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.     

高分辨率CT在非结核分枝杆菌肺病诊治中的价值

搜集广州市胸科医院2015年3月至2017年9月经菌种鉴定为非结核分枝杆菌(NTM)肺病、并行胸部高分辨率CT(HRCT)检查的99例患者,回顾性分析肺内病灶部位、数量、形态、大小、密度、边界、分布及淋巴结的CT征象;评估99例NTM肺病患者治疗前后HRCT的表现。HRCT检查表现为斑点片状渗出、实变93例,支气管扩张78例,空洞60例,纤维条索状影59例,结节状影58例,树芽征55例,磨玻璃样影46例,淋巴结肿大45例,胸膜增厚18例,胸腔积液9例,病变通常以多种形态混杂存在。91例NTM肺病患者经克拉霉素、利福平、乙胺丁醇及阿米卡星治疗6~18个月后CT复查,显示病灶均减少;8例患者经HRCT精准定位后行患侧肺叶切除术,术后肺部病灶明显减少,但均出现术侧胸膜肥厚粘连。胸部HRCT对NTM肺病的诊断及治疗具有重要的应用价值。     

A rapid response of lung squamous cell carcinoma following treatment with sintilimab combined with recombinant humane endostatin injection and nab-paclitaxel in an elderly patient: A case report

Rationale:At present, the prognosis of patients with giant lung squamous cell carcinoma (LSCC) is poor, and there is no safe and effective treatment for elderly patients with large LSCC.Patient concerns:Here, we reported a 77-year-old man admitted to the hospital with cough for 3 months and significant chest pain. Computed tomography (CT) imaging showed a large mass in the left lung with pleural effusion.Diagnoses:Chest CT scan revealed a 12.5 cm × 7.3 cm mass in the left upper lobe adjacent to the pulmonary vein, with left pleural effusion. Pulmonary tumor markers were significantly elevated, and CT-guided percutaneous lung mass biopsy specimens showed LSCC.Interventions:After diagnosis, the patient was treated with sintilimab combined with endostar and nab-paclitaxel. After 2 cycles of treatment, the lung mass in the patient shrank rapidly and the clinical symptoms were relieved.Outcomes:The patient''s tumor dramatically shrank, and the pleural effusion was decreased after 4 cycles of treatment without any adverse effects. Meanwhile, the high-level tumor marker resumed normal.Lessons:Sintilimab combined with endostar and nab-paclitaxel may be a good treatment option for lung squamous cell cancer, especially for that in elderly patients.     

A case of very late onset overlap syndrome of systemic sclerosis and systemic lupus erythematosus

A 88-year-old woman was admitted with appetite loss and dehydration in April 1999. She first noticed finger swelling in May 1996 and systemic sclerosis (SSc) was diagnosed in February 1997 on the basis of a clinical picture of low-grade fever, diffuse skin thickening, Raynaud's phenomenon, and pulmonary fibrosis. Retrospectively pulmonary fibrosis could have been identified on chest X ray film in September 1995. Although her appetite loss and dehydration were improved by hydration, pleural effusion continued. After detailed examinations, anti-topoisomerase 1 (Scl-70) antibody, anti-Sm antibody, and an anti-double-stranded DNA antibody (dsDNA) were found in her serum. However, the other antibodies to anti-SS-A, SS-B, Jo-1, and RNP were not detected. These results suggest that this elderly case was a very late onset overlap syndrome of systemic lupus erythematosus (SLE) and SSc. Thus, the pleural effusion in this case may have been caused by SLE-associated pleuritis. Although the late onset elderly cases with overlap syndrome are very rare, SLE, SSc, and their combination can be found in aged patients over 80 years old. SLE and SSc should be carefully considered for the differential diagnosis of pleural effusion and skin thickening even in elderly patients.     

A case of sparganosis with eosinophilic pleural effusion]

A 61 year-old man was admitted to our hospital complaining of exertional dyspnea and presented with left pleural effusion. Laboratory findings showed peripheral eosinophilia and a slightly elevated inflammatory reaction. Chest X-ray film and CT revealed left pleural effusion, but there were no particular abnormal findings on the lung fields. Pleural effusion was exudative, yellowish and contained numerous eosinophils. His detailed medical history showed that he had eaten uncooked snakes, which led us to suspect parasite diseases. Multiple-dot ELISA method was performed to detect specific anti-parasite antibody. The patient was diagnosed with sparganosis after the detection of a highly positive reaction against Spirometra erinacei-europaei in both serum and pleural effusion. Parasite disease is an important consideration on differential diagnosis of eosinophilic pleural effusion, and multiple-dot ELISA method might be helpful for screening it.     

