[A CASE OF EOSINOPHILIC GRANULOMATOUS WITH POLYANGIITIS WITH SKIN LESIONS ASSOCIATED WITH PSORIASIS].

A 72-year-old woman who was undergoing treatment for bronchial asthma and psoriasis vulgaris experienced malaise three months earlier and visited our hospital on account of abnormal lung shadows. Chest computed tomography revealed ground-glass opacities in the peripheral lung fields and eosinophilia in the bronchoalveolar lavage fluid, which suggested eosinophilic pneumonia. Antineutrophil cytoplasmic antibody was negative. Her lower limbs had multiple palpable papules mixed with well-treated psoriasis and the histopathology of the skin biopsy revealed eosinophil infiltration around small vessels, suggesting the occurrence of eosinophilic granulomatosis with polyangiitis (EGPA). We were able to evaluate minor skin lesions mixed with psoriasis through collaboration between the pulmonologist and the dermatologist. In the diagnosis of EGPA, it is important to carefully examine the whole body and not overlook minor findings before starting steroids.

[FREQUENCY OF IMAGING FINDINGS RESEMBLING MYCOBACTERIOSIS AND CHARACTERISTICS OF COMORBID PULMONARY NON-TUBERCULOSIS MYCOBACTERIOSIS IN THE PATIENTS WITH ALLERGIC BRONCHOPULMONARY MYCOSIS].

OBJECTIVE: To clarify the frequency of imaging findings similar to mycobacterial infection and the characteristics of comorbid pulmonary non-tuberculosis mycobacteriosis in the patients with allergic bronchopulmonary mycosis (ABPM). SUBJECTS AND METHODS: Patients treated with ABPM at our hospital in the past 8 years were extracted from medical records, and 32 patients who met the clinical diagnostic criteria were retrospectively examined. RESULTS: The median age was 62.5 years (range 24-79 years), and 21 patients were female. Twenty-two had asthma, and four had old tuberculosis. CT findings showed central bronchiectasis in 29 cases, centrilobular nodulars in 26 cases, and mediastinal lymphadenopathy in 3 cases. Pulmonary M. avium complex (pMAC) disease was complicated in 4 cases. Regarding the time of diagnosis of pMAC disease, 2 cases were diagnosed concurrently with ABPM, 1 case was before ABPM diagnosis, and 1 case was during ABPM treatment. The main lesion of ABPM occurred in a different site from that of pMAC disease. CONCLUSIONS: ABPM and mycobacterial infection not only have similar imaging findings, but they can also occur synchronously and metachronously. Complication of ABPM and pMAC disease may be due to risk factors common to both diseases, such as the patient's constitution and living environment.

[A CASE OF PROBABLE LATE-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS WHERE THE INITIAL MANIFESTATION WAS A UNILATERAL PLEURAL EFFUSION].

A 74-year-old man developed with left pleural effusion and was suspected of benign asbestos pleural effusion and tuberculous pleurisy. Because of elevation of ADA level in the pleural effusion, diagnostic treatment for tuberculous pleurisy by anti-tuberculosis drugs was performed. However, right pleural effusion, cutaneous/mucosal lesions, leukocytopenia, and fever elevation occurred. The pathology of skin biopsy was consistent with systemic lupus erythematosus (SLE). Since clinical findings did not improve even after discontinuation of all drugs, he received steroid therapy was started and clinical findings improved. He was suspected of late-onset SLE. In conclusion, lupus pleurisy should also be differentiated when pleural effusion is seen in older. Late-onset SLE and drug-induced lupus should be carefully differentiated based on the clinical course.

[A CASE OF SUMMER-TYPE HYPERSENSITIVITY PNEUMONITIS DURING IMMUNOSUPPRESSIVE TREATMENT FOR SYSTEMIC SCLEROSIS].

A 70-year-old woman undergoing long-term treatment for systemic scleroderma and secondary Sjögren syndrome developed fever during tapering of steroids. Chest CT showed centrilobular granular shadow and ground glass opacities. The pathology of transbronchial lung biopsy and the findings of bronchoalveolar lavage fluid were consistent with hypersensitivity pneumonitis and positive for anti-Trichosporon asahii antibody. Because her symptoms and imaging findings improved after house cleaning, she was diagnosed with summertype hypersensitivity pneumonitis. When lung lesions are found in patients with collagen disease, it is necessary to distinguish various diseases. In particular, allergic diseases can be difficult to diagnose by steroid therapy. In order to make an accurate diagnosis, medical history and image interpretation should be performed carefully and histologically searched as much as possible.

[A young case of pulmonary tuberculosis with atypical tumor shadow on chest computed tomography and its difficulty in diagnosis].

BACKGROUND: Diagnosis of pulmonary tuberculosis is usually made by diagnostic imaging such as chest X-ray or computed tomography (CT), and sputum test including smear and polymerase chain reaction (PCR) test. However there is difficulty in making diagnose when atypical imaging and negative sputum test are presented, followed by diagnostic delay. CASE: A 26-year-old man from Philippines consulted other clinic because of dry cough and was pointed out mass shadow in right upper lung field in his chest CT. He visited our office because of positive interferon gamma release assay, but repeated sputum test could not find tuberculosis. Bleeding from mass lesion failed to perform biopsy by bronchoscope, and we failed to find tuberculosis by smear and PCR test from bronchial brushing and wash. Transthoracic needle biopsy from his mass lesion revealed multiple non-caseous granuloma, and lead to make a decision about starting medication. Four weeks later sputum culture from his first visit revealed positive, and diagnosis of tuberculosis was made. DISCUSSION: For avoiding therapy delay it is important to perform invasive diagnostic procedure including histological examination and clinical decision of starting medication, when conservative diagnostic procedure such as sputum test or diagnostic imaging present atypical finding for diagnosing tuberculosis.

[Central diabetes insipidus caused by pituitary metastasis of lung cancer].

A 71-year-old man was admitted with high fever, thirst, polyposia and polyuria. After examination, lung cancer (adenocarcinoma T1NOM1, Stage IV) and central diabitus insipidus caused by pituitary metastasis of lung cancer, were diagnosed. We gave him desmopressin acetate, gamma knife surgery for pituitary metastasis and chemotherapy with paclitaxel and carboplatin, and his symptoms improved. However, his lung cancer progressed. Diabitus insipidus caused by lung cancer is rare.

[Remission of pulmonary alveolar proteinosis during antituberculosis chemotherapy].

The patient was a 32-year-old man in whom pulmonary tuberculosis had occurred 5 years after the presumptive onset of pulmonary alveolar proteinosis. A diagnosis of pulmonary tuberculosis was made by sputum smears positive for acid-fast bacilli. Computer tomography of the chest showed ground glass opacities, consolidation and cavitation. Rifampicin, isoniazid and ethambutol were given daily, and streptomycin three times a week. Serial chest radiographs revealed progressive clearing not only of the new but also of the old lung infiltrates thought to be due to pulmonary alveolar proteinosis. Serum LDH and CEA returned to normal values. This case indicates the possibility of improving pulmonary alveolar proteinosis by tuberculosis infection or antituberculosis therapy.