中性粒细胞胞质抗体阴性肉芽肿性多血管炎1例

本文报道1例以肺部多发结节伴空洞为主要特征的老年男性病例。患者为73岁老年男性, 主因"干咳伴气短3个月"入院, 胸部CT示双肺多发不规则团块、结节、斑片影, 伴空洞形成, 同时合并贫血、肾功能不全, 经验性抗感染、抗结核治疗后肺部结节进展、空洞增大。多次检测血ANCA均为阴性。支气管镜下对右肺中叶病变行黏膜活检, 可见小片状坏死、局灶肉芽肿结构形成以及血管炎表现, 弹力纤维染色在坏死灶中可见残存的血管壁结构。临床诊断ANCA阴性肉芽肿性多血管炎, 给予糖皮质激素及环磷酰胺治疗后病灶缩小。     

痰中带血伴肺内结节和空洞性病变

本文报道1例中年男性患者,主因"间断咳嗽、咳痰、痰中带血1年"就诊。患者血清自身抗体阴性。病程初期于外院查胸部CT可见右肺中叶结节伴空洞形成,行手术切除病灶,术后病理诊断炎性假瘤,未予治疗后症状再发,复查胸部CT新见右肺上叶斑片实变影,上级医院会诊手术病理见血管炎改变,考虑诊断肉芽肿性多血管炎,加用激素治疗后病情仍逐渐进展,北京协和医院会诊病理诊断肺放线菌病,经抗感染治疗后病灶吸收。本患者的诊治过程加深了临床医师及病理科医师对感染与血管炎关系的理解。     

痰中带血伴肺内结节和空洞性病变

本文报道1例中年男性患者,主因"间断咳嗽、咳痰、痰中带血1年"就诊。患者血清自身抗体阴性。病程初期于外院查胸部CT可见右肺中叶结节伴空洞形成,行手术切除病灶,术后病理诊断炎性假瘤,未予治疗后症状再发,复查胸部CT新见右肺上叶斑片实变影,上级医院会诊手术病理见血管炎改变,考虑诊断肉芽肿性多血管炎,加用激素治疗后病情仍逐渐进展,北京协和医院会诊病理诊断肺放线菌病,经抗感染治疗后病灶吸收。本患者的诊治过程加深了临床医师及病理科医师对感染与血管炎关系的理解。     

双肺多发结节伴空洞形成

患者女, 64岁, 2023年2月21日因"右侧胸痛4年余, 左侧胸痛9月余"就诊于北京朝阳医院。既往有陈旧性肺结核、类风湿关节炎病史。2018年10月胸部CT示双肺多发结节。CT引导下穿刺病理未见肿瘤。胸腔积液腺苷脱氨酶升高, 考虑结核可能性大, 于2019年3月起给予抗结核治疗。2019年12月因右侧局限性液气胸, 行右肺下叶切除, 术后病理示肉芽肿性炎伴坏死。2020年5月胸部CT示肺部结节及空洞较前明显增多。2023年1月考虑不除外隐球菌肺炎, 给予氟康唑口服。最终, 术后病理会诊确诊为肺类风湿结节, 给予口服泼尼松及吗替麦考酚酯治疗1个月后复查胸部CT较前好转, 建议继续目前治疗, 定期复查胸部CT。     

IgG4相关性肺疾病1例及文献复习

目的提高对IgG4相关性肺疾病的临床特征、胸部影像学和病理组织学的认识。方法对1例经病理证实的IgG4相关性肺疾病的临床资料进行分析,并结合文献进行回顾总结。结果患者男,62岁,以胸腔积液起病,在外院先后行胸膜活检、胸腔镜肺活检等均未能明确诊断,后至我院行CT引导下经皮肺穿刺活检术,结果示活检组织内纤维组织增生伴淋巴细胞、浆细胞等炎症细胞浸润,免疫组化示大量浆细胞(+),IgG4阳性,浆细胞最密集计数约为40个/高倍视野,血清IgG4浓度示4.07 g/L(0.03 g/L~2 g/L)。诊断IgG4相关性肺疾病,给予糖皮质激素治疗,2个月后复查胸部CT示肺部病灶较前局部吸收、好转。结论IgG4相关性疾病是一种累及多器官、以血清IgG4水平升高、组织IgG4阳性浆细胞浸润为特点的淋巴浆细胞病。目前国内IgG4相关性肺疾病的报道很少,报道这一病例并进行文献复习有助于提高对IgG4相关性肺疾病的认识。     