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 post-traumatic bilateral eosinophilic pleural effusion]

A 58-year-old man was admitted to our hospital with chest pain caused by chest trauma. After admission, his chest pain decreased and he was discharged. Later, he was admitted again with a high fever and dyspnea. Laboratory findings on second admission showed a leukocyte count of 7,900/microliter (9% eosinophils) and a C-reactive protein of 17.0 mg/dl. Chest radiography and chest CT scanning on second admission showed moderate bilateral pleural effusion. Close examination showed an increase of eosinophils in the pleural effusion (14% of total cell counts on the right and 27% of total cell counts on the left) that was exudate. Post-traumatic bilateral eosinophilic pleural effusion was diagnosed. The patient was treated with antibiotic therapy and his condition improved. A chest CT scan afterwards showed improvement of the bilateral pleural effusion. The eosinophil count in the peripheral blood was 1% at chest trauma, 15% in the hospital to the max and decreased to 3% with the decrease of pleural effusion. Post-traumatic eosinophilic pleural effusion may be accompanied with inflammatory findings, and the mechanism is guessed by immunological reaction.     

A case of spontaneous rupture of the esophagus: the characteristic CT findings]

A 75-year-old man was seen in the Emergency Room of our hospital because of chest pain after drinking beer and vomiting. Chest radiography showed pleural effusion in the left pleural space. The drained effusion contained digested food. A chest CT scan demonstrated mediastinal emphysema and an esophageal tear. The contrast esophagogram confirmed the diagnosis of spontaneous rupture of the esophagus. The characteristic CT findings of esophageal tear could have been used alone for the diagnosis, without esophagography.     

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.     

A case of renal cell carcinoma complicated with interstitial pneumonitis, complete A-V block and pleural effusion during interferon-alpha therapy]

A 76-year-old man with postoperative renal cell carcinoma accompanied by multiple lung metastasis was being treated with recombinant interferon-alpha. After administration of 3 MU/day on 3 days/week for 1 month, he complained of headache and tinnitus. During continuous treatment for 3 months, he complained of appetite loss, low-grade fever and dyspnea. He was then referred to our Department of Internal Medicine. Electrocardiography indicated a complete A-V block, and chest radiography (CXR) showed a reticular shadow in both lower lung fields and bilateral pleural effusion. Chest computed tomography (CT) indicated subpleural emphysematous changes, multiple nodules, consolidation shadow with ground glass opacity in both lower lobes, and bilateral pleural effusion. The findings in the bronchoalveolar lavage (BAL) fluid included increases in the numbers of lymphocytes and eosinophils. We reached a diagnosis of interferon-alpha-induced pneumonitis on the basis of the patient's clinical course, and the CXR, chest CT and BAL fluid findings. Treatment with methylprednisolone pulse therapy for 3 days and then administration of prednisolone for 1 month resulted in marked improvement in the complete A-V block and interstitial pneumonitis. At day 7 after discontinuation of prednisolone, the serum level of C-reactive protein increased, and CXR showed bilateral pleural effusion. We therefore believe that the pleural effusion was probably also induced by interferon-alpha. Interferon is an effective drug for chronic hepatitis C and malignant diseases. Many complications have been reported during interferon therapy. However, although these complications, such as interstitial pneumonitis, complete A-V block and pleural effusion, have rarely been reported, careful attention is required during interferon therapy in case any appear.     

Chest CT findings and clinical features in mild Legionella pneumonia

OBJECTIVE: To evaluate mild Legionella pneumonia (LP) by chest CT, and clinical features. PATIENTS: In June 2000, an outbreak of LP occurred in Japan. Eight patients with mild LP (seven men, one woman; mean age 55.9 years) had fevers of more than 38 degrees C, but respiratory symptoms were observed only in four. Chest CT was performed before starting an appropriate treatment. MEASUREMENT: CT images were assessed by the distribution of ground-glass opacity (GGO), consolidation, and the existence of pleural effusion. RESULTS: Chest CT findings: multiple segments were affected in all of the patients, (pleural effusion in three, peripheral lung consolidation in seven, and GGO in seven). GGO was located around the consolidation in six patients. CONCLUSION: Mild LP may present as fever without respiratory symptoms. Chest CT findings of mild LP are bilateral, multiple affected segments and peripheral lung consolidation with GGO.     

