A case of pericostal abscess exacerbated during antituberculous chemotherapy

A 27 Year-old female with pulmonary tuberculosis in right upper lobe developed right pericostal abscess during the course of antituberculous chemotherapy. The chest x-ray films on first admission showed infiltration with cavity formation and nodular shadows in the right upper lung field. Seven months after starting the antituberculous therapy with INH, RFP and EB, a new tumorous shadow appeared in the right chest wall. Microscopic examination of the specimen obtained by needle aspiration biopsy disclosed positive acid-fast bacilli. Because of the ineffectiveness of drug therapy on lesions in the right chest wall, surgical treatment was performed and the disease was diagnosed as pericostal abscess.     

A case of pleural tuberculoma with intra-pulmonary invasion during anti-tuberculosis therapy

A 27-year-old woman who had been treated for pulmonary tuberculosis with anti-tuberculosis drugs for three months was admitted to our hospital because of pain in the chest and back. Chest CT showed improvement in the pulmonary tuberculosis lesions in the right middle lobe and S8, but there was a large pleural mass in the right lower lung field. Histopathological findings of the percutaneous biopsy showed epithelioid cell granulomas that were negative for acid-fast bacilli. We diagnosed the mass as pleural tuberculoma with intrapulmonary invasion. The pleural tuberculoma improved without any additional therapy.     

A case of pulmonary artery sarcoma successfully treated by total pneumonectomy]

A 39 year-old Japanese man who had been treated for pleuritis developed a tumor in the left lung and was admitted to our hospital. Although evidence of tuberculous pleurisy was not proved medically, he had been treated successfully with antituberculous drugs for 9 months. Two months after completion of antituberculous therapy, his X-ray showed a tumor shadow close to his left hilum. A computed tomography (CT) scan showed a left lung tumor with a diameter of 3.3cm, atelectasis in an ajacent field, and no effusion. Tumor markers targeted for lung cancer remained within normal range. Bronchofiberscopy demonstrated a polypoid tumor from left upper lobe bronchus. The pathological examination of CT guided percutaneous biopsy (CTGB) specimen revealed undifferentiated malignant tumor. A pulmonary angiogram disclosed almost complete obstruction of left pulmonary artery. He underwent total pneumonectomy of the left lung, and the final pathological diagnosis of pulmonary artery sarcoma was made. He received neither chemotherapy nor radiotherapy. He is well and disease free 3 years after resection. Surgical resection may improve the prognosis of this malignancy.     

An adult case of cervico-mediastinal lymph nodes tuberculosis followed by the development of pulmonary lesions during the treatment with antituberculous drugs

A 27-year-old man was admitted to our hospital due to a painful mass in the right neck and fever. Cervical and superior mediastinal computed tomography showed an enlargement of right supraclavicular lymph node and multiple swollen mediastinal lymph nodes, including low-density areas and contrast medium-enhanced septa and margins. Smears of the pus obtained from right supraclavicular lymph node showed acidfast bacilli identified as Mycobacterium tuberculosis by PCR method. He was treated with antituberculous drugs with INH, RFP, EB, and PZA. PZA was given for initial two months. Six months later, productive cough developed and chest X-ray films showed infiltrative shadow in the right upper lung field. One month after the onset of cough, bronchoscopy revealed a polypoid lesion with a white coating in the right main bronchus. Microscopic examination of the specimen obtained by transbrochial biopsy revealed many epithelioid cell granulomas, consistent with tuberculosis. From these findings, pulmonary lesion was suggested to be due to invasion of the mediastinal lymph node into the bronchus. After one year of antituberculous chemotherapy, the swelling of the cervical-mediastinal lymph nodes was reduced and the abnormal chest X-ray shadows disappeared.     

