[A case of Hand-Schüller-Christian disease with pulmonary fibrosis]

A 42-year-old man was admitted with dyspnea and abnormal shadows on chest roentgenogram, which showed bilateral reticulonodular shadows, multiple pulmonary cysts, and pleural effusion. A month after admission, he developed severe respiratory failure and chest X-ray revealed exacerbation of reticulonodular shadows. Steroid pulse therapy improved the symptoms and chest X-ray. He had atrophy of the mandible. Bone scintigram revealed multiple hot lesions. Bone biopsy of the right tibia showed lipogranuloma, and the diagnosis of Hand-Schüller-Christian disease (HSC) was made. The percentage of OKT6-positive cells (Langerhans cells) found by immunofluorescence was 16.1% of all cells in bronchoalveolar lavage fluid, indicating pulmonary involvement due to HSC. This is a rare case of Hand-Schüller-Christian disease with pulmonary fibrosis.

[A study on in vitro antibacterial activity and clinical usefulness in respiratory tract infections of panipenem/betamipron, a newly synthesized carbapenem antibiotic]

Panipenem/betamipron (PAPM/BP) is a combination drug of PAPM, a new parenteral carbapenem antibiotic and BP, an amino acid derivative at a weight ratio of 1:1. Its in vitro antibacterial activities against clinically isolated respiratory pathogenic bacteria were determined. It was superior to imipenem (IPM) in the in vitro antibacterial activities against Haemophilus influenzae, Haemophilus parainfluenzae, Branhamella catarrhalis, Staphylococcus aureus including MRSA, Klebsiella pneumoniae, Serratia marcescens and Escherichia coli. PAPM had antibacterial activities almost equal to those of IPM against Streptococcus pneumoniae and Enterococcus spp. Against Pseudomonas aeruginosa, however, its antibacterial activity was about 1/4 that of IPM. The clinical usefulness of PAPM/BP was studied by dissolving it in a solution containing lactate and administering the solution by intravenous drip infusion to 12 cases of respiratory tract infections. Out of 11 cases with respiratory tract infections excluding cytomegalovirus pneumonia, the efficacy rate was 90.9%, with 4 cases of excellent and 6 cases of good responses. In terms of its bacteriological efficacies, eradication of pathogenic bacteria including super-infection were observed in 2 out of 4 strains, but 2 strains of P. aeruginosa remained unchanged. Six strains appeared as superinfected bacteria during and after administration of this preparation substituting original pathogens. Side-effects were not observed in the 12 cases, and in laboratory tests, slight transient increases of S-GOT and S-GPT were found in 1 case. In conclusion, PAPM/BP is a very useful parenteral antibiotic against respiratory tract infections and can be one of the drugs of the first choice.

[Application of laser in the treatment of spontaneous pneumothorax and emphysema]

From August 1990 to August 1991, sixteen patients with bullae or blebs (pneumothorax 9, giant bullae 5, bullous emphysema 2) were treated by CO2 laser ablation under limited thoracotomy. We found the irradiation of bullae or blebs by CO2 laser quite effective in eliminating these bullous lesions which were often multiple and inoperable by conventional methods. Histological examination revealed the wall of bullae where CO2 laser was applied became thick with dense fibrous tissues and degenerated collagen fibers which, however, were not disrupted. The procedure was safe and we were able to operate patients with disabling emphysema. Because CO2 laser can penetrate only 0.2-0.3 mm of tissue thickness, it is suitable for the ablation of bullous lesions which have thin walls and rapidly shrink and collapse by irradiation leaving thick walled scar tissues. Removing multiple bullae and blebs in patients with bullous emphysema can improve gas exchange by reducing dead spaces and elevating the diaphragm which is often flat and downward displaced because of hyperinflation in these patients. We are planning to incorporate thoracoscopy for this operation to make the procedure less invasive.

[A case of brain metastasis of rhabdomyosarcoma in a child]

We report here a specific case of metastatic brain tumor orienting from rhabdomyosarcoma. An 11-year-old boy came to our hospital with complaints including headache, exophthalmos and tumors in the right frontal and left occipital region. 6 months previously subtotal removal of rhabdomyosarcoma in his right foot had been performed. CT scan demonstrated tumors in the right orbit, right frontal region and left occipital region. The tumors existed bilaterally in the skull and markedly enhanced by contrast medium. But the changes of the cranium were mild, only the dipole was slightly dilated. MRI showed that the tumors were extraaxial masses. Right external carotid angiogram revealed numerous tumor vessels fed by the meningeal artery. On April 3rd, biopsy was performed at the right frontal region. The tumor had spread in the epidural space but the cortical surface seemed to be intact. Histologically, the tumor consisted of small round cells and revealed multinuclear giant cells. It involved the skull bone, dura mater and subdural tissues. Accordingly the tumor was diagnosed as rhabdomyosarcoma. Although tumor increased rapidly, the intracranial region did not change remarkably. It was an interesting phenomenon. Eventually, rhabdomyosarcoma metastasized to the lung, and the patient died due to respiratory distress.

