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).     

A case of chronic necrotizing pulmonary aspergillosis successfully treated with combination therapy of antifungal drugs and ulinastatin

A 64-year-old woman with a history of old tuberculosis, had a fungus ball shadow with meniscus sign in the upper right lung field on a chest X-ray film in 1991. Based on the chest X-ray findings, pulmonary aspergilloma was suspected. Because the size of the intracavitary fungus ball increased, the patient was treated with itraconazole over one year in 1995, but there was no improvement. One month later, she was admitted because of fever, hemoptysis and productive cough, and chest X-ray showed an enlargement of intracavitary mass and infiltrative shadow in the right lung. Chronic necrotizing aspergillosis was diagnosed on the basis of her clinical and radiographic features, and positive serological test. Although itraconazol and amphotericin B were given, cavity and intracavitary fungus ball shadow kept growing. Combination therapy of antifungal drugs and ulinastatin markedly improved symptoms and resulted in complete disappearance of the fungus ball on chest CT scan.     

Feasibility of stent placement above the sphincter of Oddi ("inside-stent") for patients with malignant biliary obstruction

In three cases of primary pulmonary amyloidosis the chief complaint was hemosputum. The diagnosis of amyloidosis was made using histochemical analysis of bronchial wall biopsy in all cases; multiple nodular lesions were observed in trachea and bronchi on flexible fiberoptic bronchoscopy. The surface of the tracheobronchial mucosa was smooth but bled easily. In one patient, chest X-ray film showed a solitary nodular shadow in the left lower lung field. These three cases were tracheobronchial amyloidosis, and one case was combined with nodular parenchymal type amyloidosis.     

A surgical case of liposarcoma in the chest wall within the thoracic cavity of a young patient

A 21-year-old man presented to our hospital on June 7, 1990, asymptomatic but with an abnormal shadow in his chest roentgenogram. A well-demarcated tumorous shadow was seen in the left hilum of the lung in the frontal view of the chest X-ray, and adjacent to the posterior chest wall in the lateral view. A percutaneous needle biopsy was performed, and since there were no malignant findings, the tumor was left untreated for future examinations. However, since the tumor was observed to be enlarging gradually in subsequent chest X-rays, it was resected surgically on June 18, 1991. The tumor was fist-sized and its surface smooth, and was protruding into the thoracic cavity. At surgery, the tumor was separated from the chest wall. The tumor, weighing 170 grams, was diagnosed pathologically as a liposarcoma (myxoid type). It was confirmed that there was no infiltration into the surrounding tissue and that total resection had been performed. There are few reports of liposarcomas within the thoracic cavity developing in the extra-mediastinal chest wall. As our case is the second in Japan occurring in a young patient, we present it here together with a review of the literature.     

Efficacy of serial electrical cardioversion therapy in patients with chronic atrial fibrillation after valve replacement and implications for surgery to cure atrial fibrillation

In April 1993, a 51-year-old woman had a fever, and an infiltrative shadow was seen in the left upper lobe on a chest X-ray film. Repeated sputum cultures were positive for Mycobacterium avium complex. She underwent antituberculosis therapy consisting of pyrazinamide, ofloxacin, and streptomycin. Her symptom disappeared and the abnormal shadow resolved. In January 1994, she was admitted to the hospital because of bloody sputum and abnormal chest X-ray findings consisting of a left hilar mass and atelectasis of the left upper lobe. Bronchoscopy revealed multiple polypoid lesions without necrosis in the left upper-lobe bronchus. Histological examination showed that the tumor consisted of an aggregation of lymphocytes and plasma cells, and was positive for Ziehl-Neelsen stain. The acid-fast bacillus was identified as Mycobacterium avium by the DNA probe method. Anti-tuberculosis treatment was given: rifampicin, isoniazid, sparfloxacin, and clarithromycin. Three months later, the atelectasis and the polypoid mass in the left upper-lobe bronchus had disappeared. We believe that the polypoid lesions in the left upper-lobe bronchus were due to infection by Mycobacterium avium. The patient was HIV-negative and immunocompetent. Such endobronchial lesions caused by Mycobacterium avium are rare in HIV-negative hosts.     

A case of chronic expanding hematoma resected 37 years after lobectomy

A 65-year-old man was admitted for evaluation of slowly growing mass shadow in the right lower lung field on chest X-ray film. He had undergone right upper lobectomy for pulmonary tuberculosis 37 years before. As we could not rule out a suspicion of mediastinal tumor, thracotomy was performed. Histological examination of the resected mass showed a hematoma surrounded by dense fibrotic tissue. And the mass was resultantly diagnosed as chronic expanding hematoma. The mechanism of chronic expanding hematoma is unclear. In our review of the Japanese literatures, only 10 cases including this one, resected more than twenty years after the initial trauma or operation, could be found.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

Decreased transforming growth factor beta type II receptor expression in intestinal adenomas from Min/+ mice is associated with increased cyclin D1 and cyclin-dependent kinase 4 expression

