Interaction-Induced ac Stark Shift of Exciton-Polaron Resonances

Laser-induced shift of atomic states due to the ac Stark effect has played a central role in cold-atom physics and facilitated their emergence as analog quantum simulators. Here, we explore this phenomenon in an atomically thin layer of semiconductor MoSe_{2}, which we embedded in a heterostructure enabling charge tunability. Shining an intense pump laser with a small detuning from the material resonances, we generate a large population of virtual collective excitations and achieve a regime where interactions with this background population are the leading contribution to the ac Stark shift. Using this technique we study how itinerant charges modify-and dramatically enhance-the interactions between optical excitations. In particular, our experiments show that the interaction between attractive polarons could be more than an order of magnitude stronger than those between bare excitons.

Tracheobronchitis and laryngitis associated with Crohn's disease

We report a 68-year-old woman with tracheobronchitis and laryngitis associated with Crohn's disease (CD), which was discovered during the evaluation of suspected lung cancer. She had no symptoms induced by these upper airway diseases (UADs). Bronchoscopy revealed swelling of the epiglottis with edematous change and a mass like epiglottis fold. There were nodular and edematous changes in the trachea and bilateral main bronchus. Histological findings demonstrated infiltration by numerous lymphocytes and plasma cells. Dexamethasone as the premedication for chemotherapy against lung cancer was efficacious for these extraintestinal manifestations of CD. Our case was rare in that bronchial lesion and UADs appeared concomitantly.

Six-week oral prednisolone therapy for immune-related pneumonitis: a single-arm phase II study

BACKGROUND

There has been no prospective trial for treatment of immune-related pneumonitis (irP) occurred after immune checkpoint inhibitors (ICIs).

METHODS

In this single-arm phase II study, patients with cancer with grade ≥2 irP received oral prednisolone (1 mg/kg/day), tapered over 6 weeks. The primary endpoint was a pneumonitis control rate at 6 weeks from the start of the study treatment, defined as complete disappearance or partial improvement of irP in high-resolution CT of the chest.

RESULTS

Among 57 patients enrolled, 56 were included in the final analysis. The most frequent cause of irP was single ICI therapy (51.8%), followed by combination with chemotherapy plus ICI (39.3%). Thirty-five (62.5%) patients had grade 2 irP and 21 (37.5%) had grade ≥3. Fifty-one (91.1%) patients completed the study treatment while 5 discontinued the study treatment because of relapse of irP (n=1), death from cancer (n=1), occurrence of immune-related hepatitis (n=1), extension of the treatment duration more than 6 weeks (n=1), and attending physician's decision (n=1). Six weeks after the start of the study treatment, 16 (28.5%) patients demonstrated complete recovery from irP, 35 (62.5%) had a partial improvement in irP, 1 (1.8%) had a relapse of irP, and 4 (7.1%) were not evaluable. The pneumonitis control rate at 6 weeks was 91.1% (95% CI, 80.7% to 96.1%). Twelve weeks after the start of the study treatment, 5 (8.9%), 27 (48.2%), and 15 (26.8%) patients demonstrated complete recovery, partial improvement, and relapse, respectively, and 9 (16.1%) were not evaluable. The pneumonitis control rate at 12 weeks was 57.1% (95% CI, 44.1% to 69.2%). During the observation period, 18 (32.1%) patients experienced a relapse of irP, and of those, 17 received re-treatment with corticosteroids. Grade ≥3 adverse events occurred in 10 (17.9%) patients, in which hyperglycemia was most frequent (n=6). There was no treatment-related death.

CONCLUSIONS

In this first prospective study for irP, prednisolone at 1 mg/kg/day, tapered over 6 weeks, demonstrated a promising clinical benefit and manageable toxicity, suggesting a potential treatment option for irP.

TRIAL REGISTRATION NUMBER

jRCT: 1041190029.

Cytokine profiling identifies circulating IL-6 and IL-15 as prognostic stratifiers in patients with non-small cell lung cancer receiving anti-PD-1/PD-L1 blockade therapy

Whether circulating levels of specific cytokines at baseline link with treatment efficacy of immune checkpoint blockade (ICB) therapy in patients with non-small cell lung cancer remains unknown. In this study, serum samples were collected in two independent, prospective, multicenter cohorts before the initiation of ICB. Twenty cytokines were quantified, and cutoff values were determined by receiver operating characteristic analyses to predict non-durable benefit. The associations of each dichotomized cytokine status with survival outcomes were assessed. In the discovery cohort (atezolizumab cohort; N = 81), there were significant differences in progression-free survival (PFS) in accordance with the levels of IL-6 (log-rank test, P = 0.0014), IL-15 (P = 0.00011), MCP-1 (P = 0.013), MIP-1β (P = 0.0035), and PDGF-AB/BB (P = 0.016). Of these, levels of IL-6 and IL-15 were also significantly prognostic in the validation cohort (nivolumab cohort, N = 139) for PFS (log-rank test, P = 0.011 for IL-6 and P = 0.00065 for IL-15) and overall survival (OS; P = 3.3E-6 for IL-6 and P = 0.0022 for IL-15). In the merged cohort, IL-6^high and IL-15^high were identified as independent unfavorable prognostic factors for PFS and OS. The combined IL-6 and IL-15 status stratified patient survival outcomes into three distinct groups for both PFS and OS. In conclusion, combined assessment of circulating IL-6 and IL-15 levels at baseline provides valuable information to stratify the clinical outcome of patients with non-small cell lung cancer treated with ICB. Further studies are required to decipher the mechanistic basis of this finding.

