An autopsy case of chronic empyema-associated angiosarcoma that presented with a rapidly growing chest wall mass]

A 76-year-old woman with chronic tuberculous empyema presented with bloody sputa and anorexia in April 2005. Chest X-ray and CT scan showed no obvious change compared with previous films. She complained of a left chest pain in June 2005, and chest CT scan showed a tumor shadow enhanced heterogeneously on the left chest wall and chronic empyema. After admission, the chest wall mass grew rapidly. Neither CT- nor sonographically guided biopsy yielded a definitive diagnosis. Dynamic MRI showed a high signal intensity unlike hematoma. She died of respiratory failure 2 months after the onset of her chest pain. Autopsy revealed angiosarcoma. We should always keep in mind the early diagnosis of malignant tumor and tuberculosis in patients presenting with a chest wall mass and constitutional symptoms during follow-up of chronic tuberculous empyema.     

A case of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall

A 61-year-old woman with schizophrenia that had been treated in a psychiatric hospital was admitted to our hospital because of subileus and back pain. Though subileus was improved, she had a sudden attack of fever 7 days later and developed right pleural effusion, a cold abscess in the anterior chest wall and swelling of a thumb-sized right cervical lymph node which broke through the skin. We made a diagnosis of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall due to the biopsy findings of the specimen taken from the cervical lymph node, examination of pleural effusion, chest CT, bacteriological examination of the cold abscess and spinal MRI. We started chemotherapy with the antituberculous drugs (HRSZ) and symptoms except back pain improved. She complained of paresis of the both lower extremities, which completely paralyzed 8 months later in spite of continued chemotherapy. Thereafter her paralysis was gradually improved and she was able to walk by herself after 12 months chemotherapy.     

Malignomsuspekte pulmonale Raumforderung

A 31-year-old patient presented with chronic cough and thoracic pain. A pulmonary mass was seen on chest x-ray, and pulmonary segmental resection was done. Histopathologically, a pulmonary abscess cavity due to actinomycosis was found. Three months later, recurrence of actinomycosis at the thoracic wall was observed. Antibiotic therapy with penicillin was administered. Five months later, with the patient receiving continued antibiotic therapy, a thoracic wall abscess and fistula was diagnosed. Four weeks after abscess drainage and repeat intravenous antibiotic therapy, the patient was symptom-free and had remained symptom-free at 10 months of follow-up.     

A case of pulmonary lymphangiomyomatosis induced by pregnancy

A 35-year-old primigravida was admitted to the Department of obstetrics complaining of dyspnea and left back pain at 21 weeks' gestation. Chest roentgenogram revealed diffuse reticulonodular shadows predominantly in both lower lung fields and arterial hypoxemia was present. Pulmonary function tests showed restrictive impairment and decreased carbon monoxide diffuse capacity. From these results, interstitial pneumonia was suspected and she was first treated with prednisolone. However during her pregnancy, spontaneous pneumothorax occurred. Following spontaneous delivery of healthy infant at 37 weeks, left chylothorax occurred, and pleurodesis was performed with OK432. Thereafter the histological diagnosis of pulmonary lymphangiomyomatosis was made by transbronchial lung biopsy and treatment of prednisolone was stopped. She was treated with tamoxifen. In addition, progesterone-receptor was detected in the pulmonary tissue obtained at open lung biopsy. She was treated with cyclophosphamide in addition to tamoxifen. At present, shortness of breath has decreased slightly in comparison with one year previously, but no improvement has been seen in lung function tests or chest roentgenogram.     

A case of pulmonary tuberculosis in a long-term survivor with small cell carcinoma of the lung

A 64-year-old woman complained of chest pain, back pain and dry cough. Chest X-ray film showed marked left hilar enlargement and left pleural effusion. Biopsy of the bronchial mucosa and demonstrated small cell carcinoma of the lung. Treatment with cisplatin, adriamycin and etoposide led to regression of symptoms and chest X-ray findings within 3 months. She received maintenance chemotherapies at the outpatient clinic for 2 years after the first therapy. Thirty-months after the first admission, chest X-ray film showed multiple small nodules in the left upper lobe. Chest tomography and high-resolution computed tomography showed acinar or lobular nodules disseminated in the left upper lobe. Mycobacterium tuberculosis was obtained from bronchoalveolar lavage fluid of the left upper lobe. Pulmonary tuberculosis in a long-term survivor of small cell carcinoma of the lung is very rare.     

