A case of pulmonary Mycobacterium gordonae infection with pleural effusion]

A 65-year-old woman, treated with prednisolone (5 mg daily) for rheumatoid arthritis, visited our hospital because of right chest pain. Chest CT showed small nodular shadows in the right lung accompanied with right pleural effusion. A pulmonary Mycobacterium gordonae infection was diagnosed, since M. gordonae was identified twice from her sputum. She was treated with rifampicin, ethambutol and streptomycin for two months, and then streptomycin was replaced with clarithromycin. Three months after the initial treatment, M. gordonae was eradicated from her sputum. Pleural puncture revealed bloody, exudative, lymphocytotic pleural effusion, but no malignant cells were identified. Although pathological diagnosis by thoracoscopic pleural biopsy could not be performed, it is likely that the pleural effusion was associated with the pulmonary M. gordonae infection in the present case.     

A case of Mycobacterium intracellulare pleurisy without active lung lesion

Pleural effusion without occurrence of active pulmonary lesion due to nontuberculous mycobacteria is extremely rare. We report a case of Mycobacterium intracellulare pleurisy in an 84-year-old woman. The patient was admitted to a nearby hospital because of dyspnea. Massive right pleural effusion was observed on chest roentgenogram. Bacteriological examinations, smear and culture of the sputum or pleural effusion were negative. First we thought pleurisy was caused by M. tuberculosis as pleural effusion showed predominant lymphocyte count and high adenosine deaminase level. However, M. intracellulare was identified by the polymerase chain reaction method from pleural effusion. Based on clinical findings and laboratory data, we suspected pleurisy was due to M. intracellulare infection. Clarithromycin, kanamycin, rifampicin and ethambutol were administered. After four months of treatment pleural effusion disappeared without accompanying the active pulmonary lesion. Therefore, we diagnosed this case as pleurisy without pulmonary lesion due to M. intracellulare.     

Mycobacterium avium complex pleuritis

Non-tuberculous mycobacterium infection is rarely accompanied by pleural involvement. We report a very rare case of Mycobacterium avium-intracellurare complex (MAC) pleuritis with massive pleural effusion. The patient was a non-compromised 67-year-old female and had been treated for pulmonary non-tuberculous mycobacterium infection. She was admitted to hospital because of general malaise, low-grade fever and right pleural effusion. Cytological examination of the effusion did not show malignant cells. MAC was only identified by culture and PCR. No other bacteria were detected. Complete resolution of the pleural effusion occurred after administration of anti-tubercular agents (isoniazid, rifampin, ethambutol) and clarithromycin.     

A case of Mycobacterium avium pulmonary disease accompanied with pleural effusion

Nontuberculous mycobacterial infection is seldom complicated with pleural involvement. We report a very rare case of M. avium pulmonary disease accompanied with pleural effusion. A 76-year-old man was admitted to our hospital because of cough and low-grade fever. A chest radiograph and computed tomograph showed centrilobular nodules in the right middle lobe and left lingula, and right pleural effusion. The patient had had a right spontaneous pneumothorax 50 days before his admission. The sputum smear was negative for acid fast bacilli. The smear of pleural effusion was positive for acid fast bacilli, the level of adenosine deaminase in the effusion was markedly elevated, and pleural effusion was positive for M. avium as assessed by polymerase chain reaction (PCR). The pleural biopsy specimen showed fibrous change without granuloma, while the transbronchial biopsy specimen showed noncaseous epithelioid granulomas. We considered that the pneumothorax was caused by the spread of pulmonary M. avium infection to the visceral pleura with its perforation.     

肺萎陷与气胸鉴别方法初探

目的探讨鉴别肺萎陷与气胸的方法。方法5名肺癌患者,其中合并气胸3例。合并右胸腔积液1例,合并以积液为主右液气胸1例。合并胸腔积液患者先行闭式胸腔引流术加负压抽完胸液后,影像学检查尚见气胸,进行闭式胸腔引流抽气却未见气体抽出,合并气胸者进行闭式胸腔引流抽气亦未见气体抽出。所有患者在CT引导下,将含有10ml气体的注射器穿刺进入胸腔,见气体吸人胸腔。结果考虑5例患者存在肺萎陷。结论肺萎陷与气胸的鉴别方法：胸部影像学示气胸,行闭式胸腔引流术抽气未见气体抽出,可在CT引导下将含有10ml气体的注射器穿刺进入胸腔,见气体吸入胸腔者,考虑存在肺萎陷。     

Mycobacterium intracellulare pulmonary infection which co-existed and mimicked lung cancer

We report a case of Mycobacterium intracellulare (M. intracellulare) pulmonary infection with co-existing lung cancer and presenting as a solitary pulmonary nodule requiring differentiation from lung cancer. Computed tomography showed two nodules (20 mm) with spicula formation and pleural indentation on the right lower lobe of the lung (right S6 and S8). Transbronchial biopsies from the right S6 and S8 nodules revealed mycobacteriosis and adenocarcinoma, respectively. Thereafter, a right lower lobectomy was performed. Cases of pulmonary M. intracellulare disease with solitary nodule are rare. Moreover, M. intracellulare pulmonary infection with co-existing lung cancer is extremely rare.     

