Effects of inhaled corticosteroid and short courses of oral corticosteroids on bone mineral density in asthmatic patients : a 4-year longitudinal study

BACKGROUND

It is not certain whether inhaled corticosteroid (ICS) therapy reduces bone mineral density (BMD) in asthmatic patients. In addition, the potential risk of osteoporosis associated with the rescue use of short courses of oral corticosteroids (SC-OCS) is unclear.

OBJECTIVE

To evaluate the effect of inhaled beclomethasone dipropionate (BDP) and SC-OCS on BMD in asthmatic patients.

DESIGN

A 4-year longitudinal study.

METHOD

Lumbar BMD was measured twice by dual-energy x-ray absorptiometry at a mean (+/- SD) interval of 4.2 +/- 0.1 years in 35 asthmatic adults (15 men and 20 postmenopausal women; mean age at the second evaluation, 60.6 +/- 11.5 years) who had been treated with BDP and SC-OCS.

RESULTS

The average period of BDP treatment was 7.7 +/- 2.2 years (range, 4.8 to 13.0 years) at the second evaluation. During the study period, the daily dose of BDP was 765 +/- 389 microg (range, 100 to 1,730 microg), and the frequency of SC-OCS was 1.9 +/- 2.7 courses per year (range, 0.0 to 8.9 courses per year). As a whole, lumbar BMD was unchanged during the course of the study, whereas the Z score (ie, the percentage of normal value predicted from age and sex) increased significantly. Changes in BMD and Z scores in patients receiving high doses of BDP (ie, > 1,000 microg/d; n = 9) were not significantly different from those of patients receiving lower doses (ie, <or= 1,000 microg/d; n = 26). However, patients receiving frequent SC-OCS (ie, > 2.5 courses per year; n = 9) showed a significantly greater loss in BMD and Z score compared with those receiving sporadic courses (ie, <or= 2.5 courses per year; n = 26) (p = 0.002 and p = 0.035, respectively).

CONCLUSIONS

ICS therapy per se does not affect BMD, whereas frequent SC-OCS may do so.

[Outpatient chemotherapy for advanced lung cancer]

We reviewed the records of outpatient chemotherapy for advanced lung cancer in our institution. Thirty-two patients received 122 courses of cisplatin-free chemotherapy as outpatient treatments. Before outpatient treatment, every patient received the first chemotherapy as an inpatient treatment and the dose of cytotoxic drugs was reduced accordingly when side effects were judged to be untolerable. Only 1 patient needed hospitalization because of pneumonia with grade IV neutropenia. The overall response included partial responses (PR) 18%, no change (NC) 55%, progressive disease (PR) 11% and the median survival from the start of outpatient chemotherapy was 384 days. The monthly average cost of medical care per inpatient was more than three times as high as that of outpatients. Cisplatin-free chemotherapy for advanced lung cancer should be given as outpatient treatment not only to maintain the quality of life of patients, but also to restrain the total cost of medical care and to use hospital beds efficiently.

Duration of systemic corticosteroids in the treatment of asthma exacerbation; a randomized study

OBJECTIVE

To determine an appropriate duration for a short course of oral steroids in cases of asthma exacerbations.

SETTING

A 1,000 bed city hospital in Kobe, Japan.

PATIENTS

Patients with asthma exacerbations who needed hospital admission.

METHODS

Following an initial treatment with a 3-day course of intravenous methylprednisolone, patients were allocated to either a 1-week (1 W) or a 2-week (2 W) course of oral prednisolone (PSL, 0.5 mg/kg).

OUTCOME MEASURES

Peak expiratory flow rate (PEF) and rate of unscheduled hospital visits and readmission.

RESULTS

Twenty patients were enrolled (10 in 1 W, 10 in 2 W). Mean PEF just before starting oral PSL in 1 W and 2 W were 51 and 58% of each patient's best value. PEF was significantly improved and to a similar degree over the course of time in both 1 W and 2 W. The frequency of unexpected hospital visits during a 3-month period after discharge was similar (2 in 1 W and 2 in 2 W). No readmission occurred during the same period.

CONCLUSIONS

Because both the 1-week and the 2-week course of oral PSL were equally effective in the treatment of asthma exacerbations, 1 week may be appropriate as the maximum duration of a short rescue course of oral steroids.

