[A Case of Pulmonary Carcinoid That Has Regressed Spontaneously].

A 65-year-old woman who had diabetes mellitus was referred to the Department of Diabetes Internal Medicine of our hospital in June 201X due to disease progression. Chest radiography revealed an abnormal shadow, and computed tomography( CT)showed a 2 cm nodular shadow in the right S10. Lung cancer was suspected because of increased serum progastrin- releasing peptide(ProGRP)level and smoking history. She was referred to our department and was diagnosed with carcinoid on transbronchial biopsy. After 1 month, CT demonstrated regression of the carcinoid and improved serum ProGRP level. After more than 1 month, the carcinoid size did not change, and serum ProGRP level slightly increased. We expected that it would be difficult for the carcinoid to regress. After glycemic control was improved, the patient underwent right lower lobectomy via video-assisted thoracoscopy. In the resected specimen, the border of carcinoid was clear. She was diagnosed with a typical carcinoid. The carcinoid was not accompanied by inflammation or necrotic tissue. A carcinoid is a low-grade malignant tumor and does not usually regress spontaneously. However, in this case, it regressed spontaneously.

Fulminant fatal bacteremic pneumonia due to Aeromonas hydrophila in a non-immunocompromised woman.

A 75-year-old woman became ill suddenly with pneumonia two weeks after operation for colon cancer. Despite intensive support measures in the intensive care unit she died six hours after admission and 12 hours after her first symptom. Autopsy showed necrotizing pneumonia. Aeromonas hydrophila was isolated from a blood culture taken at admission and from the lung at autopsy. In patients who develop a fulminant disease of pneumonia, particularly those who have underlying medical conditions, Aeromonas hydrophila infection, though rare, should be considered.

The use of non-invasive ventilation for life-threatening asthma attacks: Changes in the need for intubation.

BACKGROUND AND OBJECTIVE: Although non-invasive ventilation (NIV) has been shown to be effective in a wide variety of respiratory diseases, its role in severe asthma attacks remains uncertain. The aim of this study was to clarify the effectiveness of NIV in patients experiencing severe attacks of asthma. METHODS: A retrospective cohort study was performed, comparing the periods November 1999-October 2003 (pre-introduction of NIV) and November 2004-October 2008 (post-introduction of NIV). The data and clinical outcomes for patients who experienced severe attacks of asthma, and who fulfilled the inclusion criteria, were retrieved and compared. RESULTS: Fifty events (48 patients) from the pre-NIV period and 57 events (54 patients) from the post-NIV period, which required hospitalization, were included in the analysis. Nine of the 50 pre-NIV events (mean PaO(2)/fraction of inspired O(2) (FiO(2)) 241 +/- 161; PaCO(2) 79 +/- 40) were treated primarily by endotracheal intubation (ETI), while 17 of the 57 post-NIV events (PaO(2)/FiO(2) 197 +/- 132, P = 0.39; PaCO(2) 77 +/- 30, P = 0.95) were treated primarily by NIV. The rate of ETI decreased in the post-NIV period (2/57 (3.5%) vs 9/50 (18%), P = 0.01). NIV was started earlier than mechanical ventilation (MV) with ETI (mean time interval between arrival and start of MV 171.7 +/- 217.9 min vs 38.5 +/- 113.8 min for NIV, P < 0.05). In the post-NIV cohort, there was a trend towards a reduction in the duration of MV with ETI or NIV (36.9 +/- 38.4 h vs 20.3 +/- 35.8 h, P = 0.09), and hospital stay was shortened (12.6 +/- 4.2 vs 8.4 +/- 2.8 days, P < 0.01). No deaths occurred during this period as a consequence of asthma attacks. CONCLUSIONS: The need for ETI in patients with severe attacks of asthma was decreased after introduction of NIV. The ready availability of NIV enabled the rapid commencement of MV and may decrease the need for ETI. NIV is an acceptable and useful method of stabilizing patients experiencing severe attacks of asthma.

[A case of cavitating pneumococcal pneumonia developed during the treatment with etanercept for rheumatoid arthritis].