Incipient stage of pulmonary Langerhans-cell histiocytosis complicated with pulmonary tuberculosis was examined by high-resolution computed tomography

A 29-year-old man with a smoking history of 20 pack years was diagnosed with tuberculosis because Mycobacterium tuberculosis was detected in his gastric juice. His chest radiograph showed multiple nodular opacities on left upper lobe. He was treated with anti-tuberculosis drugs in our hospital. Six months after the therapy, he began to complain of dry cough and shortness of breath on exertion. Chest radiograph showed reticular opacities in both upper and middle lung fields. Multiple thick- and thin-walled bizarre-shaped cysts and ill-defined centrilobular opacities were seen mainly in upper and mid-lungs on high-resolution computed tomography (HRCT). He was diagnosed with pulmonary Langerhans-cell histiocytosis (PLCH) by transbronchial lung biopsy specimens from right upper lobe. HRCT findings before the treatment of tuberculosis were retrospectively examined. Several small thin-walled centrilobular cysts were scattered in the right upper and middle lung fields without apparent nodular lesions. We must consider the possibility of PLCH when these findings are detected on HRCT.     

A case report of large cell lung cancer detected in the course of antituberculous therapy after a giant bullectomy

A case of a 60-year-old who male developed lung cancer after surgical resection of a emphysematous giant bulla. At first, he showed a emphysematous giant bulla associated with infected bulla in the right lung on the chest roentgenograph. After a giant bullectomy the resected specimen, suggested possible pulmonary tuberculosis. Thereafter, he was followed for one year with antituberculous therapy. Nevertheless, the chest roentgenograph taken one year after surgery, showed a new tumor density (1.5 x 2.0 cm) in the right lung. Due to the rapid growth of the lung tumor, right upper lobectomy was performed. The histological diagnosis was a large cell lung cancer (giant cell type). The postoperative staging of the tumor proved to be T2N0M0. He was treated with systemic chemotherapy of CDDP 120 mg, VDS 4.5 mg, and MMC 12 mg. Unfortunately, he died of cancer recurrence 5 months after lobectomy. Clinical evaluation of the emphysematous giant bulla associated with lung cancer was performed.     

Three pulmonary resections for metastatic lung cancer from hepatocellular carcinoma

We describe a patient who underwent pulmonary resection three times for metastatic lung cancer from hepatocellular carcinoma (HCC). A 56-year-old man, who had a past history of right hepatic lobectomy for HCC, was referred to our department with an abnormal finding on chest computed tomography (CT). Chest CT showed three abnormal shadows, in the right upper lobe (S3b), right middle lobe (S5), and right lower lobe (S10), respectively, and there was no evidence of intrahepatic recurrence. He underwent surgical resections (right upper lobectomy and partial resections) for the metastatic lung cancer from HCC. Subsequently, 12 and 16 months after the first pulmonary resection, metastatic lung cancer recurred, in right S6 and S9, respectively. Because there was no evidence of intrahepatic recurrence and because of the feasibility of curative resection, we performed partial pulmonary resections. He had no postoperative morbidity, and is alive with no evidence of disease 60 months after the first pulmonary resection. Twelve cases of repeat pulmonary resections for metastatic lung cancer from HCC have been reported in the literature, and the authors of these reports described that repeated pulmonary resections for metastatic lung cancer from HCC resulted in long-term survival. Repeat pulmonary resections for metastatic lung cancer from HCC can be an effective treatment for patients with such metastases.     

Central nervous system (CNS) tuberculosis following allogeneic stem cell transplantation

Tuberculosis is an uncommon infectious complication after stem cell transplantation. We report a patient who presented with a brain mass, 3 months after pulmonary tuberculosis had been diagnosed and while he was receiving triple antituberculous therapy. He had extensive chronic GVHD. The diagnosis was made after biopsy of the lesion. The cerebral mass was excised, antituberculous treatment was maintained and the patient made a complete neurologic recovery. Six months later, he died of gram-negative septic shock. Mycobacterial infections should be considered in allograft recipients with chronic GVHD and solid lesions in the brain. Bone Marrow Transplantation (2000) 25, 567-569.     

Case of multi-drug resistant pulmonary tuberculosis with bilateral cavitary lesions successfully treated by surgical treatment

A case was 38 years old male. He was pointed out abnormal shadow on chest X-ray and complained respiratory infection symptoms. He had not past history of tuberculosis. He was diagnosed as multi-drug resistant tuberculosis (MDR-TB) in a certain hospital and was referred to our hospital to undergo treatment. His drug sensitivity test by Ogawa medium was resistant to all anti-tuberculosis drugs except for kanamycin (KM) and enviomycin (EVM). His chest X-ray revealed large cavities in the right upper field and infiltrations in the right lower field and small cavitary lesions in the left lower field. The right pneumonectomy was done because he took anti-tuberculosis drugs but his sputum examinations continued to be smear and culture positive without improvement of the lesions. After the surgical treatment (right pneumonectomy), he continued anti-tuberculosis drugs therapy and the chest X-ray improved including the collapse of left lower cavitary lesions. This case was a difficult case to treat because of bilateral cavitary lesions. However he was successfully treated by the surgical treatment.     