[Impact of discontinuing peak flow monitoring in stable asthma]

We conducted a prospective study to examine the influence of discontinuing peak flow monitoring (PFM) in stable asthmatics who had already been properly educated and were monitoring their own peak expiratory flows (PEF). All subjects had been performing PFM for at least 3 months prior to their entry into the study, and PFM was then stopped for a period of 3 months. Comparisons of endpoints were made between a period of 3 months prior to, and after discontinuing PFM. Forty patients with a mean age of 52 were studied. Only one patient experienced a single emergency room visit either before or after discontinuing PFM. Short courses of oral steroids were administered in 6 patients (15%), both before and after discontinuing PFM. There was no significant change in pulmonary function, beta 2-agonist use and asthma symptoms during a 3-month period before and after discontinuing PFM. These results suggest that simply continuing PFM in stable, educated asthmatics may have little impact on asthma control, although its long term influence should be carefully examined.

[Peripheral blood stem cell harvest in patients with limited stage small-cell lung cancer]

Chemotherapy plus granulocyte colony-stimulating factor (G-CSF) induced mobilization of peripheral blood stem cells (PBSC) was performed in patients with limited stage small-cell lung cancer. Chemotherapy consisted of cisplatin/etoposide or cisplatin/adriamycin/etoposide. The amounts of CD34 positive cells and granulocyte-macrophage colony forming units (CFU-GM) collected during 2-3 courses of apheresis were 3.1 +/- 2.9 x 10(6)/kg (n = 10) and 3.1 +/- 1.5 x 10(5)/kg (n = 8), respectively. Adequate amounts of PBSC were also harvested even in patients treated with concurrent chemoradiotherapy. Eight patients were successfully treated with high-dose chemotherapy consisting of ifosfamide, carboplatin and etoposide with PBSC transfusion. The patients'-bone marrow reconstruction was rapid and no treatment-related death was observed.

[Endoscopic approach to pulmonary diseases: Transbronchial needle aspiration]

Transbronchial needle aspiration (TBNA) is a bronchoscopic technique to obtain cytologic and histologic specimen from deep site of bronchial wall. We investigated the utility and safety of TBNA in 200 patients who had mass lesions in the lung or in the mediastinum. 101 patients had submucosal or peribronchial malignant lesions (central malignancy) and TBNA was the only diagnostic method in 28 patients (28%). 39 patients had peripheral malignant lesions (peripheral malignancy) and TBNA was the only diagnostic method in 12 patients (31%). The other 60 patients had benign lesions and TBNA was diagnostic in only 5 patients (8%); bronchogenic cyst in 2, tuberculous lymph adenitis in 1, parathyroid adenoma in 1 and lung abscess in 1. In central malignancy, the yield of TBNA as exclusive means of diagnosis was higher for mediastinal tumor than for lung cancer. In peripheral malignancy it was higher for metastatic lung tumor than for primary lung tumor. In order to stage patients of lung cancer, we sampled 39 lymph nodes and 21 of them were proved to be positive. TBNA was thought to be of greatest value in the diagnosis of peritracheal mediastinal tumor and peribronchial metastatic lung tumor and in the staging of lung cancer. We used 19-gauge transbronchial histology needle in 8 patients and 2 cases were diagnostic. Low diagnostic yields were probably due to the lack of our experience and it was expected that training on this technique would increase diagnostic utility of the histology needle. No significant complications occurred and all patients tolerated TBNA well.

[Evaluations of MTD and Amplicor Mycobacterium for direct detection of Mycobacteria from clinical specimens]

MTD (GEN-PROBE AMPLIFIED MYCOBACTERIUM TUBERCULOSIS DIRECT TEST) for Mycobacterium tuberculosis, and Amplicor Mycobacterium for Mycobacteria (AMP-M. tb for M. tuberculosis, AMP-M. av for M. avium and AMP-M. in for M. intracellulare) were used for the detection of relevant Mycobacterium. Their sensitivity and specificity were evaluated. Total 244 clinical specimens including 164 sputa were examined by the above two tests. The results were compared with those obtained by the conventional methods. Of 244 samples, number of the M. tuberculosis positive samples by microscopy, cultural test, MTD and AMP-M. tb were 32, 33, 38 and 35, respectively. Among 33 culture positive samples, 25 were MTD positive and 26 were AMP-M. tb positive. Therefore, sensitivity of MTD and AMP-M. tb were 75.8% and 78.8%, and their specificity were 93.8% and 95.7%, respectively. When only sputa were used for the tests as the clinical specimens, both sensitivity of MTD and AMP-M. tb were increased to 94.4%. For MAC, positive samples of M. avium complex by culture, M. avium by AMP-M. av and M. intracellulare by AMP-M. in were 13, 16, and 8, respectively. Sensitivity and specificity of AMP-M. av/M. in were 100% and 95.2%, respectively. Clinical findings of the patients whose MTD tests were positive but negative by culture were reexamined. Three of 9 specimens were also positive in AMP-M. tb. From the records of the isolations of tubercle bacilli or other important pathogens from the other kind of clinical specimens, smear tests and patients' response to tuberculosis chemotherapy, four of 9 specimens were confirmed as true positive, three were suspected as positive, and two other specimens were false positive which might be caused by contamination. From these observations, it could be concluded that MTD and AMP-M. tb are more sensitive than conventional culture method, and MTD is more sensitive than AMP-M. tb but needs more careful treatment to avoid the contamination.