Pulmonary tuberculosis accompanied by a transient increase in serum carcinoembryonic antigen level with tuberculous empyema drainage

We present a case of pleural effusion with encapsulation that was observed in the right thorax of a patient. PCR analysis of the patient's pleural effusion showed positivity for Mycobacterium tuberculosis. After six months, his chest CT showed the development of niveau and pulmonary consolidation. We definitively diagnosed him as having chronic pulmonary tuberculosis with tuberculous empyema drainage. At the time of his hospital admission, his serum carcinoembryonic antigen (CEA) level was elevated. After we started treatment using antituberculosis drugs, the infiltration shadow in his lung fields disappeared, and the serum CEA level decreased. The results suggest that the serum CEA level reflects the extent of the development of pulmonary tuberculosis lesions.     

A case of pulmonary mycobacterium intracellulare infection complicated with pneumothorax and pleurisy

A 74 year-old female complaining of increased cough and sputum was admitted to our hospital on June 14th 2004. She had been diagnosed as Mycobacterium intracellulare (M. intracellurare) infection since 2002 and had been treated from March to October 2003 in the Department of General Medicine in our hospital. Chest CT on admission showed diffuse small nodular shadows in the lung, a cavity, pneumothorax, and pleural effusion in the right lung. The sputum smear was positive for acid-fast bacilli and sputum PCR examination was positive for M. intracellulare. She was diagnosed as the recurrence of non-tuberculous mycobacterium (NTM) infection and treatment of NTM infection was started. No other infections were suspected and the pneumothorax and pleural effusion gradually improved with the treatment. We concluded that the pneumothorax and pleural effusion were caused by NTM infection. Since pneumothorax is an extremely rare complication in NTM infections we thought it is worth-while to report our case.     

右腋下纵行直切口在未成年先天性心脏病患者手术中的临床应用

目的总结和分析我科在右腋下纵行直切口体外循环下,矫治房间隔缺损、室间隔缺损及肺动脉瓣狭窄未成年患者的临床资料,并对该径路的优缺点进行评价。方法：回顾性分析我科2011年1月-2012年10月,经右腋下纵行直切口治疗的280例未成年先天性心脏病（CHD）患者的临床资料,包括：体外循环时间、主动脉阻断时间和主要并发症。结果：280例全部手术患者体外循环时间平均为52．35 min,主动脉阻断时间为22．36 min,无死亡及其它严重并发症,但术后80例有不同的并发症：心包积液19例、心包积气2例、右下肺感染27例、右肺感染2例、双肺感染1例、右侧胸膜增厚及黏连1例、右侧气液胸（胸腔积液）1l例、伴肺组织压缩3例、右侧气胸4例、右上叶不张3例、右侧胸壁皮下气肿2例、左侧胸腔积液3例、双侧胸腔积液1例及右侧肋骨骨折伴胸腔积液1例。结论：采用右腋下纵行直切口径路治疗CHD具有创伤小、出血少、关胸快,术后胸腔及心包引流量少、胸廓稳定性好、可避免术后胸骨裂开、鸡胸等并发症及美观效果好等优点。在充分判断患者体质量、年龄的基础上明确诊断,并可预见性地预防术后相关肺部并发症的发生,值得广泛应用。     

M. kansasii lung infection occurring in a compromised host with idiopathic pulmonary fibrosis

A 61-year-old man was admitted to our hospital because of persisting cough, sputum and shortness of breath for four months. Brushing specimens and BALF bronchoscopically obtained revealed acid-fast bacilli and TBLB showed pathological findings consistent with interstitial pneumonia. Based on these results, clinical symptoms, chest roentgenograms on admission and identification of M. kansasii, a diagnosis of M. kansasii lung infection occurred in idiopathic pulmonary fibrosis was made. The patient's symptoms consistent with M. kansasii lung infection and his sputum became negative 6 weeks after antituberculosis chemotherapy with INH, SM and RFP. Because of an increasing dyspnea due to pulmonary fibrosis, however, the patient received oxygen therapy. This case suggested an increasing tendency of compromised hosts associated with M. kansasii lung infection.     