A case of severe thrombocytopenia after the first exposure to rifampicin

Severe immune thrombocytopenia is a rare side-effect of rifampicin (RFP) and can be life-threatening. Here, we report the case of a 74-year-old male with tuberculous pleurisy who developed severe thrombocytopenia after first exposure to RFP. Platelet count decreased to 1 × 10³/μL after 7 days of treatment with RFP, isoniazid, ethambutol, and pyrazinamide. After all the drugs were discontinued, the platelet count recovered. As thrombocytopenia did not occur after re-administration of drugs other than RFP, the patient was diagnosed with RFP-induced thrombocytopenia. Clinicians should be aware that RFP can induce acute and severe thrombocytopenia even without previous exposure to this drug.

Predictors of poor clinical outcomes including in-hospital death and low ability to perform activities of daily living at discharge in hospitalized patients with chronic obstructive pulmonary disease exacerbation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity worldwide. Many patients with COPD experience exacerbations that require hospitalization, which is associated with an increased risk of in-hospital death and impaired ability to perform activities of daily living (ADL). Declining ability to perform ADL is a critical issue for these patients.

OBJECTIVES

To identify predictors of poor clinical outcomes, including in-hospital death and low ability to perform ADL at discharge, in patients who are hospitalized with exacerbation of COPD.

DESIGN

This retrospective study involved a cohort of patients with exacerbation of COPD who were admitted to Iwata City Hospital in Japan between July 2015 and October 2019.

METHODS

We collected clinical data, measured the cross-sectional area of the erector spinae muscles (ESM_CSA) on computed tomography (CT) scans at admission, and investigated the associations of poor clinical outcomes (in-hospital death and severe dependence when performing ADL, defined as a Barthel Index (BI) of ⩽40 at discharge) with clinical parameters.

RESULTS

Overall, 207 patients were hospitalized for exacerbation of COPD during the study period. The incidence of poor clinical outcomes was 21.3%, and the in-hospital mortality rate was 6.3%. Multivariate logistic regression analyses showed that older age, long-term oxygen therapy, an elevated D-dimer concentration, and a reduced ESM_CSA on chest CT at admission were significantly associated with poor clinical outcomes (in-hospital death and a BI of ⩽40).

CONCLUSION

Hospitalization for exacerbation of COPD was associated with high rates of in-hospital mortality and a BI of ⩽40 at discharge, which may be predicted by assessment of ESM_CSA.

BNT162b2 coronavirus disease-2019 vaccination accelerated rheumatoid arthritis disease activity in chronic eosinophilic pneumonia: A case report

RATIONALE

The relationship between rheumatoid arthritis (RA) and eosinophilic inflammation is unclear. According to recent studies, it has been suggested that T helper 2 cell responses play a role in the inhibition of RA. It is unclear how the immunological response after coronavirus disease-2019 (COVID-19) vaccination affects T cell immune reactions.

PATIENT CONCERNS AND DIAGNOSES

Here, we report the case of an 88-year-old woman diagnosed with RA and chronic eosinophilic pneumonia (CEP). She was diagnosed with CEP about 20 years ago, and, through steroid treatment, she improved and had no relapse for 16 years. At the time of diagnosis of CEP, the rheumatoid factor (RF) was increased; however, there were no joint symptoms. After receiving the COVID-19 vaccine, joint and respiratory symptoms gradually worsened. Laboratory examinations showed increased RF, anti-cyclin citrullinated peptide antibody, and peripheral absolute eosinophil count. Musculoskeletal ultrasonography showed synovitis.

INTERVENTION AND OUTCOME

Methylprednisolone pulse therapy improved respiratory and joint symptoms immediately; RA and CEP stabilized with no relapses.

LESSONS

Eosinophilic and rheumatoid reactions following COVID-19 vaccination were an-reported adverse events. Eosinophilic inflammation might be reflected on an anti-inflammatory reaction in initial phase of RA.

Chemotherapy for patients with advanced lung cancer with interstitial lung disease: a prospective observational study

Introduction:

Although recent advances in chemotherapy for lung cancer are remarkable, most clinical trials have excluded patients with interstitial lung disease (ILD) due to the concern of developing acute exacerbation (AE) of ILD. Hence, accumulating original evidence of cancer treatment for this population is important.

Methods:

Between 2016 and 2020, a prospective observational study was conducted across 11 Japanese hospitals. Patients with chemotherapy-naïve, inoperable, advanced lung cancer with ILD were included. The primary outcome was the frequency of AE-ILD after registration; the secondary outcomes were the risk factor of AE-ILD and the efficacy of chemotherapy.

Results:

Among 124 patients enrolled, 109 patients who received chemotherapy were analyzed. The median age was 72 years, and the majority showed usual interstitial pneumonia (UIP)/probable UIP pattern upon chest computed tomography. The median percent-predicted forced vital capacity (%FVC) was 81% (interquartile range: 66–95%). After registration, 23 patients (21.1%; 95% confidence interval [CI]: 14.4–29.7%) developed AE-ILD. The logistic analysis revealed that lower %FVC slightly but significantly increased the risk of AE-ILD (odds ratio per 10% decrease: 1.27; 95% CI: > 1.00–1.62). Overall response rates/median overall survival times in non-small-cell lung cancer and small-cell lung cancer for the first-line chemotherapy were 41% (95% CI: 31–53)/8.9 months (95% CI: 7.6–11.8) and 91% (95% CI: 76–98)/12.2 months (95% CI: 9.2–14.5), respectively.

Conclusion:

AE-ILD during chemotherapy is a frequent complication among patients with lung cancer with ILD, particularly those with lower %FVC. Conversely, even in this population, passable treatment response can be expected.