[Legionella longbeachae pneumonia in a gardener]

A 52-year-old male gardener, who traveled to Guam Island several days ago, was admitted to our hospital with fever, cough and dyspnea. His chest X-ray showed bilateral infiltration and he was severely hypoxic and hypotensive on admission. He died of multiple organ failure in spite of intensive treatment with mechanical ventilation antibiotics including erythromycin. Legionella longbeachae serotype 1 was isolated from his sputum and was regarded as the etiologic agent. Legionella longbeachae was not isolated from the same type of leaf mold that he used as potting soil. This is the first case of Legionella longbeachae pneumonia from whom the organism was isolated in Japan.

Increased use of inhaled corticosteroids and reduced hospitalizations in adult asthmatics: 11 years' experience in a Japanese hospital

Until recently, inhaled corticosteroids have not been recognized as a first-line drug mainly because of the traditional polypharmaceutical approach to asthma in Japan. To examine the trend more precisely following the introduction of inhaled corticosteroids, we retrospectively analysed the relation between the number of prescriptions for anti-asthma drugs including inhaled corticosteroids and the number of hospitalizations due to asthma exacerbation, near fatal episodes and deaths from asthma for a period of 11 years from 1986 to 1996 at Kobe City General Hospital (KCGH). A marked decline in these actual indices in patients attending KCGH, which shows the improvement in asthma control, started coincidentally with the increased use of inhaled corticosteroid, which was followed by both a discontinuation of the trend for increased use of inhaled beta-agonists and the decreased use of oral anti-asthma agents. There was no significant difference in the mean duration of hospital stays between 1988 and 1996. Although the intensification of patient education is likely to play an important role in enhancing the protective effect of inhaled corticosteroids, we highly suspect that the major contributory factor in the great decline in hospitalizations is the increased use of inhaled corticosteroids.

[A comparison of a 3 day course with a 2 week course of oral prednisolone in patients with chronic asthma]

To investigate an appropriate duration of short course of a oral prednisolone (PSL), we compare the results of a 3 day course of PSL (3D) with those of a 2 week course of PSL (2W) in 20 patients with chronic asthma. All subjects had been inhaling beclomethasone dipropionate (BDP, mean daily dose: 1325 micrograms), and had been self-monitoring their peak expiratory flow rate (PEF) for at least 6 months. Mean +/- SE of the best PSL-induced PEF in 2W (2W-best) was not different from that in 3D (397 +/- 29 and 356 +/- 23 L/min, respectively, p = 0.26). Mean weekly morning PEF/2W-best before and 1, 2, 3 and 4 weeks after PSL was 60, 76, 80, 76 and 76% in 2W, and 63, 73, 67, 67 and 65% in 3D, respectively. Both changes over the course of time were significant. The frequency of emergency room visits and/or unscheduled hospital visits was not significantly different between 2W and 3D. However, both the frequency of use of inhaled beta 2 agonists and the symptom score significantly decreased only in 2W. Seven patients (35%) did not need additional oral PSL during the 4-week period after initiating 3D, and among these patients, emergency room visits and/or unscheduled hospital visits were completely controlled. In conclusion, although the effect of 3D was inferior than that of 2W, it was a sufficient duration in 35% of the patients, and thus, may be appropriate as a initial duration of rescue course of oral steroids.

[Computed tomographic findings in septic pulmonary emboli secondary to renal abscess]

A 73-year-old woman with diabetes mellitus and hypothyroidism had been well until 4 days before she presented with fever, productive coughing, and general malaise. Dyspnea gradually worsened, and she was admitted to Kobe City General Hospital. She appeared toxic and was in moderate respiratory distress on admission. There were scattered rales in both lung fields. The abdomen was soft with no tenderness. A chest roentgenogram showed peripheral infiltrates in both lung fields. Arterial blood gas analysis showed a Po2 of 48.6 Torr and Pco2 of 27.2 Torr. A blood culture on admission showed Escherichia coli. Computerized tomography of the chest showed multiple nodules of various sizes in the peripheral lung fields. Some nodules had necrotic centers and feeding vessels. Wedge-shaped lesions abutting the pleura were also seen. These findings strongly suggested septic pulmonary emboli. An abscess in the left kidney, which was considered to be the source of the septic pulmonary emboli, was found with Ga scintigraphy, ultrasonography, and computerized tomography of the abdomen. Treatment with antibacterial drugs was effective against the lung lesions but not the renal abscess. A left nephrectomy was done. In the proper clinical setting, characteristic CT features of septic emboli can contribute to early diagnosis of this disease.