A 54-year-old woman who had been treated for rheumatoid arthritis (RA) with the anti-TNF-alpha drug, etanercept, was referred to our department on 27 April 2006 because of dyspnea and shock. Chest X-ray and computed tomography on admission indicated bilateral pneumonia which was proved to be caused by Streptococcus pneumoniae with positive blood culture results. The patient had recovered from multiple organ failure with intensive treatments such as NIPPV and cardiovascular support with cathecolamines, however, the left upper lobe of her lung had developed a large cavity that had been producing viable pneumococci on sputum culture for more than one month. As the development of lung necrosis and subsequent formation of a cavity is rare in patients with pneumococcal pneumonia, this case should be noted in terms of the relevance of both the fulminating pathogenecity of Streptococcus pneumoniae and the anti TNF-alpha drug treatment.

[An autopsy case of racemose hemangioma of bronchial arteries associated with neovascularization from the chest wall after ligation and frequent embolizations].

We report an autopsied 33 year old pregnant woman with racemose hemangioma of the bronchial arteries. She was first given a diagnosis of racemose hemangioma of the bronchial arteries at age 19 and underwent surgical ligation. Nevertheless, she had to be admitted to the hospital for bronchial artery embolizations every time hemoptysis recurred. In her 21st gestational week, she was admitted to our hospital because of her 9th recurrent massive hemoptysis and dyspnea. Bronchial artery embolizations were repeatedly performed under intubation to ventilate the healthy left lung separately. We succeeded in temporarily stopping the hemoptysis, but her case was complicated by bacterial pneumonia and septic shock. Her baby was born dead on day 11 and she died on day 12. The autopsy revealed abnormal convoluted and dilated arteries branching from the right intercostal and subclavian arteries and intruding into the lung parenchyma through adhesion caused by her previous thoracostomy. The connections of these abnormal arteries with pulmonary arteries and veins, which had been shown by angiography, were confirmed by autopsy. The autopsy findings suggest that temporal surgical procedures with thoracostomy in this condition can induce abnormal neovascularization via pleural adhesion.

Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU.

BACKGROUND: Trial of noninvasive ventilation (NIV) in the emergency department (ED) for heterogeneous acute respiratory failure (ARF) has been optional and its clinical benefit unclear. METHODS: We conducted a retrospective cohort study comparing between two periods, October 2001-September 2003 and October 2004-September 2006, i.e., before and after adopting an NIV-trial strategy in which NIV was applied in the ED to any noncontraindicated ARF patients needing ventilatory support and was then continued in the intermediate-care-unit. During these two periods, we retrieved cases of ARF treated either invasively or with NIV, and compared the patients' in-hospital mortalities and the length of ICU and intermediate-care-unit stay. RESULTS: Compared were 73 (invasive 56, NIV 17) and 125 cases (invasive 31, NIV 94) retrieved from 271 and 415 emergent admissions with proper pulmonary etiologies for mechanical ventilation, respectively. Of their respiratory failures, type (hypercapnic/non-hypercapnic, 0.97 vs. 0.98) and severity (pH 7.23 vs. 7.21 for hypercapnic; PaO(2)/FiO(2) 133 vs. 137 for non-hypercapnic) were similar, and the rate of predisposing etiologies was not significantly different. However, excluding those with recurrent aspiration pneumonia for whom NIV was mostly used as "ceiling" treatment, significant reductions in both overall in-hospital mortality (38%-19%, risk ratio 0.51, 95% CI 0.31-0.84), and median length of ICU and intermediate-care-unit stay (12 vs. 5 days, P<0.0001) were found. CONCLUSIONS: NIV-trial in the ED for all possible patients with ARF of pulmonary etiologies, excluding those with recurrent aspiration pneumonia, may reduce overall in-hospital mortality and ICU stays.

[Legionella longbeachae pneumonia infection from home garden soil].

A 72-year-old critically ill and intubated man was transferred to our hospital, because of worsening pneumonia unresponsive to Cefazolin and Meropenem, from the hospital where he had been admitted 8 days before to start maintenance hemodialysis for chronic renal failure but had fever from admission. In a few days his critical condition rapidly subsided with the initiation of Ciprofloxacin and his sputum culture on GVPC medium indicated Legionellosis, which was afterwards identified as L. longbeachae by PCR and DNA-DNA hybridization. After recovery he said that he had been fond of gardening and had been gardening immediately before the initial admission. Moreover, several reports from Australia suggested inhalation of aerosolized potting soil as the route of L. longbeacachae infection; therefore, we examined the soil of his home garden and identified it. Thus, we present this case as the first of L. longbeachae pneumonia in Japan, proved to be infected via inhalation of aerosolized home garden soil.