Clinically amyopathic dermatomyositis with interstitial lung disease double-positive for anti-MDA5 and anti-PL12 antibodies

Anti-melanoma differentiation-associated gene 5 (MDA5) and anti-aminoacyl-tRNA synthetase (ARS) antibodies are two major myositis-specific autoantibodies with distinct clinical features. However, the clinical course remains unclear in patients with clinically amyopathic dermatomyositis (CADM)-interstitial lung disease (ILD) who have co-existing anti-MDA5 and anti-ARS antibodies. Here, we describe the case of a 32-year-old woman with CADM-ILD who had anti-MDA5 and anti-PL12 antibodies. Her serum ferritin level was within the normal range. However, chest computed tomography revealed bilateral lower-lobe consolidation and ground-glass opacities. Treatment with prednisolone and immunosuppressants was successful in improving the skin lesion and ILD, but relapse occurred on reducing the dose of prednisolone. These clinical features match those of anti-ARS antibody-positive dermatomyositis-ILD. Because these two conditions show significantly different clinical features and require different intensities of treatment, clinicians should carefully follow-up these patients throughout the course of the disease.

Multicentric Castleman disease with infiltration of eosinophils to the lung

A 41-year-old man presented with multiple superficial lymph nodes (LNs) swollen with elevated levels of serum immunoglobulin (Ig)G4 and C-reactive protein. Histological findings of his left inguinal LN revealed lymphoplasmacytic infiltration with numerous IgG4-positive plasma cells; IgG4⁺/IgG⁺ plasma cell ratio >40%. Chest computed tomography (CT) showed poorly defined centrilobular nodules, interlobular septal thickening, consolidations, and mediastinal LNs swelling. Bronchoalveolar lavage fluid (BALF) showed elevated eosinophils. A surgical lung biopsy showed focal dense eosinophil infiltration, in addition to lymphoplasmacytic infiltration, but few IgG4⁺ plasma cells. The diagnosis of multicentric Castleman disease (MCD) was made because of serum interleukin-6elevation. Treatment with prednisolone and tocilizumab improved his symptoms and lung lesions. This case shows that overlapping clinical and pathological features of MCD and IgG4-related disease may present in a single patient, showing the difficulty in distinguishing between these two diseases.

Evaluation of Programmed Death Ligand 1 (PD-L1) Gene Amplification and Response to Nivolumab Monotherapy in Non-small Cell Lung Cancer

IMPORTANCE

Robust predictors for response to anti-programmed death 1 and its ligand (PD-1/PD-L1) immunotherapy in non-small cell lung cancer (NSCLC) are not fully characterized.

OBJECTIVE

To evaluate whether PD-L1 (CD274) copy number gains (CNGs), comprising amplification and polysomy, in pretreatment specimens assessed by fluorescence in situ hybridization are associated with response to nivolumab monotherapy in NSCLC.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study enrolled 200 patients, of whom 194 had assessable tumors, with advanced or recurrent NSCLC who were treated with nivolumab after progression following prior treatment at 14 institutions in Japan between July 2016 and December 2018. Median (interquartile range) duration of follow-up was 12.6 (5.6-20.4) months. Data were analyzed from December 2019 to February 2020.

EXPOSURES

Sequential nivolumab was given on day 1 of a 14-day cycle. Response was assessed every 4 cycles using Response Evaluation Criteria in Solid Tumors version 1.1.

MAIN OUTCOMES AND MEASURES

Overall response rate (ORR) according to the PD-L1 copy number status. Additional end points were progression-free survival, overall survival, and PD-L1 tumor proportion score (TPS) assessed by immunohistochemistry based on PD-L1 copy number status.

RESULTS

A total of 6 of the 200 patients were excluded because of poor-quality tumor specimens for the biomarker study, resulting in 194 assessable patients. Of these, 155 (79.9%) were men, with a median (range) age of 69 (43-83) years. PD-L1 CNGs were identified in 32 patients (16.5%), including 5 (2.6%) with amplification and 27 (13.9%) with polysomy. The ORR among patients with and without PD-L1 CNGs was 28.1% (95% CI, 13.7%-46.7%) and 17.9% (95% CI, 12.3%-24.7%), respectively. Although patients with PD-L1 polysomy did not demonstrate improved ORR (18.5% [95% CI, 6.3%-38.1%]) compared with those without PD-L1 CNGs, 4 of 5 patients (80.0% [95% CI, 28.4%-99.5%]) with PD-L1 amplification showed response, among whom median duration of response was not reached. Patients with PD-L1 amplification showed excellent survival outcomes for progression-free and overall survival. Overall, 3 PD-L1-amplified tumors (60.0%) showed PD-L1 TPS of at least 80%, but 2 (40.0%) had PD-L1 TPS of 15% or less.

CONCLUSIONS AND RELEVANCE

In this study, tumor PD-L1 amplification but not polysomy was associated with response to nivolumab monotherapy among patients with NSCLC. External validation with a larger sample size is warranted.

Localized circumferential narrowed bronchial wall lesions in allergic bronchopulmonary aspergillosis

We present a 67-year-old man with allergic bronchopulmonary aspergillosis (ABPA), whose chest computed tomography (CT) scans showed localized circumferential bronchial wall thickening in the right main bronchus to middle truncus. Chest CT scans showed high-attenuation mucus in the right B8 bronchus. Bronchoscopy showed narrowing of the right main bronchus and inspissated mucus plugging in the right B8 bronchus. Histological examination of the right main bronchus revealed bronchial inflammation with numerous neutrophils and plasma cells. Treatment with corticosteroid and antifungal agents resulted in resolution of the symptoms and right bronchial lesions. The clinical course may indicate that the bronchial lesions were associated with ABPA.