老年急性嗜酸粒细胞性肺炎1例及文献复习

目的：探讨急性嗜酸粒细胞性肺炎(acute eosinophilic pneumonia,AEP)患者的临床特点、诊治和预后,提高临床诊治水平。方法分析北京医院收治的1例老年男性 AEP 患者的临床、影像学和病理学特点,并结合文献复习加以总结。结果患者以咳嗽、咳痰、发热起病。胸部 CT 示双肺多发斑片影伴少量胸腔积液,抗感染治疗无效。经皮肺穿刺活检病理提示 AEP,给予糖皮质激素治疗后好转。结论 AEP 是一种少见病,易被误诊为细菌性肺炎,对糖皮质激素敏感,早期明确诊断,规范治疗,治愈后无复发,预后良好。     

淹溺后双肺变化的斑片磨玻璃影

老年男性患者, 因淹溺伴意识丧失入院, 影像学主要表现为双肺多发的斑片磨玻璃影, 最初沿重力分布, 短期内演变为沿支气管血管束分布, 支气管肺泡灌洗液呈先浅后深的血性液体, 诊断考虑淹溺后的吸入性肺炎, 继发肺水肿伴肺泡出血。经验性抗感染治疗、有创机械通气、糖皮质激素抗炎后患者病情好转, 顺利出院, 复查胸部CT可见双肺斑片及磨玻璃影大部吸收。     

矽肺伴急性纤维素性机化性肺炎

本文报道1例矽肺伴急性纤维素性机化性肺炎病例在2013年6月至2019年5月的病情演变.患者男,31岁,磨石工人,以“反复咳嗽、咳痰3年,气喘半年,加剧伴发热7d”为主诉于2013年6月27日首次就诊.胸部CT提示纵隔及双肺门多发淋巴结肿大伴钙化,双肺见多发斑片状高密度病灶,以双下肺明显.CT引导肺穿刺病理符合尘肺合并急性纤维素性机化性肺炎.诊断为矽肺合并急性纤维素性机化性肺炎,给予全身糖皮质激素(激素)治疗,短期效果好,但易复发.2013年9月至2016年9月先后出现6次复发,胸部CT提示双肺病灶呈多发性、多形性、复发性及游走性改变.激素加量治疗仍然有效,但总体治疗效果逐渐变差.2017年8月至2019年5月多次复查胸部CT提示双肺多发巨块型矽结节形成并逐渐加重,肺功能逐渐恶化.患者活动后气喘逐渐加剧,目前已无法耐受体力活动,基本丧失劳动能力.     

IL-6、血小板计数在肺结核中的研究进展

正临床上评价肺结核严重程度主要依据临床表现的轻重、胸部CT提示肺部病变范围大小,而经过抗结核药物治疗后评价好转或恶化的最客观的指标就是胸部CT提示肺部病变的吸收程度。故肺结核患者在经抗结核治疗后一般每1-2月需复查胸部CT了解肺部病变吸收情况,但肺结核治疗时间长,频繁复查胸部CT,费用相对较高,导致患者依从性差,故不能及时评价抗结核药物治疗的疗效。故寻找简单而有效的反映肺结核病情严重程度、监测治疗疗效     

肺活检确诊肺隐球菌病4例并文献复习

目的提高对肺隐球菌病的认识。方法回顾性分析2008年1月～2009年3月期间经肺活检病理确诊的4例肺隐球菌病患者的临床资料。结果男性3例,女性1例,年龄24～58岁。农民2例（其中1例曾经种蘑菇7年）,小商贩和教师各1例。1例8年前因右肺球孢子菌病行右下叶肺切除术。4例人类免疫缺陷病毒（HIV）抗体检测均阴性。胸部X线和CT检查：4例均为双肺多发斑片状、斑点状、结节或团块状阴影,伴有透亮区3例。诊断及病理：经纤支镜肺活检病理示隐球菌性肉芽肿3例,其中过碘酸雪夫（PAS）染色阳性1例;经皮肺活检病理示隐球菌性肉芽肿1例。治疗和随访：4例患者住院41～119天;经抗真菌治疗6个月,患者症状均缓解或减轻,复查胸部CT示病灶均有吸收好转。结论经纤支镜和经皮肺活检是确诊肺隐球菌病简便、易行、微创的方法。     

Sj?gren's syndrome with multiple bullae and pulmonary nodular amyloidosis]

We report a case of Sj?gren's syndrome with pulmonary involvement diagnosed by open lung biopsy. The patient was a 62-year-old woman with antiphospholipid antibody syndrome. Her chest radiograph and CT scan showed multiple bullae diffusely scattered throughout the lung. The open lung biopsy specimens revealed marked inflammatory mononuclear cell infiltration and nodular amyloid deposits in the bronchiolar walls. The mechanism of bulla formation appeared to be the check valve mechanism caused by the narrowing of the airway by the bronchiolitis. The patient was treated with oral corticosteroids, and her symptoms and laboratory findings became stable.     