An elderly case with group B streptococcal bacteremia, subcutaneous abscess and reactive polyarthritis

We report a 77-year-old woman with Group B streptococcal bacteremia, subcutaneous abscess and reactive polyarthritis. Two years previously she suffered from atrial fibrillation and osteoarthritis of the knee. After she was admitted for treatment of the knee joint with hyaluronate sodium, she complained of pain in the left shoulder and both knees. Pyogenic arthritis was suspected and administration of cefazolin was started immediately after blood culture. One set of blood cultures showed Group B streptococcus. Therefore the antibiotic was changed to ampicillin. To investigate the cause of polyarthritis, enhanced CT of the left shoulder and both knees was performed and demonstrated fluid collection with marginal enhancement, suggesting a bacterial abscess. However, findings of arthrocentesis and synovial fluid culture were incompatible with bacterial arthritis. A subcutaneous abscess, which appeared at 5 days after admission to the hospital, was not connected to the synovial fluid, suggesting reactive arthritis was the main cause of her polyarthritis. We performed drainage surgery and one week later, the clinical symptoms and inflammatory findings mostly disappeared. Several microbes are able to cause reactive arthritis, however, cases with Group B streptococcus are very rare. Group B streptococcus infection should be taken into consideration not only in patients with diabetes and cerebrovascular disease but also in elderly patients.     

A case of hypereosinophilic syndrome associated with pulmonary infarction and hepatic vein obstruction (Budd-Chiari syndrome)

A 21-year-old man was admitted in March 1987 with low grade fever and chest pain. Eosinophilia had been pointed out and PIE syndrome was diagnosed in another hospital a month before admission. Steroid therapy had been started. On the first admission, the chest roentgenogram showed bilateral pleural effusion and a nodular shadow in the left lower lung field. Open lung biopsy was performed and a diagnosis of pulmonary infarction was made. Eosinophilia, low grade fever and chest pain were improved by steroid therapy. He was discharged in April 1987. He was readmitted in September 1987 because of fever, back pain and abdominal distension. On the second admission, eosinophilia (4,510/mm3) was pointed out. The case was diagnosed as hepatic vein obstruction by hepatic vein angiography, liver biopsy and ultrasonic examination. He had transient remission on corticosteroid and anti-coagulant therapy. This case was considered as a rare case of hypereosinophilic syndrome associated with pulmonary infarction and Budd-Chiari syndrome.     

A case of pulmonary metastasis from carcinosarcoma of uterus with subcutaneous implantation of tumor cells along the needle tract after percutaneous needle biopsy of lung]

A 68-year-old female who had undergone total hysterectomy for carcinosarcoma five months previously was noted to have a solitary nodular shadow in the right lung on chest X-ray. Percutaneous needle biopsy of the lung was performed via the right anterior chest wall, and the histologic findings showed metastasis from carcinosarcoma of uterus. Two months after needle biopsy, a chest wall mass appeared of the site of puncture of the lung needle biopsy. The mass was resected to relieve the chest wall pain and the specimen showed carcinosarcoma of uterus histologically. We consider that tumor cells were implanted to the chest wall along the needle tract after percutaneous needle biopsy of the lung. The postoperative chest computed tomogram showed the route of tumor implantation from the metastasis of right lung into the right chest wall. Dissemination and chest wall implantation of malignant cells after percutaneous lung needle biopsy have been rarely reported. However there are no reports of tumor implantation of sarcoma. The possibility of implantation of tumor cells along the needle tract after percutaneous lung needle biopsy should be carefully considered in cases of carcinosarcoma.     

A case of allergic granulomatosis and angiitis without symptoms of asthma]

We present a case of allergic rhinitis in a 68-year-old woman in whom eosinophilia was found when she complained of common cold-like symptoms. The patient noticed a mass lesion on her left neck, which improved with antibiotic treatment, but her coughing continued and edema of both lower extremities appeared. She was admitted to our hospital, because of abnormalities in her electrocardiogram and cardiomegaly seen in a chest radiograph. The discomfort due to the edema in the soles of both feet remained even after steroid therapy. Her chest radiograph revealed ground-glass opacity, and a transbronchial lung biopsy revealed granulation tissue with the infiltration of eosinophils into the interstitium. Allergic granulomatosis angiitis was diagnosed because of granulomatosis vasculitis resulting from sural nerve biopsy. This was a rare case of allergic granulomatosis angiitis because her lung function was normal, she had no history of bronchial asthma, and there were no clear symptoms of bronchial asthma.     

