Infected emphysematous bullae in a patient with diabetes mellitus

A 42-year-old woman with diabetes mellitus was admitted to our hospital because of fever, coughing, and dyspnea. Coarse crackles were audible and respiratory sounds were weak in the right lung field. Laboratory examination revealed a high erythrocyte sedimentation rate, a high level of serum C-reactive protein, a high blood sugar level, and hypoxemia. A chest roentgenogram revealed cystic lesions with fluid levels, and an infiltration shadow in the right lung field. A chest computed tomographic scan revealed many cystic lesions with fluid levels and an infiltration shadow. Our diagnosis was infected emphysematous bullae. A tube was inserted percutaneously for drainage and to allow injection of antibiotics into the cystic lesion. The cystic lesion then vanished. Percutaneous drainage and washing with antibiotics can be used to treat infected emphysematous bulla that have thick closed cystic walls.     

Successful treatment of a giant bulla by thoracoscopic excision and laser ablation

A 39-year-old male complaining of shortness of breath on mild exertion. Radiographs revealed that a giant bulla occupied more than half the area of the right lung field. Thoracoscopic excision of the giant bulla was performed using some autosutures. After the emphysematous lesion was consolidated by laser ablation, it was sutured using PDS thread. The bulla in the left lung was similarly excised 3 weeks after the first procedure. The FEV1.0% improved from 72% to 89% after excision and laser ablation of a giant bulla and bullae. Thoracoscopic excision and laser ablation of a giant bulla appears to be an effective alternative to conventional thoracotomy.     

Neovascularization and HGF: neovascularization in proliferative diabetic retinopathy and intraocular HGF

We experienced a case of multiple bilateral giant bullae of the lungs and treated by thoracoscopic bilateral resection. A 46-year-old male was admitted to our hospital on the diagnosis of bilateral giant bullae of the lungs. Chest CT scan and lung perfusion scintigraphy showed giant bullae at the apex of both lungs and at the left lower lobe. The border of the bullae was relatively clear, and the other lung was almost normal although it was compressed by the bullae. We evaluated this case and found that it was a good indication for a thoracoscopic bilateral resection. The patient was positioned on his back, and a successful thoracoscopic bilateral resection was performed. The patient was discharged from the hospital on the 10th day postoperatively. Chest CT scan, lung perfusion scintigraphy and respiratory function test performed 2 months postoperatively, showed remarkable improvement. We would recommend this surgical technique in patients with similar diagnosis.     

Detection of emphysematous bullae in spontaneous pneumothorax by three-dimensional computed topography

The patient was a 20-year-old woman with spontaneous pneumothorax, who had had pneumothorax twice on each side. Three-dimensional computed topographic (CT) images were made as follows. The range 12.5 cm caudad from the pulmonary apex was scanned by rapid helical CT, and three-dimensional images were obtained with the surface-rendering technique at a voxel extraction threshold ranging-850 HU to 1,600 HU. The three-dimensional CT images provided a stereotactic rendering of the lung surface. Irregular findings were observed at both pulmonary apices; they indicated the presence of one emphysematous bulla in the right lung and many emphysematous bullae of various sizes in the left lung. These findings were highly consistent with the sites and structures of the emphysematous bullae, as observed during thoracoscopy, which suggests that three-dimensional CT is a useful method for diagnosing and evaluating emphysematous bullae in patients with spontaneous pneumothorax.     

Usefulness of computed tomography and scintigraphy in diagnosis of emphysematous bullae in the lung

The x-ray examinations usually do not reveal morbid changes after lung expansion in the treatment of spontaneous pneumothorax. In our observation computed tomography (CT) and scintigraphy enable not only the exact determination of the extent of changes but also they disclose bullae invisible in conventional chest radiographs. 15 patients with cured spontaneous pneumothorax and 10 patients with radiographic evidence of a bulla or bullae were examined. CT scans showed bullae from 3 to 18 cm in diameter involving predominantly the upper lobes. 4 patients had additionally subpleural or intraparenchymal bullae of various degrees. In all patients with cured spontaneous pneumothorax, CT scans revealed intraparenchymal bullae, and in 6 cases bilateral intraparenchymal bullae were revealed. Only in sites of large bullae, no isotopic marker or its low elimination was shown in perfusion and inhalation scintigraphy. 10 patients with giant bullous emphysema were operated; in 6 patients enucleation of bullae, in 3 lobectomy and in one patient bullectomy were performed. CONCLUSION: CT is a method of choice in the diagnosis of lung emphysematous bullae and it enables the detection of the changes undetectable in chest radiographs. Perfusion and inhalation scintigraphy is helpful in the diagnosis of large emphysematous bullae and postoperative follow-up examination.     