A case of lung tuberculosis showing no chest radiograph findings with recurrent hemoptysis

A 59-year-old male was referred to our hospital because of hemoptysis. A chest X-ray film and 7 mm-slice CT scan showed no abnormal finding. Bronchoscopy revealed hemorrhage in the right upper bronchus (B1a) Bronchial lavage of the lesion was performed, but Mycobacterium tuberculosis was not detected. Because of repeated hemoptysis, he was admitted to our hospital. Right bronchial artery angiograph showed vascular hyperplasia in the peripheral part of the upper lobal branch, and this lesion was suggested to be a bleeding point. There were no vascular malformations. Thin slice (0.5 mm-thick) CT scan showed mild infiltrative shadow in the right upper lobe. After admission, sputa smear for mycobacteria and PCR for M. tuberculosis became positive, and he was diagnosed as pulmonary tuberculosis. After starting antituberculous chemotherapy, hemoptysis disappeared, and sputa smear and culture for mycobacteria converted to negative. This case suggests that lung tuberculosis should be suspected in patients having hemoptysis, even though they had no chest X-ray film abnormality.     

A case of multidrug-resistant (MDR) tuberculosis with collapse of the left lung after hemoptysis

An 82-year-old female was admitted to our hospital with multidrug-resistant (MDR) tuberculosis, defined as resistance to both isoniazid and rifampicin. Chest X-ray showed massive infiltrates with a large cavitary lesions in the left lung field. No antituberculous agents were useful in improving her clinical condition and at 6th months after admission, she exhibited sudden onset of massive hemoptysis, which was successfully treated by bronchial artery embolization. After hemoptysis, her chest X-ray showed collapse of the left lung and computed tomography showed a coagula-like shadow in the left main bronchus, and sputum examination revealed no Mycobacterium tuberculosis colonies. The patient was discharged 5 months after the onset of hemoptysis.     

A case of small-cell lung cancer during treatment for active pulmonary tuberculosis after surgery for non-small-cell lung cancer]

A 76-year-old man taking anti-tuberculous drugs for active pulmonary tuberculosis was admitted to our hospital requiring further examination of a pulmonary mass in the left upper lobe. He had had right lower lobectomy and partial middle lobectomy for non-small-cell lung cancer two years before admission. Retrospectively, the left upper lobe mass had been gradually growing for about 2 months. We performed a transbronchial lung biopsy of the pulmonary mass, and diagnosed small-cell lung cancer. This report describes a rare case of small-cell lung cancer appearing during treatment for active pulmonary tuberculosis after non-small-cell lung cancer surgery.     

A case of cervical-mediastinal lymph node tuberculosis progressed to pulmonary lesion through a bronchial fistula]

The patient was a 25-year-old man who had been admitted to a local hospital due to fever and trachelophyma. Tubercle bacillus was detected in pus culture obtained by biopsy of the trachelophyma, but not in sputum culture. Because combined therapy with 3 antituberculous drugs (RFP, INH and SM) failed to reduce the fever or drainage from the biopsy region, the patient was transferred to our hospital. Chest X-ray films taken on admission revealed dilatation of the superior mediastinal shadow; chest CT images revealed cervical and mediastinal lymphadenopathy and an anterior mediastinal abscess, but no pulmonary lesion. About 2 months after admission, cough developed and Gaffky type 2 was detected in the patients sputum. Bronchoscopy and bronchography revealed a bronchomediastinal fistula. Forty days after the onset of cough, reticulogranular shadows were observed in the right upper lobe on chest X-ray films, and a diffuse centrilobular lesion was observed in the right upper lobe on chest CT images. From these clinical observations, the patient was given a diagnosis of cervical-mediastinal lymph node tuberculosis, which had progressed to pulmonary lesion through a bronchial fistula due to lymphadenitis.     