Pneumocystis jirovecii Pneumonia in a Patient with Breast Cancer Receiving Neoadjuvant Dose-dense Chemotherapy

We herein report a 38-year-old woman with breast cancer who developed Pneumocystis jirovecii pneumonia (PCP) during neoadjuvant dose-dense chemotherapy combined with dexamethasone as antiemetic therapy. Chest computed tomography showed bilateral ground-glass opacities and consolidation. The serum β-D-glucan levels were elevated, and P. jirovecii DNA was detected from the bronchoalveolar lavage fluid by polymerase chain reaction. Her clinical findings improved with trimethoprim/sulfamethoxazole and adjunctive steroid therapy. Clinicians must be mindful of the manifestations of PCP in non-human immunodeficiency virus (HIV)-infected immunocompromised patients and include the possibility of PCP in the differential diagnosis when confronted with breast cancer on dose-dense chemotherapy showing diffuse lung disease.

Endobronchial Small-cell Lung Cancer with Intraluminal Growth Pattern Showing "Finger-in-glove" Appearance

Invasion of the endobronchial mucosa by cancer cells is frequently seen in small cell lung cancer (SCLC), but an intraluminal polypoid growth pattern is extremely rare. We herein describe the case of a 69-year-old woman with limited-stage SCLC who had a pedunculated mass in the orifice of the right upper bronchus. Thin-section CT of the lung showed an endobronchial protruding mass accompanied by tubular and branching opacities (the so-called finger-in-glove sign) in the right upper lobe bronchus, which were enhanced by contrast media. She responded well to chemotherapy with concurrent radiation therapy. Although very rare, SCLC patients can have intraluminal polypoid growth, as was observed in this case.

Endobronchial mucosal nodular lesions in allergic bronchopulmonary aspergillosis

Bronchoscopic findings often show mucoid impaction in patients with allergic bronchopulmonary aspergillosis (ABPA); however, endobronchial mucosal nodular lesions have not been reported. We herein present the first such case of a 52-year-old woman with ABPA with endobronchial mucosal nodular lesions. The endobronchial lesions were located in the orifice of the mucoid impaction, and disappeared after 4 weeks of treatment with prednisolone and itraconazole. Aspergillus fumigatus was cultured from bronchial lavage fluid collected from the site of mucoid impaction. Based on these clinical findings, we speculate that the bronchial lesions were caused by an inflammatory and allergic reaction to Aspergillus antigens.

Minute Pulmonary Meningothelial-like Nodules Showing Multiple Ring-shaped Opacities

Chest computed tomography (CT) findings of minute pulmonary meningothelial-like nodules (MPMNs) usually show tiny nodules (2-5 mm in diameter) of ground-glass attenuation. However, diffuse, thin-walled cavities have rarely been reported. We herein report a 56-year-old woman with MPMNs showing diffuse, thin-walled cystic lesions on a thin-section chest CT scan. Clinicians need to be aware of the imaging characteristics of this conditions to guide appropriate management of lung diseases, as these CT findings may resemble certain metastatic lung neoplasias and primary adenocarcinoma of the lung.

Olanzapine-containing antiemetic therapy for the prevention of carboplatin-induced nausea and vomiting

PURPOSE

There remains an unmet clinical need for the control of chemotherapy-induced nausea and vomiting (CINV), particularly in the prevention of nausea and the delayed phase control. We evaluated the efficacy and safety of antiemetic therapy with olanzapine, a neurokinin-1 receptor antagonist, a 5-hydroxytryptamine-3 (5-HT₃) receptor antagonist and dexamethasone in patients receiving carboplatin-containing chemotherapy. Olanzapine inhibits signalling via multiple neurotransmitter receptors involved in CINV.

METHODS

Chemotherapy-naïve patients with lung cancer who received carboplatin-containing chemotherapy were enrolled in this phase-II study. Patients received olanzapine, aprepitant, a 5-HT₃ receptor antagonist and dexamethasone. The primary endpoint was the complete response rate (no vomiting and no rescue therapy) during 120 h after administration of chemotherapy agents.

RESULTS

Thirty-three patients received olanzapine-containing antiemetic therapy. The overall complete response rate was 93.3% (95% confidence interval, 80.4-98.3%). The frequency of nausea was 15.2% in the delayed phase and 18.2% in the overall phase. Somnolence was observed in 16 patients.

CONCLUSION

Adding olanzapine to antiemetic therapy with aprepitant, a 5-HT₃ receptor antagonist and dexamethasone improved CINV control in patients receiving carboplatin-containing chemotherapy.

Chronic pulmonary aspergillosis may cause eosinophilic granulomatosis with polyangiitis via allergic bronchopulmonary aspergillosis

An 84-year-old man visited our hospital with a prolonged productive cough. Chest computed tomography showed a thick wall cavity and bilateral consolidations. Laboratory findings revealed peripheral blood eosinophilia, increased total IgE and elevated myeloperoxidase anti-neutrophil cytoplasmic antibody. Specific IgE and IgG antibodies and an immediate skin reaction against Aspergillus showed positive results. The histological findings of the lung parenchyma were compatible with eosinophilic pneumonia and bronchial biopsy showed eosinophilic vasculitis. Bronchoalveolar lavage fluid culture yielded Aspergillus fumigatus. These results met the diagnosis criteria for both allergic bronchopulmonary aspergillosis (ABPA) and eosinophilic granulomatosis with polyangiitis (EGPA). This case thus suggests that A. fumigatus might be a pathogen common to both diseases, and prolonged exposure to A. fumigatus in some patients with ABPA may promote progression to EGPA.