Two cases of cavitary lung cancer with pulmonary aspergillosis were experienced. Case 1 was a 45-year-old male. Chest X-ray and Chest CT revealed a round shadow in the thin-wall cavity of the upper lobe of the right lung. Upper lobectomy of the right lung was performed. Histologically large cell carcinoma was found to invade the entire cavity wall, and aspergillus was not detected in the intracavitary space. Case 2 was a 75-year-old male. Chest X-ray and Chest CT revealed a round shadow in the thin-wall cavity of the upper lobe S1 + 2 of the left lung. As a result of upper lobectomy of the left lung and S6 partial resection, large cell carcinoma was found to invade the entire cavity wall, and aspergillus was not detected in the intracavitary space. Only 19 cases including ours are reported about cases of lung cancer complicated by pulmonary aspergillosis at the same site in Japan. The mechanism of aspergillus infection had not been clarified in the discussions of the reported literature and nothing characteristic could be pointed out in our cases except for the assumption that the presence of cancer was a factor triggering Aspergillus implantation.     

Transient inhibition of L929 cell mitosis and locomotion by argon ion laser irradiation

A 48-year-old woman was admitted to our hospital because of abnormal shadow on the chest X-ray. Chest contrast CT scan showed roundly mass in the posterior mediastinum which were combined with and without contrast elements, and chest MRI (T2 weighted) showed high signal intensity. These features suggested mediastinal cyst or extralobar sequestration. The operation was performed through left 6th intercostal thoracotomy. Two different lesions connected to the mediastinum were confirmed, a cystic tumor and small accessory lung. The former was diagnosed as bronchogenic cyst and the latter as extralobar pulmonary sequestration.     

A case of chronic lung abscess showing a cloudy shadow of the right upper lobe, diagnosed by transbronchial aspiration cytology

A 58-year-old healthy woman was admitted to our hospital on 8th October, 1991 for detailed investigation of an abnormal shadow on chest roentgenogram, which was detected by mass survey. The chest roentgenogram showed a cloudy shadow of the right upper lobe, and retrospectively, this abnormal shadow had been present since 1986. Flexible fiberoptic bronchoscopy showed complete obstruction of right B1b bronchus by regenerated bronchial mucosa. Aseptic pus was detected in the obstructed bronchus by means of transbronchial aspiration cytology (TBAC) and chronic lung abscess was diagnosed. The chest roentgenograms of this case is very unusual, and we were unable to find a similar case of chronic lung abscess diagnosed by means of TBAC.     

Atypical mycobacteriosis (Mycobacterium xenopi) with "initial aggravation"

A 66-year-old man was admitted to Nara Medical University Hospital because of sputum production and fevre. A chest X-ray film obtained on admission revealed many cysts and an infiltrative shadow in the right upper lung field. The patient was treated with antimycobacterial drugs (isoniazid 400 mg, streptomycin 0.75 g, and rifampicin 450 mg) because acid-fast bacilli were detected in his sputum. Although the symptoms and laboratory data improved, a new infiltrative shadow developed in the right lower lung field two months after the start of treatment. Transbronchial biopsy specimens showed intraluminal organizing exudate and alveolitis. The new lesion resolved when treated with the same antimycobacterial drugs. Mycobacterium xenopi was cultured from the sputum 80 days later. This is the third reported case of atypical mycobacteriosis (non-tuberculous mycobacteriosis) due to M. xenopi in Japan with the "initial aggravation" seen in some patients with typical pulmonary tuberculosis.     

Study of superior vena cava syndrome--aetiopathology, diagnosis and management

Thirty two patients of superior vena cava syndrome (SVCS) were studied. Clinical features noted were diffuse neck swelling, breathlessness, chest pain, engorged neck veins, facial swelling and dilated engorged veins over chest wall. Radiography revealed a superior mediastinal mass in 31.2% of patients and right upper lobe mass in 50% patients. FNAC of lung showed aetiology in 34.5% patients and lymph node biopsy in 31.2% patients. Aetiology of SVCS was benign in 12.5% patients and malignant in 87.5% patients. Squamous cell carcinoma was the commonest cause of SVSC. Radiotherapy proved to be the most beneficial form of treatment. The mean survival period in patients due to malignant etiology was 6 months.     

Informative value of Hemoccult test according to the number of positive slides in mass screening of colorectal cancer]

Desmoid tumors develop in the muscle or aponeurosis, but rarely in the chest wall. We report a patient with desmoid tumor in the chest wall. A 30-year-old female visited our hospital due to an abnormal shadow in the chest detected at a health examination. No definite diagnosis could be made by chest CT, MRI, or Ga scintigraphy, and finally a biopsy demonstrated desmoid tumor. The left anterior chest and posterolateral chest (lung apex) were opened, and tumors were resected together with the chest wall. No radiotherapy was performed. No recurrence has been observed for 1.5 years after operation. This tumor does not yield distant metastasis, but its recurrence rate is very high. Therefore, we intend to follow this patient for a long period.     

Pulmonary agenesis with intrathoracic upper limb

A 10-week-old boy was referred because of respiratory distress, absence of right upper limb, and a mass in the right upper chest and shoulder region. Investigations showed agenesis of the right lung; the right hemithorax was filled by a mass that was mainly cystic but also contained a deformed right upper limb. When surgery was performed at the age of 13 weeks, the mass was delivered out of the chest and removed together with the deformed limb. The upper 5 cm of the shaft of the humerus could be preserved, and the chest wall could be repaired satisfactorily. Recovery was uneventful. The embryology of the malformation is briefly discussed.     