Case of spontaneous regression of metastatic lesions of leiomyosarcoma of the esophagus

A rare case of spontaneous regression of esophageal leiomyosarcoma is reported. A 63-year-old woman underwent esophagectomy and reconstruction at our hospital after diagnosis of leiomyosarcoma. Nineteen months after esophagectomy, a coin lesion was detected in the right lung and right thoracotomy revealed pleural dissemination. The lesion in the right lung was resected and was confirmed histologically as recurrence of leiomyosarcoma. During further surgery, metastatic lesions were found in the spleen and pleura. However, all metastatic lesions were found to decrease without any anti-cancer therapy.     

A case of tuberculous peritonitis

We report a case of a 73-year-old man with tuberculous peritonitis. He had sought treatment at a clinic near his house for his fever and abdominal distension. Massive ascites were found and he was referred to our hospital. The endoscopy and abdominal CT scan performed on admission revealed no abnormal findings except the massive ascites. Mycobacterium tuberculosis (MT) DNA was detected in the ascitic fluid by polymerase chain reaction (PCR) and ascitic adenosine deaminase (ADA) activity was 127.6 U/l. He was diagnosed as tuberculous peritonitis and transferred to the Department of Respiratory Medicine. A chest CT scan showed predominant right pleural effusion with no other abnormal findings in bilateral lung fields. His sputum were all positive by smear acid-fast staining, MT DNA and culture on MT. His final diagnosis was tuberculous peritonitis, pulmonary tuberculosis, and tuberculous pleuritis. Treatment was started by anti-tuberculosis drugs with combined use of isoniazid, rifampicin, ethambutol, and pyrazinamide. The therapy was continued for 6 months. The culture for MT (Mycobacteria Growth Indicator Tube) converted to negative after 2 weeks of treatment and the C-reactive protein level became normal after a month. The pleural effusion and ascites disappeared after 2 and 3 months, respectively. Tuberculous peritonitis is a relatively rare disease, however when we encounter unexplained ascites, MT PCR and the measurement of ADA should be done considering a rapid diagnosis of tuberculous peritonitis, before invasive diagnostic laparoscopy.     

A case of pulmonary Mycobacterium kansasii infection complicated with pleural effusion

A 60-year-old man was admitted to our hospital complaining of general malaise for a few months, discomfort of the right shoulder and fever in May 2003. Chest X-ray film showed an infiltrative shadow in the right lung field and chest CT scan revealed right pleural effusion. Pulmonary tuberculosis complicated with pleurisy was first suspected from the findings of high ADA level of the effusion and positive result of PPD skin test. But, microscopic examination of the specimens obtained by transbronchial lung biopsy disclosed granulomatous lesions and Mycobacterium kansasii was identified from all specimens; sputum, fluids of brushing and bronchial washing. The patient was diagnosed as pulmonary Mycobacterium kansasii infection and treated with anti-tuberculous drugs including RFP. His clinical course was good and no recurrence of pleural effusion was seen. This case was a rare case of pulmonary Mycobacterium kansasii infection complicated with pleural effusion.     

An adult case of cervico-mediastinal tuberculous lymphadenitis]

We reported a case of cervico-mediastinal tuberculous lymphadenitis followed by the development of pulmonary lesions and recurrent laryngeal nerve palsy. A 48-year-old man was admitted to our hospital due to fever, dry cough, and loss of body weight. He had no medical history of tuberculosis or other significant diseases. On admission, a right cervical tumor was palpable and chest X-ray films revealed widened superior mediastinum. Chest computed tomography showed multiple swollen mediastinal lymph nodes, including multiple low-density areas and contrast medium-enhanced septa and margins. Gallium-67 scintigraphy demonstrated abnormal uptake in the right cervix and mediastinum. A PPD skin test was strongly positive and ribosomal RNA of tubercle bacilli was detected in aspirated gastric juice. Although anti-tuberculous chemotherapy was initiated, fever and cough persisted, and hoarseness due to left recurrent laryngeal nerve palsy developed. One month later, chest X-ray films showed abnormal infiltration in the left upper lung field. The patient was sero-negative for HIV. To confirm the diagnosis, right supraclavicular lymph node biopsy was performed. Microscopic examination of the biopsy specimen revealed acid-fast bacilli and granuloma with central caseous necrosis surrounded by Langhans' giant cells and epithelioid cells. After 9 months of extended anti-tuberculous chemotherapy, the cervical and mediastinal masses receded and the abnormal chest X-ray shadows disappeared. Because the incidence of tuberculosis in Japan is gradually increasing among young people as well as the elderly, the differential diagnosis of this disease will become more necessary.     