Simulating binocular visual field status in glaucoma

A 73-year-old male was admitted to our hospital because of productive cough and infiltrate on the chest roentogenogram. The underlying diseases was found to be multiple myeloma. He received a physical examination in June, 1996. The chest X-ray and CT scan on admission showed an infiltrative shadow with multiple bulla in the left upper lung field. Internal use of antibiotics and drip infusion of IPM/CS were ineffective. The chest X-ray showed air-fluid level in left upper peripheral bullous lesion and a percutaneus needle aspiration of the lung was performed. The specimen was pus with blood and microscopical examination of smears revealed no acid-fast bacilli, but Mycobacterium szulgai was isolated and identified by DNA-DNA hybridization method. The patient was treated with isoniazid and rifampicin, and improved in a few months. There are a few case reports of pulmonary infection due to M. szulgai associated with emphysematous bulla of the lung in Japan. M. szulgai infection of the lung is similar to M. kansasii infection in respect to clinical features (improvement of chest abnormal shadow, efficacy of drug).     

Management of a giant fluid-filled bulla by closed-chest thoracostomy tube drainage

A 53-year-old man was admitted to the hospital for management of pneumonia and a giant fluid-filled bulla. He appeared acutely ill and had persistent fever despite prolonged therapy with parenteral antibiotics and aggressive bronchial drainage. Percutaneous placement of an 8.5F catheter into the bulla enabled drainage of both fluid and air within the bulla and led to resolution of his symptoms within 24 h. This report demonstrates that drainage of giant fluid-filled bullae may lead to rapid resolution of symptoms and describes a novel management technique for this condition.     

Rupture of the aortic arch due to bacterial aortitis--a case report of a patient undergoing successful surgical therapy

A 59-year-old man came to our hospital because of hoarseness and chest pain. On initial examination, a chest roentgenogram showed no abnormality. Three weeks later, while the patient was waiting to undergo a computed tomographic (CT) scan, shock suddenly developed. A chest roentgenogram revealed an extremely wide mediastinal shadow. A CT scan revealed rupture of the aortic arch near the base of the left subclavian artery, although there was no aneurysm. An emergency operation was performed. The ruptured aortic arch was replaced with an artificial graft during cardiopulmonary bypass with selective cerebral perfusion. A diagnosis of infectious aortitis was not made until a pathologist discovered colonies of gram-positive cocci in the resected specimen of the aortic arch. Postoperatively, antibiotics were administered for only four days. The patient is well about two years after the operation. Infectious aortitis had a very low prevalence and rarely involves the thoracic aorta. However, we should be aware of that it may cause aortic rupture even in the absence of aneurysmal dilatation.     

Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery

In 5 cases, an infectious giant bulla was opened with the use of video-assisted thoracoscopic surgery (VATS). Because all bullae adhered to the thoracic wall and were noncommunicating with the airway, they were opened without complete resection, leaving their inside walls at the lung and lateral walls on the thoracic wall. The expansion of remnant lung was excellent, and postoperative air leakage did not occur in any case. The postoperative vital capacity and FEV1 improved significantly over the preoperative condition (p<0.01). Because the bronchial communication of bulla is frequently obliterated after infection within the bulla, opening of a bulla is curative and simpler, more effective, and less invasive than complete resection.     

Peripheral primitive neuroectodermal tumor in parietal pleura]

A 19-year-old woman was admitted to Kushiro city general hospital due to chest pain and dyspnea. Chest radiographs and computed tomographic scan showed a large intrathoracic mass adjacent to the pleura. Angiographs disclosed feeding veins of the tumor arising from lateral thoracic artery. Fine-needle aspiration cytology of the tumor revealed small round cells with a large nuclear/cytoplasmic ratio. Immunocytochemical study demonstrated that the tumor cells were positive for neuron-specific enolase and MIC 2 gene product. The diagnosis was primitive neuroectodermal tumor of the parietal pleura (also known as Askin tumor). Chemotherapy combined with peripheral blood stem cell transplantation reduced the size of the tumor significantly. However, multiple bone metastasis recurred, and the patient died 35 months after the start of therapy.     

