Swyer-James Macleod Syndrome With Progressive Hyperinflation.

Swyer-James Macleod syndrome (SJMS) is a rare disorder characterized by unilateral lung or lobar hyperlucency on chest radiographs. We present a case of SJMS with progressive enlargement of the bulla. A lobectomy was performed because the bulla in the right middle lobe had enlarged and compressed the upper and lower lobes, resulting in severe dyspnea. This treatment improved severe dyspnea and pulmonary function. Surgical resection is a viable option for SJCM patients experiencing short-term progression.

[Fourteen Cases of Implanted Central Venous Access Port-Related Bloodstream Infection].

We conducted a clinical study involving cases of central venous(CV)port-related infection in Tokyo Rosai Hospital. Fourteen patients with suspected CV port-related infection at Tokyo Rosai Hospital between April 2015 and January 2017 were observed. Identical bacterial types were detected from 2 sets of blood cultures and cultures from the catheter tip, and a definitive diagnosis was made. Data on patient background, causative bacteria, quick sequentialorgan failure assessment (qSOFA)score, CV port placement period, presence or absence of local inflammatory findings, and prognosis were analysed. The causative bacteria were coagulase-negative Staphylococcus(CNS)in 7 cases(50%), Staphylococcus aureus in 3(21%), and Candida in 4(29%). Most CNS-infected cases(71%)exhibited a qSOFA score of 1 or less at the examination time, which indicated that even if bacteremia occurred in CNS cases, organopathy might not occur easily. Local inflammatory findings were found in only 3 CNS cases. Cases without local inflammatory findings showed methicillin-resistant Staphylococcus aureus(MRSA)(18%)or Candida(36%)at high proportions, indicating that treatments might be difficult.

Non-contact diagnostic system for sleep apnea-hypopnea syndrome based on amplitude and phase analysis of thoracic and abdominal Doppler radars.

Full-night polysomnography (PSG) has been recognized as the gold standard test for sleep apnea-hypopnea syndrome (SAHS). However, PSG examinees are physically restrained for the full night by many contact sensors and obtrusive connecting cables, inducing mental stress. We developed a non-contact SAHS diagnostic system that can detect apneic events without inducing stress in monitored individuals. Two Doppler radars were installed beneath the mattress to measure the vibrations of the chest and abdomen, respectively. Our system determines apnea and hypopnea events when the radar output amplitude decreases by <20 and 70 %, respectively, of the amplitude of a normal breath (without SAHS events). Additionally, we proposed a technique that detects paradoxical movements by focusing on phase differences between thoracic and abdominal movements, and were able to identify three types of sleep apnea: obstructive, central, and mixed. Respiratory disturbance indexes obtained showed a higher correlation (r = 94 %) with PSG than with pulse oximetry (r = 89 %). When predicting the severity of SAHS with an apnea-hypopnea index (AHI) of >15/h or >30/h using PSG as a reference, the radar system achieved a sensitivity of 96 and 90 %, and a specificity of 100 and 79 % with an AHI of >15/h and >30/h, respectively. The proposed radar system can be used as an alternative to the current airflow sensor, and to chest and abdomen belts for apnea-hypopnea evaluation.

[A Case of Brain Abscess Caused by Nocardia farcinica in which the Test Results for Drug Susceptibility Conflicted with the Actual Clinical Course].

Sulfamethoxazloe-trimethoprim is one of the most frequently used antibiotics in the treatment of Nocardia infection. However, in vitro studies have shown an increase in sulfonamide resistance among Nocardia species. Here, we present a case with a brain abscess caused by Nocardia farcinica in which the test results for drug susceptibility to sulfonamide conflicted with the actual clinical course. A 74-year-old woman with autoimmune hepatitis who has being treated with oral prednisolone (16 mg/day) was admitted because of headaches and fever. A CT scan and MRI revealed a brain abscess that had ruptured into the lateral ventricle. She was empirically treated with antibiotics, but her condition did not resolve. Therefore, the abscess was drained surgically. Gram and Kinyoun stains for pus revealed a modified acid-fast branching filamentous bacterium consistent with Nocardia species. The pathogen was identified as Nocardia farcinica based on its 16S rRNA sequence. Consequently, the patient was treated with sulfamethoxazole -trimethoprim and amikacin. However, susceptibility testing (broth microdilution method) showed that the strain was completely resistant to sulfamethoxazole-trimethoprim. We therefore changed the therapeutic regimen to imipenem-cilastatin and amikacin, but her symptoms worsened and the treatment was thought to have failed. She was then re-treated with sulfamethoxazole- trimethoprim, and her symptoms resolved. Some reports have suggested that interpreting the results of Nocardia susceptibility testing may be difficult especially the susceptibility of Nocardia to sulfamethoxazole-trimethoprim. The present case suggests a confliction between susceptibility testing and the clinical course of a patient with Nocardia infection.