Crucial role of plasmacytoid dendritic cells in the development of acute colitis through the regulation of intestinal inflammation

Disruption of intestinal homeostasis can lead to inflammatory bowel diseases endowed susceptibility genes and environmental factors affecting intestinal accumulation and activation of colitogenic phagocytes. Plasmacytoid dendritic cells (pDCs) are immune cells that had been proposed to control innate and adaptive immunity through the massive secretion of type I interferon (IFN-I). However, the contribution of pDCs to the progression of intestinal inflammation remains unclear. Here we show a critical role of pDCs in the initiation of acute colonic inflammation using T-cell-independent acute colitis model with a selective ablation of pDCs. Although pDCs accumulated in the inflamed colon upon mucosal injury, deficiency of pDCs attenuated the development of acute colitis independent of IFN-I signaling, accompanied by the diminished colonic production of proinflammatory cytokines. Furthermore, deficiency of pDCs impaired the mobilization of colitogenic phagocytes into the inflamed colon possibly mediated by the abrogated mucosal production of C-C chemokine receptor 2 ligand. Thus, our findings highlight a critical role of pDCs in the induction of the colonic inflammation that regulates the colonic accumulation of inflammatory phagocytes leading to the initiation and exacerbation of acute colitis, and they may serve a key role in controlling gut mucosal immune homeostasis.

Granulomatosis with polyangiitis involving the epiglottis

Granulomatosis with polyangiitis (GPA) frequently involves the upper respiratory tracts, but involvement of the epiglottis is extremely rare. This report describes a patient initially presenting with dysphagia and increasing stridor due to epiglottitis. Bronchoscopy showed swelling of the epiglottis with partly whitish nodular lesions, with biopsy specimens showing neutrophil infiltration and necrosis. Chest computed tomography showed multiple nodular consolidations in the bilateral lung parenchyma, and histological findings were consistent with vasculitis. The patient was diagnosed with GPA and responded well to treatment with prednisolone and cyclophosphamide. Although an uncommon manifestation, GPA should be included in the differential diagnosis of epiglottitis, especially in patients with lung parenchymal lesions suggestive of GPA.

MR Imaging of the Liver before and after Transcatheter Hepatic Chemo-Embolization for Hepatocellular Carcinoma

Transcatheter chemo-embolization (TCE) in hepatocellular carcinoma (HCC) was performed in 38 patients. The patients were examined by MR imaging before TCE as well as one week and 4 to 5 weeks after TCE. The tumor signal intensity in T2 weighted images increased in 13 cases and decreased in 19 cases after TCE. Increased intensity seemed to reflect intra-tumoral hemorrhage or liquefaction accompanying tumor necrosis. Decreased intensity seemed to reflect coagulation necrosis. In 9 of 18 cases followed over a 2-month period the signal intensity had decreased in both T1 and T2 weighted images. In these patients the tumor showed no recurrence at angiography and the decreased signal seemed to reflect the completion of coagulation necrosis. A hyper- and/or hypointense rim around the tumor appeared in 22 cases. These changes were thought to be perifocal edema or granulation tissue around the tumor. MR imaging was useful in evaluating the necrotic process of the tumor after TCE.

Morphological changes in small pulmonary vessels are associated with severe acute exacerbation in chronic obstructive pulmonary disease

BACKGROUND

Pulmonary vascular remodeling is essential for understanding the pathogenesis of chronic obstructive pulmonary disease (COPD). The total cross-sectional area (CSA) of small pulmonary vessels has been reported to correlate with the pulmonary artery pressure, and this technique has enabled the assessment of pulmonary vascular involvements. We investigated the contribution of morphological alterations in the pulmonary vessels to severe acute exacerbation of COPD (AE-COPD).

METHODS

This study enrolled 81 patients with COPD and 28 non-COPD subjects as control and assessed the percentage of CSA (%CSA) less than 5 mm(2) (%CSA<5) and %CSA in the range of 5-10 mm(2) (%CSA5-10) on high-resolution computed tomography images.

RESULTS

Compared with the non-COPD subjects, the COPD patients had lower %CSA<5. %CSA<5 was positively correlated with airflow limitation and negatively correlated with the extent of emphysema. COPD patients with lower %CSA<5 showed significantly increased incidences of severe AE-COPD (Gray's test; P=0.011). Furthermore, lower %CSA<5 was significantly associated with severe AE-COPD (hazard ratio, 2.668; 95% confidence interval, 1.225-5.636; P=0.010).

CONCLUSION

%CSA<5 was associated with an increased risk of severe AE-COPD. The distal pruning of the small pulmonary vessels is a part of the risk associated with AE-COPD, and %CSA<5 might be a surrogate marker for predicting AE-COPD.

Cumulative incidence of tuberculosis in lung cancer patients in Japan: A 6-year observational study

BACKGROUND

Tuberculosis (TB) remains a health-related problem worldwide, and certain malignancies are known to be associated with an increased risk of TB. Lung cancer is the leading cause of cancer-related death, and the number of patients with lung cancer has been reportedly increasing. As the prognosis of lung cancer remains poor, aggressive comprehensive therapies have been used. The immunosuppression caused by cancer itself and treatment-associated immune modulation may increase the risk of TB. The present study was conducted to investigate the cumulative incidence of TB in lung cancer patients.

METHODS

This observational study included 904 consecutive patients diagnosed with histologically confirmed lung cancer from March 2007 to March 2013 and followed until March 2015 (mean 25.2 months). The cumulative incidence of TB was estimated using the Kaplan-Meier method.

RESULTS

Nine lung cancer patients (1.00%) developed TB during the observation period. In all cases, TB occurred within 2 years of the diagnosis of lung cancer. The cumulative incidence of TB at 6 months, 1 year, and 2 years was 0.65%, 1.15%, and 1.38%, respectively.

CONCLUSIONS

The cumulative incidence of TB in lung cancer patients was 1.38% in Japan.

Low WSS and High OSI Measured by 3D Cine PC MRI Reflect High Pulmonary Artery Pressures in Suspected Secondary Pulmonary Arterial Hypertension

Purpose:

Institutional Review Board (IRB)-approved prospective study was conducted to test whether objective and quantitative hemodynamic markers wall shear stress (WSS) and oscillatory shear index (OSI) measured by three-dimensional (3D) cine phase-contrast (PC) can reflect pulmonary arterial hypertension (PAH).