Swyer-James syndrome with pneumomediastinum and subcutaneous emphysema due to bronchial asthma

A 24-year-old woman was admitted to our hospital due to moderate asthmatic attacks. Dyspnea and hypoxemia progressed gradually despite medication. A chest roentgenogram revealed left unilateraly hyperlucency with pneumomediastiumn and subcutaneous emphysema. Swyer-James syndrome was diagnosed. Several cases of Swyer-James syndrome with bronchial asthma airway hyperresponsiveness have been reported, but we know of no reports of Swyer-James syndrome with pneumomediastinum and subcutaneous emphysema due to prolonged asthmatic attacks. Pneumomediastinum and subcutaneous emphysema may be caused by abnormally high pressures in the bronchial lumen and alveolar space during asthmatic attacks, because the emphysematous lesion may be structurally weak.     

The pulmonary air meniscus sign in a case of sclerosing hemangioma

A 57-year-old woman was admitted to our hospital because of a slowly growing pulmonary tumor with a 34 year history. Chest roentgenogram on admission showed a 42 mm sharply demarcated solitary tumor in the left upper lobe. Chest CT revealed a slit-like pulmonary air meniscus. Left upper lobectomy was performed. A specimen from the resected lung histologically showed solid, papillary and hemorrhagic patterns, and the diagnosis of pulmonary sclerosing hemangioma was therefore made. Pulmonary air meniscus sign in pulmonary sclerosing hemangioma is rare. We think one possible mechanism in the production of an air meniscus sign in sclerosing hemangioma is bleeding in communication with a bronchus.     

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.     

Pneumonia caused by granulomatous Pneumocystis carinii in a patient with the acquired immunodeficiency syndrome

A 54-year-old man was admitted to the hospital because of fever and general fatigue. A chest roentgenogram on admission showed lobular opacities and ill-defined opacities in both lower lobes. The pneumonia was successfully treated with antibiotics. The acquired immunodeficiency syndrome was diagnosed because ELISA and PCR tests for antibodies to the human immunodeficiency virus were positive and the CD 4+ lymphocyte count was 39 per cubic millimeter. Examination of bronchoalveolar lavage fluid revealed no Pneumocystis carinii. Trimethoprim and sulfamethoxazole were given prophylactically, but were withdrawn because of a rash. The patient began to receive aerosolized pentamindine and was discharged. On the next day, he was readmitted to the hospital because of a high fever. A chest roentgenogram showed diffuse miliary opacities. Chest CT scan also showed diffuse small nodular opacities in both lungs. Examination of a transbronchial biopsy specimen revealed well-defined, noncaseating granulomas with pneumocystis organisms in their centers. Cultures for tuberculosis and fungi were all negative. We diagnosed granulomatous pneumonia caused by Pneumocystis carinii, which is an atypical manifestation of Pneumocystis carinii pneumonia. The patient died of sepsis and cardiac tamponade. Microscopically, the lung tissue was found to have foamy intra-alveolar exdates, which is a typical histological feature of Pneumocystis carinii pneumonia.     

Mediastinal cyst involving the oesophagus: diagnosis and results of surgical treatment

OBJECTIVE: To describe our experience with mediastinal cysts involving the oesophagus. DESIGN: Retrospective study. SETTING: University hospital, Italy. SUBJECTS: 11 patients who presented to our department with a mediastinal cyst from 1976-1994. INTERVENTIONS: Excision of the mass through a posterolateral thoracotomy (n = 10) or by video-assisted thoracoscopy. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: 8 patients presented with retrosternal or epigastric pain, three of whom had mild dysphagia. In the remaining 3 the tumour was asymptomatic and an incidental finding on a chest radiograph. Endoscopic ultrasonography and computed tomography (CT) allowed preoperative diagnosis of an extramucosal cyst in 5 of the 7 patients investigated by both tests. Masses were excised through a formal thoracotomy (n = 10) or by video-assisted thoracoscopy. Histological examination confirmed a benign cyst in all cases. There was no operative morbidity and nine patients are free of symptoms after a median follow-up of 2.3 years. CONCLUSION: Excision, preferably by thoracoscopy, is the treatment of choice for mediastinal cysts that involve the oesophagus. Special attention should be paid to the vagal nerves, and as many as possible of the muscular layers of the oesophagus should be preserved.     