Pulmonary disease caused by Mycobacterium avium presenting as a solitary cavity with a thickened wall]

A 46-year-old man was admitted for evaluation of a solitary pulmonary cavity in the apey of the left lung. Because two transbronchial biopsies followed by brushing and washing and sputum cytology did not yield any diagnostic findings, the patient was treated with INH, RFP and SM under a tentative diagnosis of pulmonary tuberculosis. The shadow decreased over two months with combination therapy, but increased again after the dose of SM was decreased. We performed a left upper lobectomy to diagnose either multi-drug-resistant pulmonary tuberculosis or lung cancer. Pathological examination of the resected lung revealed epitheloid cell granulomas with areas of caseous necrosis. Smooth chromophoric colonies were isolated on an Ogawa egg medium, and were identified as M. avium by PCR and DDH. A diagnosis of pulmonary M. avium was made. A chest X-ray film taken two years later was normal. Pulmonary M. avium disease developed in this patient, who had no predisposing lung pathologies.     

Tc-99m MIBI uptake in simultaneous thyroid and lung cancers

The authors present a patient with simultaneous follicular thyroid and small-cell lung cancers, both of which showed Tc-99m MIBI uptake. CT scans showed two masses: one involving the right lower neck including the right supraclavicular area and the right superior mediastinum, and the other involving the peripheral portion of the right upper lobe of the lung. I-131 imaging showed increased uptake in the right neck mass only. Tc-99m MIBI imaging, which was performed for evaluation of chest pain, showed intense uptake in the neck mass (tumor to heart ratios in planar and tomographic images were 0.92 and 0.96, respectively), and less uptake in the lung mass (tumor to heart ratios in planar and tomographic images were 0.53 and 0.40, respectively). Biopsy of the right supraclavicular mass revealed a follicular carcinoma, and a bronchoscopic biopsy of the right upper lobe mass revealed a small cell carcinoma.     

A case of malignant lymphoma of the thyroid accompanied by interstitial pneumonitis during radiation therapy after systemic chemotherapy

We reported a case of malignant lymphoma of the thyroid accompanied by interstitial pneumonitis during radiation therapy after systemic chemotherapy. Thyroid malignant lymphoma is a rare malignant tumor, which usually responds well to irradiation and systemic chemotherapy. Interstitial pneumonitis occurred during radiation after systemic chemotherapy. In this case, irradiation was simultaneously done with the chemotherapy. The radiation field included the neck and upper mediastinum. Chest X-ray showed multiple patchy shadows in both the middle and lower lung field, and it changed to contraction shadows after steroid pulse therapy. 67Ga scintigram showed multifocal increase of uptake, when chest X-ray patchy shadows were seen only in the middle and lower lung fields. 67Ga scintigraphy and CT were considered useful for evaluation of drug-induced interstitial pneumonitis.     

A case of mediastinal teratoma discovered availing of pneumonia

A 42-year-old woman was admitted to our hospital with hemosputum and an abnormal shadow on chest X-ray. Although her hemosputum disappeared after the treatment of pneumonia, the abnormal shadow was not improved. Chest CT showed a mediastinal mass. She underwent thoracotomy and the tumor, measuring 6 x 5 x 5 cm in size, was resected. Pathological diagnosis was a mature type teratoma with direct invasion to the lung. We have to take mediastinal teratoma into consideration as one of the causes of pneumonia.     

Horner's syndrome associated with a solitary bone plasmacytoma of the first rib

A case of solitary plasmacytoma originated in the left first rib in a 45-year-male is presented. The initial symptomatology was a Horner's syndrome. A chest X-ray, gammagraphy, TAC and arteriography showed a tumor shadow in the left chest wall; no evidence of plasmacytoma after clinical study found use where. The treatment was surgical excision and postsurgical radiotherapy. The histological investigation revealed a plasmacytoma of the rib. The patient have been followed for two years. The patient is asymptomatic, without evidence of local recurrence and systemic spread of the disease two years after treatment.     

Nontuberculous Mycobacterium pulmonary infection with pleural effusion caused by Mycobacterium kansasii

A 28 year-old man was admitted to our hospital because of fever, cough and chest pain. A chest X-ray film taken on admission showed infiltrate in the left upper lung field with ipsilateral pleural effusion. Microscopical examinations of stained specimens of sputa and pleural effusions disclosed no acid-fast bacilli. The level of adenosine deaminase (ADA) in pleural effusion was 46.4 IU/l. A tuberculin skin test was moderately positive. The most probable diagnosis was pulmonary tuberculosis with pleural effusion. Isoniazid (INH) and rifampicin (RFP) were administered on the 5th hospital day and continued to lower the fever and reduce the pleural effusion. The cultured specimens of sputa and pleural effusions yielded Mycobacterium kansasii. After six months of treatment, chest X-ray film showed improvement and the administration of INH, RFP was discontinued without recurrence.