Patients and Methods:

Seventeen consecutive patients of suspected secondary PAH were examined for pulmonary artery pressures (PAPs) with right heart catheterization (RHC) and three-dimensional (3D) cine PC MR. Based on the RHC data, patients were subdivided into two groups of 12 non-PAH (median age of 74.5 years) and 5 PAH (median age of 77 years) patients. Based on 3D cine PC magnetic resonance (MR), hemodynamic parameters including spatially averaged systolic WSS (sWSS), diastolic WSS (dWSS), mean WSS (mWSS), OSI and blood vessel section area (BVSA) at the pulmonary arterial trunk were calculated. Streamline images in the pulmonary arteries were also assessed. All the parameters were compared between non-PAH and PAH groups.

Results:

sWSS (N/m²) and mWSS (N/m²) of PAH group was lower than that of non-PAH group (0.594 ± 0.067 vs. 0.961 ± 0.590, P = 0.001), (0.365 ± 0.035 vs. 0.489 ± 0.132, P = 0.027). OSI of PAH group was higher than that of non-PAH (0.214 ± 0.026 vs. 0.130 ± 0.046, P = 0.001). sWSS, mWSS, and dWSS were inversely correlated and OSI was positively correlated to mean PAP or systolic PAP with r values of –0.638 (P = 0.005), –0.643 (P = 0.005), –0.485 (P = 0.049), and 0.625 (P = 0.007); or –0.622 (P = 0.008), –0.629 (P = 0.007), –0.484 (P = 0.049), and 0.594 (P = 0.012), respectively. sWSS was also inversely correlated to BVSA with r value of –0.488 (P = 0.049), and OSI was correlated to BVSA with r value of 0.574 (P = 0.016). Vortex or helical flows were observed more frequently in PAH patients.

Conclusions:

The low sWSS and mWSS as well as high OSI measured with 3D cine PC MR could be potential hemodynamic markers for the increased PAP in suspected secondary PAH patients.

Organizing pneumonia associated with myeloperoxidase anti-neutrophil cytoplasmic antibody

Organizing pneumonia (OP) is a clinicopathological entity that occurs idiopathically or in association with several conditions, but there are few reports about myeloperoxidase anti‐neutrophil cytoplasmic antibody (MPO‐ANCA)‐associated OP. We describe a patient with OP whose clinical conditions improved spontaneously. Moreover, serum MPO‐ANCA titers paralleled the clinical activity of the disease, which disappeared in association with disease quiescence. Based on these findings, a subset of patients may have OP related to MPO‐ANCA. ANCA testing should be considered in the work‐up of patients with suspected OP.

Diffuse alveolar hemorrhage caused by exposure to organic dust

Diffuse alveolar hemorrhage, a life-threatening disease, can complicate various conditions. We herein describe, for the first time, a patient with diffuse alveolar hemorrhage caused by exposure to organic dust. A 49-year-old woman who worked as a cantaloupe farmer in a greenhouse was referred to our hospital for sudden onset of dyspnea 3 h after exposure to organic dust. A chest X-ray and computed tomography scan performed on admission showed diffuse ground-glass opacities in both lung fields. Suspecting hypersensitivity pneumonitis, fiberoptic bronchoscopy was performed. Mucopurulent sputum was present in the trachea and both bronchi, and bronchoalveolar lavage revealed a progressively bloody return, typical of diffuse alveolar hemorrhage. Based on the history and bronchoscopy findings, she was diagnosed with diffuse alveolar hemorrhage following exposure to organic dust and was treated with antibiotics and corticosteroids. Diffuse alveolar hemorrhage should be considered in the differential diagnosis of diffuse ground-glass opacities observed on radiographs in farmers following exposure to organic dust.

[Case of organizing pneumonia associated with sweet's syndrome]

A 76-year-old male was admitted to our hospital because of fever and erythema on the face and extremity. Skin biopsy of the erythematous lesions showed dense neutrophilic infiltrations and diagnosis of Sweet's syndrome was made. Chest computed tomography on admission revealed ground glass opacities in the right upper and lower lung fields. Bronchoalveolar lavage (BAL) showed increased lymphocytes and neutrophils. A search for bacteria, mycobacteia and fungi in BAL fluid was negative. Trans-bronchial lung biopsy revealed intraluminal organization and fibrinous exudates. Neutrophilic infiltrations were scant. These pathological findings were compatible with organizing pneumonia. Bone marrow aspiration was performed because of slight anemia and thrombocytopenia, and a diagnosis of myelodysplastic syndrome was made. Oral prednisone (PSL) of 30 mg/day induced rapid resolution of radiologic and cutaneous lesions and was tapered to 10 mg/day, then radiologic lesions worsened. Steroid pulse therapy followed by PSL 45 mg and immunosuppressive agent resulted in a resolution of his conditions. This case was rare in that organizing pneumonia was associated with Sweet's syndrome.

Serial QuantiFERON TB-2G testing over a four-year period in healthcare workers at a city hospital

OBJECTIVE

To evaluate the performance and practicality of QuantiFERON TB-2G (QFT-2G) testing for screening healthcare workers (HCWs) at a city hospital in Japan without a tuberculosis (TB)-specific ward.

METHODS

We performed a chart review of 951 HCWs (251 men and 700 women) who underwent QFT-2G testing as a part of their pre-employment or annual employee screening between April 2007 and March 2010.