A case of essential thrombocythemia with pulmonary hypertension and bilateral pleural effusions

A 79-year-old woman was admitted with general fatigue. Chest roentgenogram showed diffuse reticular shadows and bilateral pleural effusion. Peripheral blood studies revealed an elevation of platelet count (203.3 X 104/mm3). The case was diagnosed as essential thrombocythemia and treated with ACNU. The platelet count decreased. Bilateral pleural effusions increased gradually and their characteristics changed from bloody exudate to transudate. Biopsy of her pleura and thoracoscopy were carried out without significant results. Later, systemic edema, which suggested right heart failure, developed. The diagnosis of pulmonary hypertension and right heart failure was made by echocardiogram and right cardiac catheterization. Because perfusion scan of the lung revealed some perfusion defects, complication of pulmonary embolism was suspected. Bilateral pleural effusion and pulmonary artery pressure decreased with treatment by nifedipine, furosemide and isosorbide dinitrate. This is the first case report of essential thrombocythemia, pulmonary hypertension, right heart failure and bilateral pleural effusion.     

Primary pleural non-Hodgkin's lymphoma without chronic pyothorax]

Most cases of primary pleural malignant lymphoma develop following chronic pyothorax. We report a case of primary pleural non-Hodgkin's lymphoma without chronic pyothorax. A 63-year-old woman was referred and admitted to our hospital with a right pleural effusion that was detected during a routine physical checkup. Her liver, spleen, and superficial lymph nodes were not palpable on physical examination. The massive right pleural effusion and a pleural mass were demonstrated on chest X-ray films and thoracic computed tomograms. Diffuse large B-cell non-Hodgkin's lymphoma was diagnosed by needle biopsy from the pleura, and the clinical stage was IE. Pleural effusion specimens contained no identifiable lymphoma cells, and examinations for Mycobacterium species were also negative. Human herpes virus 8 (HIV-8) DNA was detected in lymphocytes from the peripheral blood and pleural effusion. Epstein-Barr virus-encoded small RNAs and HHV-8 DNA were both negative in biopsied tissue from the pleural mass. Although a complete remission was achieved, the lymphoma relapsed about 8 months later. The patient is currently receiving salvage chemotherapy. Cases of primary pleural non-Hodgkin's lymphoma with massive pleural effusion that are not preceded by chronic pyothorax or Kaposi's sarcoma are very rare.     

Pulmonary and disseminated infection due to Mycobacterium kansasii: a decade of experience

Fifty-five patients with Mycobacterium kansasii isolates (47 pulmonary and eight disseminated) were identified at a large Texas hospital from 1975 to 1985. The mean age of patients was 60 years, and there was a slight male predominance. Isolation of M. kansasii usually represented disease. The great majority of patients with pulmonary infection due to M. kansasii had underlying pulmonary diseases, and 70% had nonpulmonary predisposing factors. M. kansasii pulmonary disease clinically and radiographically resembled pulmonary tuberculosis. Disseminated M. kansasii infection occurred in severely immunocompromised patients, who frequently had pulmonary predispositions as well. Disseminated infection most of ten involved the lung, reticuloendothelial system, bone, joint, and skin and presented with signs and symptoms related to these organs. Despite only moderate in vitro susceptibility of M. kansasii to routine antituberculous drugs, most patients responded to rifampin-containing regimens. The prognosis of patients with M. kansasii disease was determined primarily by their underlying diseases.     

Pulmonary Mycobacterium kansasii infection in Israel, 1999-2004: clinical features, drug susceptibility, and outcome