A case of pyothorax caused by Mycobacterium avium]

A 74-year-old woman was admitted to our hospital in December, 2003 because of anorexia and weight loss lasting from August, 2003. Chest CT scan showed empyema with a niveau in the right lung and infiltrative and nodular shadows in the left lung. Acid-fast bacilli were detected in pleural effusion. Polymerase chain reaction (PCR) test was negative for Mycobacterium tuberculosis (M. tuberculosis) but positive for Mycobacterium avium (M. avium). PCR test for M. avium was also positive in bronchial lavage fluid, and many colonies of M. avium complex ( MAC) were cultured from pleural effusion. After we administered 4 drugs including RFP, EB, SM, and CAM, cultured colonies of M. avium decreased, the inflammatory reaction improved, and infiltrates in the left upper lobe has disappeared. These improvements confirmed the diagnosis of empyema caused by M. avium. Since nontuberculous mycobacteria induced empyema has rarely been reported, the clinical features of this disease should further be examined.     

Successful treatment of non-small cell lung cancer by gefitinib in an elderly patient with poor performance status

A 91-year-old woman was admitted to our hospital with dyspnea. A chest radiograph and chest CT films revealed a large amount of pleural effusion in the right side pleural cavity. After serial thoracentesis, chest CT films showed a mass shadow in the right S(6). Adenocarcinoma cells were found in the pleural effusion, leading to a diagnosis of non-small cell lung cancer (stage IIIB). After administration of gefitinib, the mass shadow and pleural effusion reduced and her performance status improved. Gefitinib may be a well-tolerated therapeutic strategy in elderly and poor performance status patients with advanced non-small cell lung cancer.     

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.     

Two younger male patients with rapidly progressing pulmonary pleomorphic carcinoma]

We report 2 cases of pulmonary pleomorphic carcinoma. The patient in case 1 was a 44-year-old man who was admitted to our hospital complaining of dry cough and dyspnea on exertion. Chest radiography and CT showed a huge tumor with left pleural effusion. Percutaneous biopsy suggested malignancy. As distant metastasis was not found and as cytological examination of pleural effusion gave a result of class II, we attempted to perform left pneumonectomy. However, we performed partial resection of the tumor because it had invaded the aorta, pulmonary artery, pericardium and pleura. The pathological diagnosis was pleomorphic carcinoma, p-T4 N2 M0. After the operation, we performed systemic chemotherapy, including cisplatin and irinotecanm with little effect (PD). The patient died of progression of the tumor. Case 2 was a 34-year-old man who was admitted to our hospital complaining of fever and general malaise. Chest radiography and CT showed a tumor in the left upper lobe. As no distant metastasis was found, we tried left upper lobectomy. However, we performed left upper segmentectomy and lymph node dissection because of invasion of the aorta and the chest wall, and because of hypersegmentation of the left upper lobe. Pathological diagnosis was pleomorphic carcinoma, p-T4 N0 M0. After the operation, the mediastinum was subjected to radiation therapy. However, a metastatic tumor was found in the pelvis after this radiation was given. We performed systemic chemotherapy with substances including cisplatin, gemcitabine and vinorelbine, but with little effect (PD). The patient died of peritonitis and pleuritis due to the recurrence and progression of the tumor. Both cases had rapidly growing neoplasms showing little sensitivity to chemotherapy or radiotherapy. Pulmonary pleomorphic carcinoma is suggested to be type of lung cancer with a poor prognosis when the tumor is not resected in the early stages.     

A case of small cell carcinoma of the lung with carcinomatous lymphangiosis-like shadow]

A 60-year-old man was admitted to our hospital on January 29, 1991 with dry cough, shortness of breath on exertion, appetite loss and abnormal shadows on chest X-ray. Chest X-ray on admission showed marked vascular shadows in both lung fields accompanied by left interlobar effusion. Chest CT showed thickening of vessels and bronchial walls with prominent interlobular septa in the subpleural regions. These findings suggested that the lesions were located in the peribronchial and perivascular interstitium and interlobular septa. Biopsy specimens of bronchial epithelium, lung tissue and right supraclavicular lymph nodes revealed small cell carcinoma (intermediate cell type). Because of the absence of lesions in other organs, the initial diagnosis was carcinomatous lymphangiosis of small cell carcinoma of the lung. However, the mild symptoms, normal arterial blood gas and good response to chemotherapy suggested the possibility of extensive small cell carcinoma of longitudinal spread type. Although small cell carcinoma of the lung is not a rare disease, this case suggests two possibilities. 1) Carcinomatous lymphangiosis of small cell carcinoma may have different symptoms, clinical course and prognosis from that of non-small cell carcinoma. 2) Carcinomatous lymphangiosis of small cell carcinoma may not be a clinical entity and in fact may simply represent extensive small cell carcinoma of longitudinal spread type.     