[Effect of timing of granulocyte-colony stimulating factor administration on leukopenia induced by systemic chemotherapy in patients with non-small-cell lung cancer--multi-center randomized crossover study]

Sixty-six chemotherapy-naive patients with non-small-cell carcinoma of the lung were given two courses of systemic chemotherapy consisting of mitomycin C, vindesine, and cisplatin. The effect of the timing of administration of grannulocyte colony-stimulating factor (G-CSF) on the incidence of neutropenic fever, the nadir leukocyte count, the duration of neutropenia ( < or = 1000/mm3), and the time needed for recovery from neutropenia was studied. Patients were assigned at random to begin receiving G-CSF (50 microns/m2, subcutaneously) either when the leukocyte count was less than or equal to 1000/mm3 (group I) or when it was between 1000/mm3 and 2000/mm3 (group II), in a crossover fashion. The nadir leukocyte count was lower in group I than in group II (859/mm3 and 1215/mm3, respectively). The duration of leukopenia (defined as a leukocyte count less than or equal to 1000/mm3) was greater in group I than in group II (1.5 days and 0.8 day, respectively), as was the time needed for recovery to a leukocyte count of 2000/mm3 (1.9 days and 1.6 days, respectively) (p < 0.05). No differences were found in the incidence of neutropenic fever (group I: 44%, group Ii: 45%), in the duration of fever (group I: 2.3 days, group II: 2.8 days), or in the duration of G-CSF use (group I: 6.3 days, group II: 6.8 days). There were no treatment-related deaths in either group. We conclude that when this type of combination chemotherapy is given for non-small-cell carcinoma of the lung, administration of G-CSF can be postponed without clinical problems until the leukocyte count is less than of equal to 1000/mm3.

Influence of high dose inhaled steroids on hypothalamo-pituitary-adrenal axis function in Japanese patients with asthma: a comparison over the course of time

Although the influence of high dose inhaled steroids on hypothalamo-pituitary-adrenal (HPA) function in patients with asthma has been extensively studied worldwide, there has been limited information on Japanese asthmatics, especially in terms of a prospective analysis of HPA function in the course of time. We analyzed the changes in HPA function using 2 serial short tetracosactrin tests (STT) separated by an interval of one year in 11 Japanese asthmatics who were treated with high dose inhaled steroids alone [beclomethasone dipropionate (BDP); mean dose 982 micrograms/day] during the period between 2 STTs. Mean values of plasma cortisol before administration of ACTH, maximum cortisol and the rise in cortisol in response to ACTH in the 2 STTs were 7.8, 20.5 and 12.7 micrograms/dl for the 1st test, and 8.9, 23.6 and 14.7 micrograms/dl for the 2nd test, respectively. Overall, there was no significant change in the course of time in each of these 3 values. Although the results of the 1st STT proved to be abnormal in 3 patients who had been receiving systemic steroids before their 1st STT, they improved uniformly in their 2nd STT. In the remaining 8 patients, who had never received systemic steroids, 4 patients showed improvements while the other 4 showed deterioration in HPA function in their serial STTs over the course of time. The dose of BDP was 800 micrograms/day in the former 4 patients, while it was 1,200 micrograms/day in the latter 4. Furthermore, only one patient, in whom BDP had been increased from 800 micrograms/day to 1,200 micrograms/day between the 2 tests, developed an abnormal response in the 2nd STT. On the other hand, one patient whose BDP dose was increased from 800 micrograms/day to 1,600 micrograms/day showed an improvement in HPA function in the 2nd test. These results indicate that the threshold dose of BDP which may cause HPA suppression in Japanese asthmatics lies between 800-1,200 micrograms/day, although there is a large inter-individual variation in terms of such doses.

[Bronchoscopy in the diagnosis of diffuse pulmonary infiltrates, and corticosteroid treatment in patients with acute respiratory failure]