Long-term low-dose administration of erythromycin to patients with diffuse panbronchiolitis

Although diffuse panbronchiolitis (DPB) has carried a poor prognosis, long-term low-dose administration of erythromycin (EM) is very effective. We administered EM at a daily dose of 400-600 mg to 19 DPB subjects for more than 2 months. Sixteen subjects were relieved from productive cough and dyspnea, and their chest X-ray pictures were improved. We performed a pharmacokinetic study of EM in 11 DPB subjects (8 responders; 3 nonresponders) after the long-term low-dose administration. The maximal serum and sputum levels of EM were below the MICs of clinically pathogenic H. influenzae and P. aeruginosa which were often isolated from the sputum of DPB patients. No difference was observed in the absorption of EM between responders and nonresponders. The results suggested that DPB patients might respond favorably to EM due to mechanisms other than antibacterial activity. Individual variation in the absorption of EM was observed. As EM was effective at very low serum and sputum levels, it was suggested that even 200 mg/day of EM would be effective in DPB patients who had high serum and sputum EM levels and it was necessary to monitor the concentrations of EM in serum and sputum for the treatment of DPB to determine the appropriate dose of EM individually.

[Tuberculosis sequelae: secondary bacterial infections]

Bacterial infections is one of the most important complications in the patients with pulmonary tuberculosis. We reported the causative microorganisms in these cases with special reference to various clinical features and presented the recommended treatment and prophylaxis against respiratory bacterial infections in the patients with pulmonary tuberculosis sequelae. In 1988 and 1989, 63 patients with tuberculosis sequela were demonstrated to have been infected with respiratory pathogenic bacteria by the quantitative sputum culture method (greater than or equal to 10(7)/ml) in Tokyo National Chest Hospital. The male/female ratio of these patients was 3.5, and their average age was 62.5 years. Causative microorganisms of the secondary infections in the patients with tuberculosis sequela were essentially similar in those with other lower respiratory tract infections, i.e., chronic bronchitis, bronchiectasis, diffuse panbonchiolitis, chronic pulmonary emphysema, etc. Pseudomonas aeruginosa, other glucose-nonfermentative Gram-negative bacilli (GNF-GNB), and glucose-fermentative Gram-negative bacilli (GF-GNB) were the major pathogenic bacteria responsible for the chronic respiratory failure and/or fatal outcome in the post-tuberculous patients. Patients with complications, including aspergillosis, atypical mycobacteriosis, bronchial asthma, and so forth, showed no specific causative microorganism for the secondary infections except frequent isolation of Haemophilus influenzae. Our clinical observations clearly demonstrated that there were differences between the causative microorganisms in patients hospitalized during 1988 to 1989 and those in patients without admission. Gram-negative bacilli, including P. aeruginosa, GNF-GNB and GF-GNB, and Staphylococcus aureus were predominant in hospitalized patients. On the contrary, Streptococcus pneumoniae, H. influenzae, and Branhamella catarrhalis were major pathogenic bacteria in patients without hospitalization.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of Recklinghausen's disease associated with multiple emphysematous bullae and lung cancer]

A 36-year-old man was admitted with cough and sputum. He had cafe-au-lait spots and multiple subcutaneous neurofibromas. Chest X-ray revealed multiple emphysematous bullae in bilateral upper lobes and a tumor in the bulla of the right upper lobe. Needle aspiration biopsy of the tumor showed small cell carcinoma. Although chemotherapy and radiation resulted in decrease in tumor size, it subsequently increased in size and he died 11 months after admission. Including this case there have been 7 reports of Recklinghausen's disease associated with multiple lung cysts and 8 reports with lung cancer in Japan. However, cases with lung cysts and cancer are very rare. The cancer of this case was considered to be associated with emphysematous bulla rather than Recklinghausen's diseases.

Fat in the dural sinus--CT and anatomical correlations

Two cases of fat in midline dural sinuses, detected by high-resolution CT, were studied anatomically. The fat nodules were not located in the sinus lumen, but in the sinus wall. They were composed of normal adipose tissue without fibrous encapsulation. Our findings have proved that the fat deposit as demonstrated by CT within these dural sinuses represents normal adipose tissue in the sinus wall and does not necessarily mean the presence of a fatty tumor.