Wandering pneumonia caused by dabigatran.

We herein describe the case of a 74-year-old man who experienced pulmonary consolidation and chest pain following administration of dabigatran, a novel oral anticoagulant. The consolidation settled spontaneously in another lung area, a condition sometimes referred to as "wandering pneumonia." Although we did not find specific pathological evidence of interstitial lung disease on transbronchial lung biopsy, a lung opacity spontaneously disappeared following discontinuance of dabigatran, and there was no recurrence. There are no other reports of dabigatran-induced lung injury, except alveolar hemorrhage and eosinophilic pneumonia. We should consider that any novel drug could cause various types of pulmonary injuries.

Noncontact screening system with two microwave radars for the diagnosis of sleep apnea-hypopnea syndrome.

There were two key problems in applying Doppler radar to a diagnosis system for sleep apnea-hypopnea syndrome. The first is noise associated with body movements and the second is the body positions in bed and the changes of the sleeping posture. We focused on the changes of the amplitude of the radar output signal corresponding to the changes in the tidal volume, and proposed a method of detecting the change of the respiratory amplitude value without the influence of body position in bed. In addition, we challenged the detection of the apnea-hypopnea event confirmed by accompanied rise of heart rates. To increase the accuracy of heart rate measurement, we propose a new automatic gain control and a real-time radar-output channel selection method based on a spectrum shape analysis. A prototype of the system was set up at a sleep disorder center in a hospital and field tests were carried out with eight subjects. Despite the subjects engaging in frequent body movements while sleeping, the system was quite effective in the diagnosis of sleep apnea-hypopnea syndrome (the correlation coefficient r = 0.98).

Non-contact screening system with two microwave radars in the diagnosis of sleep apnea-hypopnea syndrome.

There are two key problems in applying Doppler radar to a diagnosis system for sleep apnea-hypopnea syndrome. The first is noise associated with body movement and the second is the body position in bed and the change of the sleeping posture. We propose a new automatic gain control and a real-time radar-output channel selection method which is based on a spectrum shape analysis. There are three types of sleep apnea: central sleep apnea, obstructive sleep apnea and mixed sleep apnea. In this paper we paid attention to the obstructive sleep apnea and attempted to detect the disorder of corrugated shape compared with usual breathing or the paradoxical movement of the reversed phase with chest and abdominal radar signals. A prototype of the system was set up at a sleep disorder center in a hospital and field tests were carried out with eight subjects. Despite the subjects engaging in frequent body movements while sleeping, the system was quite effective in the diagnosis of sleep apnea-hypopnea syndrome (r=0.98).

[A case of Wegener granulomatosis after treatment for non-tuberculous mycobacteriosis].

A 67-year-old woman with a history of non-tuberculous mycobacteriosis due to Mycobacterium avium in 2002 and 2006 was admitted because of low-grade fever and cavitary lesions in both lungs on chest computed tomography (CT). Bronchial brushing cytology by bronchoscopy did not yield mycobacterium. Her serum antineutrophil cytoplasmic antibodies (MPO-ANCA) level was elevated and PR3 ANCA was negative. A surgical lung biopsy revealed basophilic necrosis with cavitary lesions and necrotizing vasculitis compatible with Wegener granulomatosis (WG). In the resected specimen, several hyalinizing nodules with caseous necrosis, probably associated with previous mycobacterium infection, were also seen. Because her disease was limited to the lungs, we successfully treated her with corticosteroids and methotrexate. WG is considered to be a type of ANCA-associated vasculitis, and microbial infections have been associated with initiation and relapse of WG. This case clearly demonstrated that lesions of WG occurred after mycobacterial infection in the lung. We believe that this case was ANCA production in association with bacterial infection.

[Sputum smear-positive tuberculosis diagnosed after hospitalization].

A tuberculosis infection-control program is based on a 3-level hierarchy of measures, including administrative, environmental, and respiratory protection. The most important level of tuberculosis controls is the use of administrative measures to reduce the risk of exposure to patients who might have infectious tuberculosis. In 126 patients tuberculosis was given diagnosed in our hospital over 10 years, and 51 patients among them had bacilli-positive sputum smears, of whom 26 were given diagnoses after admission, and 15 patients of these, in whom tuberculosis was not strongly suspected on admission, were considered to be at risk of nosocomial infection. The mean age of these 15 patients was 66.3 years, and 9 of them were given diagnoses of pneumonia. Duration until tuberculosis diagnosis was within 3 days in 11 patients, 4 to 7 days in 2, and more than 8 days in 2 patients. Twelve patients were admitted from the emergency room or belonged to other departments than respiratory medicine. We believe that it is important to consider tuberculosis when deciding about admission, in order not to delay diagnosis. Furthermore, ventilation of general rooms must be sufficient when dealing with the unexpected admission of patients with tuberculosis, and ability of health-care workers to use N95 respirators should be confirmed.

