[A case of endobronchial tuberculosis associated with bronchial asthma treated with high doses of inhaled corticosteroid]

A 46-year-old woman had been treated with 1,600-2,000 micrograms/day of beclomethasone dipropionate (BDP) and oral theophylline on the basis of a diagnosis of bronchial asthma in 1993. Eosinophilic pneumonia was diagnosed in June 1999, and she was then treated with 40 mg/day of oral prednisolone (PSL), which was gradually tapered off, and then stopped in October 1999. She was referred to our hospital because acid-fast bacilli were found in the sputum on January 18, 2000. Her chest radiographs and CT scans showed partial atelectasis of the right upper lobe, and fiberoptic bronchoscopy revealed bronchial inflammatory changes and whitish mucosal nodular lesions in the walls of the lower trachea, the right main bronchus and the orifice of the right upper lobe bronchus. She was found to have endobronchial tuberculosis. Anti-tuberculosis treatment with isoniazid, rifampicin, streptomycin and pyrazinamide was started. Serum levels of interferon-gamma were markedly elevated on admission. Asthma symptoms improved for a period of one month after the beginning of anti-tuberculosis treatment, despite the termination of inhaled corticosteroid. However, as the tuberculosis improved, the frequency and severity of the asthma increased and so corticosteroid inhalation was started again. Four months after administration of the anti-tuberculosis drug, fiberoptic bronchoscopy revealed that the endobronchial lesions had improved without any stenosis or constrictive changes. It was speculated that high doses of inhaled corticosteroid may have the potential to cause endobronchial tuberculosis whilst, ironically, at the same time preventing bronchial stenosis by endobronchial tuberculosis. This is an interesting case in which the asthma symptoms first decreased during the acute phase of endobronchial tuberculosis and then increased again after the tuberculosis improved.

Lobar distribution of emphysema in computed tomographic densitometric analysis

RATIONALE AND OBJECTIVES

The aims of this study were to determine the extent of emphysema in individual lobes and to investigate whether the lobar distribution of emphysema influences pulmonary function.

METHODS

Helical CT and pulmonary function tests were performed in 50 emphysema patients. Percentages of low attenuation volume (extent of emphysema) were calculated for each lobe by using CT densitometric analysis.

RESULTS

The extent of emphysema of the whole lung in these patients was 44%. Airflow limitation (r = -0.82, P<0.0001) and residual volume (r = -0.52, P<0.01) were closely correlated with the extent of emphysema in both lower lobes. Diffusing capacity (r = -0.61, P<0.0001) was closely correlated with the extent of emphysema in both upper lobes. On the basis of the lobar distribution of emphysema as determined by CT densitometry, we divided these emphysema patients into predominantly upper-lobe disease and predominantly lower-lobe disease groups. The predominantly lower-lobe disease group had significantly greater severe airflow limitation (P<0.0001), greater residual volume (P<0.01), and greater total lung capacity (P<0.05) than did the predominantly upper-lobe disease group.

CONCLUSIONS

CT densitometry showed a distinct lobar distribution of emphysema. Pulmonary function is significantly different between predominantly upper- and lower-lobe emphysema groups.

Serum levels of Clara cell 10-kDa protein are decreased in patients with asthma

Clara cell 10-kDa protein (CC10), the predominant product from nonciliated cells in the epithelial lining of bronchioles (Clara cells), has been shown to have immunomodulatory and antiinflammatory activity and may play a role in controlling airway inflammation. This study was designed to measure serum CC10 concentrations in healthy and asthmatic nonsmokers. Serum CC10 concentrations in asthmatic nonsmokers were significantly lower than in healthy nonsmokers. Asthmatic patients with a long duration of the disease (>/=10 years) had significantly lower serum CC10 levels than those with a short duration of the disease (<10 years). There was no significant difference in serum CC10 levels in asthmatic patients between the time of the asthmatic attack and the stable condition. Serum CC10 levels may reflect decreased production of CC10 caused by remodeling of the small airways in asthma.

Relationships between radiological pattern and cell-mediated immune response in Mycoplasma pneumoniae pneumonia

The aim of this study was to determine the relationship between the radiological pattern of Mycoplasma pneumoniae and the level of cell-mediated immunity of the host. Computed tomographic (CT) scans of the chest and the results of the purified protein derivative (PPD) test were studied during the acute stage of infection in 54 patients with M. pneumoniae pneumonia. The CT findings were used to divide the patients into two groups: one group had a predominance of nodular opacities with a centrilobular distribution (Group N; n = 29); and the other showed a predominance of an airspace consolidation (Group C; n = 25). Forty out of 54 subjects had negative tuberculin skin tests ( < 10 mm induration). The positive rate of PPD reaction was higher in Group N (13 out of 29) compared to Group C (1 out of 25) (p = 0.0005); whilst pleural effusion appeared more frequently in Group C (10 out of 25) than in Group N (3 out of 29) (p = 0.023). There was no significant difference between Groups N and C in white blood cell and lymphocyte counts, level of antibodies to M. pneumoniae in sera, and severity of the disease. These findings suggest that the characteristics of the host cell-mediated immunity might influence the pattern of pulmonary lesions in M. pneumoniae infection.