Forty patients with acute respiratory failure underwent fiberoptic bronchoscopy for evaluation of diffuse pulmonary infiltrates. Immunohematological diseases were the commonest underlying conditions; they were present in 48% of patients. Twenty-five percent of patients had pulmonary disease. Fiberoptic bronchoscopy was done 2.2 days after confirmation of the pulmonary lesion. Seventy-three percent of patients had already received antibiotics and 28% required mechanical ventilation at the time of fiberoptic bronchoscopy. Arterial blood gas analysis done just before fiberoptic bronchoscopy revealed that PaO2 and PaCO2 were 62 Torr and 36 Torr, respectively. A specific diagnosis was made in 29 patients (73%): pneumonia in 13; pulmonary fibrosis in 4; summer-type hypersensitivity pneumonitis in 3; and leukemic cell infiltration in 2. Fifty-two percent of patients were successfully treated with specific therapy. The complications of fiberoptic bronchoscopy were bleeding in 3 patients, pneumothorax in 3 patients, and exacerbation of respiratory failure in one patient. There were no procedure-related deaths, and fiberoptic bronchoscopy was judged to be safe and useful in the diagnosis of pulmonary infiltrates in patients with acute respiratory failure. Twenty-five patients (68%) received high doses of methylprednisolone. The average initial dose was 851 +/- 373 mg, and more than 100 mg was administered for 8 +/- 6 days. Seventeen of these patients recovered from the pulmonary disease. A controlled randomized study is needed to reevaluate the role of corticosteroids in the treatment of acute respiratory distress syndrome.

[Successful treatment of carcinoid syndrome in two cases of bronchial carcinoid]

We encountered two patients with typical bronchial carcinoid and metastases to the liver who presented with typical carcinoid syndrome. In typical bronchial carcinoid without metastases to regional lymph nodes, recurrence and distant metastasis after curative resection are generally thought to be rare. The first patient was a 62-year-old woman who was admitted to our hospital because of facial flushing and diarrhea. She had undergone curative resection of a typical bronchial carcinoid 9 years earlier, and the postsurgical pathological stage was I. On the second admission, she was found to have multiple liver metastases. The second patient was a 59-year-old woman who was admitted to our hospital because of facial flushing, dyspnea, and dehydration due to diarrhea. She had undergone curative resection of a typical bronchial carcinoid 21 months earlier, and the postsurgical pathological stage was I. On the second admission, she was found to have multiple intrabronchial, bone, and liver metastases. Both patients were treated with subcutaneous injections of octreotide, and with transhepatic arterial chemoembolization. In addition, the second patient underwent percutaneous ethanol injection under ultrasonic guidance. Signs and symptoms disappeared soon after therapy began and the patients survived longer than expected. Hepatic artery chemoembolization and simultaneous chemotherapy can relieve symptoms in patients with carcinoid syndrome and multiple liver metastases, and self-administration of octreotide is the treatment of choice for immediate relief.

[Ultrasonically guided needle biopsy of small mediastinal and peripheral pulmonary nodules]

From 1983 to 1993, we performed ultrasonically guided percutaneous needle biopsies on 320 thoracic tumors. Of these, 77 tumors were smaller than 3 cm in diameter and were peripherally located adjacent to the chest wall (n = 71) or in the posterior mediastinum (n = 6). We evaluated the efficacy and safety of UGNB for diagnosing these small lesions. The mean tumor size was 2.0 +/- 0.7 cm. Nine nodules were less than 1.0 cm in diameter, 38 were between 1.1 and 2.0 cm, and 30 were between 2.1 and 3.0 cm. Biopsies were done with a 17-gauge Trucut needle; a 21-gauge needle was used to aspirate specimens for cytological study. A definitive diagnosis was made in 31 (77%) of 40 malignant lesions and in 19 (51%) of 37 benign lesions. Complications included pneumothorax (n = 5) and hemoptysis (n = 3), but no special medications were needed. Thus, real-time sonographic guidance is a safe, easy, and reliable biopsy method for small pulmonary and mediastinal nodules adjacent to the chest wall.

[Concurrent chemoradiotherapy followed by surgery for advanced stage III non-small cell lung cancer (NSCLC)]

Forty-two patients with stage IIIA (bronchoscopically T3 and/or bulky N2) and stage IIIB NSCLC were treated with concurrent chemoradiotherapy (CRT). Treatment consisted of CDDP, 20 mg/m2 and etoposide, 40 mg/m2 by continuous infusion (day 1-5) of weeks 1 and 5 simultaneously with chest radiotherapy (RT), 50 Gy, 2 Gy/Fx, 5 Fx/week. Surgery was attempted 3-5 weeks after RT in pts clinically downstaged. Between 10/90 and 12/92, 43 previously untreated pts were enrolled and 42 were eligible. Pts characteristics were: male/female = 37/5; mean age, 61 yrs (range, 31-74 yrs); stage IIIA/IIIB = 10/32; 15 adenocarcinoma, 24 squamous cell, 2 large cell, 1 unclassified; PS 0/1/2 = 11/24/7. Excluding 1 ineligible pts, 42 pts were evaluated for CRT response. The response rate was 81% (1 CR, 33 PR, 5 NC, 1 PD, 2 NE). Clinical downstaging was achieved in 20 pts (48%). Twenty-one pts (50%) received surgery and 19 of them were completely resected. In 7 resection specimens, no tumor was observed. Toxicity of CRT was well tolerable (Grade 4 leukopenia, 15%; Grade 2-3 esophagitis, 15%). We conclude that this intensive combined modality therapy is acceptable and appears to increase the response rate as well as resectability. Prospective randomized studies should be conducted for further evaluation of this treatment modality.