RESULTS

The initial QFT-2G test was interpreted as positive in 28 (2.9%) HCWs, negative in 884 HCWs (92.9%) and indeterminate in 39 HCWs (4.1%). During the four-year study period, 37 HCWs were diagnosed as being positive at least once. Nine (0.98%) of the 923 HCWs with indeterminate or negative results on the initial testing converted to a positive status, including 6/479 (1.25%) nurses, 2/100 (2.0%) office staff members and 1/147 (0.68%) physicians. No HCWs with a positive result had a history of tuberculosis (TB) or any apparent contact with active TB patients and did not opt for treatment of latent TB. Seven (25%) of the 28 HCWs who were determined to be positive on the initial testing reverted to an indeterminate or negative status.

CONCLUSION

In a series of annual serial QFT-2G tests, some HCWs exhibited conversion and/or reversion. Therefore, caution is required when interpreting mild fluctuations in interferon-γ responses.

Clinical significance of interleukin 33 (IL-33) in patients with eosinophilic pneumonia

BACKGROUND

Interleukin 33 (IL-33) works as a functional mediator in allergic disease by enhancing the activity of eosinophils and inducing expression of T helper 2 (Th2)-associated cytokines. However, the role of IL-33 in pulmonary eosinophilia has not been elucidated. We investigated the levels of IL-33 in eosinophilic pneumonia (EP) together with associated cytokines, and discussed the clinical significance of IL-33 in EP.

METHODS

Sera and bronchoalveolar lavage fluid (BALF) were obtained from 16 patients with EP, including acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP). Twelve patients with acute respiratory distress syndrome (ARDS) were also included for comparison. The concentration of IL-33 and Th2 cytokines (IL-4, IL-5, IL-13) were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The concentration of serum IL-33 was significantly higher in patients with AEP than in CEP. In CEP, only patients with atopic factors showed mild increase of serum IL-33. The concentration of BALF IL-33 was also significantly elevated in AEP, however, it remained quite low in CEP. Among Th2 cytokines, IL-5 was significantly increased in both serum and BALF in AEP, and the level of IL-5 was positively correlated with that of IL-33. ARDS showed no increase of serum and BALF IL-33.

CONCLUSIONS

The remarkable increase of BALF IL-33 in AEP indicated the local production of IL-33 in lungs. IL-33 is considered to be a local key molecule for triggering pulmonary eosinophilia, together with IL-5. BALF IL-33 appears to be a useful marker for discriminating AEP from CEP and ARDS.

Multidetector-row computed tomography assessment of adding budesonide/formoterol to tiotropium in patients with chronic obstructive pulmonary disease

BACKGROUND

In patients with chronic obstructive pulmonary disease (COPD), multidetector-row computed tomography (MDCT) showed that tiotropium dilated the inner diameters in airways from the third to the sixth generation of the bronchi. Here we aimed to evaluate the morphological effect by adding a budesonide/formoterol combination to tiotropium in COPD patients using three-dimensional MDCT.

METHODS

Pulmonary function tests, St. George's Respiratory Questionnaire (SGRQ) and MDCT imaging studies were performed at the beginning and after budesonide/formoterol combination treatment for 12 weeks in 14 patients with COPD.

RESULTS

The median age was 73.5 years and the mean forced expiratory volume in 1 s (FEV1) as a percentage of the predicted value was 57.2 ± 18.3%. The luminal area in the fifth generation bronchi and the emphysema volume/CT-derived total lung volume were significantly correlated with FEV1 at baseline (r = 0.682, p < 0.02 and r = -0.868, p < 0.001, respectively). The average luminal area and wall area percentage in the third, fourth and fifth generations were correlated with the SGRQ total score. Budesonide/formoterol induced insignificant pulmonary function changes and significant symptoms improvement. CT images showed an increased inner luminal area and decreased wall area after budesonide/formoterol treatment. Average luminal area was significantly increased from 24.3 ± 9.7 to 26.0 ± 9.9 mm(2) in the third generation, 13.0 ± 6.5 to 14.7 ± 7.3 mm(2) in the fourth generation, 8.0 ± 4.8 to 9.4 ± 4.9 mm(2) in the fifth generation and 5.6 ± 2.7 to 6.7 ± 3.6 mm(2) in the sixth generation (p < 0.01). The average increase of the third generation luminal area was correlated with the FEV1 increase (r = 0.632, p < 0.03). The wall area percentage significantly decreased from 51.5 ± 9.2 to 49.1 ± 9.7 in the third generation, 56.1 ± 9.7 to 53.0 ± 11.1 in the fourth generation, and 62.3 ± 9.9 to 57.6 ± 9.8 in the fifth generation (p < 0.05). Emphysema volume/CT-derived total lung volume was unchanged with treatment.

CONCLUSION

MDCT demonstrated budesonide/formoterol induced bronchodilation in the non-small airway. CT imaging can evaluate drug therapeutic effect and may provide additional insights into pharmacotherapy for COPD.

[Interstitial pneumonia with anti-PL-7 antibody difficult to distinguish from rheumatoid lung]

A 63-year-old woman had abnormal shadows on a chest radiograph taken on a medical examination during treatment for rheumatoid arthritis. The chest radiograph showed linear and reticular shadows and ground glass opacities in the bibasilar lung fields. Though we considered rheumatoid arthritis due to joint disorder and a positive reaction for serum anti-CCP antibody, there were no bone lesions or articular narrowing on radiographs of the fingers. We diagnosed antisynthetase syndrome after we obtained a positive reaction for serum anti-PL-7 antibody. Antisynthetase syndrome demonstrates findings similar to those of rheumatoid arthritis, and this disease should be taken into consideration if chest computed tomography demonstrates consolidation with predominant patchy and irregular bronchovascular bundle thickening with a subpleural distribution.