Sudden hearing loss as the initial manifestation of neurosarcoidosis

We report two cases of sudden hearing loss as the initial manifestation of neurosarcoidosis. The patients had no symptoms suggesting central nervous system or meningeal involvement. Eighth nerve involvement is an uncommon feature in patients with sarcoidosis. We discuss the pathophysiologic basis of sarcoid-induced hearing loss.

Malignant hemangioendothelioma of the aorta

We present a rare case of aortic malignant hemangioendothelioma with a mural growth pattern in which the endothelial nature was confirmed by immunohistochemical demonstration of Factor VIII-related antigen. Aortic sarcomas and malignant hemangioendotheliomas in the literature are reviewed.

Malignant fibrous histiocytoma presenting as an endobronchial polyp of the carina

A 64 year old man was admitted to hospital due to dyspnoea and stridor. A peduncular polyp of the carina was found at bronchoscopy. Histological examination of the tumour after resection with endoscopic electronsurgery revealed malignant fibrous histiocytoma (MFH) of myxoid type. With endoscopic neodymiumyttrium aluminium garnet (Nd-YAG) laser surgery, residual tumour was eliminated. To our knowledge this is the first case with malignant fibrous histiocytoma appearing as a polyp of the carina.

[Effect of fog on diurnal changes in peak expiratory flow rates in an asthmatic]

To evaluate the effects of fog on asthmatics, we analyzed the symptoms of a 45-year-old female during the foggy season and the relation between diurnal peak expiratory flow rate (PEFR) and fog and other meteorological factors. Her asthma attacks had been induced by specific smells: perfume, smoke from burning grass or industrial smoke. Two years previously, she had moved to the suburbs of Sapporo, where fog frequently occurs. From that time her asthmatic symptoms had been exacerbated, so it was suspected that the fog might have had some influence. We analyzed 251 measures of PEFR from June to August 1994. The average and standard deviation of PEFR in the absence of fog and specific smells was 403 +/- 40 L/min (n = 195). PEFR was significantly lower (p < 0.01) when it was foggy (347 +/- 60 L/min; n = 40), when specific smells were present (333 +/- 60 L/min; n = 5) and when there were both fog and specific smells (340 +/- 53 L/min: n = 11). On the other hand, there were no changes associated with other meteorological factors: barometric pressures, relative humidity, mean temperature, minimal temperature and most frequent wind direction. These results suggested that the inhalation of fog decreases PEFR and is an exacerbating factor in bronchial asthma.

[High dose steroid inhalation therapy using a large spacer: laboratory and clinical study on usefulness of the 4-puffs/inhalation method]

We investigated whether or not the inhalation method of beclomethasone dipropionate (BDP) influences patient compliance and the clinical effects of therapy in chronic bronchial asthma, together with a basic study on the lung deposition of BDP using a twin Impinger when various numbers of puffs were discharged into three different spacers (Volumatic, InspirEase, Aerochamber). It was clearly shown that only the spacer, Volumatic maintained a high deposition rate of BDP in the lung model with a dose of 4-puffs/inhalation. Eighteen chronic asthmatic patients were studied. The patients inhaled BDP (800-1600 micrograms/day) by 1-puff/inhalation using a large spacer, Volumatic, for 12 weeks, and they then inhaled the same dose of BDP as given in the previous period by 4-puffs/inhalation using the spacer for 16 weeks. We compared the compliance of BDP, attack score, %PEFR and frequency of beta-agonist inhalation between these two periods. The compliance of BDP was markedly improved after changing from 1-puff/inhalation (92.8%) to 4-puffs/inhalation (99.8%). In the 4-puffs/inhalation period, attack score and %PEFR were significantly improved as compared to the 1-puff/inhalation period. The frequency of beta-agonist inhalation use in the 4-puffs/inhalation period was significantly lower than that in the 1-puff/inhalation period. These results indicate that when high dose steroid inhalation is given with a large spacer in chronic asthmatic patients, we should advice them of the appropriate inhalation method in order to obtain good compliance and clinical effects.

[A case of influenza B viral bronchopneumonia followed by CT]

A 69-year-old male with bronchial asthma was admitted to a hospital with fever, dyspnea, and productive cough. Arterial blood gas analysis revealed sever hypoxemia (PaO2 54.8 torr, PaCO2 28.8 torr). Chest roentgenogram showed diffuse reticulonodular shadows predominantly in the upper filed and a small amount of bilateral pleural effusion. CT image of the lung showed nodular opacities at the peripheral branches of the pulmonary arteries and bronchi, some of which had become confluent. The bronchoarterial bundle had become thicker compared with a CT taken 18 months before this admission. Three days treatment with antibiotics and gamma globulin did not change the symptoms or radiologic findings. After commencing methylprednisolone therapy, the pneumonia showed rapid improvement. Based upon the significant elevation of serum influenza B (B/Singapore/79) virus antibody titer, the patient was diagnosed as having influenza B viral bronchopneumonia. Twenty-three days after initiation of steroid therapy, slight nodular opacities were observed on CT. This finding suggests that bronchiolitis has a relatively prolonged course in influenza viral bronchopneumonia.