Pulmonary lymphangiomyomatosis (LAM) developing chylothorax

We describe a case of pulmonary lymphangiomyomatosis (LAM) with chylothorax that developed in a 46-year-old Japanese woman. This patient exhibited clinical symptoms of dyspnea and chest X-ray showed right pleural effusion. Thoracocentesis demonstrated chylous effusion. Chest computed tomography (CT) scan revealed multiple cystic lesions. Subsequent thoracoscopy revealed the chylorrhea from swelled vessels on the diaphragm. The clinical diagnosis, based on histological examinations with biopsy specimens obtained by thoracoscopy, was pulmonary LAM. Although the hormone therapy was not effective, chylous effusion was improved by the pleurodesis. Pulmonary LAM developing chylothorax is rare in Japan.     

A case of colon cancer with tension pneumothorax and empyema as a consequence of colo-pleural fistula]

A 63-year-old man was admitted to our hospital with fever and chest pain. Chest radiography revealed left pleural effusion with left pneumothorax and small nodular shadows in the right lung field. On CT of the chest and abdomen, multiple nodules were seen in both lung fields, and masses appeared in the liver and spleen. Fiberoptic colonoscopy showed obstruction at the end of the transverse colon. Biopsy of this obstruction proved it to be cancer. In this patient, a colo-pleural fistula was also diagnosed using thoracoscopy under local anesthesia and from the inflow of contrast medium from the colon into the thoracic cavity seen in abdominal radiographs. This was a rare case of a colo-pleural fistula without diaphragmatic deficiencies. Medical thoracoscopy is useful for the diagnosis of complicated pleural effusions as was seen in this case.     

A case of polyangiitis overlap syndrome]

A 25 year old man was admitted to our hospital on June 1, 1989 because of general fatigue and pleural effusion. He had noticed purpuras and nodules on his bilateral lower legs in July 1988. He was admitted to Nihon University Hospital and was diagnosed as allergic granulomatous angiitis. Methylprednisolone was administered. In March, 1989, a nodular shadow was detected in his lung CT films. From the findings of TBLB a granulomatous lesion was suspected. However, his clinical course was rather stable so he was discharged from the hospital. Two months later, he was suffered from fever and general fatigue. On his chest X ray film pleural effusion was detected in the lower part of his left lung. The nodular shadow was increasing gradually. Laboratory findings on his admission showed leukocytosis, thrombocytosis, elevated CRP and a high titer of RA factor. He was diagnosed as hypersensitivity angiitis in a broad sense based on his biopsy findings of the skin lesion. Furthermore, the diagnosis of an early stage of Wegener's granulomatosis (WG) or limited type of WG was also made from the clinical course of his lung lesion. The combination therapy with cyclophosphamide and methylprednisolone was started. It was so effective that the nodule of his left lung was almost disappeared. It seems that this case is one of the polyangiitis overlap syndrome proposed by Fauci.     

A rare presentation of intrapericardial hematoma 20 months post aortic valve replacement

We report the successful treatment of a rare case of chronic intrapericardial hematoma which presented with congestive cardiac failure 20 months after aortic valve replacement surgery for severe calcific aortic stenosis. Chest roentgenograph demonstrated paracardiac mass over lower left ventricle border, left pleural effusion and pulmonary venous hypertension. An echocardiographic study demonstrated intrapericardial mass posterolateral to left ventricle compressing left ventricular cavity both during systole and diastole causing septum to bulge into right ventricle. Computed tomography showed a loculated pericardial mass in left heart margin, left pleural effusion, bilateral axillary and mediastinal lymphadenopathy. Surgical resection was planned to relieve the symptoms and to confirm the diagnosis of the mass. The mass was completely resected through left anterolateral thoracotomy and histopathology findings confirmed the diagnosis of hematoma with cystic degeneration. Postoperative course was uneventful, and his symptoms improved markedly.