy, but she refused the operation. As this disease is generally found in younger patients, diagnosis in older age, as in the present case, is rare. In this report we also summarize 39 other reports of this disease in Japan.

Prominent isovolumic relaxation flow in a patient with cardiac tamponade.

We present herein the case of a 72-year-old man who presented with orthopnea and was diagnosed with cardiac tamponade due to carcinomatous pericarditis. Pulsed Doppler echocardiogram showed prominent isovolumic relaxation flow (IVRF) directed from the cardiac base toward the apex. Such flow is rare in pericardial effusion and may be due to enhanced early diastolic untwisting, sphericalization of apex, and restriction of wall motion by epicardial fibrous tissue. We describe herein a rare case of prominent IVRF with interesting underlying mechanisms.

Triphasic mitral inflow in acute coronary syndrome: A case study.

An 86-year-old woman was referred to our hospital for the management of rapid onset of chest pain. Blood analysis showed increased levels of cardiac enzymes and B-type natriuretic peptide. An electrocardiogram showed poor R wave in precordial leads and a QS wave in lead V4. A chest roentgenogram showed mild pulmonary congestion. An echocardiogram showed hypokinesis of the broad anterior wall of the left ventricle (LV). A pulsed Doppler echocardiogram of mitral inflow revealed an abnormal relaxation pattern. After increasing the preload by leg elevation, an intermittent triphasic mitral inflow pattern emerged. The patient underwent emergent cardiac catheterization for acute coronary syndrome (ACS). A pressure study after leg elevation disclosed an elevation in LV diastolic pressure and a "dip-up-down pattern." The patient underwent percutaneous coronary intervention of the left anterior descending artery. This case showed that a triphasic mitral inflow pattern is observed not only in hypertrophic diastolic heart failure but also in ACS. The triphasic pattern may be observed in the case of low LV distensibility and markedly increased preload. This is the first case report describing triphasic mitral inflow in ACS and demonstrating the pathophysiology of a triphasic mitral inflow pattern.

[A case of pulmonary nontuberculous mycobacteriosis aggravated during treatment with etanercept for rheumatoid arthritis].

A 81-year-old woman with rheumatoid arthritis (RA) was admitted to our hospital because of a productive cough and bloody sputum. She had been treated with etanercept, a tumor necrosis factor (TNF) antagonist, for 9 months before admission. A chest CT scan on admission showed small nodules, bronchiectasis and consolidations in bilateral lung fields. A diagnosis of pulmonary nontuberculous mycobacteriosis (NTM) was established by positive cultures for Micobacterium intracellulare both in her sputum and bronchial secretions obtained by bronchoscopy. It has been reported that bacterial pneumonia, tuberculosis (TB) and pneumocystis pneumonia (PCP) occur during treatment with etanercept or infliximab. However, there were few reports of NTM in post-marketing surveys of etanercept or infliximab in Japan. As pulmonary is NTM related to treatment with etanercept or infliximab and may progress rapidly with few drugs effective against NTM, we should be aware of pulmonary NTM as well as TB and PCP in the treatment of RA with etanercept or infliximab.