Radiographic features of Mycoplasma pneumoniae pneumonia: differential diagnosis and performance timing.

BACKGROUND: The Japanese Respiratory Society guidelines propose a differential diagnosis for atypical pneumonia and bacterial pneumonia using a scoring system for the selection of appropriate antibiotic. In order to improve this scoring system, the guidelines are seeking new specific parameter. The purpose of this study was to clarify the pattern of abnormalities with Mycoplasma pneumoniae pneumonia on chest computed tomography (CT) and whether the radiographic findings could distinguish M. pneumoniae pneumonia from Streptococcus pneumoniae pneumonia. METHODS: A retrospective review was performed of the CT findings of 64 cases and 68 cases where M. pneumoniae and S. pneumoniae, respectively, were the only pathogen identified by the panel of diagnostic tests used. RESULTS: Of the 64 patients with M. pneumoniae pneumonia, bronchial wall thickening was observed most frequently (81%), followed by centrilobular nodules (78%), ground-glass attenuation (78%), and consolidation (61%). Bronchial wall thickening and centrilobular nodules were observed more often in M. pneumoniae patients than in S. pneumoniae patients (p < 0.0001). The presence of bilateral bronchial wall thickening or centrilobular nodules was only seen in patients with M. pneumoniae pneumonia. Using the scoring system of the Japanese Respiratory Society guidelines and chest CT findings, 97% of M. pneumoniae patients were suspected to be M. pneumoniae pneumonia without serology. When comparing the CT findings between early stage and progressed stage in the same patients with severe pneumonia, the radiographic features of early stage M. pneumoniae pneumonia were not observed clearly in the progressed stage. CONCLUSION: The present results indicate that the diagnosis of M. pneumoniae pneumonia would appear to be reliable when found with a combination of bronchial wall thickening and centrilobular nodules in the CT findings. However, these CT findings are not observed in progressed severe M. pneumoniae pneumonia patients.

Clinical evaluation of the T-SPOT.TB test for patients with indeterminate results on the QuantiFERON TB-2G test.

OBJECTIVE: To evaluate the clinical utility of the T-SPOT.TB test for patients with indeterminate results on the QFT-2G test. MATERIALS AND METHODS: Forty patients (10.6%) showed indeterminate results among 378 patients who underwent QFT-2G test because active TB disease was clinically suspected. T-SPOT.TB test was performed for these 40 patients before the initiation of antituberculous treatment. RESULTS: Forty patients (10.6%) were judged as showing indeterminate results on QFT-2G test because the positive control presented a lower IFN-gamma level. Elderly patients (68.2 versus 57.7) or immunocompromised patients receiving immunosuppressive treatments and patients with a decrease in lymphocyte count, serum protein and albumin were more frequently recognized in the patients with indeterminate results compared to those with determinate results on QFT-2G test. T-SPOT.TB test could clearly demonstrate the results in 26 of the 40 patients (65.0%) with indeterminate results of QFT-2G test; these were divided into six patients with positive results and 20 with negative results of T-SPOT.TB test. Elderly patients (73.5 versus 64.3) or patients with underlying diseases such as malignant disease and those receiving immunosuppressive treatment and patients with hyponutritional conditions were more frequently recognized in the patients with indeterminate results compared to patients with determinate results on both tests. CONCLUSION: We think it may be necessary to introduce T-SPOT.TB test to increase the diagnostic rate of TB disease including latent tuberculosis infection because indeterminate results of QFT-2G test might be further decreased using T-SPOT.TB test. Although 14 patients showed indeterminate results on both tests, the lymphocytes of these patients may not possess functional cytokine production activity.

Long-term follow-up of the QuantiFERON TB-2G test for active tuberculosis disease.

OBJECTIVE: To evaluate transitional changes in QuantiFERON TB-2G (QFT-2G) test results in the serial testing on the same patients and to reevaluate the optimal threshold of positive response of QFT-2G test as a cure of TB infection. METHODS: We prospectively investigated transitional changes of QFT-2G test results in 22 patients with active tuberculosis (TB) over three years after the initiation of treatment with antituberculosis drugs. Treatment using antituberculosis drugs was performed for six months in all patients. RESULTS: The positive rate of QFT-2G test results decreased 50% at the treatment completion. Thereafter, although the positive rate of QFT-2G test results has been decreased 45% six months later even if treatment was finished, it decreased slightly to 41% two years later and 36% three years later. If the cut-off value was situated below 50% (IFN-gamma level three years later/ IFN-gamma level of baseline peak value), we could judge the conversion of QFT-2G test in most cases except for two cases three years after the initiation of antituberculosis treatment through this study. CONCLUSION: It may be difficult to monitor markers in the cure of TB infection using QFT-2G tests. The cut-off level for a positive response on QFT-2G test may need to be reconsidered when the test is used to monitor the response of active TB to therapy.

Clinicopathological analysis of multifocal micronodular pneumocyte hyperplasia associated with tuberous sclerosis in Japan.