A case of primary pulmonary sporotrichosis

We report the first case of primary pulmonary sporotrichosis in Japan. A 53-year-old man was admitted to our hospital for further examination of the abnormal shadows on chest X-ray film. Six months before admission, he was admitted to another hospital because of alcoholic liver disease and diabetes mellitus. Since the initial chest film showed cavities with infiltration in the left upper lung field, he was treated with antituberculous drugs despite negative sputum cultures for mycobacterium. In spite of the medication, his chest X-ray film revealed another cavitary lesion, so he was referred to our hospital. He had been asymptomatic during this period. Chest X-ray on admission disclosed multiple cavities in the left upper lobe and a cavity in the right lower lobe. Repeated sputum specimens, bronchial washings and brushings for cytology and cultures were all negative. In an attempt to clarify the pathogen, percutaneous lung aspiration (PLA) was performed. The PLA sample yielded a positive culture of Sporothrix shenckii. After the diagnosis, S. schenckii was also cultured from sputa. A sporothrix skin test and yeast agglutination test for S. schenckii were positive. In the absence of a history for skin lesion, the patient was diagnosed as a primary pulmonary sporotrichosis. As iodide therapy was ineffective, he was started on a regimen of intravenous amphotericin B. However his renal function progressively deteriorated, so amphotericin B was discontinued. Now he receives miconazole intravenously and is still under careful observation. As far as we know, this is the first report of primary pulmonary sporotrichosis in Japan. The possibility of sporotrichosis should be considered in any cases of undiagnosed cavitary lung diseases.     

Lymphomatoid granulomatosis (LYG) occurring in a patient with follicular lymphoma during remission]

A 49 years-old man presented with dry cough, low grade fever, and abnormal shadow on a chest X-ray. He had suffered from follicular lymphoma of the liver 5 years previously. He received irradiation therapy in combination with chemotherapy for approximately three years and had been in complete remission. Physical and radiological examination revealed pleural effusion and softly dense masses in the right lung. The laboratory data were within normal limits. He was diagnosed as having lymphomatoid granulomatosis (LYG) by open lung biopsy. The lung lesion was mainly infiltrated with T cells. The patient received prednisolone and the lung lesions disappeared. However, when a lung mass was noted two months later, he started to receive combination chemotherapy consisting of cyclophosphamide, adriamycin, vincristine, and prednisolone every three months. He has not shown relapse of LYG so far. To investigate the association between the preceding follicular lymphoma and subsequent LYG at this time, DNA analysis using the PCR technique was carried out. The LYG lesion did not show a rearranged band for the JH probe, while the paraffin-embedded specimen of the preceding follicular lymphoma had shown rearranged band for the JH band. Southern blot analysis of the LYG lesion, showed no rearrangement for TCR beta, gamma or JH probe. These findings indicate that the LYG was different from the preceding follicular lymphoma in terms of origin. LYG is considered to be induced in the immunosuppressive state due to lymphoma.     

Three cases of localized pleural tuberculosis which looked exacerbated during antituberculous chemotherapy

We reported three cases whose pleural tumorous shadows enlarged during the intensive chemotherapy for tuberculosis. The patients were 39 year-old female, 63 year-old female, and 22 year-old male. Their chest X-ray films on admission showed pleural effusion or infiltration, but no tumorous shadows. Eight to 16 weeks after starting the antituberculous therapy with INH, RFP and SM, new tumorous shadows appeared in the right chest wall (case 1, 3) or the left chest wall (case 2). The mass extracted from case 1 contained granuloma with caseous necrosis. The tumorous shadows on chest X-ray films in case 2 and 3 disappeared by continuous antituberculous therapy. We can not definitely conclude that the disease of these 3 cases were same diseases to be called either percostal tuberculosis, peripleural abscess or peripleuritis tuberculosa as observed in case 1. The phenomenon observed in case 2 and 3 is suspected to be caused by some allergic mechanism eg. Jarisch-Herxheimer reaction which is observed during the therapy for syphilis.