BACKGROUND: Mycobacterium kansasii infection is one of the most common causes of nontuberculous mycobacterial lung disease in world. However, little is known about its background characteristics or drug sensitivity in nonendemic areas. DESIGN: We assessed the clinical features, radiologic findings, and drug sensitivity associated with M kansasii infection in Israel. METHODS: Patients with a culture-positive diagnosis of M kansasii infection between April 1999 and April 2004 were identified from a clinic database of tuberculosis centers. Mycobacterial cultures were performed with standard methods. Data on patient background and clinical features were collected from the medical files. RESULTS: Mean age (+/- SD) of the 56 patients was 58 +/- 18 years, and 64% were men; 59% had associated lung disease. Fifteen percent were receiving immunosuppressive medications. None had HIV infection. Systemic comorbid diseases were noted in 27%. The most common clinical presentations were chest pain, cough, hemoptysis, fever, and night sweats. Cavitation was noted only in 54%. Older patients had more noncavitary disease than younger patients (p = 0.01, r = 0.35). Lower-lobe predominance was very rare (4%). None of the patients presented with pleural effusion or lymphadenopathy. Only seven patients (11%) underwent bronchoscopy for diagnosis. M kansasii isolates showed the highest sensitivity to rifampin, ethambutol, clarithromycin, and ofloxacin, and the highest resistance to ciprofloxacin and capreomycin. The mean duration of treatment was 21 +/- 7.2 months. There were no disease-related deaths. CONCLUSIONS: M kansasii disease in Israel has no association with HIV, more systemic comorbid diseases and associated lung disease, and fewer cavitations. Following appropriate treatment, patients with M kansasii disease have an excellent prognosis.     

Development of a case of Mycobacterium avium complex disease from right pleural effusion]

Moist pleurisy in patients with Mycobacterium avium Complex (MAC) is rarer than tuberculosis. We encountered an extremely rare case of MAC disease in a 75-year-old man who initially had only right pleural effusion. Gaffky VII was detected in the pleural effusion, and Mycobacterium avium was identified by culture and PCR. Although administration of antitubercular agents (RFP, INH, EB, and SM) + CAM and thoracic lavage were repeated, the Gaffky persisted strongly. Accordingly, pulmonary decortication and filling of the cavity with an omental flap were performed as surgical treatments. However, fistulas were formed between the remaining empyema cavity and the surgical wounds. Fenestration was also carried out. Postoperatively, centriacinar abnormalities appeared on computed tomography (CT). It has been reported that MAC disease begins with centriacinar abnormalities and the incidence of the lymphatic developmental pattern was low. Tuberculosis (the idiopathic pleuritis type) is considered to be caused this pattern from the primary infection focus. Therefore, the onset of unilateral effusion is extremely rare in patient with MAC disease, suggesting that the lymphatic developmental pattern occurs less frequently in patients with MAC disease. Furthermore, in this case, we speculated that centriacinar abnormalities were the MAC infection foci and could be detected by CT due to surgical invasion.     

Cutaneous and Mediastinal Lymphadenitis due to Mycobacterium kansasii

Mycobacterium kansasii most commonly causes a slowly progressive pulmonary disease. Skin and disseminated infections are seen less frequently and only in immunocompromised hosts. To our knowledge, no case of Mycobacterium kansasii infection or skin infection associated with additional organ involvement in an immunocompetent patient has been reported.     

Pulmonary tuberculosis following successful treatment of pulmonary infection with Mycobacterium kansasii.

A case of pulmonary tuberculosis following successful treatment of pulmonary infection with Mycobacterium kansasii is presented. The immunizing effect of an infection with M kansasii and and other nonspecific immune factors are discussed.     

Mycobacterium kansasii infection following primary pulmonary malignancy.

The purpose of this study was to determine whether any of the Mycobacterium kansasii cases were the consequences of primary lung malignancy. The records and chest x-ray films of 295 patients with M kansasii pulmonary infection were reviewed. The infection was found to complicate the primary lung neoplasm in four cases. Three patients had had treatment for malignancy: one patient with small cell carcinoma received chemotherapy, steroids and radiation; one with adenocarcinoma underwent a lobectomy and radiation; and the third patient had a lobectomy and radiation for malignant fibrohistiocytoma. The fourth patient developed the infection three years after lung malignancy manifested itself, which was only a few months before the clinical evidence of distant metastasis with adenocarcinoma was detected. We suggest that this infection be considered in patients from M kansasii endemic areas, especially after they have received radiation treatment for lung malignancy. This association has never been described before.     

Clinical investigation of pulmonary dirofilariasis with unusual abnormalities on chest roentgenograms

The authors recently encountered three cases of pulmonary dirofilariasis with unusual abnormalities on chest roentgenograms. In case 1, with right upper and lower lobe masses and right pleural effusion, the right lower lobe mass and pleural effusion spontaneously disappeared one month after admission. In case 2, chest roentgenograms and chest CT scanning revealed a small mass with cavity formation. In case 3, with a right lower lobe mass and pleural effusion, steroid therapy resulted in disappearance of the mass and a remarkable reduction of pleural effusion. Human pulmonary dirofilariasis is a rare disease. In Japan, only 32, including our cases, have been reported in the literature of pulmonary dirofilariasis with unusual abnormalities on chest roentgenograms. The literature was reviewed.     

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.