[Patient with MPO-ANCA-associated disease with interstitial pneumonia and lower cranial nerves palsy who was previously exposed to asbestos].

A 65-year-old man who was occupationally exposed to asbestos for 40 years was admitted to our hospital with fever and cough. Chest CT revealed paraseptal emphysema, subpleural fibrosis in both lungs, and pleural plaques. On bronchoalveolar lavage fluid contained elevated levels of lymphocytes and neutrophils (15% and 17%, respectively), and asbestos bodies were also found. Because serum MPO-ANCA titer was elevated to 188 EU, we suspected ANCA-associated disease with interstitial pneumonia. Prednisolone was begun at 30 mg/day and his lung opacities partially disappeared. Six weeks later, he complained of headache, dysphagia and hoarseness, and was admitted to the neurology department of the hospital. Under a diagnosis of either hypertrophic pachymeningitis or neuritis due to angiitis of the lower cranial nerves, steroid pulse therapy was performed. Asbestos exposure may have been a contributing factor for ANCA generation in this case. Furthermore, the fact that cranial nerves palsy occurred in spite of steroid therapy may also be important.

Pulmonary tuberculosis accompanied by a transient increase in serum carcinoembryonic antigen level with tuberculous empyema drainage.

We present a case of pleural effusion with encapsulation that was observed in the right thorax of a patient. PCR analysis of the patient's pleural effusion showed positivity for Mycobacterium tuberculosis. After six months, his chest CT showed the development of niveau and pulmonary consolidation. We definitively diagnosed him as having chronic pulmonary tuberculosis with tuberculous empyema drainage. At the time of his hospital admission, his serum carcinoembryonic antigen (CEA) level was elevated. After we started treatment using antituberculosis drugs, the infiltration shadow in his lung fields disappeared, and the serum CEA level decreased. The results suggest that the serum CEA level reflects the extent of the development of pulmonary tuberculosis lesions.

[A male case of acute sarcoidosis with fever, polyarthralgia, erythema nodosum, and bilateral hilar lymphadenopathy: Löfgren's syndrome].

A 27-year-old man initially had low back pain and ankle arthralgia. He was admitted because fever, cough, and polyarthralgia developed and continued for three months. Chest X-ray and CT revealed bilateral hilar and mediastinal lymphadenopathy with pulmonary lesions. Furthermore, elevated serum-ACE level and noncaseating epitheloid cell granuloma obtained by TBLB confirmed the diagnosis of sarcoidosis. After hospitalization, erythema nodosum appeared and ocular involvement was demonstrated. As a result, this case fulfilled the criteria of Löfgren's syndrome (arthritis, erythema nodosum, and BHL). Löfgren's syndrome is not uncommon in European countries, but is extremely rare in Japan. So far, only six cases with Löfgren's syndrome were reported in Japan, and all were female cases. This is the first male case in Japan. Löfgren's syndrome is usually a self-limiting disease. We used steroids for this case and remission has been maintained after the beginning of the treatment for the past one year.

[A case of pulmonary low-grade B cell lymphoma (MALT type) presenting seven years after gastric lymphoma resection].

A 71-year-old man was admitted to our hospital because of systemic edema and exertional dyspnea. Chest radiographs revealed infiltrative shadows in both lung fields, pleural effusion, and pericardial effusion. Seven years before, he had undergone gastric surgery for a gastric ulcer with lymphoid hyperplasia. In the pathologic diagnosis based on the percutaneous lung biopsy, hyalinizing granuloma was suspected. For a more thorough diagnosis, the patient was subjected to an open lung biopsy, and the final diagnosis was low-grade B-cell lymphoma of the MALT (mucosa-associated lymphoid tissue) type. Gallium scintigraphy showed accentuated accumulation in the left neck and hypothyroidism was present. Histologic re-examination of the resected stomach revealed infiltration of centrocyte-like cells and lymphoepithelial lesions, compatible with the pathologic features of MALT lymphoma. We considered that the gastric neoplasm and the pulmonary, pleural, and thyroid tumors of MALT lymphoma had occurred seven years apart in this case. Thyroid hormone replacement and CHOP therapy improved the symptoms and decreased the lung tumor size by 73%. MALT lymphomas tend to remain localized for a long period. The multiorgan involvement seen in this case is rather rare.