Primary cardiac angiosarcoma of the right auricle with difficult-to-treat bilateral pleural effusion

A 70-year-old woman was admitted to our hospital with pleuritis and pericarditis. Cytological examination of pleural and pericardial effusion, and pleural biopsy specimens under thoracoscopy revealed no specific pathological findings. The pleural effusion was drained continuously; however, she died of circulatory insufficiency at day 45 from admission. At autopsy, a fragile hemorrhagic mass arising from the right auricle had invaded bilateral pleura and the pericardium directly without distant metastasis. Immunohistochemical staining showed that the tumor cells expressed endothelial markers such as CD31 and CD34 antibodies, and factor VIII-related protein. These findings supported the diagnosis of a poorly differentiated angiosarcoma.

Serum VEGF increases in diabetic polyneuropathy, particularly in the neurologically active symptomatic stage

AIM

To identify the relationship between vascular endothelial growth factor (VEGF) and diabetic polyneuropathy (DPN).

METHODS

Two hundred and twenty diabetic patients participated, 113 with DPN and 107 without DPN. All patients were also classified according to the four stages of DPN (no neuropathy: stage 0; asymptomatic neuropathy: stage 1; symptomatic neuropathy: stage 2; disabling neuropathy: stage 3). Serum VEGF concentration was measured using an enzyme-linked immunosorbent assay (ELISA) and levels between the patients with and without DPN and also between the different stages of DPN, were compared.

RESULTS

The mean serum VEGF level in all patients was 264.6 +/- 218.8 pg/ml. The mean serum VEGF level was higher in patients with DPN (310.1 +/- 224.3 pg/ml) than in the patients without DPN (216.5 +/- 204.0 pg/ml, P = 0.0014). Serum VEGF was higher in the 'symptomatic' stage (stage 2, 364.8 +/- 225.9 pg/ml) in comparison with the 'asymptomatic' (stage 1, 256.7 +/- 224.4 pg/ml, P = 0.015) and 'disabling' (stage 3, 180.3 +/- 109.4 pg/ml, P = 0.042) stages. The mean serum VEGF level in patients with diabetic retinopathy (261.1 +/- 210.6 pg/ml) and in patients with diabetic nephropathy (241.5 +/- 185.7 pg/ml) was not increased.

CONCLUSIONS

The serum VEGF level is increased in patients with DPN, particularly in patients in the neurologically active 'symptomatic' stage.

[Thyroid involvement of sarcoidosis]

A 54-year-old woman was found to have abnormal shadows on her chest radiograph taken on an annual medical examination. The chest radiograph showed multiple nodules in the bilateral middle and lower lung fields accompanied with bilateral hilar lymphadenopathy. A computed tomography of the neck and chest revealed nodules in her right middle lobe and bilateral lower lobes with an enlarged thyroid. A metastatic malignant disease involving both thyroid and lungs was suspected, therefore thyroid and lung biopsies were performed. The histological examination of the thyroid and the lung specimens revealed non-caseating epithelioid cell granulomas which were compatible with sarcoidosis. Although the thyroid involvement of sarcoidosis is rare, it should be included in the differential diagnosis with patients with thyroid swelling.

[Case of rapid progressive interstitial pneumonia associated with primary Sjogren syndrome]

A 72-year-old woman with a dry cough and dyspnea on exertion was admitted to our hospital. A chest radiograph showed reticular opacities and volume loss in both lower lung fields. She was troubled with xerostomia and her laboratory test showed positive reaction for anti SS-A and SS-B antibody. Labial biopsy led to a diagnosis of primary Sjogren's syndrome (pSjS). Lung biopsy specimens obtained by video-assisted thoracoscopic surgery (VATS) revealed interstitial pneumonia. On the sixth postoperative day, hypoxemia acutely worsened and her chest radiograph showed widespread diffuse ground-glass attenuation. A diagnosis of acute exacerbation was made, and steroid and immunosuppressive therapy was started. In spite of intensive therapy, she died due to respiratory failure. We report a rare case of interstitial pneumonia with pSjS resulting in acute exacerbation.

[A case of psittacosis showing a localized peripheral air-space consolidation]

A 29-year-old man was admitted with fever and anorexia. Radiographic examinations of the chest showed a localized peripheral non-segmental air-space consolidation in the right lower lobe. He had a history of exposure to parakeets, and psittacosis was diagnosed based on the elevated serum complement fixation titer against Chlamydia psittaci. The common radiographic finding of psittacosis is ground-glass attenuation radiating from the hilar areas. We report a rare case of psittacosis presenting a localized consolidation, clearly limited to the subpleural region of the lung.

[A case of sarcoidosis with atypical high resolution CT findings]

A 36-year-old woman was referred to our hospital for investigation of erythema on the upper arms and thighs and abnormal radiological findings in the chest. A chest radiograph showed poorly defined fine nodules in both lung fields and high-resolution CT revealed fine nodular opacities with a random distribution throughout both lungs. No lymph node enlargement or peribronchovascular interstitial thickening were seen. Bronchoscopic evaluation revealed bronchial mucosal hypervascularity. Transbronchial lung biopsy and skin biopsy specimens showed noncaseating epithelioid cell granulomas. These findings confirmed the diagnosis of sarcoidosis. This is a rare case of sarcoidosis presenting with atypical high-resolution CT findings, which are difficult to differentiate from those of miliary tuberculosis or metastatic carcinoma.

Pulsed-field gel electrophoresis in differentiation of erysipelothrix species strains

We report here the first analysis of Erysipelothrix spp. using pulsed-field gel electrophoresis (PFGE). Seventy strains of Erysipelothrix spp. were analyzed. SmaI, AscI, and NotI were tested for the ability to cleave the DNA extracted from those strains, and among them, SmaI was the most reliable enzyme. Sixty-three distinct PFGE patterns were produced, and no DNA degradation was observed, allowing the identification of all of the strains. Based on these results and on those of a previous analysis using randomly amplified polymorphic DNA and ribotyping, PFGE with SmaI might be considered to be more sensitive than those methods and to be the best method for epidemiological studies of strains of this genus.