Two cases of inflammatory pseudotumor of the lung

Two cases of inflammatory pseudotumor of the lung were reported. Case 1. A 68 year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. He had a history of pneumonia in the right upper lobe five months before. The chest X-ray film revealed a coin lesion in the right upper lung field (S1), the same segment as the previous pneumonia. Although RPF and INH were administered for three months, the shadow did not change, and cough and sputum continued. In order to confirm the diagnosis, open thoracotomy was performed and microscopic findings of the resected tumor showed inflammatory pseudotumor; proliferation of fibrous tissue with infiltration by inflammatory cells (plasma cells, lymphocytes and a few neutrophils). Case 2. A 35 year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray, i.e. a coin lesion with vascular indentation in the left lower lung field (S8). A wedge resection including the mass was performed, and histopathologic examination revealed inflammatory pseudotumor, or plasma cell granuloma; proliferation of fibrous connective tissue with infiltration by predominantly mature plasma cells. Both patients have been doing well after the operation. We also reviewed 46 cases reported in the Japanese literature and discussed various aspects of this disease. Of 10 patients who had a history of previous respiratory tract infection, 8 had histopathologic features with various inflammatory cells, including many lymphocytes, as in our Case 1. Although the common etiology of inflammatory pseudotumor is obscure, we suppose that in some cases the lesion may be a result of post-inflammatory repair process.     

A case of multicentric Castleman's disease with pulmonary involvement]

In a man aged 34 who had been experiencing frequent coughing since November 2001, a chest radiograph showed infiltration shadows in both lung fields. Chest CT showed diffuse centrilobular nodules and multiple mediastinal lymphadenopathy. Laboratory examination revealed high values for C-reactive protein and the erythrocyte sedimentation rate, together with polyclonal hyperimmunoglobulinemia and an elevated interleukin-6 level. We suspected multicentric Castleman's disease, and so performed thoracoscopic mediastinal lymph node biopsy and lung biopsy. The former disclosed follicular hyperplasia and plasma cell infiltration in the interfollicular area, suggesting a diagnosis of Castleman's disease, plasma cell type. The lung biopsy showed heavy infiltration of plasma cells. The diagnosis was therefore multicentric Castleman's disease (MCD) with pulmonary involvement. The chest CT findings were tpical characteristics of pulmonary involvement in patients with MCD.     

A case of pulmonary inflammatory pseudotumor with hypergammaglobulinemia, elevated ANA, and uveitis]

A 63-year-old man presented with a chronic myeloproliferative disorder complicated with left pneumonia. His pneumonia was cured with antibiotics, but a nodular lesion remained in his chest radiographs together with hypergammaglobulinemia, a high titer of anti-nuclear antigen, and uveitis with secondary glaucoma. Specimens obtained by transbronchial lung biopsy showed a mixed accumulation of plasma cells, lymphocytes, and histiocytes as well as a spindle cell proliferation diagnosed as pulmonary inflammatory pseudotumor. The specimen did not show any recombination indicative of a heavy or a light chain of immunoglobulin in Southern blotting analysis. Oral prednisolone treatment improved the pulmonary nodular lesion, the abnormal laboratory data, and the uveitis. These findings suggest that much of the gammaglobulin produced by plasma cells in the inflammatory pseudotumor caused a variety of clinical symptoms.     

A case of pulmonary sarcoidosis with pneumothorax and pleural effusion after improvement of pulmonary impairment]

A 23-year-old man was admitted to our hospital for a complete medical evaluation of abnormal pulmonary shadows found on a chest radiograph during his annual check-up. Chest radiography and chest CT showed a diffuse spread of micronodules in both lung fields and mediastinal lymphadenopathy. A transbronchial lung biopsy demonstrated evidence of noncaseating epithelioid cell granuloma with multinucleated giant cells, and a diagnosis of sarcoidosis was made. The pulmonary shadows improved without therapy. Twenty months later, the patient was readmitted to the hospital because of chest pain and dyspnea. Pneumothorax appeared on the right in a chest radiograph, but subsided after drainage therapy, and two weeks later, a right side pleural effusion was seen. We determined that the pleura was involved in the sarcoidosis, and the patient was treated with oral prednisolone 20 mg daily. The pleural effusion gradually subsided. This is the first reported case in Japan of pulmonary sarcoidosis with pneumothorax and pleural effusion after improvement of pulmonary impairment.     