Metastatic abscess formation in a preexisting chest wall tumor: a rare initial presentation of Klebsiella pneumoniae liver abscess

The common infectious agents in the chest wall include Mycobacterium tuberculosis, Actinomyces, fungi, Nocardia, Entamoeba histolytica, and other aerobes and anaerobes. Klebsiella pneumoniae is an uncommon etiological agent. We describe a case of ankylosing spondylitis in a 45-year-old man, who had exhibited a painless lump in the left posterior chest wall for 3 months and who presented with acute-onset pain, erythematous change, and fever in the 2 weeks before admission. Cultures of the blood and chest wall abscess both showed Gram-negative bacilli, which were classified as K. pneumoniae. A contrast-enhanced computed tomography scan of the abdomen revealed a nonenhancing cystic abscess measuring 4.9 × 6.5 × 6.4 cm in segment 6 of the liver and communicating with the chest wall. Drainage of the liver abscess under ultrasound guidance and open surgical drainage of the chest wall abscess combined with adequate antibiotic treatment resolved the abscess.     

Report of a case of lung cancer with metastasis to the myocardium which showed electrocardiographic findings similar to acute myocardial infarction and intramyocardial mass on echocardiography

A 61-year-old man was admitted to our hospital with complaints of cough and left back and chest pain. He had suffered from left tuberculous pleurisy at the age of 20 years. Chest X-ray film and CT revealed atelectasis of the left lung, a left hilar mass and an irregular left atrial wall. Depressed P-Ta segment in the inferior limb and anterior chest leads and an abnormal P wave were found on ECG. Transbronchial lung biopsy showed squamous cell carcinoma. After radiation therapy, the patient complained of chest oppression. ECG revealed a normalized P-Ta segment deviation, markedly elevated ST segment in the inferior limb and lateral chest leads and a depressed ST segment in the anterior chest leads. These findings persisted until his death. An obscure appearance of the pericardium and an echogenic intramyocardial mass in the posteroinferior and lateral wall were evident by echocardiography. The patient died due to heart failure. Postmortem needle biopsy showed scattered intramyocardial tumor cell nests with keratinization. CPK, GOT and LDH were within normal limits throughout the course, but CPK-MB was slightly increased. Cardiac metastasis with an ECG appearance similar to that of acute myocardial infarction has been rarely reported. Our present case showed peculiar feature including 1) ECG findings similar to atrial and ventricular myocardial infarction, and 2) an echogenic intramyocardial mass and an ill-defined pericardium on echocardiography. These findings suggested direct invasion of squamous cell carcinoma of the lung to the ventricular myocardium.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac failure following group A streptococcal infection with echocardiographically proven pericarditis,still insufficient arguments for acute rheumatic fever: a case report and literature update

We recently encountered a 49-year-old female who developed fever due to group A streptococcal (GAS) bacteriaemia spreading to an abscess in the iliac muscle and a bacterial monarthritis of the right knee with a sterile arthritis of her left knee. Treatment was started with a six-week course of intravenous penicillin. She developed a mitral valve insufficiency and pericarditis on the tenth day of admission. In the third week heart failure developed with, on echocardiograph, a high output left ventricular failure without signs of valvulitis or myocarditis. Using a diuretic regimen she was recompensated. Because of the pericarditis with mitral valve insufficiency corticosteroids were given, which had a rapid beneficial effect. A discussion follows on the position of acute rheumatic fever versus post-streptococcal reactive arthritis in this clinical picture and the literature is updated.     

A case of occult thyroid cancer detected as a solitary nodular lung metastasis

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.     

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 neurogenic myocardial stunning presenting transient left ventricular mid-portion ballooning simulating atypical takotsubo cardiomyopathy

A 57-year-old female patient, who was initially suspected to have subarachnoid hemorrhage, was admitted to our hospital. She experienced severe dyspnea and chest pain owing to pneumonia on the fourth admission day. Electrocardiography showed ST-segment elevation in leads V(2) through V(5), and echocardiography revealed hypokinetic left ventricular wall motion. No stenosis was found in the coronary arteries by urgent coronary angiography. However, left ventriculography revealed that the basal and apical areas were hyperkinetic and the mid portion was akinetic. After a month, left ventricular wall motion was improved and coronary artery spasm provocation tests were negative. Although the clinical course of this patient was similar to that of neurogenic myocardial stunning, the shape of her left ventricle was not typical.     

Wegener's granulomatosis in a woman with asymptomatic primary biliary cirrhosis

A 60-year-old woman was admitted to our hospital in June 1985, complaining of fever, cough and right lower chest pain, with a five-year history of asymptomatic primary biliary cirrhosis. Chest X-ray on admission showed an infiltrative shadow in the right lower lung field. She was first treated with various antibiotics unsuccessfully. Hemoptysis continued. Dyspnea and anemia appeared. Chest X-ray 17 days after admission showed multiple infiltrative shadows in the both lung fields. She was treated with steroid pulse therapy successfully. During prednisolone treatment decreasing nodular shadows with cavities appeared on chest X-ray. An open lung biopsy was performed in March 1986. The histologic findings showed a necrotizing vasculitis with granuloma and perivascular fibrosis. She was treated with prednisolone and prednisolone-azathioprine therapy unsuccessfully, but successfully with prednisolone-cyclophosphamide therapy. This case was a rare case of Wegener's granulomatosis with transition from fulminant type to granulomatous type. No similar case of Wegener's granulomatosis with asymptomatic primary biliary cirrhosis has been reported in the literature.     