Pulmonary hypertension. Response of vasoactive peptides to a nonionic contrast medium in patients undergoing pulmonary angiography

A 46-years-old male was admitted to our hospital because of productive cough and infiltrates on the chest roentogenogram. The patient had a history of left upper bullectomy ten years prior to the admission. The CT scan of the chest on admission showed infiltrats with cavitation in the left apex and multiple bullae in almost whole lung. Microscopical examination of smears of sputum and bronchoalveolar lavage fluid revealed acid-fast bacilli. They were identified as Mycobacterium szulgai by DNA-DNA hybridization method. The patient was treated with isoniazid, streptomycin and rifampicin. After treatment for about a month, the culture of sputum converted to negative for M. szulgai. After about three months hospitalization, the infiltrates decreased and the cavity wall became thin, and no recurrence sign has been observed after the discharge. There are a few case reports of pulmonary infection due to M. szulgai associated with bullous disease of the lung in Japan.     

Treatments for hepatocellular carcinoma in cirrhosis : practical aspects]

A 44-year-old woman was admitted to our hospital for evaluation of an abnormal lung shadow. Chest computed tomography (CT) revealed a tumor surrounded by air-space and an infiltrative shadow in the right S2. Right upper lobectomy was performed and pulmonary sclerosing hemangioma was diagnosed. Usually, pulmonary sclerosing hemangioma shows a solitary round nodule on a chest CT scan. We report a case of pulmonary sclerosing hemangioma with an unusual shadow on a chest CT scan, and review the literature.     

Pulmonary cavernous hemangioma--identification of its endothelial cell origin by immunohistological staining

A 45-year-old woman was referred to our hospital because of a tumorous shadow in the S10 segment of the left lung. A chest computed tomography (CT) scan showed a nodular lesion with a slightly irregular margin and no contrast enhancement. CT-guided aspiration biopsy was tried but did not result in a histological diagnosis. The tumor was excised during video-assisted thoracoscopic surgery. Histological examination of the specimen revealed cavernous hemangioma. Most cells lining the lumen of the cavernous structure stained positively for von Willebrand factor antibody and negatively for anti-epithelial membrane antigen antibody, which suggests that the tumor was associated with endothelium. To the best of our knowledge, this is the first report of a case in which the diagnosis of pulmonary cavernous hemangioma was confirmed with an immunohistological study.     

Idiopathic giant bullous emphysema (vanishing lung syndrome): imaging findings in nine patients

OBJECTIVE: We reviewed the imaging findings in nine patients with idiopathic giant bullous emphysema. This progressive condition is characterized by large bullae, usually seen in association with several forms of emphysema, and usually occurs in young men, most of whom are smokers. MATERIALS AND METHODS: Nine patients with chest radiographic evidence of a bulla or bullae occupying at least one third of a hemithorax, who had also been examined with high-resolution CT, were included in this retrospective study. We examined the size, distribution, and locations of bullae. On high-resolution CT scans, bullae were categorized as predominantly subpleural or intraparenchymal. RESULTS: In eight of the nine cases, the chest radiographs showed variable asymmetry in the distribution of bullae. Bullous disease involved predominantly the upper lobes. High-resolution CT showed bullae from 1 to 20 cm in diameter, but most were 2-8 cm in diameter. Paraseptal emphysema and subpleural bullae were the predominant findings in all nine patients. Seven patients had separate centrilobular emphysema of various degrees and intraparenchymal bullae. None of the intraparenchymal bullae were larger than 2-3 cm. Additionally, two non-small-cell lung cancers were seen in our series. CONCLUSION: The dominant and consistent feature seen on high-resolution CT scans in both smokers and nonsmokers is extensive paraseptal emphysema merging into giant bullae. Associated centrilobular emphysema, seen in cigarette smokers, is the important variable finding for determining the extent of underlying parenchymal disease, which may help in the preoperative assessment of giant bullous lung disease.     

Giant cell arteritis manifesting as chronic cough and fever of unknown origin

A 57-year-old white man sought medical attention because of chronic cough and fever of unknown origin. An extensive work-up over 4 weeks, including repeated blood cultures, chest roentgenograms, a gallium scan, and computed tomographic scans of the sinuses, chest, and abdomen, was nondiagnostic. The patient was referred to our institution for bronchoscopy. Further analysis of his history revealed that he had a headache in conjunction with the cough and an episode of a flashing color design in his left eye 1 week before assessment. The erythrocyte sedimentation rate was 115 mm in 1 hour. A biopsy of the temporal artery showed granulomatous inflammation of the vessel wall with multinucleated giant cells, histiocytes, lymphocytes, plasma cells, and few eosinophils. The multinucleated giant cells were closely related to the fragmented elastic lamina. Corticosteroid therapy resulted in prompt resolution of the chronic cough and fever. Giant cell arteritis should be considered in the differential diagnosis of chronic cough.