Long-term follow-up of patients with a history of near fatal episodes; can inhaled corticosteroids reduce the risk of death from asthma?

We retrospectively studied the use of inhaled corticosteroids in patients who experienced near fatal episodes (NFE) to determine whether such therapy reduces the risk of death. Forty-eight patients who had near fatal episodes of asthma between January 1981 and December 1989 were divided into two groups. Group A comprised 19 patients who received beclomethasone dipropionate (BDP) daily (mean dose of BDP:687 micrograms/day: 200-2,000) following NFE, and Group B, 28 patients who did not take BDP or who took less than 6 mg BDP/month. During the follow-up period (Group A:82.9 months, Group B:66.2 months), no patients in Group A died, but eight deaths occurred in Group B (mean period between near fatal episode and death was 31.5 months: 12-66). These results suggest that the regular use of inhaled corticosteroids, even at low doses, may reduce the risk of death in patients who experience NFE.

[A case of sarcoidosis with systemic lymph node involvement presenting as multiple high-density masses on chest and abdominal CT]

We report a case of sarcoidosis with mediastinal and abdominal lymph node involvement presenting as multiple high-density masses on chest and abdominal CT. The patient was a 43-year-old housewife who came to our hospital because of a dry cough and exertional dyspnea. A chest radiograph showed bilateral diffuse reticulo-nodular shadows and widening of the mediastinum. On CT of the chest and the abdomen, lymph nodes were swollen throughout the mediastinum and the para-aortic area of the abdomen. They appeared as very-high-density masses on plain CT. Bronchoscopy revealed involvement of the bronchial walls. Punch biopsy of the bronchial wall, TBLB, and biopsy of the anterior mediastinal lymph node all revealed non-caseous epithelioid cell granulomas. These granulomas contained lamellated, irregularly shaped and darkly-stained structures (Schaumann bodies) that caused the high density of the involved lymph nodes on CT. This case shows at least a part of the mechanism of calcification of lymph node lesions in patients with sarcoidosis.

[A case of mediastinal parathyroid adenoma diagnosed by transtracheal needle aspiration]

Chest radiography of a 73-year-old man with upper abdominal pain showed hypercalcemia and an upper mediastinal mass. Functional mediastinal parathyroid adenoma was diagnosed, because of abnormally high levels of PTH in his serum and in fluid collected by transtracheal needle aspiration from the mediastinal mass. We resected the adenoma operatively. It a cystic tumor located behind the superior vena cava and the trachea. The inferior end of the tumor was as low as the aortic arch, and superiorly the tumor was attached to the inferior pole of the thyroid gland by a vascular pedicle. Histologically adenoma cells were predominant. This tumor was a mediastinal parathyroid adenoma by location, but because it was attached to the thyroid gland superiorly, it may have originated from the superior parathyroid gland and then descended because of its weight into the posterior superior mediastinum. Thus, it cannot be considered an ectopic parathyroid adenoma in origin. Mediastinal parathyroid adenoma is a rare disease, and these tumors are usually so small that correct localization of the adenoma is often difficult even by CT scan or scintigram. This is the first reported case of a mediastinal parathyroid adenoma that appeared as a mediastinal mass on a plain chest radiography and in which the level of PTH in the fluid collected from the mass by transtracheal needle aspiration was high.

[Effects on bone metabolism of asthma treatment with beclomethasone dipropionate (BDP) inhalation and short term burst of oral steroids]