BACKGROUND AND OBJECTIVE: This study investigated the clinical and pathological findings of lung disease in tuberous sclerosis complex (TSC) as previously reported in Japan. METHODS: The clinical and pathological findings in 15 patients diagnosed as having multifocal micronodular pneumocyte hyperplasia (MMPH) with TSC were analysed. RESULTS: The majority of patients (80%) were women and the mean age was 37 years. Three patients had a family history of TSC. The radiological findings were small multiple nodular shadows with ground-glass opacity randomly distributed in the bilateral whole-lung fields in most patients. Differentiation from multiple atypical adenomatous hyperplasia or metastatic lung cancer was necessary in most patients. In 11 patients, the diagnostic method used to identify pulmonary lesions of MMPH with TSC was VAT. Among the complications of MMPH with TSC, lymphangioleiomyomatosis was recognized in 53% of patients. The prognosis was comparatively good because only one patient died of respiratory failure. The histological findings were papillary or tubular proliferation of type II pneumocytes without nuclear atypia lining the thickened alveolar septa and lymphocyte infiltration. Immunohistochemical staining for cytokeratin, and surfactant proteins A and B was positive in alveolar lining cells of all MMPH lesions. However, staining for HMB-45, alpha-smooth muscle actin, p53, carcinoembryonic antigen and hormonal receptor was negative in most patients. CONCLUSIONS: Surgical investigation and immunohistochemical staining for pathological markers are useful for diagnosing MMPH when the radiological findings indicate multiple micronodules with ground-glass opacity in patients with TSC.

An asymptomatic case of pulmonary cryptococcosis with endobronchial polypoid lesions and bilateral infiltrative shadow.

A case of pulmonary cryptococcosis with focal endobronchial polypoid lesions is described. A 64-year-old woman consulted our hospital for further evaluation of an abnormal shadow on a chest radiograph. She had been prescribed corticosteroid for rheumatoid arthritis. Chest radiographs revealed an infiltrative shadow in the right lower and left middle and lower lung fields, and chest computed tomography (CT) revealed bilateral airspace consolidations and multiple nodules. A bronchoscopic finding revealed white polypoid lesions at the orifice of the posterior basal bronchus in the left lower lobe. Histopathological examination of transbronchial biopsy specimens demonstrated cryptococcal organisms. After fluconazole therapy for 4 months, the infiltrate had decreased in size and the bronchial polypoid lesions had disappeared.

[Asthma control test (ACT) faultiness and the remediation by peak flow (PEF) measurement at outpatient department].

BACKGROUND: To grasp the asthma patients' control level, an asthma control test (ACT), an easy questionnaire, is getting to be used as the alternative method of asthma diary recording. ACT is based on the patient's 4-week memory and the accuracy is not confirmed thoroughly METHODS: Two hundred and eighty three visits of 88 asthmatics (male 29, female 59) were subjected. The accuracy of ACT to detect "truly good control" was analyzed by comparing with the asthma diary (symptoms and PEF were recorded). RESULTS: Sensitivities, specificities (chi square values) for extraction of truly good control were 0.88, 0.42 (23.7) by the threshold of ACT > or =23, 0.77, 0.51 (18.1) by ACT > or =24, and 0.54, 0.69 (12.9) by ACT=25, significantly (p<0.001, respectively). When PEF% predicted > or =80% was added as the second factor, the chi square values improved to 29.9 by ACT > or =23 and to 30.3 by ACT > or =24 significantly (p<0.001, respectively). CONCLUSION: Addition of PEF measurement on visit on ACT may help understanding the asthmatic patient condition.

Multifocal micronodular pneumocyte hyperplasia associated with tuberous sclerosis: differentiation from multiple atypical adenomatous hyperplasia.

We report a peculiar case of multifocal micronodular pneumocyte hyperplasia (MMPH) in a 54-year-old woman with tuberous sclerosis complex (TSC) diagnosed during antituberculous treatment. Findings were initially detected by chest computed tomography (CT) to check for complication of pulmonary tuberculosis. Chest CT demonstrated multiple small nodules with ground-glass opacity, measuring up to 5 mm diameter, presenting in the bilateral lung fields, without cystic change. Because the differentiation from multiple atypical adenomatous hyperplasia (AAH) was necessary, we finally performed a diagnosis of MMPH based on specimens obtained by video-assisted thoracoscopic surgery. Histologically, type II pneumocytes without nuclear atypia lined the thickened alveolar septa and proliferated papillary structures. There was no proliferation of immature smooth muscle cells suggestive of lymphangioleiomyomatosis. Although immunohistochemical stains for cytokeratin and surfactant apoprotein A and B were positive for alveolar lining cells in each MMPH lesion, those for HMB-45, alpha-smooth muscle actin, p53 and carcinoembryonic antigen were negative. We must consider MMPH as part of the differential diagnosis along with multiple AAH when multiple small nodules with ground-glass opacity were observed on chest CT in patients with TSC.