Plasma cell granuloma: a case report of multiple lesions in the lung and review of the literature

BACKGROUND: Although plasma cell granuloma is a rare tumor in the lung, it must be considered in the differential diagnosis of lung cancer. It typically presents as a solitary lesion. Involvement with multiple lesions can be a presenting picture of plasma cell granuloma; however, the incidence is much lower than that of a solitary lesion. PROCEDURES AND FINDINGS: A 35-year-old man was evaluated for intermittent chest pain over a 6-year period. CT showed the presence of one mass and three nodules in the left lung. The initial diagnosis was metastatic lung cancer. CT guided biopsy suggested the diagnosis of plasma cell granuloma. All the lesions were resected with a thoracotomy procedure. Pathology evaluation confirmed the diagnosis. For the 3 years he received follow-up care, he remained asymptomatic. CONCLUSIONS: Multiple lung nodules or masses can be a presenting manifestation of plasma cell granuloma. It should be differentiated from metastatic neoplasm. Surgery resection is the treatment of choice.     

A case of pulmonary eosinophilic granuloma diagnosed by TBLB]

A case of pulmonary eosinophilic granuloma which was diagnosed by TBLB was presented. A 24-year-old male was admitted complaining of cough and fever of unknown etiology. He had a history of fever which had disappeared spontaneously 9 months previously. Laboratory examinations including blood gas analysis and pulmonary function tests showed no significant abnormalities. Chest roentgenogram showed faint linear opacities. Computed tomography revealed multiple small cysts and small nodular lesions mainly in the upper lung field. CT findings were strongly suggested pulmonary eosinophilic granuloma. TBLB was performed and 6 specimens were obtained, of which 4 showed granulomatous lesions consisting of histiocytosis X cell and inflammatory cells with infiltration of eosinophils. Furthermore, granulomatous lesions were positive for S-100 protein staining. The effectiveness of open lung biopsy has been emphasized in the diagnosis of pulmonary eosinophilic granuloma, however, TBLB is also useful for diagnosis, especially in the active or early stage of this disease.     

Two cases of pulmonary eosinophilic granuloma with multiple nodular shadows]

We encountered two rare cases of pulmonary eosinophilic granuloma with multiple nodular shadows in both lungs. The patient in case 1 was a 54-year-old man complaining of dry cough and chest pain. He had smoked 20 cigarettes a day for 36 years. The patient in case 2 was a 37-year-old woman complaining of dry cough. She had smoked 15 cigarettes a day for 20 years. Chest radiography and CT revealed multiple nodular shadows in both lungs. Diagnosis was made by open lung biopsy in case 1 and by percutaneous lung biopsy in case 2. After smoking cessation, symptoms improved markedly and the shadows in the chest radiographs and CT disappeared. In cases of bilateral multiple nodular shadows, other than metastatic lung tumor cases, pulmonary eosinophilic granuloma should be considered.     

Improvement of extrapulmonary lesions of eosinophilic granuloma after cessation of smoking]

We encountered a case of pulmonary eosinophilic granuloma complicated with pneumothorax. A 24-year-old man was admitted to our department because of respiratory difficulty. Chest radiography on admission showed a right pneumothorax. A thoracic catheter was therefore inserted, and the pneumothorax was improved. A chest radiograph obtained after treatment showed diffuse linear reticular shadows; and a chest CT scan showed starlike nodular lesions and multiple cysts in the lungs, and a large nodule in the left rib. Because an ulcer had been diagnosed in the oral cavity 1 year previously, a mandible biopsy was performed, and a granulomatous lesion consisting of eosinophils was recognized. Taken together with the pulmonary findings, an eosinophilic granuloma was diagnosed. The patient was instructed not to smoke and the clinical course was observed. The pulmonary, mandibular, and costal lesions improved.     

Inflammatory pseudotumor of the lung with infiltration identified radiographically and hemoptysis]

The patient was a 53-year-old man whose chief complaint was a dry cough and hemoptysis. Chest X-ray films and computed tomographic scans revealed a hazy shadow with unclear margins in the left middle lobe. A diagnosis of inflammatory pseudotumor was made because transbronchial lung biopsy specimens showed proliferation of plasma cells and lymphocytes. Initially, in response to steroid therapy, his clinical condition and pulmonary infiltration improved, but about 30 days after the start of steroid therapy, hemoptysis occurred and the shadow increased, and therefore left segmentectomy was performed. Histology revealed not only proliferation of acute and chronic inflammatory cells but also changes in the vessels. These pathologic findings were considered to be related to the infiltration shadows and the hemoptysis.