Inhaled steroids are currently the first-line treatment of chronic asthma. Because each metered dose of beclomethasone dipropionate (BDP) is small (50 micrograms), short term burst or continuous use of oral steroids are combined in moderately to severely asthmatic patients. The effect of these treatments on bone metabolism remains unclear. Bone mineral density (BMD), osteoclacin (OC), PTH, Ca, and ALP were assessed in 130 asthmatic patients. There were 3 groups: the first group [B+R] consisted of 17 patients taking BDP (1190 +/- 536 micrograms/day) and also taking oral steroids (8.0 +/- 3.8 mg/day, 8.11 +/- 5.52 years), the second group [B+S] had 35 patients taking BDP (885 +/- 320 +/- g/day) and short-term bursts of oral steroids (PSL 20-40 mg/day, 3-7 days/course, 7.51 +/- 4.54 courses/year) and the third group [B alone] consisted of patients who were taking BDP (480 +/- 260 micrograms/day) alone. BMD was measured by dual energy X-ray absorptiometry (DEXA). In the [B+R], [B+S], and [B alone] groups, the BMD of vertebra (L1-4) was 0.75, 0.86, and 0.90 g/cm2, respectively. The percentages of predicted values based on age and sex were 92.0, 102.7, and 106.9% respectively. BMD and percent decrease were significantly lower in the [B+R] group than in the [B+S] or [B alone] group. It is likely that this phenomenon is caused by long-term use of oral steroids rather than by BDP inhalation but there is no significant difference between the [B+S] and the [B alone] groups. Daily BDP dose did not correlate with BMD by multiple regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment modalities and hypothalamo-pituitary-adrenal (HPA) axis suppression in Japanese patients with asthma]

We examined HPA axis function using a short tetracosactrin test in 94 asthmatics treated with three different modalities. The first group, (B + S), consisted of 41 patients taking BDP (910 +/- 320 micrograms, daily) plus a short term burst of oral steroids (20-40 mg daily, 3-7 days/course, 1-18 courses/year). The second group, (B + R), consisted of 19 patients taking BDP (1076 +/- 410 micrograms, daily) plus continuous oral steroids (2.5-20 mg/day for 1.8-24 years). The third group, (B alone), consisted of 34 patients taking BDP only (615 +/- 258 micrograms, daily). All patients had been inhaling BDP for more than 1 year. The rise in cortisol in response to tetracosactrin in B + S, B + R, and B alone was 12 +/- 4.3 micrograms/dl, 7.0 +/- 5.0 micrograms/dl and 14 +/- 4.5 micrograms/dl, respectively, and achieved cortisol was 21 +/- 4.5 micrograms/dl, 12 +/- 7.2 micrograms/dl and 23 +/- 4.2 micrograms/dl;, respectively. Both values were significantly lower in the B + R group than in either B + S or B alone. However, there was no difference between B + S and B alone, although the BDP dose was significantly larger in the B + S group. Significant HPA axis suppression (rise in cortisol < 7 micrograms/dl and achieved cortisol < 18 micrograms/dl) was seen in 7 patients. Although HPA axis suppression was more frequently seen in B + R (10/19), no significant difference was seen between B + S and B alone (4/41 and 1/34, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Can patients with chronic asthma discontinue inhaled corticosteroid?]

As an initial investigation to determine whether or not inhaled corticosteroids can be discontinued, we evaluated the results of discontinuation in patients who had been well controlled with inhaled corticosteroids for more than one year prior to this study. The average dose of BDP which the patients had been inhaling at the start of this study was 365 micrograms/day. To determine the effect of discontinuing inhaled corticosteroids, we compared the patients' peak expiratory flow rates and the frequency of beta-agonist use between the 4-week observation period and follow-up periods of varying duration. Only three out of twenty patients enrolled were able to maintain their discontinuation of BDP, while the remaining seventeen patients restarted after a mean period of 30.8 days. Mean peak flow values began to fall during the first week after discontinuation, and decreased morning peak flow values became significant in the 2nd, 3rd and 4th weeks. The mean peak flow value during the observation period was 85.2% of each patient's personal best, but had dropped to 68.8% of this level just before restarting inhaled corticosteroid. The frequency of beta-agonist use during the study period (2.99 +/- 3.39 times a day) was significantly higher than during the observation period (1.94 +/- 2.95 times a day). This finding strongly suggests that the patients' asthmatic conditions had become unstable during the study period. These results suggest that any decision to discontinue the use of inhaled corticosteroid, even in well controlled patients with chronic asthma, should be taken with great care.

[A case of adult respiratory distress syndrome likely due to measles and Mycoplasma pneumoniae]

We described a case of adult respiratory distress syndrome (ARDS) likely due to measles and Mycoplasma pneumoniae. A 24-year-old, previously healthy man was referred to our hospital because of respiratory arrest. He was unconscious and cyanotic. He had erythematous and polymorphic eruptions of his extremities and trunk, but his face was spared. His chest roentgenogram showed consolidation with air bronchograms affecting the whole bilateral lungs. After mechanical ventilation with positive end-expiratory pressure and administration of intravenous hydrocortisone and protease inhibitor "urinastatin" and so on, the patient recovered from his critical condition. No attributable organisms were isolated from the specimens investigated in his acute phase. Serological examinations of the specific IgM antibody to measles during the course indicated a recent measles infection. Mycoplasma pneumoniae indirect hemagglutination test rose from a titre of less than 1/40 to 1/60. ARDS is a rare complication of measles or Mycoplasma pneumoniae infection. Moreover he received measles vaccine before 1970 in Japan, so this case was suspected to be atypical measles.