A case of large cell carcinoma of the lung which is suspected of producing granulocyte colony-stimulating factor]

A 41-year-old male complaining of fever and left shoulder pain was admitted to our hospital for further examination of an abnormal shadow on chest X-ray film. His laboratory data on admission showed marked leukocytosis and elevation of serum alkaline phosphatase. The diagnosis of large cell carcinoma of the lung was made by percutaneous biopsy and he was staged clinically as T3N0M0. Chemotherapy including CDDP and VDS resulted in resolution of symptoms and normal laboratory data. After three courses of chemotherapy, he underwent left upper lobectomy with chest wall resection. Pathological diagnosis of the resected tumor was large cell carcinoma with giant cells, and he was staged postoperatively as T3N0M0. Since colony stimulating activity was demonstrated in both homogenate of tumor cells and tumor conditioned medium, and preoperative serum granulocyte colony-stimulating factor (G-CSF) was 105 pg/ml, we concluded that leukocytosis in this patient was caused by G-CSF produced by tumor cells. The patient was in good health two years after surgery with no signs of recurrence.     

A case of lymphoma which developed bone, liver, and skin lesions two years after the diagnosis of lymphoid interstitial pneumonia

We reported a case of lymphoid interstitial pneumonia (LIP) in 1985. The patient, a 37-year-old housewife, had suffered from cough and dyspnea. Her chest roentgenograms revealed bilateral diffuse micronodular shadows. After open lung biopsy in 1983, the lesion was interpreted as LIP in the premalignant state. After pulse therapy her condition remarkably improved. She was readmitted because of fever and shoulder pain in 1985. X-ray films revealed punched out lesions on the extremities. As liver dysfunction and skin eruptions had been recognized to wax and wane since the first admission, transcutaneous liver biopsy and skin biopsy was done. The diagnosis was middle- to large-sized T cell lymphoma. CHOP therapy seemed effective. However there appeared dyspnea and cotton-like patchy shadows in both lung fields. Despite chemotherapy, she died of pulmonary fungal and cytomegaloviral infection in 1986. As a result of the reevaluation of the open lung biopsy specimen, we concluded that this case should have been considered as lymphoma at onset.     

A case of pneumonitis due to sho-saiko-to

We reported a case of pneumonitis due to Sho-saiko-to. A 71-year-old woman was admitted to our hospital because of pneumonia. She complained of dry cough, pyrexia and severe dyspnea. Fine crepitation was heard on physical examination of the chest and a chest X-ray film revealed diffuse reticulo-nodular shadow in both lung fields. We suspected summer-type hypersensitivity pneumonitis and followed her up, however her condition deteriorated. Under a suspicion of drug-induced pneumonitis, all drugs were stopped and she was given prednisolone. Consequently her complaints, laboratory data and chest X-ray findings markedly improved. Microscopic examination of a transbronchial lung biopsy specimens showed interstitial pneumonitis. The results of a lymphocyte stimulation test were positive for sho-saiko-to. She gave informed consent after receiving an explanation of the challenge test. She was tested with 2.5 g sho-saiko-to twice and developed high fever and dyspnea with hypoxia, while the chest X-ray film also revealed diffuse infiltrative shadows similar that on admission. Based on these findings, we diagnosed this case as pneumonitis due to sho-saiko-to. To our knowledge, there has been no previous case of pulmonary hypersensitivity due to sho-saiko-to reported in the world.     

Primary lung cancer with myocardial metastasis mimicking acute myocardial infarction]

A 78-year-old man was admitted to our hospital because of chest and back pain. Fourteen months previously his chest X-ray showed a tumor shadow with cavitation in the left middle field. On admission cardiomegaly was found. Chest CT without contrast enhancement did not detect an intra-myocardial tumor. The electrocardiogram and serological examination suggested acute onset of myocardial infarction. However, emergency coronary angiography detected neither significant stenosis nor occlusion. Thereafter, chest CT with contrast medium demonstrated an intra-myocardial tumor. There wes no pericardial effusion. We clinically diagnosed a myocardial tumor metastatic from lung cancer. He received symptomatic treatment, but died on the 31st hospital day. Autopsy revealed that most of the myocardium had been replaced by lung cancer cells. They did not invading the pericardium directly. These findings supported the clinical diagnosis that myocardial tumor was hematogenous metastasis from lung cancer.