[Use of beta-agonist inhalation concomitantly with regular beclomethasone dipropionate in patients with bronchial asthma--as required or on a regular basis]

We investigated whether regular use of beta-agonist inhalation concomitantly with regular beclomethasone dipropionate (BDP) inhalation is necessary in chronic bronchial asthma. Twenty chronic asthmatic patients who were stable on regular BDP and beta-agonist inhalation were studied. After a 2 week observation period, the patients were randomly assigned to two groups. One group received BDP 400 micrograms/day (2 puffs 4 times) and beta-agonist inhalation as required for 4 weeks. This period was followed by 4 weeks of treatment with BDP 400 micrograms/day and regular beta-agonist inhalation. The other group received these treatments in the reverse order. No significant differences among the two groups were observed in attack score, ADL score, sleep score, and %PEFR. In addition, no differences were detected in these parameters between the periods of regular use of beta-agonist and the periods of use as required. The frequency of inhalation of beta-agonist during the use as required period correlated with the sleep score and difference in %PEFR between morning and night, and was significantly lower than the frequency of inhalation during the period of regular. From these results, we conclude that inhalation of beta-agonist on a regular basis is not necessary to achieve the same degree of relief of symptoms as treatment with beta 2-agonist and BDP inhalation on regular basis in patients with chronic asthma.

[A resected case of mediastinal tuberculous lymphadenitis with pericostal tuberculosis]

A case of 22-year-old female with mediastinal tuberculous lymphadenitis and pericostal tuberculosis was reported. Her complaint was right chest pain and subcutaneous mass on the right chest wall. Chest contrast CT showed right paratracheal lymph node swelling with central low density area and surrounding rim enhancement, which has been reported as typical characteristics of mediastinal tuberculous lymphadenitis. Pigeon-egg sized subcutaneous mass with fluctuation was palpable on the right sternal border and the smear of its content showed acid-fast bacilli. In spite of two months therapy with antituberculous drugs, both masses were unchanged in size. The lesions resected surgically, were both encapsulated abscesses containing yellowish pus, and microscopic examination of these specimen disclosed the finding of tuberculosis. Mycobacterium tuberculosis was cultured from contents of both masses. After nine months of anti-tuberculous therapy, no sign of recurrence is observed until now. Both masses were discontinuous and the possibility of lymphangitic spread of organism was speculated as its etiology.

[A case of summer type hypersensitivity pneumonitis resulting in chronic respiratory failure and cor pulmonale]

A female case of Japanese summer-type hypersensitivity pneumonitis who was a smoker developed in chronic respiratory failure several years later. Biopsy specimen on first admission showed findings of granulomatous bronchioloalveolitis distributed in the center of secondary lobules. Pulmonary function studies demonstrated restrictive disease with high RV% and low airway conductance. In spite of steroid therapy, dyspnea persisted and the same symptoms were found on next summer. Six years later symptoms of chronic respiratory failure and cor pulmonale developed. Chest X-Ray showed dilated pulmonary artery, cardiomegaly and overinflation without apparent fibrosis. Hypoxemia and hypercapnia were also seen on blood gas analysis. Pulmonary function was unchanged compared to the findings on first admission. Since then long term oxygen therapy was started. It was thought that irreversible small airway disease caused by hypersensitivity pneumonitis was attributable to cor pulmonale and chronic respiratory failure because of her smoking habit and long period of exposure to antigen. As a patient with summer type hypersensitivity pneumonitis always has a possibility of chronic disease developing after long term exposure to antigen, such as a farmer's lung, the cessation of exposure to antigen by complete cleaning up of the patient's environment or moving out were considered to be important.

[A strain of Pseudomonas vesicularis isolated from shower hose which supports the multiplication of Legionella]

In Japan, a fatal case due to Legionella micdadei was first recognized in our laboratory in 1986. On the epidemiological study just after the case, no Legionella was detected from the environmental samples of the patient's residence, such as shower water, tank water and so on. In the course of prospective investigations, no Legionella was isolated, but many organisms were grown on BCYE alpha and MWY agar plates. In the retrospective study, one of these organisms was found to support satellite growth of Legionella on BCYEagar without L-cysteine. This was the isolate from the shower hose and identified as Pseudomonas vesicularis with the biochemical and DNA-DNA hybridization test. And P. vesicularis type strain ATCC11426 also supported satellite growth of Legionella. Especially in the water supply system, the existence of P. vesicularis seemed to be effective on the growth of Legionella. It must be taken into consideration that efforts made to isolate the nutrient produced organisms as well as Legionella are needed.